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What You Need to Know about the Primary Care First (PCF) Alternative Payment Model

Overview

On October 24, 2019, the Center for Medicare and Medicaid Services (CMS) released the Request for Applications (RFA) and Practice Application for the Primary Care First (PCF) demonstration model. Practices interested in participating in the model, including those interested in the Seriously Ill Population (SIP) track, must submit an application by January 22, 2020 in order to be eligible for the first performance year beginning in January 2021.

Model Updates in the RFA

There were a number of important model details released in the RFA that were not reflected in CMS’ previous educational webinars from earlier this summer. Those updates include:

  • CMS will restrict participation in the second cohort of the demonstration (performance years 2022-2027) to practices currently participating in Comprehensive Primary Care Plus (CPC+).
  • The flat visit fee will be reduced to $40.82 (CMS previously listed the rate as $50.42)
  • Seriously Ill Population (SIP) track practices (and practice risk groups 3 and 4 in the General track) will not use the acute hospitalization utilization (AHU) performance measure; instead, performance for these groups will be measured on the Advance Care Plan and Total Per Capita Cost (TPCC) measures in Year 1, followed by an additional experience of care survey measure in year 2, with a Days at Home and 24/7 Access to a Practitioner measure included for quality measurement in years 3-5.
  • As part of the required transition process under the SIP track, SIP-only and hybrid practices (General + SIP) must develop a transition plan, communicate the transition plan to the SIP beneficiary and obtain their approval, transfer the beneficiary’s detailed care plan to the receiving practitioner (if different than the SIP practitioner), and have a conversation with the receiving practitioner about the beneficiary (if different than the SIP practitioner).If a SIP-only or hybrid practice is transitioning a beneficiary to a different health care provider, they must have a care agreement with that provider that governs the transition and expectations of support and care coordination after the transition.

Participation Options

There are three participation options available to practices under PCF:

  1. Primary Care First (PCF) General Component Only (i.e., PCF-General Practices)
  2. Seriously Ill Population (SIP) Component Only (i.e., SIP-Only Practices)
  3. Both PCF General and SIP Components (i.e., Hybrid Practices)

CMS recently held two informational webinars on the PCF updates. Links to the slides from those sessions can be found below:

Seriously Ill Population (SIP) Track:

SIP (both SIP-only and within Hybrid practices) is designed to serve only as a time-limited intervention that provides increased financial resources to clinically stabilize patients with serious illness who exhibit a pattern of care fragmentation. Once patients are stabilized, they must then transition to a longer-term health care arrangement.

Practices interested in participating in the SIP model must provide a description of the service area(s) in which they are interested in participating using zip codes and must define the maximum number of SIP beneficiaries the practice has the capacity to manage. In service areas with multiple SIP practices, CMS will randomly assign beneficiaries to each practice.

In order to be eligible for SIP, Medicare beneficiaries must meet the following two criteria:

1. Fragmented Pattern of Care (at least one of the following)
a. No single practice (TIN) provides more than 50% of a beneficiary’s E/M visits
b. Beneficiary has 2 or more ED visits or observation stays in past 12 months
c. Other claims-based criteria as may be set forth in Participation Agreement

AND

2. Serious Illness (at least one of the following)
a. Have significant chronic or other serious illness (i.e., HCC score > 3.0)
b. High hospital utilization (i.e., HCC score between 2.0 and 3.0 AND 2 or more unplanned hospital admissions in 12 months)
c. Signs of frailty as evidenced by a DME claim for hospital bed or transfer equipment

According to CMS, the SIP population is expected to account for roughly 2%-3% of Medicare beneficiaries.

Practices will be encouraged to maintain an 8-month annual average length of attribution (LOA) for their SIP beneficiary population. Individual SIP beneficiaries will be allowed to remain in SIP for a maximum of 12-months (except in rare cases where a practice petitions CMS to extend SIP enrollment for individual beneficiaries on a case-by-case basis). A practice’s annual LOA will be calculated at the end of the performance year, and if a practice exceeds the 8-month average LOA, it will receive a $50 per beneficiary per month (PBPM) reduction to their monthly SIP payment through the quality adjustment.

Additionally, SIP-only practices will not be required to use Certified Electronic Health Record Technology (CEHRT) in the first model performance year (2021), but will have to implement CEHRT by Year 2 (2022). It is unclear how much support will be provided by CMS in meeting the CEHRT 2021 requirement, but SIP-only practices should consider if acquiring CEHRT will be feasible by year two.

What to Consider When Applying:

PCF represents an important opportunity for providers that care for the seriously ill and their families to participate in a truly value-based model that will reward them for achieving high-quality clinical and cost-saving outcomes. It is important for every organization to closely review the RFA and additional informational materials CMS has released, in order to fully understand the implications and feasibility of participating in PCF.

C-TAC recognizes multiple opportunities for our diverse membership within this model. Smaller, community-based palliative and hospice organizations with less experience in risk-based payment models should consider their capacity to take responsibility for the primary care needs and increased financial risk associated with assigned beneficiaries, as well as their ability to provide 24/7 access to a practitioner that can carry out a meaningful clinical response. For smaller organizations that are not accustomed to taking on high levels of financial and clinical risk, partnering with larger primary care organizations that do have this value-based experience  may represent the most feasible and high-impact participation option.

Larger physician practices, health systems, and more advanced hospice and palliative care providers that are comfortable with risk-based arrangements and can deliver comprehensive primary care as CMS defines it, may have the capacity to undertake a hybrid approach in which they are responsible for both SIP-track and General-Track beneficiaries. CMS expects that in most cases, hybrid practices will continue to care for a beneficiary after they transition off SIP, under their PCF-General component.

Next Steps

In the RFA, CMMI noted that they are still open to continued stakeholder feedback on PCF model details. C-TAC encourages organizations to express questions and concerns to CMMI as they finalize the model. Questions and comments should be sent to PrimaryCareApply@telligen.com.

C-TAC will continue to analyze the RFA and work with our members and partners to develop guidance to support the application process, as well as structured feedback for CMMI as they refine and finalize model components.

If you have any questions about C-TAC’s policy work, please email Davis Baird, Policy & Advocacy Manager, at dbaird@thectac.org.

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