Healthcare stethoscope and charts

On March 16, 2021, CMS issued a request for applications for the second cohort of the Primary Care First (PCF) payment model. The PCF model was initially launched in January 2020 and includes a set of voluntary, alternative five-year payment options that reward practices for achieving quality and value metrics through innovative payment structures supporting primary care delivery.

CMS understands that primary care is essential to the care provided to a community. This model emphasizes the provider-patient relationship and provides flexibility to practitioners, allowing them to spend more time caring for their patients and enhance the care provided to those patients through the following functions:

  • Access and continuity of care
  • Care management
  • Comprehensiveness and coordination
  • Patient and caregiver engagement
  • Planned care and population health

Practices that elect to participate in the PCF model will be eligible for a simplistic and predictable payment structure that includes:

  • A flat payment that encourages patient-centered care and compensates practices for face-to-face treatment
  • An attributed population payment to provide more flexibility in the provision of care
  • A performance-based adjustment providing an upside benefit of 50 percent of model payments, as well as a small downside risk of 10 percent of model payments to assist in the reduction of costs and improvement of quality 
  • These performance-based adjustments will be assessed on a quarterly basis

CMS will make practice- and patient-specific performance metrics available to participating practices in an effort to provide the practice with a better understanding of past performance and areas of opportunity.

It should be noted that not all practices that apply to the PCF model will be accepted. CMS will screen all received applications and may reject practices based on that screening. CMS also will seek to partner with other payors, including Medicare Advantage Plans, commercial payors, Medicaid managed care plans, and state Medicaid agencies to participate in the PCF program and implement similar payment models, quality measurements, and data sharing.

Practices interested in participating in the PCF model must meet the following eligibility criteria:

  • Practice in family medicine, internal medicine, general medicine, or hospice and palliative care
  • Have a minimum of 125 attributed Medicare fee-for-service beneficiaries
  • Have 50 percent of practice revenue generated by primary care services
  • Have experience with value-based payment arrangements or payments based on cost, quality, shared savings, performance-based incentive payments, episode-based payments, and/or full or partial capitation
  • Adopt and maintain Certified Electronic Health Record Technology (CEHRT) capable of the following:
  • Electronic clinical quality measure (eCQM) reporting for eCQMs in the Primary Care First measure set
  • Support data exchange with other providers and health systems via application programming interface (API)
  • Connect to regional Health Information Exchange (HIE)
  • Be located in the following areas eligible for participation in the PCF model:
  • Alaska
  • Arkansas
  • California
  • Colorado
  • Delaware
  • Florida
  • Greater Buffalo Region (New York)
  • Greater Kansas City Region (Kansas and Missouri)
  • Greater Philadelphia Region (Pennsylvania)
  • Hawaii
  • Louisiana
  • Maine
  • Massachusetts
  • Michigan
  • Montana
  • Nebraska
  • New Hampshire
  • New Jersey
  • North Dakota
  • North Hudson-Capital Region (New York)
  • Ohio and Northern Kentucky Region (Ohio and partial state in Kentucky)
  • Oklahoma
  • Oregon
  • Rhode Island
  • Tennessee
  • Virginia

Unfortunately, not all practices engaged in primary care will be eligible for participation in the PCF model. The following practice types are not eligible to participate:

  • Concierge practices that charge patients a retainer fee or intend to do so at any point in the five-year performance period
  • Rural health clinics (RHC)
  • Federally qualified health centers (FQHC)
  • Critical access hospitals that have elected to bill under Method II

Key Considerations for Interested Practices

  • Voluntary program with ability to terminate after 60 days’ notice
  • Practice applications due April 30, 2021
  • Payor applications due May 28, 2021
  • Program begins January 2022 with five-year performance period
  • PCF will qualify as an Advanced APM under MACRA
  • Quarterly performance-based adjustment payment ranging from 50 percent to -10 percent based on performance related to:
  • Acute Hospital Utilization (AHU)
  • Total Per Capita Cost (TPCC)
  • Meeting or exceeding minimum performance on a set of predefined quality measures each year

How BKD Can Help

BKD has successfully helped many organizations enroll and succeed in CMS Innovation Models such as CPC+ and ACOs. Many of our clients have improved the financial gains and continue to look for new Innovation Models that increase their ability to care for patients. Our team of clinicians, data analysts, and service-line professionals is prepared to help your organization in the following ways:

  • Application process (two months to apply)
  • Strategic data analysis to evaluate whether PCF represents a positive clinical and business opportunity for your practice/organization
  • Program development and structure
  • Provider engagement and alignment
  • Ongoing monitoring of claims and quality data

For more detailed information regarding PCF cohort 2 and the operational or financial effect it may have on your practice or organization, reach out to your BKD Trusted Advisor™ or submit the Contact Us form below.

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