The Centers for Medicare and Medicaid Services (CMS) is launching two new alternative payment models in 2020 aimed at incentivizing primary care providers who serve patients with comprehensive, continuous, and coordinated care.

The potential benefits for providers are significant — including greater flexibility in how care is delivered and performance-based adjustments of up to 50% of revenue for positive outcomes.1 But providers who want to participate will need the appropriate software tools to capture, track, and report the required data and to help identify opportunities for continuous improvement.

Called Primary Care First, the five-year alternative payment program focuses on advanced primary care practices in 26 states. Participating providers should be prepared to assume financial risk for their patients’ care, in exchange for reduced administrative burdens and performance-based payments.

Participants will need to meet quality care standards focused on defined clinical quality and patient experience measures relevant for seriously ill patients and those with complex chronic conditions. Such measures will include advanced care planning, colorectal cancer screening, patient experience surveys, ability to manage high blood pressure, and control of hemoglobin A1c levels in patients with diabetes.

In addition to the potential performance-based adjustment of up to 50% of revenue, participating providers also would face possible downside losses of up to 10% of revenue if they fail to meet quality standards and reduce costs. A second Primary Care First payment model will offer higher incentives for primary care providers serving high-need populations, including Medicare recipients with complex, chronic conditions or those with serious illnesses who do not currently have a primary care provider or effective care coordination.

Ultimately, the program is designed to test whether the delivery of advanced, continuous primary care to some of the nation’s sickest patients can help reduce the total cost of care. Primary Care First targets patients who contribute a majority of the country’s healthcare costs.

An estimated 60% of American adults have at least one chronic condition, but those patients drive approximately 90% of healthcare spending.2

For example, an estimated 1.6 million people are diagnosed with cancer each year, and about 600,000 die from the disease annually. The cost of cancer care is expected to reach $174 billion by 2020. Diabetes is more prevalent, affecting 30 million Americans at an estimated annual cost of $237 billion.3

Having the Tools to Succeed

Primary Care First aims to incentivize a seamless continuum of care, improving access to palliative care services for patients with serious illnesses such as cancer and diabetes. Participating providers must be certified in internal medicine, general medicine, geriatrics, family medicine, and/or hospice and palliative medicine.

Primary care practices that are experienced in caring for the elderly are well-positioned to participate in the Primary Care First models. Such practices are seasoned in engaging physician extenders, and they embrace an interdisciplinary model of care, integrating case managers, nutritionists, behavioral psychologists, pharmacists, and others as part of the care team. Geriatricians also are an asset to the team, especially for practices that are more physician-dominant.

Previous experience with value-based payment models and in leveraging Meaningful Use standards will also be beneficial. These practices are well-versed in transmitting data, researching the required measures, and providing their data in a timely manner.

Key focus areas for Primary Care First include:

  • Access and continuity

  • Care management

  • Comprehensiveness and coordination

  • Patient and caregiver engagement

  • Planned care and population health

Providers interested in participating should conduct a thorough assessment of their current software capabilities compared to what is needed to accurately and efficiently track, collate, and analyze the data required for the program.

Software should enable participants to simultaneously access data on utilization, quality, patient satisfaction, cost, and external and internal benchmarks. Having the ability to create physician and physician group reports with safety, quality, cost, and satisfaction measures would be beneficial in helping practices identify opportunities for improvements that, if effectively implemented, would help them improve patient outcomes and earn higher payment adjustments through the Primary Care First program.

Even primary care providers located outside of the program’s initial 26-state roll-out area should pay attention and begin building these capabilities, if they have not already. Given the aging population and longer life expectancies, accountable care is a must for federal, state, and commercial payers. These models will continue to be tested and refined, becoming a permanent part of the nation’s evolving healthcare payment methodologies.

 


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1 CMS: “Primary Care First Model Options.” CMS Innovation Center, Updated Aug. 20, 2019. https://innovation.cms.gov/initiatives/primary-care-first-model-options/

2 Rand Corporation: “Chronic Conditions in America: Price and Prevalence.” Rand Review, July 12, 2017. https://www.rand.org/blog/rand-review/2017/07/chronic-conditions-in-america-price-and-prevalence.html

3 CDC: “Health and Economic Costs of Chronic Diseases.” National Center for Chronic Disease Prevention and Health Promotion, Updated Feb. 11, 2019. https://www.cdc.gov/chronicdisease/about/costs/index.htm