Primary care has always been “central to a high-functioning healthcare system” as an April, 2019 press release from the Centers for Medicare and Medicaid Services (CMS) stated. But as the industry moves from fee for service (FFS) to value-based care, that role has become even more important.
CMS has recognized this through the introduction of its Primary Care First program, which officially launches January 1, 2020 although enrollment has already started. Primary Care First is a set of voluntary five-year payment options that support and promote advanced primary care by rewarding value and quality in the delivery of care to Medicare beneficiaries in 26 regions across the U.S.
How is this different than other programs, such as Comprehensive Primary Care Plus (CPC+) or Advanced Primary Care (APC) that CMS has introduced in the past? In football terms, if those other programs moved the value-based care ball down the field, Primary Care First’s objective is to push the healthcare industry into the Red Zone. According to Nicholas Minter, Director, Division of Advanced Primary Care of the CMS Innovation Center, at a recent PCMH event, the Primary Care First Model is part of a continuum to move US healthcare towards Value Based Care payment models. Primary Care First aims to improve quality, improve patient experience of care, and reduce expenditures
The key difference is that under the Primary Care First models, primary care physicians (PCPs) receive an up-front per member per month (pmpm) payment for each patient and a flat fee visit rate together with performance based adjustments. rather than being paid for services rendered. Practices can then use that money to support patient access both in and out of the office especially for complex conditions. , such as adding care managers, telehealth or other options CMS hasn’t traditionally paid for directly in the past.
Practices that enroll in the program will have their outcomes payment based on three different benchmarks. They can earn bonuses of up to 50%; if they are above the thresholds, however, they can also be penalized up to 10% of what they received. The quality measures themselves should sound familiar to most PCPs, as they include the patient experience, controlling high blood pressure, controlling HbA1c levels in people with diabetes, advanced care planning and colorectal cancer screening.
Obviously, Primary Care First is not a program to be entered into lightly, especially given that the benchmarks practices will be measured against include data from the top-performing health systems in the country. So how does a practice decide whether it’s ready?
One easy marker is if your practice has already qualified as patient-centered medical home (PCMH) you probably are moving in the right direction towards being an advanced primary care. Congratulations!
If you’re not a PCMH, following are the areas to address first.
· 24x7 access to care with real-time access to electronic health records (EHR) – When patients can’t see their physicians when they want, they opt for more expensive choices such as the emergency department (ED). After a couple of those instances, the ED becomes their PCP. To succeed in Primary Care First, PCPs must make their care teams easily accessible. That doesn’t mean PCPs must be open 24x7. But they must have mechanisms in place for same-day appointments or appointments within a couple of days (depending on severity) and to respond to patient concerns when they occur. They must also be able to manage care transitions such as hospital or ED discharges. Telehealth (including video appointments) offers a great way to address this need.
· High-quality understanding/documentation of Hierarchical Condition Codes (HCCs) – The pmpm for each patient is calculated based on risk. There is no going back after the fact because the patient required more care than anticipated. Therefore, it is critical that all of a practice’s physicians are well-versed in the nuances of HCC documentation accuracy. If not, they should seek help with gaining that understanding quickly.
· Good team-based care in-place – Physicians can no longer be eagles soaring alone. Improving outcome quality requires a team effort. Physicians, nurses, care coordinators/managers, dieticians, behavioral health specialists, pharmacists and more must all work together to drive population outcomes. Fortunately, the up-front payments in Primary Care First can help PCPs shore up areas where they’re currently need improvements.
· Powerful analytics – Analytics are essential for succeeding in Primary Care First. PCPs must be able to risk-stratify their patient populations (low-medium-high) with a high degree of accuracy, using all the data (including those HCCs mentioned earlier). PCPs must know who their patients are, what their barriers to better health are, and have staff aligned to that population. This includes capturing data on social determinants of health (SDoH), which must be a top priority. Consider that PCPs see most patients for maybe two hours a year. The rest of the time, their health is being influenced by the safety of their neighborhood, the availability of fresh produce versus fast food (or even whether they eat regularly at all), the quality of the air and water, housing stability and dozens of other social factors. Understanding those factors, and ensuring they are included in the EHR, can give physicians and care teams insights into the unseen drivers behind patient health so they can make better, more effective care decisions. Making community-based organizations (CBOs) that assist patients with SDoH issues part of the extended care team can help overcome barriers (including a lack of trust of physicians and medical professionals generally) as well.
Yet analytics aren’t only valuable in understanding patients. They can also help practices understand how well their physicians and care teams are performing. To do so, they may have to take the uncomfortable step of un-blinding their performance measurements to understand exactly where improvements need to be made. The outcome measures are not only related to provider effort but to the overall team caring for the population of that provider. The success of the practice in Primary Care First depends on all of their provider teams performing at a high level. If four are meeting the quality measures and one is not, what could be a bonus can quickly turn into a penalty. Analytics will help uncover any opportunities, so they can be strengthened.
Finally, there are the quality measurements themselves. While part of the attraction of Primary Care First is the reduction of administrative burden (versus other programs), PCPs must still be out-perform the national benchmarks. Real-time analytics will help show what’s needed now so practices can make adjustments where needed – rather than finding out after the fact that they missed out on bonuses they could have secured. Practices that don’t have strong analytics in place already may want to work with a partner that understands them – especially a partner with expertise in qualifying as a PCMH since the requirements are similar. Additionally, Primary Care First is not a “set-it-and-forget-it” type of program. PCPs will be expected to make continuous improvement in their performance measurements in order to accrue bonuses in subsequent years, which is even more incentive to develop an ongoing relationship with an organization that has expertise in performance improvement.
· Process for patients/caregivers to provide feedback – One easy way to accomplish this is to include one or more patients/caregivers on the Board. They can then offer the patient perspective on practice improvements that will help elevate the patient experience – a critical, ongoing measure.
With the introduction of Primary Care First, it’s clear that CMS is now going all-in on transitioning to value-based care. The good news is a lot of the heavy lifting on WHAT to do has already been done by a few innovative health systems, so there are lessons learned available, and people who can help get new health systems started on the right foot. Others have pioneered the process and made the missteps. PCPs today can follow their lead and implement the program improvements and technologies that have demonstrated their effectiveness, and set themselves up for success in the years to come.