Primary Care First Model Options

Primary Care First is a voluntary alternative five-year payment model that rewards 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 principles underlying the existing Comprehensive Primary Care Plus (CPC+) model design: prioritizing the clinician-patient relationship; enhancing care for patients with complex chronic needs, and focusing financial incentives on improved health outcomes.

Primary Care First is offered in 26 regions: Alaska (statewide), Arkansas (statewide), California (statewide), Colorado (statewide), Delaware (statewide), Florida (statewide), Greater Buffalo region (New York), Greater Kansas City region (Kansas and Missouri), Greater Philadelphia region (Pennsylvania), Hawaii (statewide), Louisiana (statewide), Maine (statewide), Massachusetts (statewide), Michigan (statewide), Montana (statewide), Nebraska (statewide), New Hampshire (statewide), New Jersey (statewide), North Dakota (statewide), North Hudson-Capital region (New York), Ohio and Northern Kentucky region (statewide in Ohio and partial state in Kentucky), Oklahoma (statewide), Oregon (statewide), Rhode Island (statewide), Tennessee (statewide), and Virginia (statewide).

Primary Care First includes two cohorts of participating practices: Cohort 1 began in January 2021 and Cohort 2 began in January 2022.

There are approximately 2,100 practices participating in Primary Care First across both cohorts, and 17 payer partners. To view an interactive map of this Model, visit the Where Innovation is Happening& page, and select this model from the drop-down menu on the left side of the page.

Select anywhere on the map below to view the interactive version
Source: Centers for Medicare & Medicaid Services

 

Highlights

  • Patients who do not regularly see a primary care doctor are significantly less likely to get regular health screenings, monitoring for emerging health issues, and other preventive health care. These patients may see their health issues worsen, causing them to seek higher cost care, such as hospitalization, trips to the emergency room, or greater need to use specialty care.
  • The Primary Care First model is designed to help primary care practices better support their patients in managing their health — especially patients with complex, chronic health conditions — and enables primary care doctors to offer a broader range of health care services that meet the needs of their patients. For example, practices may offer around-the-clock access to a clinician and support for health-related social needs.
  • Strengthening the primary care doctor–patient relationship and enabling patients to receive more care from their primary care doctor can help improve the quality of patient care and reduce avoidable hospitalizations.

Background

Primary care is central to a high-functioning healthcare system and thus, there is an urgent need to preserve and strengthen primary care as well as a need for support of serious illness care services for Medicare beneficiaries.

Primary Care First addresses these needs through seamless coordinated care and accommodates a continuum of interested practices and clinicians. The model tests whether delivery of advanced primary care can reduce total cost of care, accommodating practices at multiple stages of readiness to assume accountability for patient outcomes. Primary Care First focuses on advanced primary care practices ready to assume financial risk and receive performance-based payments.

Primary Care First prioritizes patients by emphasizing the clinician-patient relationship. The Centers for Medicare & Medicaid Services (CMS) will prioritize patient choice in the assignment of Medicare beneficiaries to Primary Care First practices.

Model Design

Primary Care First aims to foster practitioner independence by increasing flexibility for primary care, providing participating practitioners with the freedom to innovate their care delivery approach based on their unique patient population and resources. PCF participants may receive additional revenue based on their performance on easily understood, actionable outcomes.

In Primary Care First, CMS uses a focused set of clinical quality and patient experience measures to assess quality of care delivered at the practice. A PCF practice must meet standards that reflect quality care in order to be eligible for a positive performance-based adjustment to their primary care model payments. These measures were selected to be actionable, clinically meaningful, and aligned with CMS’s broader quality measurement strategy. Measures include a patient experience of care survey, controlling high blood pressure, diabetes hemoglobin A1c poor control, colorectal cancer screening, and advance care planning. CMS assesses quality of care based on a separate, focused set of measures that are clinically meaningful for patients with complex, chronic needs, and the serious illness population.

To amplify the impact of the model, Primary Care First is designed as a multi-payer model. Primary Care First payer partners commit to aligning with the model’s payment methodology, quality measurement strategy, and data sharing approach in order to align resources and incentives across a participating practice’s entire patient population. Payer partners include Medicare Advantage plans, commercial health insurers, State Medicaid agencies, and Medicaid managed care plans (to the extent permitted and consistent with the Medicaid managed care plan’s contract with the state).

Model Goals

Primary Care First aims to improve quality, improve patient experience of care, and reduce expenditures. CMS believes that the model will achieve these aims by increasing patient access to advanced primary care services. PCF has elements specifically designed to support practices caring for patients with complex chronic needs or serious illness. The specific approaches to care delivery are determined by practice priorities. Practices are incentivized to deliver patient-centered care that reduces acute hospital utilization or total per capita cost. PCF is oriented around five comprehensive primary care functions:

  1. Access and continuity;
  2. Care management;
  3. Comprehensiveness and coordination;
  4. Patient and caregiver engagement; and
  5. Planned care and population health.

Primary Care First aims to be transparent, simple, and hold practitioners accountable by:

  • Providing model payments to practices through a simple payment structure, including:
    1. A flat payment that encourages patient-centered care, and compensates practices for in-person treatment;
    2. A population-based payment to provide more flexibility in the provision of patient care along with a flat primary care visit fee; and
    3. A performance-based adjustment providing an upside of up to 50% of model payments as well as a small downside (negative 10% of model payments) incentive to reduce costs and improve quality, assessed and paid to practices on a quarterly basis.
  • Providing practice participants with performance transparency, through identifiable information on their own and other practice participants’ performance to enable and motivate continuous improvement.

Primary Care First provides the tools and incentives for practices to provide comprehensive and continuous care, with a goal of reducing patients’ complications and overutilization of higher cost settings, leading to higher quality of care and reduced spending.

Cohort 2 Eligibility Requirements

Eligible Primary Care First Cohort 2 applicants are primary care practices that:

  • Are located in one of the 26 Primary Care First regions.
  • Include primary care practitioners (MD, DO, CNS, NP, and PA) certified in internal medicine, general medicine, geriatric medicine, family medicine, and hospice and palliative medicine.
  • Provide primary care health services to a minimum of 125 attributed Medicare beneficiaries at a particular location.
  • Have primary care services account for at least 50% of the practice’s collective billing based on revenue. In the case of a multi-specialty practice, 50% of the practice’s eligible primary care practitioners’ combined revenue must come from primary care services.
  • Have experience with value-based payment arrangements or payments based on cost, quality, and/or utilization performance such as shared savings, performance-based incentive payments, and episode-based payments, and/or alternative to fee-for-service payments such as full or partial capitation.
  • Adopt and maintain, at a minimum, health IT meeting the definition of CEHRT at 42 CFR 414.1305 and the certification criteria found at 45 CFR 170.315(c)(1)-(3) for electronic clinical quality measure (eCQM) reporting, using the most recent update available on January 1 of the Measurement Period, for the eCQMs in the Primary Care First measure set; support data exchange with other providers and health systems via Application Programming Interface (API); and connect to their regional health information exchange (HIE).
  • Attest via questions in the Practice Application to a limited set of advanced primary care delivery capabilities, such as 24/7 access to a practitioner or nurse call line and empanelment of patients to a practitioner or care team.
  • Are able to meet the requirements of the Primary Care First Participation Agreement.

Eligible practitioners are those in internal medicine, general medicine, geriatric medicine, family medicine, and/or hospice and palliative medicine. Each practice applicant must identify each eligible practitioner by National Provider Identifier (NPI) in its application. CMS will conduct a program integrity screening on the practice and the eligible practitioners that it intends to include in PCF. CMS may reject an application on the basis of the results of a program integrity screening. CMS notes that PCF Cohort 2 participants must meet the eligibility requirements as described in the PCF model participation agreements.

Timelines

The practice solicitation period for PCF Cohort 2 opened on March 16, 2021 and closed on May 21, 2021. The payer solicitation period for PCF Cohort 2 began on March 16, 2021, and closed on June 18, 2021.

Practice and payer selections will take place in Summer or Fall 2021. Cohort 2 will begin participation in PCF in January 2022. CMS plans to focus on onboarding participating practices and payer partners to the model in Fall and Winter 2021.

Stay up to date on the latest Primary Care First Model Options updates by subscribing to the PCF Model Options listserv.

Information for Interested Stakeholders

For questions about the model, please email PCF@telligen.com.

Information for Cohort 2 Applicants (2022 Starters)

Webinars

Evaluation

Latest Evaluation Report

Prior Evaluation Report

Additional Information

Where Health Care Innovation is Happening