Introduction to Primary Care First and Direct Contracting Models - PowerPoint PPT Presentation

Introduction to Primary Care First and Direct Contracting Models

Introduction to Primary Care First (PCF) Primary Care First Goals Primary Care First Overview 5-year alternative payment model To reduce Medicare spending by 1 preventing avoidable inpatient hospital Offers greater flexibility , increased admissions transparency , and performance-based To improve quality of care and access to payments to participants care for all beneficiaries, particularly those 2 Payment options for practices that specialize with complex chronic conditions and serious in patients with complex chronic illness conditions and high need, seriously ill populations Fosters multi-payer alignment to provide practices with resources and incentives to enhance care for all patients, regardless of insurer 2 Comprehensive Primary Care Plus CMS Primary Cares Initiatives Center for Medicare & Medicaid Innovation

Overview of CMS Innovation Center Primary Care Models CMS primary care models offer a variety of opportunities to advance care delivery, increase revenue, and reduce burden. 2 1 PCF CPC+ Track 1 is a pathway for Primary Care First rewards CPC+ Track 2 is a pathway practices ready to build the outcomes , increases for practices poised to capabilities to deliver transparency , enhances care for increase the comprehensive primary care. high need populations , and comprehensiveness . reduces administrative burden . 3 Comprehensive Primary Care Plus CMS Primary Cares Initiatives Center for Medicare & Medicaid Innovation

PCF Payment Model Option Emphasizes Flexibility & Accountability PCF Payment Model Option Goals Reward high-quality, Transition primary care Promote patient access from fee-for-service payments to patient-focused care to advanced primary care value-driven, population-based that reduces preventable both in and outside of the payments hospitalizations office, especially for complex chronic populations PCF Payments Performance-based adjustments Professional population-based payments up to 50% of revenue and a 10% and flat primary care visit fees to help downside, based on a single practices improve access to care and transition outcome measure, with focused from FFS to population based payments quality measures 4 Comprehensive Primary Care Plus CMS Primary Cares Initiatives Center for Medicare & Medicaid Innovation

PCF – High Need Populations Model Payment Option Seriously Ill Population Participation Options Multiple pathways to participate: Engage newly identified seriously ill population (SIP) patients who lack a practices may limit participation to primary care practitioner or care coordination exclusively caring for SIP patients Opportunity for clinicians enrolled in Enhanced payments to ensure that care Medicare who typically provide hospice is coordinated and SIP patients are or palliative care services to participate clinically stabilized 5 Comprehensive Primary Care Plus CMS Primary Cares Initiatives Center for Medicare & Medicaid Innovation

Where PCF Will Be Offered in 2020 In 2020, Primary Care First will include 26 diverse regions: Current Track 1 and 2 regions New regions added in Primary Care First 6 Comprehensive Primary Care Plus CMS Primary Cares Initiatives Center for Medicare & Medicaid Innovation

PCF Will Launch in Early 2020 Fall-Winter 2019 January 2020 April 2020 Summer 2019 Spring 2019 Practices and Model launch Payment changes Practice Practice payers selected begin applications due; applications open Payer solicitation Practice and payer Practice application selection period period 7 Comprehensive Primary Care Plus CMS Primary Cares Initiatives Center for Medicare & Medicaid Innovation

PCF Benefits for Participating Practices Simple payment model so providers can spend more time with patients and deliver care based on patient needs Options for practices that specialize in complex, chronic and high need, seriously ill populations Focus on single outcome measure that matters most to patients: acute hospital utilization Enhanced access to actionable, timely data to inform care and assess your performance relative to peers 8 Comprehensive Primary Care Plus CMS Primary Cares Initiatives Center for Medicare & Medicaid Innovation

Introduction to Direct Contracting

Direct Contracting: Model Goals Transform risk-sharing Empower beneficiaries to Reduce provider burden to arrangements in Medicare personally engage in their meet health care needs Fee-For-Service (FFS) own care delivery. effectively. 10

Direct Contracting: Design Approach in Brief • Build off the Next Generation Accountable Care Organization Model to offer new forms of population-based payments (PBPs), enhanced cash flow options, and flexibilities to increase providers’ tools to meet beneficiaries’ medical and non-medical (e.g., social determinants of health) needs • Expand emphasis on voluntary alignment and beneficiary choice, while retaining claims-based alignment approaches • Reduce burden by focusing quality reporting on select measures • Create a more predictable, prospective spending target by capitalizing on Medicare Advantage rate calculations for purposes of the regional component to the benchmark and the trend adjustment • Focus on dually eligible, complex chronic and seriously ill patients • Create participation opportunities for organizations new to Medicare FFS, and for Medicaid Managed Care Organizations interested in taking accountability for Medicare cost and quality where already accountable for Medicaid spending 11

Direct Contracting Model Options Professional PBP Global PBP Geographic PBP (proposed) • ACO structure with • ACO structure with • Would be open to entities Participants and Preferred Participants and Preferred interested in taking on Providers defined at the Providers defined at the regional risk and entering TIN/NPI level TIN/NPI level into arrangements with providers in the region • 50% shared savings/shared • 100% risk losses with CMS • 100% risk • Choice between Total Care • Primary Care Capitation Capitation for all services • Would offer a choice equal to 7% of total cost of provided by Participants between Full Financial Risk care for enhanced primary (and optionally Preferred with FFS claims care services Providers), or Primary reconciliation and Total Care Capitation Care Capitation Lowest Risk Highest Risk 12

Direct Contracting Entities • Generally, must have at least 5,000 aligned Medicare FFS beneficiaries • “On ramp” for organizations new to Medicare FFS • Added flexibility for organizations serving dually eligible, chronically ill populations Geographic PBP model option would be open to innovative Participants Preferred Providers organizations, including • Core providers and suppliers • Not used to align beneficiaries health plans, health • Used to align beneficiaries to the to the Direct Contracting Entity care technology Direct Contracting Entity • Participate in downstream companies, in addition • Responsible for reporting quality arrangements, certain benefit to providers and through the Direct Contracting enhancements and/or payment supplier organizations. Entity and improving the quality rule waivers, and contribute to of care for aligned beneficiaries Direct Contracting Entity goals 13

Benchmarking Methodology • Professional PBP and Global PBP • Prospective blend of historical spending and adjusted Medicare Advantage regional expenditures used to develop benchmark (segmented by Aged & Disabled and ESRD) • Historical baseline expenditures trended forward by US Per Capita Cost growth, with adjustments to account for population risk and geographic price factors • Discount applied in Global PBP with potential for quality bonus • Considering innovative approaches to risk adjustment, including for complex and chronically ill populations • Geographic PBP (proposed) • Would be based on a one-year historical per capita FFS spend in the target region trended forward (no historical/regional blend) with negotiated discounts • Final methodology would be informed by responses to the Request for Information 14

Quality Quality strategy reduces clinician burden… Professional PBP and Global PBP Geographic PBP (proposed) • DCEs report a focused, core set of • DCEs would propose focused, core set measures of measures to be reported on their geographically aligned FFS population • DCEs’ quality performance impact discounted benchmark amounts in • The measures would have to be Global PBP and final shared savings or approved by the CMS Innovation Center losses in Professional PBP prior to participation and be tied to payment …and focuses on relevant, actionable measures. Direct Contracting is expected to be an Advanced APM in 2021. 15