Primary Care First: What you need to know

DATE: 08/25/2020

The Centers for Medicare and Medicaid Services is implementing new alternative payment models to address patient care areas that are likely to benefit from more value-based services. In addition to the Kidney Care First model, CMS is rolling out the Primary Care First model, targeted at primary care practices with advanced primary care capabilities.

Building on the lessons learned from previous models like Comprehensive Primary Care Plus, PCF is designed to assess whether changing how Medicare pays for primary care will reduce hospital utilization and lower the cost of care, while maintaining or improving quality. The program has two components: PCF-General and PCF-Seriously Ill Population. Practices can choose to participate in one or both programs.

Top PCF objectives and benefits

PCF aims to achieve three core goals:

  1. Reduce Medicare spending by preventing avoidable inpatient hospital admissions.
  2. Improve quality of care and access to care.
  3. Increase the focus on complex chronically ill and seriously ill patients.

For seriously ill patients, PCF participants are expected to stabilize patients’ critical conditions while establishing a meaningful, long-term doctor-patient relationship. Providers will be accountable for coordinating and managing patient care long term to improve outcomes.

The program offers several benefits to participants. Here are the top five:

  1. the opportunity to increase revenue with performance-based payments that reward participants for reducing acute hospital utilization;
  2. fewer administrative burdens so providers can limit care fragmentation, spend more time with patients and focus their care efforts on patient needs;
  3. enhanced payments for practices serving high-need populations;
  4. increased access to timely, actionable data; and
  5. the potential to participate in an Advanced Alternative Payment Model.

How PCF works

In terms of the payment structure, PCF is a five-year model that offers flexibility and transparency. Thanks to its multi-payer alignment, the program provides practices with resources and incentives to enhance care for patients, regardless of their insurer.

One of the biggest shifts from the CPC+ model is that CMS will pay practices primarily for outcomes, rather than making upfront investments in care delivery functions. On the whole, and especially in terms of payment, this program represents a significant step away from fee-for-service payments toward population-based payment.

PCF will be offered in 26 states and regions beginning in 2021 and will run for a total of six performance years. Participants began the onboarding process this summer; the first payment will begin in January 2021.

Preparation tips

As the program ramps up it will be critically important for participants to get a strong handle on understanding all of their data. That requires deep analysis of past trends and a strategic plan for how to improve, including setting detailed benchmarks for success. This is foundational to participants’ ability to thrive in the program.

To learn more about PCF, including participant definitions, visit CMS’ website. To find out how to use effective data analysis to succeed in the program, reach out to DataGen for a free consultation today.