Effective primary care has been shown to have significant effects on overall health with positive correlations to mortality, lower rates of fatal disease and lower healthcare utilization.
Still – even with this base of evidence – primary care has been traditionally sidelined for higher cost (and higher profit) specialty care services.
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In an effort to promote primary care as part of the national shift to value-based care, the Centers for Medicare and Medicaid have announced new payment models meant to shift more primary care providers to outcomes-based reimbursement.
Dubbed the CMS Primary Cares Initiative, the program aims to reduce administrative burden for providers, while incentivizing clinicians to spend more time with patients and focus on preventive care.
“As we seek to unleash innovation in our healthcare system, we recognize that the road to value must have as many lanes as possible,” CMS Administrator Seema Verma said in a statement. “Our Primary Cares Initiative is designed to give clinicians different options that advance our goal to deliver better care at a lower cost while allowing clinicians to focus on what they do best: treating patients.”
While all the new payment models are voluntary, the agency estimates that the Primary Cares Initiative could shift nearly 11 million traditional Medicare beneficiaries into value-based payment relationships. The range of programs are meant to give clinicians an option in how much risk they decide to assume over their Medicare population.
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During a press conference laying out the program at the American Medical Association’s headquarters in Washington, D.C., officials from CMS and HHS and underscored the potential of the program to boost competition among primary care providers thereby improving cost and quality.
The five payment models are split into two major buckets: Primary Care First and Direct Contracting. Most of the new payment models are scheduled to begin on January 2020.
The Primary Care First path is meant to reduce total Medicare expenditures by allowing individual primary care practices the ability to shift to value-based payment structures in an efficient and streamlined matter.
Clinicians taking part in the payment models will receive a simplified monthly payment tied to performance-based metrics associated with patient experience and clinical quality measures like controlling high blood pressure and colorectal cancer screenings.
There is an additional payment model that pays out additional rewards for the care of high-need beneficiaries (such as those in hospice or palliative care) that lack a primary care practitioner or strong care coordination resources.
CMS officials said in order to help independent practices make the jump to value-based care, the organization is building improved reporting and feedback systems that can provide clinicians insight into their month-to-month performance. CMS officials said that doctors earning $200,000 could earn up to $300,000 under the new models if they effectively keep their patients healthy.
The second major pathway laid out by CMS is Direct Contracting, which is targeted toward a larger range of care delivery organizations, including more complex operations like next-generation ACOs.
In the Professional Population-Based Payment (PBP) track, healthcare entities bear risk for 50 percent of shared savings or losses on the total cost of care for services covered by Medicare Part A and B. Organizations will receive capitated, risk-adjusted monthly payments for enhanced primary care services that are equal to seven percent of the total cost of care for the services.
The Global PBP model has organizations absorbing 100 percent of the risk for shared savings or losses on their Medicare population. Providers within this model have the choice of receiving a capitated payment tied to enhanced primary care services or a payment that covers all services provided by the program participant and its associated preferred providers.
CMS is also developing a Direct Contracting payment model based on geography where entities will bear 100 percent of total risk for beneficiaries in a target region. These entities will be selected through a competitive application process and are required to commit to provide CMSa specified discount amount off of total cost of care. This Geographic PBP model is not expected to launch until January 2021.
“CMS Primary Cares is a clear effort to shift one quarter of our Medicare population to outcomes based payments,” Adam Bohler, the director of the CMS Innovation Institute, said at the press conference. “It’s time to dismantle the old broken fee-for-services system and replace it with one that is focused on outcomes and quality.”
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