Primary Care First payment models delayed until 2021

October 28, 2019

The program was originally slated to start in January 2020, but will now begin in January 2021. 

The Centers for Medicare & Medicaid Services new alternative payment model, Primary Care First, has been delayed by a year. The program was originally slated to start in January 2020, but will now begin in January 2021, with applications being accepted through January 22 of 2020.

Primary Care First is geared toward primary care practices that are ready to accept financial risk in exchange for more flexibility, increased transparency, and performance-based payments that reward participants for outcomes, according to CMS. In addition, CMS will provide higher than historical Medicare fee-for-service payments for practices that care for complex, chronically ill patients who exhibit fragmented care.

The program will run for six years, with cohorts starting in both 2021 and 2022. It will test several new concepts:

·      Shifting focus to outcomes. Practices will be accountable for their attributed patient population through a two-tiered payment structure: a total primary care payment, consisting of a population-based payment and flat primary care visit fee, and a performance-based adjustment with greater financial upside than downside potential (which would be?) tied to acute hospital utilization.

·      Increasing reimbursement for practices that care for patients with complex, chronic needs. Practices serving these patients will receive a larger population-based payment for Medicare services compared to traditional fee-for-service reimbursement. The larger payment is intended to account for the higher disease burden in these populations and the increased resources required to serve them.

·      Supporting high need, seriously ill populations. CMS’ goal is to identify seriously ill patients whose care is not well managed and then provide additional financial resources for practices to proactively engage these patients, address their intensive care needs through comprehensive and person-centered care, help them achieve clinical stabilization, and create a (stronger?) relationship between the beneficiary and practitioner.

Primary Care First will not require participating practices to adhere to a lengthy set of care delivery requirements. Because practices are expected to already be delivering advanced primary care at the time they apply to participate in the program, they will be given flexibility under the model to use their own individualized approaches to caring for patients as long as they satisfy a minimum threshold of care delivery requirements.

Eligibility requirements for the program include providing health services to at least 125 Medicare beneficiaries, having primary care account for at least 70 percent of the practice’s billing, and using a 2015 Edition Certified Electronic Health Record.

Applications can be submitted here: https://app1.innovation.cms.gov/PCF