Primary Care First makes it easier to integrate care management
by Tina Dufresne, RN, BSN, MSM, CCM
Published on Jun 14, 2021
What is Primary Care First, PCF and how can this advance alternative payment model help support care management services?
Since the start of alternative payment models in 2012, the Center for Medicare & Medicaid Innovation (CMMI) continues to develop and test new models supporting providers in transitioning from fee for service to value-based care. One of the newest iterations is enhancement from the work done in the Comprehensive Care Plus (CPC+) model called Primary Care First (PCF).
Primary Care First is a set of voluntary alternative five-year payment options that reward value and quality by offering an innovative payment structure to support the delivery of advanced primary care. In response to input from primary care clinician stakeholders, Primary Care First is based on the existing Comprehensive Primary Care Plus (CPC+) model design principles, prioritizing the clinician-patient relationship, enhancing care for patients with complex chronic needs, and focusing financial incentives on improved health outcomes. PCF is offered in 26 regions:
PCF includes two cohorts of participating practices: Cohort 1 began in January 2021 and Cohort 2 will start in January 2022. There are currently 827 practices participating in Cohort 1 of Primary Care First (List) and 14 payer partners as of April, 2021. The applications deadline for Cohort 2 closed on May 21st, 2021.
PCF is one of the various Advanced Alternative Payment Models (APM) that offer providers a 5 percent incentive payment for achieving various threshold levels. If a provider achieves these thresholds, they become a Qualifying APM Participant and are excluded from the Merit Incentive Payment System (MIPS) reporting requirements and payment adjustment. In addition to the 5% incentive payment, PCF offers:
- The attributed population is grouped into tiers based on Hierarchical Condition Codes (HCCs) with corresponding PBPM rate ranges.
- Prospective payment to providers that can far exceed the current fee for service revenue even without the bonus potential.
- Freedom to be innovative in how practices care for their patients to include enhancing their care management service, telehealth, home visits and other services.
- A provider can participate in PCF while remaining in any of the ACO models.
- Risk is limited to 10% which in the higher tiers would still result in a positive revenue.
- Frees up practices from meeting the billing requirement associated with chronic care management and transitional care management billing which is often difficult to achieve.
- Multi payer program to allow for aligned incentives.
- Only one quality metric to meet in the first year.
In the first year, the single outcome measure and the quality gateway to performance-based payments is through managing acute hospital utilization (AHU) HEDIS measures for the attributed population. The second through fifth year will also include patient experience via the Patient Experience of Care Survey, Hemoglobin A1c Poor Control (>9%) eCQM, Controlling High Blood Pressure eCQM, Advance Care Plan CQM and Colorectal Cancer Screening eCQM.
Participating practices should consider that most practices have been working towards improving quality, decreasing cost and improving the beneficiary experience for more than a decade. These three elements often referred to as the Triple Aim. Agency for Healthcare Research and Quality (AHRQ) recent findings suggests care management has emerged as a leading practice-based strategy to manage the health of populations.
A comprehensive care management program can be costly and often not justified with past payment models. However, the PCF model provides a solution for this by offering up-front, partially capitated payments to allow for funding this foundational program. It is important for a practice to:
- Identify the right population of beneficiaries with modifiable risks.
- Align Care Management services to the needs of the population.
- Identify, prepare, and integrate appropriate personnel to deliver the needed services.
Research has shown 2% -5% of the population accounts for 80% of cost, therefore it is necessary to identify the right population with modifiable risks. High risk or high-cost populations are often identified as the right population however there may be patients who care management interventions would have little impact. Practices must accurately identify individuals and entire populations that can control risk factors which will in turn improve their health.
Aligning care management services with population needs promotes a synergistic relationship between providers and patients which is a critical component of successful delivery of primary care. Care management serves as the building block to a stronger relationship between the patient and provider and helps extend that relationship to the care team. This allows for effective coordination of care, self-management support, and outreach. Identifying and training personnel appropriate to the needed care management services is critical.
Today, care management programs are often lacking in communication, coordination or just missing altogether to develop a longitudinal plan of care which allows for the PCP to appropriately manage patient care demonstrated through improved quality, improved beneficiary experience and reduced cost. The PCF model recognizes this and offers the flexibility for practices to address their gaps to achieve the Triple Aim.