- CMS on Monday announced a new voluntary Medicare payment model for primary care providers. The two-pronged program has paths for small practices and large organizations and a range of options from partial shared risk to full downside risk.
- The agency projects as many as a quarter of traditional Medicare fee-for-service beneficiaries will be incorporated into the five-year program, called Primary Cares Initiative. It is slated to roll out in January, with a call for applications expected in about a month.
- CMS is also asking for input on an additional model in the program that would give one organization responsibility for the total cost of care for an entire Medicare population in a geographic area. That model would begin in January 2021.
Center for Medicare and Medicaid Innovation Director Adam Boehler noted in a press conference unveiling the model that primary care makes up only a small fraction of the country's total healthcare spend (and of Medicare spending), but emphasized its potential to have great affect on downstream costs and quality outcomes.
"A strong primary care foundation is essential to an effective healthcare system broadly," Boehler said.
HHS Secretary Alex Azar said the Primary Cares Initiative represented a pivotal moment for the agency as it pushes providers toward value-based care arrangements, and he hoped the Medicare program would have ripple effects. "This initiative is specifically designed to encourage state Medicaid programs and commercial payers to adopt similar approaches," he said at the press conference.
CMS has been active lately in introducing alternative payments models. In February, the agency put forward the Emergency Treatment, Triage and Transport program, which pays for onsite or virtual care from EMTs as well for ambulance transports to urgent care clinics or other non-hospital settings.
The new primary care model's first path, Primary Care First, is designed for small or individual physician practices and has two models. Both would involve a monthly, per-patient payment, but one would also include higher payments for practices that specialize in treating patients with chronic conditions
The second path, Direct Contracting, is for larger practices and health systems. It has three models, including the still-in-development geographic model. The professional model gives providers a risk-sharing arrangement of 50% of savings and losses, along with a monthly capitated payment. The global model has 100% shared risk.
Boehler said CMS arrived at its participation estimates after stakeholder discussions and based on the model's incentives. Other voluntary payment programs, however, have seen providers drop out — often at the moment they're scheduled to take on more risk.
Only about 40% of the hospitals originally participating in Medicare's Bundled Payments for Care Improvement - Advanced payment model stayed in long enough to potentially face penalties for poor performance, according to the Government Accountability Office.
The new model incorporates aspects of the Next Generation ACO model, which saw declining participation for this year, with 12 organizations leaving or being removed for 2019. There are now 41 accountable care organizations involved, down from the high of 58. Many of the organizations, however, have left for a different alternative payment model, the Medicare Shared Savings Program.
Some experts argue that mandatory alternative payment programs are the way to go, guaranteeing enough prolonged participation for a model effectiveness to be studied. While Azar hasn't ruled out that approach, providers have pushed back and previous Trump administration officials have balked at such a requirement.