The CMS Primary Care First Model Options: Program Overview, Payment Structures & How to Prepare

The CMS Primary Care First Model Options: Program Overview, Payment Structures & How to Prepare

COVID-19’s impact on physician organizations has amplified the risks of variability with fee-for-service (FFS) payment models, and highlighted the importance of shifting towards value-based care and alternative reimbursement models. Primary care physicians will have increased opportunities to embrace value-based care models in 2021, with CMS’s Primary Care First Model Options scheduled to begin in January for the Primary Care First (PCF) component, and April for the Seriously Ill Population (SIP). The voluntary payment builds on the existing Comprehensive Primary Care Plus payment model, with the goals of reducing Medicare spend and improving quality and patient access to care for patients with complex conditions.

Model Payment Structure

In an effort to reduce organizational administrative and billing burdens, CMS has intentionally focused on making the Primary Care First Model’s payment mechanisms simple and straightforward for participants. A monthly population-based payment and flat primary care visit fees make up a “Total Primary Care Payment” for participants, which is then adjusted by up to 50% based on performance measures.  Below are the details for each component of the model’s payment structure:

Monthly Population Payment:

  • Monthly population payment that supports practice enhancements and services to effectively care manage patient populations
  • Monthly payment per beneficiary ranges from $28 PBPM to $175 PBPM, with the amount standardized for all patients within a practice and dictated by the risk level of a participant’s population
  • Monthly payment amount is reduced with a leakage adjustment, accounting for if patients receive primary care outside of participant’s practice

Flat Primary Care Visit Fee:

  • Payment for in-person treatment, simplifying billing process and payment projections
  • Flat visit fee of $40.82 per face-to-face encounter

Performance-Based Adjustment:

  • Quarterly performance adjustment to the Total Primary Care Payment of up to 50% upside or 10% downside
  • Specific performance measures depend on participant’s risk level
  • Acute Hospital Utilization will be a key measure for lower-risk participants in year 1 and Total Per Capita Cost will be a key measure for higher risk participants in year 1

Preparing for Success

Primary Care First Model Options offers participants the opportunity to meaningfully increase practice revenue, remove the variability of FFS reimbursement, and strengthen relationships between patients and providers. As participants plan their strategies for success, it is important to consider capabilities that maximize the performance-based adjustment measurements as they support optimal patient outcomes and can drive up to 50% more revenue for practices. Real-time admission, discharge, and transfer (ADT) data that provides actionable insights into patient care events will be a critical resource for success, as it drives targeted intervention to reduce avoidable hospital and post-acute utilization. This real-time data will enable participants to excel in the Acute Hospital Utilization or Total Per Capita Cost performance measures included within this model.

Bamboo Health supports provider success in Primary Care First and other value-based care models by optimizing encounter efficiency, reducing avoidable utilization, and ensuring patients are receiving critical care when they need it.

For more information on how Bamboo Health can support success in Primary Care First, contact us at [email protected], or complete our contact form.