Population Health Update

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Voluntary Alternative Payment Models Delayed By CMS: What’s The Effect On Population Health?

Programs that are expected to help reform healthcare delivery in the United States by paying Medicare providers for the value of their care while offering incentives to manage chronic illnesses more effectively are reportedly being delayed by the Centers for Medicare & Medicaid Services (CMS). Officials announced the decision to postpone the start of the Primary Care First Model Options, a set of voluntary five-year payment options for healthcare providers that reward value and quality through a payment structure that supports delivery of advanced primary care, until 2021—a timeline that delays implementation of the payment models for one year. 

Anticipated financial rewards for providers who choose to be involved in the model will include those for achieving better quality of care delivery, improved patient satisfaction, and reduced healthcare spending, but applications for enrollment will reportedly not be available for at least a few weeks.1

The program, which was initially slated to launch this coming January, will also reportedly increase reimbursement for those practices that care for patients who are living with complex, chronic needs and pay a larger population-based payment to providers for Medicare services, as compared to traditional fee-for-service reimbursement models. The larger payment is intended to account for the higher disease burden in these populations and the increased resources required to serve them.2 Other goals of the program are to identify poorly managed care among those patients who are seriously ill and provide additional financial resources for those providers who proactively engage these patients through comprehensive, person-centered care while helping them to be clinically stable.2

Primary Care First Availability & Strategy

According to CMS officials, Primary Care First Model Options will be offered in 26 regions for the 2021 start date, including Alaska, Arkansas, California, Colorado, Delaware, Florida, Greater Kansas City (Kansas and Missouri), Greater Philadelphia (Pennsylvania), Hawaii, Louisiana, Maine, Massachusetts, Michigan, Montana, Nebraska, New Hampshire, New Jersey, New York (Greater Buffalo and North Hudson-Capital) North Dakota, Northern Kentucky, Ohio, Oklahoma, Oregon, Rhode Island, Tennessee, and Virginia.

In response to input previously gathered by CMS from primary care clinician stakeholders, this model will be based on the principles of the existing Comprehensive Primary Care Plus program, a national advanced primary care medical home model that aims to strengthen primary care through regionally based multi-payer payment reform and care delivery.3

In response to what is considered to be an urgent need to preserve and strengthen primary care while providing support services to care for those patients living with serious illness, CMS officials say the Primary Care First model has been designed to address these needs through the development of a continuum of care that is seamless among participating providers. The payment options will reportedly test whether delivery of advanced primary care can reduce total cost of care and accommodate practices at multiple stages of readiness to assume accountability for patient outcomes, according to CMS officials. Primary Care First will also focus on advanced primary care practices that are ready to assume financial risk in exchange for reduced administrative burdens and performance-based payments. Thorough a second payment option, this model is also expected to encourage advanced primary care practices, including those clinicians who are enrolled in Medicare who typically provide hospice or palliative care services, to take responsibility for high-need, seriously ill beneficiaries who lack a primary practitioner and/or effective care coordination. The Primary Care First model will also prioritize patients by emphasizing the doctor-patient relationship and seek to improve patients’ experiences by reducing administrative burdens and allow providers for more time with patients. 

CMS will utilize a set of measures based on clinical quality and patient experiences to assess quality of care being delivered. Participating practices must meet these standards to be eligible for a positive performance-based adjustment to revenue. Measures include a patient experience of care survey, controlling high blood pressure, diabetes hemoglobin A1c control, colorectal cancer screening, and advance care planning. 

Eligible practitioners will include those in internal medicine, general medicine, geriatric medicine, family medicine, and/or hospice and palliative medicine, according to CMS officials, who will reserve the authority to deny applications if an integrity screening does not produce optimal results. As part of the model’s goals, will other payers will be encouraged to align payment, quality measurement, and data sharing with CMS in support of Primary Care First practices, officials said.

Impact on Population Health 

Practices that are serving patients who are living with complex, chronic needs will reportedly receive a larger population-based payment for their Medicare services rendered compared to traditional fee-for-service reimbursement.2 Larger payments are intended to help offset costs related to higher disease burden among these patient populations and the increased need for resources required to care for these patients effectively. The stated goal of identifying seriously ill patients whose care is not well managed and subsequently providing additional financial resources for providers to better engage these patients in their care and offer comprehensive, person-centered care is also expected to improve patients’ day-to-day health and improve their relationships with their clinicians.2 

The application process opened on Oct. 24 and will remain active until Jan. 22, 2020. 

CMS has also released a set of other timelines related to the new launch structure.4

References

  1. Brady, M. CMS delays new primary-care pay model, calls for providers to join. Modern Healthcare. 2019. Accessed online: www.modernhealthcare.com/payment/cms-delays-new-primary-care-pay-model-calls-providers-join
  2. Shryock T. Primary care first payment models delayed until 2021. Medical Economics. 2019. Accessed online: https://www.medicaleconomics.com/news/primary-care-first-payment-models-delayed-until-2021
  3. Comprehensive Primary Care Plus. CMS. 2019. Accessed online: https://innovation.cms.gov/initiatives/comprehensive-primary-care-plus

  4. Primary Care First Model Options. CMS. 2019. Accessed online: https://innovation.cms.gov/initiatives/primary-care-first-model-options

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