The Financial Benefits of the Primary Care First Model for Practices

Primary Care First Model

Primary Care First (PCF) intends to increase primary care professionals’ self-governance by providing more operational adaptability and performance-based incentives, allowing them to customize care delivery depending on their specific patient groups and resources. The concept actively encourages providers to invest additional time with patients and offer coordinated, effective care by connecting health outcomes for patients to compensation received by subscribing practices.

Primary Care First encourages primary care providers to innovate by offering a financing model that shifts from fee-for-service to value-based care. The program has great potential to assist autonomous primary care practices in maintaining their financial stability.

The Center for Medicaid and Medicare Innovation (CMMI) created a system that replaced CPC+ with higher future payments, a relatively simple fee timetable for the most widely accepted primary care CPT codes, and outstanding bonus payments for setting and achieving national benchmarks for a restricted number of quality indicators.

It is worth keeping in mind that CMS can evaluate the practice and the practitioners it selects for PCF enrollment for program integrity. The findings of a program integrity evaluation may persuade CMS to decline a submitted proposal.

PCF-Specific Methods for Care Delivery and High Performance

Primary Care practices and other practitioners can have different financing model choices under the Primary Care First track:

  1. Primary Care First (PCF) – General (risk-adjusted, population-based payment)
  2. Primary Care First (PCF) – Populations with High Needs

A payment mechanism is also included in the framework to reward practices that care for Seriously Ill People (SIP track).

Primary Care First strives to be transparent, precise and to hold participating healthcare professionals responsible by

1) Offering model payments to practitioners via an easy payment framework that contains:

  • A flat payment that emphasizes patient-centered care while rewarding practitioners for delivering in-person care service.
  • A population-based payment mode to allow for greater adaptability for patient care delivery
  • A quarterly performance-based adjustment provides practitioners with an upside of up to 50% of model payments and a minor negative 10% of model payments, rewards to cut expenses and enhance performance.

2) Facilitating and fostering continual growth by giving practice stakeholders insight into their efficacy by discovering relevant data on their own and the quality and outcomes of other participants.

The complete primary care payment is intended to minimize the administrative burden by removing fee-for-service coding, reporting, and invoicing. The payments are graded based on the ascribed participants’ average Hierarchical Condition Codes (HCC).

Eligible practices will receive a net primary care payment from PCF, including a projected professional population-based payment and a fixed primary care appointment fee for qualified patient visits. Practices will be adjusted based on how well they function.

The incentive in Year One of Primary Care First is determined by how successfully the practice reduces acute hospitalizations among its approved beneficiaries. In the second year, CMS will collect patient experience metrics and a small number of clinical indicators.

Healthcare practitioners and practices are given spending liberty for care management with minimum reporting criteria and no specific permission or co-insurance standards. Suppose national benchmarks for quality criteria, acute hospitalization minimization, or overall cost are not met. In that case, a 10% adjustment will be made, but there will always be the opportunity to earn a bonus if performance targets are met. PBPM payments mean that practices will profit with Primary Care First even if they do not get a Bonus.

Link Between PCF and Other Value-Based Payment Plans

PCF is open to primary care practices and other value-based payment (VBP) models, such as Accountable Care Organizations (ACOs). The primary drawbacks are that CPC+ practices will not be able to apply until 2022, and Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) will not be able to participate.

Final Thoughts About PCF

Numerous analysts concur that using risk adjustment in this iteration of CMS’s primary care value-based pay systems would enhance patient care and build a modern paradigm for highly developed primary care.

The Primary Care First approach may be an excellent choice for the practice if the healthcare organization is weary of searching for a strategy to minimize administrative demands and boost the quality of care services while also yielding financial advantages.

The PCF model’s success will be determined by a number of crucial elements, including but not limited to:

a) The patient’s average risk score under the practitioner’s care influences the payment level for the additional compensation.

b) Annual Wellness Exams must be completed since this determines which patients are awarded.

c) Proactively detecting and rectifying care gaps improves overall performance, cuts costs, and enhances patient experience.