- Patient & Family Resources
- Public Policy
- Annual Meeting & Webinars
- Resource Library
- Career Center
New CMMI Models Announced to Support Primary Care for People with Complex Chronic Illness
The Academy is pleased to share initial details on two new Alternative Payment Models (APMs) that promote primary care of Medicare beneficiaries with complex, advanced illness. The high-level outlines of these new APMs were announced on April 22 by the Center for Medicare and Medicaid Innovation (CMMI). The Academy’s media statement is available here. These APMs are part of a new CMS Primary Cares Initiative and will offer a choice of two new payment paths. The new payment demonstrations are meant to promote value-based care, with a voluntary shift of up to 25 percent of primary care Medicare fee-for-service patients to these new models. This e-alert summarizes the information CMS has released to date about the models. Several important details, such as exact payment amounts and patient eligibility criteria, remain to be announced. We will issue additional alerts to Academy members as soon as information is made available in the coming weeks.
The two new options, Primary Care First (PCF) and Direct Contracting (DC), will offer enhanced payment for home care medicine and other providers to provide primary care for people with advanced illness. The Academy, along with others, has worked closely with CMMI to develop this new payment model, with a focus on relevant quality measures for people with advanced illness and use of outcome-based payment methods. Many core principles of the successful Independence at Home (IAH) Demonstration are included in Primary Care First. Home care medicine providers and policymakers have learned much from IAH, thanks to the foresight of our champions on Capitol Hill and the CMS leadership.
Primary Care First
The Primary Care First (PCF) path is based on the current Comprehensive Primary Care Plus (CPC+) model and includes two sub-options; one focused on advanced primary care and the other on primary care for high needs populations, defined as the “seriously ill” population (SIP). CMS will attribute SIP patients to practices which choose to participate in this option. The Primary Care First path offers appropriate payment incentives to serve the most ill population, including a per-member-per-month (PMPM) payment, a flat fee for visits, and a quarterly performance bonus based on the patient population’s risk-adjusted hospitalization rate. The performance-based payment potential is 50% upside of primary care revenue and a small downside of 10%.
According to CMS, “Payment for SIP patients differs from that established under the general payment option for Primary Care First. Payment amounts for SIP patients will be set to reflect the high need, high risk nature of the population as well as an increase or decrease in payment based on quality.” The PCF will test whether financial risk and outcome-based payments will reduce Medicare costs and improve quality of care for beneficiaries in the selected PCF regions (below).
The Primary Care First (PCF) Model will be offered in 26 states or regions for a January 2020 start date: STATEWIDE in Alaska, Arkansas, California, Colorado, Delaware, Florida, Hawaii, Louisiana, Maine, Massachusetts, Michigan, Montana, Nebraska, New Hampshire, New Jersey, North Dakota, Ohio, Oklahoma, Oregon, Rhode Island, Tennessee, and Virginia. In Local Regions of Greater Buffalo, NY, Kansas City (Kansas and Missouri), Greater Philadelphia (Pennsylvania), North Hudson-Capital Area, NY, and Northern Kentucky.
The Direct Contracting (DC) path will engage larger practices or groups of providers with a minimum 5,000 beneficiaries (including some exceptions), as well as Health systems, Accountable Care Organizations, Medicare Advantage plans, and Medicaid Managed Care Organizations. CMS notes that these new “payment model options… present an opportunity to test novel methods for organizations to manage Medicare FFS expenditures and better integrate care delivery for those dually eligible for Medicaid and Medicare, including through coordinated efforts with Medicaid Managed Care Organizations.” The DC path will include three models:
1) Professional: Entities will receive a “primary care capitation” amount—a capitated, risk-adjusted monthly payment for enhanced primary care, along with a 50% share of any savings or losses.
2) Global: Entities can choose between two ways of calculating capitation payments; Primary care capitation as in the Professional model (above) or a Total care capitation, which will be a risk-adjusted monthly payment for all services provided to attributed beneficiaries, and entities will be fully at risk (100%) for savings and losses of attributed beneficiaries.
3) Geographic: Through a competitive application process, entities will be expected to commit to providing CMS with savings in a defined, targeted region. Like the global DC option described above, entities will be fully at-risk. HHS is seeking feedback via a request for information (RFI) on the parameters for this option—comments on the RFI will be accepted through May 23, 2019.
CMS plans to release the request for application (RFA) for most model options by June 2019. All models are scheduled to begin January 2020 except the DC Geographic Option, which will begin at a later date.
The Academy looks forward to working with CMMI to help a range of home care medicine providers and others to participate in these new payment models, to expand access to skilled and compassionate care. The Academy will advocate for the Primary Care First path to expand to additional regions. The Academy believes the PCF and DC models provide a strong new framework to adopt with local payers nationwide, in every area of the U.S. The Academy sees opportunities for regional networks of providers to form under the Direct Contracting option.
CMMI will host webinars on the new models on April 30, May 2, May 7, and May 16 — Additional details are available online.
The Academy appreciates CMMI’s recognition of the essential role of primary care for the seriously ill population and looks forward to learning more about the models, which we will share with Academy members and partners as they are made available in coming weeks. As these further details are released, the Academy’s Public Policy Steering Committee and Work Groups will analyze the models and provide feedback and recommendations directly to the CMMI team.
We thank our many partners – HCCI, USMM, Aspire, Centene, Landmark, John A. Hartford Foundation, and all the provider organizations around the U.S. who have helped make this possible.