Primary Care First (PCF) is among several new primary care initiatives announced by CMS in April 2019 to accelerate innovations in the delivery of advanced primary care and increase the focus on improving quality and reducing costs. PCF is a new payment model that builds on the comprehensive primary care plus (CPC+) program, previously launched in 2017. Like CPC+, both programs include a population-based payment for each patient attributed to the practice to increase overall revenue to primary care providers and practices. The prospective payment is to help provide the practice with additional resources to meet patients’ needs outside of regular office visits (think telemedicine, care management, patient engagement).
Both programs aim to accelerate the transition to value-based payments in primary care and patient-centered care delivery. Under PCF, practices that meet program goals can earn a significant bonus and increase their overall revenues from CMS. In the PCF announcement, HHS Secretary Alex Azar said: “Building on the experience of previous models and ideas of past administrations, these models [including PCF] will test out paying for health and outcomes rather than procedures on a much larger scale than ever before. These models can serve as an inflection point for value-based transformation of our healthcare system, and American patients and providers will be the first ones to benefit.”
CMS announced the first cohort of approximately 900 practices in the fall of 2020, with the first performance period beginning in January 2021. A second PCF cohort (primarily for CPC+ practices) is slated to start in January 2022 with an application window expected sometime in 2021. This article guides you through the differences and similarities between the two programs and what interested practices should keep in mind when thinking about participating in PCF.
Common between CPC+ and PCF: Advanced Primary Care Capabilities
Similar between CPC+ and PCF, both focus on progressively building advanced primary care capabilities to improve patient care and reduce costs. CMS has described five (5) functions they consider “core” and “advanced capabilities” of comprehensive primary care – the specific requirements vary by program, but have lots in common, too, and should be familiar to CPC+ practices. The five functions are:
- Access and continuity
- Care management
- Comprehensiveness and coordination
- Patient and caregiver engagement
- Planned care and population health
First, access to and continuity of care for patients is vital. Patients can reach a member of their care team when they have needs (24/7 access). That team member can access their information in the EHR. Practices need to assign patients to a specific care team (typically referred to as empanelment) and connect with patients through a variety of methods, not just face-to-face visits – think telehealth, email, texting, and other communication and collaboration techniques.
Second, develop and utilize advanced care management techniques for patients. First, patients most at risk must be enrolled. These patients need proactive support and long-term thorough care management. Patients with acute needs should be provided short-term (episodic) care management, including follow-up after discharge and medication reconciliation. Managing transitions of care for patients moving between care settings is essential, too. Advanced capabilities include risk stratification based on data analysis of diagnoses, claims, or other electronic data, and critical input from the care team.
Next, practices must think comprehensively about patient needs and coordinate across the health system, including strengthening the focus on behavioral health and psychosocial needs. Practices are encouraged to engage community partners to meet patient needs. Collaborative relationships between primary care and specialists become as important as outcomes, and achieving patient goals become the central focus.
Fourth, implement patient and caregiver engagement strategies to help the practice drive improvement from the patient perspective. One way to accomplish this is through a Patient and Family Advisory Council. Practices and providers also need to think about how they encourage patient “self-management” through education, technology, and empowerment.
Finally, utilize data to improve care is the final function of comprehensive primary care. Measurement is critical to improvement in any environment. Plan to review and respond to feedback and monitor practice and provider level metrics from CMS and other payers on a regular schedule to stay on track and set new goals. Use data to guide testing tactics to improve care and achieve established goals under the CMS program.
These functions of advanced primary care are important and achievable. Patient centeredness, data-driven improvement, and proactive engagement will result in better care and lowered costs.
In addition to (or instead of) applying to participate in PCF, practices that typically provide hospice or palliative care can apply to take responsibility for high need, seriously ill beneficiaries under the Seriously Ill Patient, or SIP, part of the PCF model.
Financial Incentives – CPC+ vs. Primary Care First
PCF builds on CPC+ with the use of population-based payments directly to practices for their assigned patients. Providers and practices are granted spending flexibility with minimal documentation requirements and no special consent and co-insurance requirements for care management. For example, this means that high-risk patients can begin receiving care management proactively without having to consent to the program or pay out-of-pocket expenses. While some patients see the value of care management, required co-payments and confusion on the patient’s part can delay or inhibit the success of the intervention for many patients. This new flexibility is encouraging.
PCF offers significant performance-based payments as compared to CPC+. If practices meet performance metrics, they can be awarded up to a 50% positive adjustment (bonus) on their Primary Care payment. Failing to meet minimum performance thresholds put PCF practices at risk of a 10% negative adjustment. CMS announced that performance-based payments would begin in Year 2 of the program.
Here’s an overview of the financial incentives under the different programs.
Even without the performance bonus, Primary Care First significantly increases the practice’s revenue with the potential to earn a significant bonus.
Let’s look at an example. A two provider practice with 450 patients seen in the office an average of 3.5 times per year. Their average HCC puts them in Group 2 (“tier 2”) for PCF.
Under fee-for-service, visit and co-pay revenue would earn the two provider practice $197,662 per year in Medicare Part B revenue. Under Primary Care First, annual revenue would be 155% – 248% higher!
Here’s the breakdown:
Two provider practice
450 Patients seen in office an average of 3.5 times per year
1.2< HCC <1.5 (PCF Group 2)
|Fee-for-Service||Primary Care First|
|FFS Co-Pay Revenue||$29,138||$29,138|
|Per Beneficiary per Month Revenue||$0||$243,000|
|Performance Bonus||1.79%*||-10% to +50%**|
|Total||$197,662||$305,696 to $490,072|
|PCF % of FFS Revenue||155% to 248%|
* Assumes full MIPS bonus of 1.79% for 2019
** PCF quarterly bonus starts in program Y2
Performance Metrics & Incentives
While the performance metrics have some overlap with CPC+, the PCF metrics are different based on the risk group of the patients assigned to the practice. PCF practices in groups 1 and 2 will report on the following metrics:
- HgbA1c Control
- Controlling HTN
- Colorectal Cancer Screening
- Advance Care Plan
- CAHPS Survey
PCF practices in groups 3 and 4 are accountable to these metrics:
- Advance Care Plan
- CAHPS Survey
- Total Per Capita Cost
- 24/7 Access to Practitioner*
- Days at Home*
* Starting in Year 3 of the PCF Model for Tiers 3 and 4
CPC+ and PCF Performance Metrics
|Metric||CPC+||PCF (Risk Tiers 1-2)||PCF (Risk Tiers 3-4)|
|Emergency Dept Utilization||✓|
|Acute Hospital Utilization||✓||✓|
|Colorectal Cancer Screening||✓|
|Advance Care Plan||✓||✓|
|Total Per Capita Cost||✓|
|24/7 Access to Practitioner||✓*|
|Days at Home||✓*|
* Measurement begins in Year 3 of Payment Model
New for CPC+ practices, PCF practices must engage a Qualified Registry to report quality measures, including the Advance Care Plan measure. A Qualified Registry can also assist in analyzing your data to implement proactive care strategies and help you keep up with program best practices and changes. Mingle Health has been a Qualified Registry since 2012 and is ready to help you succeed with the PCF program.
Program Timeline & Eligibility
CPC+ and PCF are both 5-year payment models. The first PCF cohort applicants had to be in one of 26 regions for the 2021 start date. The second PCF cohort will be for current CPC+ practices for the 2022 start date. CMS has said they may add additional regions/locations to the 2nd cohort application.
In an October 2020 program call, CMS announced that 903 practice sites were accepted into the first cohort for Primary Care First across the 26 regions, including 4,700 clinicians caring for 518,000 Medicare beneficiaries. For comparison, approximately 2,700 practice sites are currently participating in CPC+.
Key dates & milestones:
- January 1, 2021: PCF first performance period begins
- Spring 2021: (Est.) The application window for 2nd PCF Cohort (CPC+ Practices)
- April 2021: PCF Seriously Ill Population (SIP) performance period begins
- 2022: PCF cohort becomes bonus eligible in Year 2 of PCF
|Program||Enrollment||First Performance Period||End of Final Performance Period|
|CPC+ Track 1||Summer/Fall 2016||January 1, 2017||December 31, 2021|
|CPC+ Track 2||Spring/Summer 2017||January 1, 2018||December 31, 2022|
|Primary Care First Cohort 1||Winter 2020||January 1, 2021 (SIP begins April 1, 2021)||December 31, 2025|
|Primary Care First Cohort 2 (CPC+ participants who apply)||Spring 2021 (estimated)||January 1, 2022||December 31, 2026|
How are patients attributed to my practice?
Both CPC+ and PCF use a similar algorithm to attribute patients to a practice based on these factors in this order:
- The beneficiary selected a Primary Care practitioner via MyMedicare.gov
- The PCP billed the most recent Annual Wellness or Welcome to Medicare Visit during the 24-month ‘look-back’ period?
- The PCP who has provided the plurality of primary care visits during the 24-month ‘look-back’ period
- The PCP who provided the most recent visit? (tie-breaker if needed)
Being proactive and making sure your patients have had a recent Annual Wellness Visit (AWV) will increase the likelihood that your patients are attributed to your practice and are engaged actively with your practice.
What does it take to be successful in PCF?
Primary Care First is a new payment model. Plan some time to ramp up and get going. That said, PCF builds on the CPC+ payment model so many requirements of comprehensive primary care should be familiar to providers and practices. The good news is, based on our modeling, you’ll still receive reimbursements above traditional fee-for-service even if practices receive a negative performance adjustment.
We believe the keys to success are:
- Invest in team-based care: PCF requires patients to be assigned to a care team that meets regularly to review patient needs, plan and provide care management, and review performance data; practices may need to add team members directly or indirectly through vendors, to deliver on coordination and patient care management requirements.
- Proactive and data-driven: practices need to commit to operating differently. This includes using data to engage patients who are most at risk and test new improvement projects. Do you understand how to measure and monitor the key PCF metrics for your practice? Do you understand the staffing needed to deliver comprehensive primary care? Mingle Health is ready to assist you in these efforts.
Have you applied and been accepted to PCF? Read our blog post on how to prepare for the program.
Is PCF right for me and my organization?
Innovation in the delivery of primary care is crucial in the transition to value-based care. Primary Care First provides lots of flexibility to practices, and, importantly, gives spending flexibility to practices through the population-based payment. We encourage practices to explore this exciting new payment model seriously. CMS has made it clear that they wish to see more and more care being paid for via alternative payment models such as Primary Care First.
CMS, in their PCF model briefing webinar, highlighted the following benefits to participation:
- Less administrative burden and more flexibility
- Ability to increase revenue
- Enhanced access to actionable, timely data
- Focus on a single outcome measure
- Opportunities for practices that specialize in high need, seriously ill populations
- Potential to become a Qualifying APM Participant
We agree; there are many benefits to participating in PCF, especially increased revenue for a practice to focus on improving outcomes with the flexibility to test new interventions. Read our blog post: Top 10 Reasons to be Excited About Primary Care First.
The Mingle Health team is here to help you determine if PCF is a good fit for your organization and partner with you as your Qualified Registry to bring our analytics, expertise, and support to your practice and patients.
Share your thoughts and questions about Primary Care First in the comments and we’ll be sure to share the answers with our community. You may also reach out to the team here.
The program encourages innovation and rewards outcomes in the advanced delivery of primary care.