With its new Advanced Payment Model (APM), Primary Care First (PCF), the Centers for Medicare and Medicaid Services (CMS) aims to accelerate the transition to value-based payments in primary care and patient-centered delivery.
Three things to know about Primary Care First
- PCF offers several promising benefits including less administrative burden and more flexibility, ability to increase revenue, enhanced access to actionable/timely data, focus on a single outcome measure, and the potential to become a qualifying APM participant.
- PCF uses prospective, risk-adjusted, population-based payments for primary care services and retains the ability to provide comprehensive services on a fee-for-service (FFS) basis.
- PCF primarily changes how physician practices are paid and offers the opportunity to increase overall revenue if the practice excels at lowering hospitalizations. Although the model is directionally appropriate, the adequacy of the payment levels in the PCF program is debatable.
Understanding payments in PCF
In PCF, the amount that practices receive from traditional FFS payments on evaluation and management (E&M) will be drastically reduced. Instead of getting paid $92 from an E&M visit or $133 for an annual wellness visit (AWV), practices will receive a flat visit fee of $40 for any E&M, transitional care management (TCM), AWV, or advance care planning (ACP) visit, plus a population-based payment (PBPM) that ranges from $28 to $175 based on the practice’s average hierarchical condition category (HCC) risk score for attributed beneficiaries, also referred to as the practice’s risk group bucket.
PCF practices will also receive a performance-based adjustment that ranges from -10 to 50 percent of their flat visit-fee and PBPM payments. The adjustment will be based on the practice’s performance on four quality measures, plus their performance on Acute Hospitalization Utilization compared to a national benchmark, a regional benchmark and their previous selves (continuous improvement). Participation in PCF will significantly impact a practice’s bottom line.
Will your practice leave money on the table?
This year, over 800 primary care practices started their first performance year in PCF (Cohort 1). The second cohort of practices performance year starts January 1, 2022. PCF practices should strongly consider joining a MSSP ACO, otherwise they will leave significant “money on the table” from potential shared savings.
There is significant overlap between the programs and the opportunity to be rewarded for doing the same work (e.g. reducing hospitalizations). If your practice already participates in an MSSP ACO, now is the time to evaluate how well it serves your needs. Not all ACOs are created equal, and the status quo is not a viable strategy for maximizing your success in value-based care.
The following summarizes the business case for why PCF practices should join an MSSP ACO including common program elements and measures, and financial incentives. The deadline to enroll in an MSSP ACO is quickly approaching and now is the time to position your practice for success in value-based care.
Overlaps between PCF and MSSP
In PCF, practices can maximize their revenue by reducing hospitalizations and driving down cost of care. If practices work to drive down hospitalizations in PCF they can leverage this work to achieve shared savings in MSSP by driving down total cost of care. Specifically, if a PCF practice reduces hospitalizations, they will earn a “little plus-up,” OR if that practice is also in MSSP, they can get paid a “little plus-up” in PCF and receive a percent of that hospitalization in the form of shared savings. This is significant revenue that could be earned from doing the same work.
In addition to the same hospitalization reduction goals, there is also significant overlap between quality measures, however, they are reported differently (see Tables 1-2). Risk adjustment matters in both PCF and MSSP.
Table 1 – Comparison of PCF and MSSP Key Program Elements
Table 2 – Comparison of PCF and MSSP Quality Measures
* MSSP quality metrics are for performance year 2022, based on the changes in the CY 2021 finalized physician fee schedule rule. Quality under both programs is all-patient, all-payer.
Financial incentives – PCF vs. MSSP
Unlike previous primary care initiatives, PCF practices do not need to give up anything to participate in MSSP (i.e., quality bonus). PCF funding is aligned with financing ACO work, but all PCF funding flows directly to the practice. Table 3 compares payment and financial incentives between the two models.
According to CMS data, in 2019, physician-led MSSP ACOs had gross per-beneficiary savings of $458 per beneficiary compared to $169 per beneficiary for hospital-led MSSP ACOs. Aledade MSSP ACOs had savings of $490 per beneficiary. In the new Pathways to Success program, physician-led ACOs had per-beneficiary savings of $429 while hospital-led ACOs had per-beneficiary savings of $258. Aledade ACOs had per-beneficiary savings of $663 in Pathways to Success.
For example, a practice in risk group 1 of PCF that sees their patients an average of 4.5 times per year could expect to see about $520 in revenue without accounting for deductibles and coinsurance. If that practice is also in an MSSP ACO that made shared savings, those $520 would turn to $720. For a practice with 500 attributed Medicare patients this would be a 38% increase in revenue from $260,000 to $360,000.
Table 3 – Comparison of PCF and MSSP Payment and Financial Elements
How to select an ACO partner for your practice
Making the decision to join an ACO is the first step to maximize your PCF performance and investment in staff, technology and population health management. The American Medical Association suggests providers carefully examine all clinical, operational, and financial factors when evaluating an ACO partner. A good partner will be upfront about each of these items to ensure all participants are fully informed and equipped to succeed. Access Aledade’s white paper, Key Considerations for Evaluating an ACO Partner, for more information.
For more information on joining an Aledade ACO, contact firstname.lastname@example.org or read what our ACO partners have to say about their Aledade experience in the KLAS Research ACO Enablement Services Report, April 2021.