As CMS continues the shift towards value based reimbursement models, the healthcare industry has become more focused on evaluating potential benefits from each of the new associated programs. Primary Care First (PCF) has been receiving a lot of attention due to its limited participation options and significant gains associated with success. The PCF program falls under the MACRA umbrella as an Alternative Payment Model (APM) but offers primary care providers a significant opportunity to increase revenue through demonstrated compliance and increased quality of care.

The map below illustrates the 26 regions throughout the United States that CMS is offering providers the option of participating in PCF:

The Concept

According to CMS, “Primary Care is central to a high-functioning healthcare system and thus, there is an urgent need to preserve and strengthen primary care as well as a need for support of serious illness care services for Medicare beneficiaries.”

In order to test the idea, CMS has created a payment model that allows advanced primary care practices to now assume financial risk in exchange for reduced administrative burdens and performance based payments. To put it simply, they will pay more money and require less work for those providers who excel in meeting the requirements of the program. If implemented properly, providers will have the chance to spend more time with their patients and focus on improving upon the “doctor-patient relationship” by allowing patients to choose which PCF participants they would like to assign their benefits to.

The Details

PCF participants are graded by a focused set of clinical quality and patient experience measures to asses quality of care delivered at the practice. Reporting strong performance in each of these measures will result in a positive performance based payment adjustment to their primary care revenue. Providers stand to increase revenue by up to 50% for positive performance results while risking a potential reduction of 10% for poor performance.

Measures include:

• Patient Experience of Care Surveys
• Controlling High Blood Pressure
• Diabetes Hemoglobin A1c Poor Control
• Colorectal Cancer Screening
• Advanced Care Planning (ACP)

CMS assesses the quality of care delivered based on these clinically meaningful measures for patients with complex needs, chronic conditions and the seriously ill population. Payer solicitation for the 2021 performance year is now closed but the first year of the program will start January of 2021. During this period, PCF participants are required to partner with a Qualified Registry or QCDR to report specific measure performance to CMS directly.

Next Steps

Although 2021 marks the first year of the Primary Care First performance period, we expect to see the model continue gaining traction. The concept has been proven and CMS has not indicated that COVID19 or any other disruption will prevent them from continuing the march. For those practices looking to align data and reporting with CMS, Quantician is happy to help with the quality reporting needs. Contact us to see how we can help your organization succeed in capturing the additional bonuses associated with exceptional performance.

For more information on the program and participation please see the link below:

https://innovation.cms.gov/innovation-models/primary-care-first-model-options