A Closer Look at Primary Care First

Primary Care First (PCF), a new care delivery and payment model from the CMS Innovation Center is another approach to advancing primary care. PCF eligibility and care delivery design mirror the CPC+ model in several ways, but is distinct in others. The model leverages both population-based and flat fee visit payments to promote access and better care delivery. The impact of this approach to payment is expected to vary based on practice characteristics such as beneficiary risk profile.

On October 24, 2019, the Centers for Medicare and Medicaid Services (CMS) and the CMS Innovation Center posted a request for applications (RFA) for Primary Care First (PCF). Initially announced in April 2019, PCF represents the next step in the evolution of the CMS Innovation Center’s advanced primary care model portfolio. Applications for 2021 are due January 22, 2020.

Trump Administration Adheres to Key Themes with New Delivery Model Applications

US Department of Health and Human Services Secretary Alex Azar has outlined four departmental priorities: the opioid crisis, drug pricing, health insurance reform and value-based care. Within the value-based care bucket, the Administration has focused on pioneering bold new models in Medicare and Medicaid. Through requests for information, regulatory changes and new payment models, themes that define this Administration’s value-based payment agenda have emerged:

  • Shifting risk from the federal government to providers and other entities at a local level;
  • Engaging and empowering beneficiaries; and
  • Reducing administrative burdens.

PCF adheres to these themes, introducing new elements and building on the lessons learned from previous Innovation Center models.

Primary Care First

Building on the Comprehensive Primary Care initiative and Comprehensive Primary Care Plus (CPC+), PCF is intended to test whether advanced primary care can reduce total cost of care while improving or maintaining quality. The model is designed for primary care practices with advanced primary care capabilities, including those specializing in caring for complex, chronically ill patient populations.

The model will be tested over a six-year period, with one cohort participating from 2021 through 2025 and a second participating from 2022 through 2026. Practices located in the 26 eligible PCF regions that are not currently participating in CPC+ are eligible to participate in the first cohort. The second cohort will consist only of current CPC+ practices.

Like CPC+, PCF is a multi-payer model. CMS will encourage Medicare Advantage, commercial and Medicaid plans as well as state Medicaid agencies to engage practices on similar outcomes with respect to their members. Payers have the option to submit a non-binding Statement of Interest signaling their interest in partnering in PCF. The formal payer solicitation period will open December 9, 2019, and close March 13, 2020.

Payers that want to participate in this model must commit to pursuing private payment arrangements and to using at least a partial alternative to FFS payment, such as a population-based payment, and must offer an opportunity for a performance-based incentive payment that aligns with the PCF financial model.

Practice and payer selections are currently scheduled to take place in winter/spring 2020.

PCF Eligibility and Care Delivery Design

PCF Eligible Participating Practices

To participate in PCF, practices must meet certain criteria:

  • Have at least 125 attributed beneficiaries;
  • Achieve thresholds for primary care billing based on revenue;
  • Have experience with value-based payment arrangements or payments based on quality, cost and/or utilization performance;
  • Use 2015 CEHRT, support data exchange with other providers and health systems via Application Programming Interface, and agree to connect to their regional health information exchange; and
  • Participate in one of 26 selected regions.[1]

Care Delivery Design Elements

PCF primary care practitioners are incentivized to achieve better care at a lower cost by delivering on five primary care functions: