HHS has introduced five new primary care payment models, referred to as CMS Primary Cares Initiatives, to deliver better quality primary healthcare.

CMS Primary Cares Initiatives is HHS’s new initiative for transforming primary care across the U.S. It has launched five new alternative payment models for primary care under two paths: Primary Care First and Direct Contracting. Aiming to deliver better value for patients through the healthcare system, these models assist in testing paying for health and outcomes rather than procedures.

HHS Secretary Alex Azar acknowledged these new models as the most significant step in the healthcare industry to streamline primary care delivery. Alex further added, “For years, policymakers have talked about building an American healthcare system that focuses on primary care, pays for value, and places the patient at the center.”

Primary Care First (PCF) Models

There are two models under this domain: Primary Care First Model, and Primary Care First Model for High Need Populations. Both the PCF models aim to test the financial risk and performance-based payments that reward primary care practices. They assess if these payments will reduce Medicare expenses, and preserve or enhance the quality of primary care, evaluating the final impact on health outcomes.

The PCF models offer a multi-payer system that helps create opportunities for practices that are willing to take risks through payments based on utilization outcomes. These models work through a monthly payment plan for the practices, offering the providers with incentives to reduce hospital utilization and hence, the total cost of care. Practices are rewarded through performance-based payment adjustments, which ensure meeting the objectives above.

Moreover, the models also include options for practices that specialize in the care of high need patients, such as those with complex chronic conditions. The most critical clinical measures covered under the models are controlling high blood pressure, managing diabetes mellitus, and screening for colorectal cancer.

Hence, PCF generically offers three ways to participate:

• Participate only in the PCF general model – The payment structure of primary care clinicians is altered from traditional fee-for-service to prospective payments with a potential bonus.
• Participate only in the PCF high-need-populations model – This option allows PCF practices to opt into the seriously-ill-population (SIL) portion of the model.
• Participate in both the general and high-need-population model – Practices under this model seek a hybrid PCF and SIP option.

Direct Contracting (D.C.) Payment Models

The DC models are built on the NextGen ACO model, offering novel forms of population-based payment (PBP), enhanced cashflow options, as well as increased flexibility. These models cover three important aspects of primary care delivery: global, professional, and geographic. Focusing on transforming primary care delivery, the D.C. models work with a broader vision of engaging a variety of organizations in the primary care delivery process. These include organizations with financial expertise, such as Accountable Care Organizations, as well as healthcare companies such as Medicare and Medicaid organizations. The practices, under these payment models, are offered fixed monthly payments, that can range from a portion of anticipated primary care costs to the total cost of care.

There are three payment plans under the D.C. models:

• Global Population-based payment – This option offers the providers to bear full financial risks. Therefore, there are 100 percent savings/losses for the practice.
• Professional Population-based payment – The risks under this plan are shared between the providers and the CMS. Hence, the practices enjoy 50 percent shared savings/losses.
• Geographic Population-based Payment – organizations are authorized to assume complete responsibility for the total cost of care needs of a population in a defined geographic region.

According to Gerald E. Harmon, MD, immediate past chairman of the American Medical Association Board of Trustees, “Providing adequate financial support for high-quality primary care must be an essential element of any strategy to improve the quality and affordability of our country’s healthcare system.” Gerald further recognizes that the majority of primary care physicians have long struggled to deliver quality care to their patients while maintaining the survival value of their practices under the current Medicare payment plans. Hence, these new primary care payment models are expected to facilitate practices in terms of resource optimization and flexibility of delivering the highest-quality care to their patients.

The underlying objective of all five payment models is better care delivery for patients with chronic conditions and serious illnesses. The participating practices can select models according to their personal choice as to which segment of the population they want to assist.