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New CMS payment models put patients and primary care over paperwork – how will you respond?

June 11th, 2019

While my recent blogs have put me on the defensive regarding primary care trends, I’m thrilled to see CMS not only acknowledge but reinforce the important role of primary care in achieving optimal overall health and well-being through the recent introduction of its Primary Care Initiative Medicare payment models. At the heart of the introduction is a threefold goal: reduce administrative burdens, empower PCPs to spend more quality time with patients, and reduce overall healthcare costs. I’m not the only one applauding. The Patient Centered Primary Care Collaborative (PCPCC) cites the CMS move as reinforcement of the role primary care plays not only in health, but healthcare value.

There are five models falling under one of two categories, Primary Care First (for individual practices) and Direct Contracting (for large organizations like ACOs, Medicare Advantage Plans and MCOs); all models are geared to patients with chronic conditions and serious illnesses:

  1. Primary Care First (PCF)
  2. Primary Care First – High Need Populations
  3. Direct Contracting – Global
  4. Direct Contracting – Professional
  5. Direct Contracting – Geographic

Primary Care First (PCF) is the model Medical Network One will enthusiastically recommend to high performing providers/practices. There is up to a fifty percent gain in reimbursement and only a ten percent downside risk which, at face value, appears to be a solid bet. The metrics CMS will look at in this model include: A1c control, blood pressure control, patient satisfaction and advanced care planning. These are measures our providers not only track but do well in – and are not as difficult to monitor as cancer screenings, for example. To qualify for PCF, practices need a minimum of 125 Medicare patients.

The Primary Care First – High Needs Population model is generally an add-on to the PCF model. You can either opt into this model in addition to the basic PCF model or apply for it exclusively. Essentially, patients without identified local primary care providers will be assigned to a provider whose responsibility it will be to care for them. While there is a significant upside built into this model, these patients likely do not have a PCP for a reason – adding to the risk of default and loss of a flat amount reimbursement.  


Clearly, PCF and Direct Care Funding reflect that CMS now sees value in care management, such as the evolving CPC and CPC+ and other PCMH (patient-centered medical home) activities that historically have not been funded. Additionally, social determinants of health can now be addressed by the care team. While it’s been admittedly exhausting to those of us who have championed coordinated care efforts and their reimbursement worthiness, the Primary Care Initiative announcement begs for a victory lap at least around the block. (We’ll go the extra mile when we see how this all works in real life.)


As we engage our member practices (voluntarily) in Primary Care First, I anticipate a risk agreement between us where we split potential gains/losses in an agreed-upon manner. Perhaps I’m overly optimistic, but I believe this will allow for relatively easy buy-in, given provider members can leverage our current tools, staff, and capabilities to minimize any material financial risk. Key will be to target select practices that fit the criteria and, most critically, want to be engaged in the program. (Isn’t engagement the key to success in any initiative?) It will be interesting to see how other Patient Care Organizations (aka POs) administer the PCF program. As implementation begins, I see another opportunity for Michigan’s PO community to share best practices -and make them common practices.

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