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CMS Launches “Primary Cares” Initiative

Posted in Reimbursement Matters

On April 22, 2019, the Centers for Medicare & Medicaid Services (CMS) announced five new payment model options under its “Primary Cares” initiative.  The aim of the Primary Cares initiative is to reimburse primary care practices and other providers for outcomes rather than procedures.  The Primary Cares initiative is comprised of two new voluntary tracks: (1) Primary Care First (PCF) and (2) Direct Contracting.

In general, the first track is aimed at single or smaller primary care practices and is built on the existing Comprehensive Primary Care Plus (CPC+) program.  The first model under PCF pays providers a monthly flat fee for each patient with the opportunity for greater shared savings if these patients stay healthy and out of the hospital. The second model under PCF focuses on seriously ill patients (“SIP”) and adjusts the payments to meet the needs of this population. CMS regards this second model as better suited for advanced primary care practices to take responsibility for high need, SIPs who currently lack a primary care practitioner and/or effective care coordination.

The second track, which is based on the Next Generation ACO program (previously discussed on this blog), is better suited for larger primary care organizations and those who have experience with taking on financial risk. The first model under Direct Contracting is the professional option, which allows participating providers to share in 50% of savings and losses on the total cost of care. The second model is the global option, where providers will take full risk and will earn 100% of savings on the total cost of care. The third model is the geographic option under which a provider organization would take on 100% responsibility for the total cost of care for all Medicare beneficiaries in a specific geographic region.  Geographic participating providers will be selected as part of a competitive application process and commit to providing CMS a specified discount amount off of total cost of care for the defined target region.

CMS anticipates releasing a Request for Application in Spring 2019 for the first round of payers and practices. Practices and payers will begin participation in the model in January 2020.

For more information about any of the models under PCF or Direct Contracting, see CMS’ One Pager of its Primary Cares initiative.

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