On April 22, the Department of Health and Human Services
(HHS) unveiled
new alternative payment models that it hopes will “transform” primary care to
support high-value care. Released at a
briefing hosted by the American Medical Association and attended by me and
other ACP officials and members (and hundreds of other “stakeholder” groups,
plus the news media), the proposals would create more voluntary options
for primary care physicians and their practices to be paid for keeping patients
healthy and out of the hospital.
One of the new models, called Primary Care First, “will focus
on advanced primary care practices ready to assume financial risk in exchange
for reduced administrative burdens and performance-based payments. The other, called the Direct Contracting (DC), is directed at large systems that have the
experience and capabilities to take on substantial financial risk for large
numbers of patients.
In today’s post, I am only going
to summarize the key elements of the Primary Care First (PCF) model, taken
mostly from CMS’s fact
sheet, because it’s expected to be available to far more internists than
the Direct Contracting model.
Practice
Eligibility: To be eligible to participate in the PCF model, a practice must
include “primary care practitioners, (MD, DO, CNS, NP and PA), certified in
internal medicine, general medicine, geriatric medicine, family medicine and
hospice and palliative medicine.” It must
have 125 attributed Medicare beneficiaries at a particular location, have
primary care services account for at least 70% of the practices’ collective
billing based on revenue, and in the case of a multi-specialty practice, 70% of
the practice’s eligible primary care practitioners’ combined revenue must come
from primary care services. It must also “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.”
Geographic
locale: The practice must be in one of the 26 regions selected for the
program: Alaska (statewide), Arkansas (statewide), California (statewide),
Colorado (statewide), Delaware (statewide), Florida (statewide), Greater
Buffalo region (New York), Greater Kansas City region (Kansas and Missouri),
Greater Philadelphia region (Pennsylvania), Hawaii (statewide), Louisiana
(statewide), Maine (statewide), Massachusetts (statewide), Michigan
(statewide), Montana (statewide), Nebraska (statewide), New Hampshire
(statewide), New Jersey (statewide), North Dakota (statewide), North
Hudson-Capital region (New York), Ohio and Northern Kentucky region (statewide
in Ohio and partial state in Kentucky), Oklahoma (statewide), Oregon
(statewide), Rhode Island (statewide), Tennessee (statewide), and Virginia
(statewide).
Simplified
payment structure: Each practice accepted into the program will be paid what
CMS calls a “simplified payment structure” consisting of risk-adjusted
per beneficiary per month (PBPM) payments, plus a flat set amount for each office
visit. It will get a “performance
based adjustment providing an upside of up to 50% of revenue as well as a small
downside (10% of revenue) incentive to reduce costs and improve quality,
assessed and paid quarterly.” A
different [and higher] payment structure will apply to PCF practices that agree
to treat seriously ill patients that are currently lacking a primary care
practitioner.
Quality Assessment: CMS will
assess quality of care based on “a focused set of measures that are clinically
meaningful for patients with complex, chronic needs and the serious illness
population.”
Predictable
revenue and reduced administrative burdens: CMS believes that PCF will
appeal to a wide range of primary care physicians and their practices,
including those in small and solo practices, because the risk-adjusted PBPM
payments will provide them will predictable revenue each month, with limited
downside risk (maximum 10% reduction) and substantial upside potential gains
(50% of revenue). Administrative burdens will be also less, because the flat
office visit fee eliminates the need to document different levels of office visits.
Administrative burdens might also be reduced if PCP practices only have to
report on a more focused set of quality measures.
By building the PCF program as described above, CMS believes
that primary care physicians will come to it, like the baseball fans drawn to the
cornfield baseball diamond in Field of
Dreams. CMS needs them to
come, because as a completely voluntary program, there has to be enough
physicians, practices, and patients participating to assess the model’s
effectiveness and reproducibility. But
will they?
It’s too soon to tell.
As ACP observed
in a generally supportive statement issued today, there are elements of the PCF
model that suggest that CMS is on the right track: there are a variety of
payment and delivery models offered that support internal medicine and primary
care practices, from smaller and independent practices to larger integrated
ones; there is a range of risk options available to practices, and the new
models aim to reduce administrative burdens—potentially allowing physicians to
spend more time with their patients.
However, a lot of details are still missing that may
determine how many physicians and practices will seek to participate, including
basic things like how the PBPM payments will be adjusted by risk, the amount of
those payments, and how they are to be calculated. Also, unless other payers join Medicare in
supporting PCF practices with a simplified payment structure and more focused
measures, practices may not experience the reduction in administrative burdens
and predictable revenue that CMS anticipates. Presumably, CMS will be releasing such information soon, prior to the
enrollment period it intends to begin this summer.
ACP concluded its statement with a note of caution: “The
success and viability of these models will depend on the extent that they are
supported by payers in addition to Medicare and Medicaid, are adequately
adjusted for differences in the risk and health status of patients seen by each
practice, are provided predictable and adequate payments to support and sustain
practices (especially smaller independent ones), are appropriately scaled for
the financial risk expected of a practice, are provided meaningful and timely
data to support improvement, and are truly able to reduce administrative tasks
and costs, among other things. ACP will continue to evaluate the new payment
and delivery models based on such considerations, and we look forward to
working with CMS and to continue advocating for ways to support the value of
primary care for physicians and for all patients across the health care system.”
If CMS really wants primary care physicians to come to the models they've built, these - and other practical considerations - need to be included in their design. We'll soon find out if they will.
If CMS really wants primary care physicians to come to the models they've built, these - and other practical considerations - need to be included in their design. We'll soon find out if they will.