Primary Care First - Initial Year Review
What We’ve Learned After One Year
At the end of December 2022, CMS presented their preliminary analysis of Primary Care First’s (PCF) performance for its first operational year in 2021.The evaluation found that the model is having a positive impact on primary care delivery in the US. The data showed patients experienced improved quality of care, increased access to primary care services, and greater patient satisfaction in 2021 compared to 2020. Furthermore, providers enjoyed higher revenue and reduced overhead costs due to changes in the payment model. The evaluation also found that the Primary Care First model enabled primary care providers to spend more time with their patients, leading to better patient outcomes and improved health status. Overall, CMS' evaluation demonstrates that Primary Care First is proving to be an effective primary health care model for improving care delivery in the US. With these positive results in its first year of implementation, it is likely that Primary Care First model options will continue to improve access and quality of care for patients in the coming years.
The evaluation also highlighted areas in which the Primary Care First model could be improved, such as increasing access to rural and underserved populations, providing more effective care coordination between primary care providers and other providers, and supporting better information technology resources for providers. CMS is taking steps to address these issues by increasing funding for primary care models and creating new initiatives to increase access and quality of care in rural and underserved areas. CMS is also investing in new tools to help primary care providers better coordinate care with other providers, as well as improve their use of information technology resources.
The evaluation of CMS Primary Care First is positive news for both patients and providers. The Primary Care First model has proven effective in its first year of implementation and provides a promising foundation for further improvements to primary care models in the US. With CMS' continued efforts to address areas of improvement, it is likely that Primary Care First model options will continue to have a positive impact on primary care delivery for years to come.
In summary, these are the findings of CMS’ first year evaluation of Primary Care First:
Participants and Partners
Initial Cohort
26 Regions
846 practices; 4,000 practitioners, representing over 500,000 Medicare beneficiaries
Beneficiaries are primarily white and affluent
Most practices were assigned to Risk Group 1 (lowest risk or lower acuity patients)
Payer partner participation was modest (13 payers)
Findings
CMS payments to PCF practices
Estimated PCF payments averaged about 20 percent higher than participating practices would have received under the Medicare physician fee schedule (see chart below)
FVF = flat visit fee; PBP = population-based payment; PBPM = per beneficiary per month; PCF = Primary Care First
Planned care delivery changes
Participants added staff and built on existing capabilities
Practices in the lower risk groups (1 and 2) enhanced care management strategies
Better follow up post discharge
Expansion of chronic conditions for services
Deployed strategies to reduce hospitalizations and lower the total cost of care
Telehealth utilization to improve access to care
Behavioral health integration
Practices in the higher risk groups (3 and 4) did the following
Reviewed advanced care plans
Population includes many patients that are homebound
Deployed data analytics to identify patients that need a higher level of intervention
Participating Practices did have advanced care capabilities (see chart below)
Key Takeaways
Practices extended and enhanced their advanced care capabilities, but the initial cohort had previous experience with advanced care and value based care by design.
CMS considers the estimated Primary Care First payments to be generous as they were 20% higher than the Fee For Service equivalent for the same services.
Future reports will evaluate the impact on quality of care and utilization with a particular look at improvement admissions or acute hospitalizations.
What is the Primary Care First Model Exactly?
Primary Care First also known as PCF or CMS Primary Care First is a five-year payment program with options that reward value and quality by offering an innovative payment structure to support delivery of advanced primary care. The Primary Care First model is based on the underlying principles of the existing CPC+ model design which include; prioritizing the doctor-patient relationship, enhancing care for patients with complex high-need chronic conditions, treating seriously ill patients, reducing administrative burden, and focusing financial rewards on improved health outcomes. Practices are incentivized to deliver patient-centered care that reduces the need for costly acute hospital utilization. Primary Care First is oriented around comprehensive primary care models such as; access and continuity, care management, comprehensiveness and coordination, patient and caregiver engagement, planned care and population health.
The American Academy of Family Practice (AAFP) which is one of the largest organizations of primary care physicians in the United States has supported and contributed to the Primary Care First model. According to AAFP Speaker Russell Kohl, MD, he has indicated the initiative represents an important movement toward acknowledging the vital role of primary care “by placing greater emphasis on the investments we make in family medicine and other primary care practices.”
Dr. Gerald Harmon of the American Medical Association (AMA) has also provided his support stating: “Many primary care physicians have been struggling to deliver the care their patients need and to financially sustain their practices under current Medicare payments. The primary care payment models provide practices with more resources and more flexibility to deliver the highest-quality care to their patients.”
Primary Care First Fact Sheet
Who are the Participants?
Be a primary care practitioners (MD, DO, CNS, NP, PA) in good standing with CMS
Physicians who provide health services to a minimum of 125 attributed Medicare beneficiaries
Have primary care services account for at least 70% of the practices’ collective billing based on revenue
For Cohort 2 primary care services must account for at least 50% of the practices’ collective revenue
Demonstrate experience with value-based payment arrangements
Meet technology standards for electronic medical records and data exchange
Concierge Practices, FQHCs and RHCs are not eligible to participate
Only providers in 26 states are eligible to participate
Provide a set of advanced primary care delivery capabilities
Primary Care First includes two cohorts of participating practices: Cohort 1 began in January 2021 and Cohort 2 began in January 2022
For Cohort 2 these requirements have been expressed by CMS:
Have experience with value-based payment arrangements or payments based on cost, quality, and/or utilization performance such as shared savings, performance-based incentive payments, and episode-based payments, and/or alternative to fee-for-service payments such as full or partial capitation
Adopt and maintain, at a minimum, health IT meeting the definition of CEHRT at 42 CFR 414.1305 and the certification criteria found at 45 CFR 170.315(c)(1)-(3) for electronic clinical quality measure (eCQM) reporting, using the most recent update available on January 1 of the Measurement Period, for the eCQMs in the Primary Care First measure set; support data exchange with other providers and health systems via Application Programming Interface (API); and connect to their regional health information exchange (HIE)
Are able to meet the requirements of the Primary Care First Participation Agreement
Compensation
There are two Primary Care First payment model options: one general and one for high-need populations. The “general” model includes a risk-adjusted, population-based payment, plus a flat visit fee for each face-to-face encounter with the primary care physician. This model includes an upside performance-based payment that is as much as 50% of revenue. Downside risk is capped at 10% of revenue.
According to CMS Primary Care RFA published in October 2019 the following payment components will be utilized.
Total Primary Care Payment (TPCP)
The TPCP will largely replace practices’ traditional FFS billing for primary care services. It includes two elements, a lump-sum professional population- based payment (PBP) paid on a quarterly basis and a flat $40.82 base rate per-visit primary care fee. Together, these payment mechanisms create an incentive to deliver advanced, patient- centered primary care while also compensating practitioners for face-to-face visits. It includes some adjustments to account for variations in cost of care, including a geographic adjustment, risk adjustment, and a leakage penalty to encourage practices to manage their attributed patients to limit their demand to look for care from other primary care providers.
Performance-Based Adjustment (PBA)
During performance year two, and in subsequent performance years, a practice’s TPCP will be adjusted based on its performance on five quality and patient experience of care measures, as well as a measure of acute hospital utilization (AHU). Practices may receive a maximum possible positive PBA of 50% and a maximum possible negative PBA of -10%.
Population-Based Payment
PBPM = per beneficiary per month
Timeline
Looking Forward
The Primary Care First model is intended to incentivize delivery of better care. As the program proceeds, it will be important to understand whether the CMS risk adjustment methodology accurately captures beneficiary risk. Primary Care First practices assigned to the lower risk groups may not be able to enhance care delivery to the same extent as practices assigned to higher risk groups. However, many experts believe this iteration of CMS’s primary care value based compensation programs utilizing risk adjustment will achieve improved patient care and create a contemporary model for advanced primary care.
If you participate in the Primary Care First alternative payment model, it is essential that your risk-bearing organization understands the actual disease burden of its patients and accurately documents those disease states prior to claims submission. Remember the Population-Based Payments are based on the Medicare HCC Risk Model, the same model as Medicare Advantage and the model for which ForeSee Medical was designed.
Ask yourself, does your current EHR or population health software have:
Artificial Intelligence that reads unstructured data
Smart Recapture that alerts for codes without documentation
EHR Integration at the point of care
Hyperlinks to Original Documentation allowing you to click on a disease suspect and see the exact supporting document page
AI-powered risk adjustment software from ForeSee Medical can help your organization discover opportunities using artificial intelligence and increase the profitability of your Primary Care First contracts.
Blog by: The ForeSee Medical Team