HIMSS News

CMS Releases New Plan for Driving Transformative Value-Based Care

Primary care appointment

On April 22, the Centers for Medicare & Medicaid Services (CMS) announced the latest set of primary care transformation models to come from the CMS Innovation Center, titled the Primary Cares Initiative. The major driver of this model is to reward value and quality by way of offering innovative payment model structures to support delivery of advanced primary care.

This initiative will provide primary care practices and other providers with five new payment model options under two paths: Primary Care First (PCF) and Direct Contracting (DC).

The two payment model options under PCF include:

  1. Primary Care First – General
  2. Primary Care First – High Need Populations

The three payment model options under DC include:

  1. Direct Contracting – Global
  2. Direct Contracting – Professional
  3. Direct Contracting – Geographic

To stress the importance and central nature of primary care, CMS recognizes the urgent need to preserve and strengthen this practice modality, as well as the need to support complex, chronic and serious illness care services for Medicare beneficiaries. PCF attempts to create a seamless continuum of care across many provider organizations with multiple stages of readiness to assume accountability for patient outcomes.

At its core, PCF will attempt to test whether the delivery of advanced primary care can reduce total cost of care with an underlying goal of incentivizing practices to deliver patient-centered care that reduces acute hospital utilization. CMS notes that this model is based on the underlying principles of the existing Comprehensive Primary Care Plus (CPC+) model that maximizes the objectives of prioritizing the doctor-patient relationship; enhances care for patients with complex needs and seriously ill patients; reduces administrative burden; and focuses on improving health outcomes.

The second PCF option also encourages advanced primary care practices to take on responsibility for high need, seriously ill beneficiaries who currently lack a primary care practitioner and/or effective care coordination.

PCF is a regionally based, multi-payer approach and it will include a five-year performance period. CMS anticipates releasing a Request for Application in spring 2019 for the first cohort of payers and practices to participate. PCF is set to begin in January 2020 for practices that are not currently participating in the CPC+ Model but are located in the existing 18 CPC+ regions.

The DC payment model options that are available intend to create opportunities for a broad range of organizations to participate in risk-sharing arrangements that promote value and high-quality care, while supporting the shift away from the fee-for-service paradigm. DC will also take lessons learned from existing initiatives involving Medicare Accountable Care Organizations (ACOs) as well as leverage innovative approaches from Medicare Advantage and private sector risk-sharing arrangements.

DC creates three payment model options for participants to take on risk and earn rewards, and provides participants with choices related to cash flow through Population-Based Payment (PBP), beneficiary alignment, and benefit enhancements.

Current Medicare ACOs interested in continuing their participation in Medicare risk arrangements will be eligible to participate in all three payment model options with an effective start date of January 2020.

CMS seeks additional input by way of a Request for Information, on the parameters around the DC Geographic Option. Responses to the RFI will be accepted through May 23, 2019.