How the CMS Primary Cares Initiative will affect the risk equation

These models continue CMS’s push toward broader value-based transformation and shared financial risk with providers.

The Centers for Medicare and Medicaid recently announced two transformative payment models: Primary Care First and Direct Contracting, with each having a planned start date on January 1.

These models continue CMS’s push toward broader value-based transformation and shared financial risk with providers.

Five options will be available to organizations across the two new models. Each option has a range of downside and upside risk (from 10 percent to 100 percent of cost). CMS will release more details in the coming months, with an application period soon to follow. More importantly, interested organizations will need to start strategically evaluating whether these payment models are their correct path to value-based care.

Primary Care First evolved from the Comprehensive Primary Care Plus (CPC+) program. It seeks to transform primary care delivery by simplifying the payment model and increasing primary care reimbursement with limited risk to encourage organizational investments.

The Direct Contracting model is a shift from fee-for-service (FFS) to capitation for voluntarily aligned Medicare patients with a few options for level of risk and scope of capitated amounts. In both models, CMS seeks to engage a broader set of organizations, most notably payers. Below are three areas that an organization should focus on as CMS releases more details.

The crux of any risk-sharing arrangement is performance measurement. Primary Care First has a 50% of revenue upside and 10% of revenue downside. For this model, it’s likely that performance measurement will follow the same principals as CPC+ methodology. CPC+ incentive payments are based on performance compared to national benchmarks for:
  • Consumer Assessment of Healthcare Providers and Systems (CAHPS)
  • Electronic Clinical Quality Measure (eCQM)
  • Utilization measures

Performance measurement for the Direct Contracting model will focus on market-based benchmarks with risk-adjustment. That is, providers in the same market will be competing against equitable benchmarks. This is a departure from the latest Medicare Shared Savings Program (MSSP) methodology. Under that, benchmarks are specific to the attributed population. Market-based benchmarks constitute a simplified approach dictated by voluntary beneficiary alignment over attribution-based alignment.

We anticipate this approach will fill a much-needed level of simplicity into the benchmarking process. But it will also highlight the need for organizational-focused Hierarchical Condition Category (HCC) capture and risk adjustment. If you can beat the market, you win.

Payer participation
Under both programs, CMS encourages health plan organizations to participate. The primary goals of expanded participation appear to be twofold.
  • Increase the adoption of Center for Medicare and Medicaid Innovation (CMMI) initiative structures across all payers. As providers experience "program fatigue," CMS will encourage payers to align methodologies and leverage infrastructure across all populations.
  • In the Primary Care First program, CMS encourages other payers "to align payment, quality measurement, and data sharing with CMS in support of Primary Care First practices."1 Practice participation will be limited to provider groups focused on primary care. But CMS will likely include a separate tier participation focused on adoption of payment structure and risk-sharing methodologies for payers.
  • Improve collaboration between providers and payers by allowing for contractual relationships across organization types in support of population health management.

The Professional and Global Population-Based Payment (PBP) options under direct contracting focus on provider organizations. But the Geographical PBP option (still under consideration) will enable participation of other entities like health plans and technology companies. This option would allow contracts between health plans and providers to collectively take on risk for a beneficiary population in a defined geographic region.

Interaction with other initiatives
CMS continues to modify, enhance or introduce more value-based initiatives. Many are asking how these programs will interact and overlap. Below are some areas to consider in navigating the layers of complexity across each model.
  • The Direct Contracting model attributes patients based on voluntary alignment. Patients in this model will likely be excluded from other programs like MSSP or Bundle Payment Care Initiative-Advanced (BPCI-A). Similar to CPC+, Primary Care First patients will still be included in MSSP; however, the additional payments could adversely affect performance to benchmark.
  • The BPCI-A and Comprehensive End Stage Renal Disease (ESRD) Initiatives are examples of more focused programs on specific disease states or episodes.
  • How will these new models impact a provider’s ability to participate in an Advanced Alternative Payment Model to achieve Qualifying APM Participant (QP) status from a Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) perspective? With 2020 being defined as a beneficiary alignment year, 2021 will be the first payment year the annual 5% lump-sum bonus will be achieved. (Note: the 5 percent bonus will end after 2022 under currently legislation.)

These two new models create more flexibility for an organization’s pursuit of value-based care. However, it also creates more complexity when determining which chassis to choose for a Medicare risk strategy. CMS has tested various models for shifting risk to providers for over a decade. It’s now becoming more and more critical that an organization unpacks the financial and strategic drivers of each model. In the coming months, it will be crucial to select the model that:
  • Matches your risk tolerance
  • Maximizes your ability to achieve savings
  • Enhances your organization’s strategy

More details will come, but there is one certainty underneath all of this complexity. Pure FFS economics are becoming a thing of the past.

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