CMS Looks to Reward High-Quality Primary Care with 5 New Payment Models

Last Updated: Apr 25, 2019

doctor-elderly-coupleThe U.S. Department of Health and Human Services and the Centers for Medicare and Medicaid Services (CMS) have announced the CMS Primary Cares Initiative, a set of five new value-based payment models designed specifically for primary care. 

Although primary care clinicians are on the front lines of the health care delivery system, primary care spending accounts for a small portion of the total cost of care, CMS said in a news release issued on April 22, 2019. The CMS Primary Cares Initiative seeks to address this discrepancy and align primary care payment in order to reward high quality, cost-effective care.

There are five payment model options under two paths: Primary Care First and Direct Contracting.

Primary Care First

The models in the Primary Care First path are based on the underlying principles of CMS’ Comprehensive Primary Care Plus (CPC+) payment model. The Primary Care First models are:

Primary Care First – General: Focuses on advanced primary care practices ready to assume financial risk in exchange for reduced administrative burdens and performance-based payments. Introduces new, higher payments for practices that care for complex, chronically ill patients.

Primary Care First – High Need Populations: Encourages practices to take responsibility for high need, seriously ill beneficiaries who currently lack a primary care practitioner and/or effective care coordination.

Timeline & Participation: The Primary Care First models will have a 5-year performance timeline. CMS plans to begin accepting practice and payer applications in spring 2019. The model will begin in January 2020 and will be open to practices that are not currently participating in the CPC+ Model but are located in the 18 existing CPC+ regions (which includes the Greater Philadelphia region), and to payers and practices in regions in the U.S. where there are limited comparison group practices in the ongoing CPC+ evaluation.

Fact Sheets & Resources: For details on the model’s goals, reimbursement, and who can participate, get CMS’ Primary Care First fact sheet here and visit CMS’ Innovation Center here.

CMS is conducting four informational sessions on Primary Care First. Use the links below to register for one of these sessions: 

April 30 at noon
April 30 at 3 p.m.
May 16 at noon
May 16 at 3 p.m.

Direct Contracting

The Direct Contracting (DC) models will test risk-sharing arrangements with a goal of reducing costs while preserving or enhancing care quality in Medicare Fee-for-Service. They offer choices related to cash flow through Population-Based Payment (PBP), beneficiary alignment, and benefit enhancements.

The models are:

  • Direct Contracting – Global
  • Direct Contracting – Professional
  • Direct Contracting – Geographic

Timeline & Participation: The payment model options available under DC will start in January 2020 with an initial alignment year for organizations that want to align beneficiaries to meet the minimum beneficiary requirements. Performance periods will begin January 2021 and will be five years.

CMS will request a Letter of Intent (LOI) from organizations interested in the Global or Professional options. While an LOI will not bind an organization to participate, an organization that does not submit an LOI will be ineligible to apply during the application period. CMS is currently in the request for information phase for the Geographic option and expects the application process for that model to begin in the fall of 2019.

Fact Sheets & Resources: For details on the model’s goals, reimbursement, and who can participate, get CMS’ Direct Contracting fact sheet here and visit CMS’ Innovation page here.

CMS is conducting two informational sessions on DC models. Use the links below to register for one of these sessions: 

May 2 at 3 p.m.
May 7 at 3 p.m.

Additional Resources

CMS offers a fact sheet with a general overview of the CMS Primary Cares Initiative and the five payment models here.

Pennsylvania Medical Society (PAMED) members with questions can contact our Knowledge Center at 855-PAMED4U (855-726-3348) and KnowledgeCenter@pamedsoc.org.


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