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News & Press: General Announcement

CMS Releases Additional Details on PCF Model

Friday, May 3, 2019   (0 Comments)
Posted by: ACOFP
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From The American Academy of Osteopathic Family Physicians

 

On April 30, 2019, the Centers for Medicare & Medicaid Services (CMS) Innovation Center held an informational webinar on the Primary Care First (PCF) model. During the webinar, CMS Innovation Center staff provided additional details on PCF, including its structure, payment methodology, treating of high need populations, the “Quality Gateway” and considerations for participating in PCF. 

 

Structure

There are three participation options:

  • The PCF Payment Model (the General model) focuses on advanced primary care practices ready to assume financial risk.
  • The PCF High Need Populations Payment Model (the High Need model) is intended to promote care for high need, seriously ill population (SIP) beneficiaries lacking a primary care practitioner and/or effective care coordination.
  • Participation in Options 1 and 2: practices may participate in both the General and High Need models. 

The PCF model is designed around five key primary care functions, with a corresponding PCF intervention and additional intervention for SIP patients (if applicable).

 


 

Payment Methodology

Participants will be eligible to receive two interrelated components:

  • The Total Primary Care Payment is comprised of a population-based payment and flat primary visit fee of $50.
  • The Performance-Based Adjustment (PBA) is a risk-adjusted, per beneficiary per month payment for services in or outside of the office. 

The PBA would be applied to the Total Primary Care Payment, providing participants with as much as a 50 percent increase in payment based on performance on key quality metrics. When determining the payment adjustment, CMS will perform three adjustments: (1) based on a national minimum benchmark; (2) based on the practice’s performance compared to other PCF practices; and (3) based on the practice’s performance against itself as a “continuous improvement” adjustment. 

While payments will be calculated on a monthly basis, payment will be provided on a quarterly basis. 

 

High Need Populations

Participants interested in serving SIP patients and assisting them in reintegrating into primary care, and who meet certain eligibility requirements, may opt in to be assigned SIP beneficiaries. Practices serving SIP beneficiaries would receive a $325 one-time payment for each SIP patient’s initial visit and $275 per SIP beneficiary per month for up to 12 months. These practices also would receive up to $50 based on relevant quality measures and the $50 flat visit fee.

 

Quality Gateway 

The following measures will inform the PBA and assessment of model impact.

 

Participating in PCF

Participants eligible to join the General model are practices that:

  • Include primary care practitioners (MD, DO, CNS, NP, PA) in good standing with CMS
  • Provide services to a minimum of 125 attributed Medicare beneficiaries
  • Have a primary care services account for the “predominant share” of their of collective billing based on revenue (CMMI suggests this would be 70 to 80 percent)
  • Demonstrate experience with value-based arrangements
  • Use the 2015 Edition of Certified Electronic Health Record Technology, support data exchange and connect to their regional health information exchange
  • Attest to a limited set of advanced primary care capabilities (e.g., 24/7 access to a practitioner or nurse call line, empaneling patients to a practitioner or care team) 

Participants eligible for the High Need Population model are practices that:

  • Include primary care practitioners (MD, DO, CNS, NP, PA) in good standing with CMS
  • Meet basic competencies and demonstrate relevant clinical capabilities to manage complex patients (e.g., employ interdisciplinary team-based care approach, provide comprehensive, person-centered primary care, have the ability to engage with family and caregivers, provide 24/7 access to a practitioner or nurse call line)
  • Have a network of providers in the community that can meet SIP patients’ long-term care needs
  • Use the 2015 Edition of Certified Electronic Health Record Technology, support data exchange and connect to their regional health information exchange 

Practices seeking to participate in both models must meet the requirements for both. 

 

Timeline 

The Request for Applications is expected to be released this spring, with the model launching in January 2020. Payment changes are expected to take effect in April 2020. CMS indicated that it would release additional details and specifics about the models, quality measures, model overlap and other information in the coming weeks and in the Request for Applications.

ACOFP continues to monitor and assess the PCF model in terms of opportunities for members.


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