CMS launches primary care initiative

Category: Centers for Medicare & Medicaid Services, CMS, primary care

CMS launches primary care initiative


The Centers for Medicare & Medicaid Services  (CMS) recently announced the launch of an initiative called Primary Care First.

This program builds upon the Comprehensive Primary Care (CPC) initiative, which began in October 2012, and the Comprehensive Primary Care Plus (CPC+) program, which started in January 2017. Under the CPC program, CMS worked with commercial and state health insurance plans in seven regions throughout the United States to offer population-based care management services and shared savings opportunities to support the following functions:

            (1) Risk-stratified care management;

            (2) Access and continuity;

            (3) Planned care for chronic conditions and preventive care;

            (4) Patient and caregiver engagement; and,

            (5) Coordination of care across the medical neighborhood.

Through CPC+, CMS expanded this initiative to 14 regions and focused on the implementation of a primary care medical home model.

According to CMS, Primary Care First builds upon core aspects of CPC+, such as prioritizing the doctor-patient relationship, enhancing care for patients with complex chronic needs and high-need, seriously ill patients, reducing administrative burden, and focusing financial rewards on improved health outcomes. The program will launch in 2020 and will cover 26 regions throughout the United States.

Primary Care First seeks to foster practitioner independence by increasing flexibility for primary care, and rewards participants with additional revenue for taking on limited risk based on easily understood, actionable outcomes. CMS will use a focused set of clinical quality and patient experience measures to assess the quality of care delivered at the practice, which will determine whether the practitioner is eligible for a positive performance-based adjustment to their primary care revenue. Measures include a patient experience of care survey, controlling high blood pressure, diabetes hemoglobin A1c poor control, colorectal cancer screening and advance care planning.

Primary care providers meeting the following requirements are eligible to apply for participation in the Primary Care First initiative:

  • Are located in one of the 26 regions.
  • Are primary care practitioners (MD, DO, CNS, NP, and PA), certified in internal medicine, general medicine, geriatric medicine, family medicine, and hospice and palliative medicine.
  • Provide primary care health services to a minimum of 125 attributed Medicare beneficiaries at a particular location.
  • Primary care services account for at least 70 percent of the practices’ collective billing based on revenue.
  • Have experience with value-based payment arrangements or payments based on cost, quality, and/or utilization performance such as shared savings, performance-based incentive payments, and episode-based payments, and/or alternative to fee-for-service payments such as full or partial capitation.
  • Use 2015 Edition Certified Electronic Health Record Technology (CEHRT), support data exchange with other providers and health systems via Application Programming Interface (API), and connect to their regional health information exchange (HIE).
  • Attest via questions in the Practice Application to a limited set of advanced primary care delivery capabilities, such as 24/7 access to a practitioner or nurse call line and empanelment of patients to a practitioner or care team.
  • Can meet the requirements of the Primary Care First Participation Agreement.

As an incentive to reduce costs and improve quality, a participant in the program is eligible for a performance-based adjustment equaling up to 50 percent of revenue, assessed and paid quarterly. However, the participant is also at risk of losing up to 10 percent of revenue. Participants may also opt to receive Seriously Ill Population (SIP) patients who lack a primary care practitioner or care coordination. Those participants who are willing to treat SIP patients must meet additional requirements but are eligible to receive higher compensation than under the traditional Primary Care First program (assuming quality standards are met). Like the traditional program, however, participants who accept SIP patients are still at risk of a reduction in revenue for failure to meet certain goals.

CMS stated that it plans to release a Request for Application in spring 2019, and the model will begin in January 2020. A second round of applications is expected to be accepted during 2020, to begin in January 2021. For additional information about this initiative, and dates of upcoming webinars, you can visit CMS’s Primary Care First webpage

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