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Primary Care First: There’s a lot to like about Medicare’s New Payment Model

This post was updated on April 18, 2021, with information about the 2nd PCF Cohort application.

You don’t have much time left to consider Primary Care First. The application for the 2nd cohort has been extended to May 21, 2021 (previously it was April 30, 2021) – we don’t want you to miss this opportunity to participate.

Primary Care First rewards innovation in primary care practices by providing a financial model that moves dramatically away from fee-for-service and soundly into value-based care. It shows real promise for helping independent primary care practices remain independent.

The program comes out of the Center for Medicaid and Medicare Innovation (CMMI) and picks up where CPC+ left off—with higher prospective payments, simplified fee schedule for the most common primary care CPT codes, and offers significant bonuses for meeting and exceeding national benchmarks for a limited number of quality metrics.

The completed application will be due eight weeks after release and is open to primary care practices in several states and regions across the country. More than half of the nation’s primary care providers are located in the selected regions.

Eligibility and selection requirements for practices include Medicare service volume and practice technology capabilities. The program is initially scoped to run for five years. Like most Medicare programs, it can be adjusted annually and may be revised, extended, or canceled.

The prospective professional population-based payments per beneficiary per month (PBPM) are based on attributed Medicare beneficiaries. A practice must have at least 125 to participate. The payments are also tiered, based on the average Hierarchical Condition Codes (HCC) of the attributed beneficiaries. The PBPM rate ranges from $24 per month for an average HCC of less than 1.0, to $175 per month for an average HCC greater than 2.0.

The simplified fee schedule is based on a regionally-adjusted base rate of $40.82 for the most common CPT codes in primary care.

In Year One of Primary Care First, the bonus is based on how well the practice prevents acute hospitalizations in their attributed beneficiaries. In Year Two, CMS will capture measures of patient experience and a limited number of clinical metrics.

There will be a -10% adjustment for not meeting national benchmarks for quality metrics and acute hospitalization reduction or total cost, but there is still an opportunity to earn a bonus for meeting improvement targets. Even without a bonus, the PBPM payments ensure that practices will likely come out ahead financially with Primary Care First.

In its introduction to the program CMS states, and we agree: “Primary care is central to a high-functioning healthcare system.”

Top 10 Reasons to be excited about Primary Care First

Here are the top ten reasons we like the Primary Care First model to support primary care practices:

  1. Participation is a practice level decision. The program is open to practices of all sizes from solo practitioners to practitioners in large single or multispecialty groups. You do not need to be part of a large organization or network to participate. You do not need to have access to deep pockets or expensive resources to thrive. You are not dependent on the cost-consciousness of your referral network to succeed.
  2. The practice has the freedom to be innovative in how you care for patients. There is no prescription for how you spend the PBPM payment; you can use it to provide care management, transportation or other services, spend more time with patients or add extra staff. The options are limitless and up to your imagination.
  3. The model can coexist and is synergistic with the Medicare Shared Savings Program (MSSP), now Pathways to Success. A provider can participate in Primary Care First while remaining in any of the ACO models. And a PCF practice can be successful even if the ACO is not.
  4. The attribution model is dominated by patient choice. Patients who identify their PCP at will be attributed to that PCP regardless of plurality of care.  Only those patients who do not choose a PCP will be attributed by one of the other methods.  If a patient does not choose their provider, they will be attributed based on where the patient received the Welcome to Medicare Visit or Annual Wellness visit, Care Management, or which primary care provider has the provided “Plurality of Care.” In the “Plurality of Care” model, the patient is assigned to the provider who has provided the greatest volume of primary care services.
  5. The upside is achievable and can be substantial. For example, even with no bonus, a Tier 3 practice, with 200 attributed patients and an average number of visits per patient of 4, the combined PBPM and visit fees add up to 155% of FFS.
  6. Practices still come out ahead even if they are underperforming on quality metrics. The maximum downside risk is 10%. The same Tier 3 practice with 200 patients, receiving a 10% negative adjustment for not meeting national benchmarks on metrics, would earn 141% of FFS revenue.
  7. Unlike MIPS, this program is not budget neutral. Although there is some competition for the highest bonus by comparing one practice to another, the bonus pool is not created from those practices with a negative adjustment as it in MIPS.
  8. The program frees practices from significant documentation burdens for billing and quality measure reporting. Practices can save time and money while improving provider engagement, satisfaction, and availability, leading to better patient access and outcomes.
  9. Through the Seriously Ill Population component of the program, Primary Care First addresses some of the most expensive patients in primary care – patients who lack a primary care provider or lack effective care coordination. These patients are the highest utilizers of emergency departments and hospitals. PCF will help patients by referring them to practices most prepared to care for them. CMS is proactively identifying and recognizing the challenges of caring for this population with high PBPM payments and population-relevant metrics.
  10. Like CPC+, Primary Care First is an advanced alternative payment model (AAPM) that exempts participants from MIPS and provides a 5% bonus just for participating!

Is Primary Care First a good fit for your practice?

Applications are due by April 30, 2021. Mingle Health is offering a free consultation to see if PCF is right for you. Sign up for a Consultation now before the application comes out. Use this link to let us know a time that works best for you.

Additional information on eligible regions and program details can be found as they become available on the CMS Primary Care First program website.

Learn more about Mingle Health’s Qualified Registry and practice coaching services for Primary Care First.


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