Analysis: CMMI primary care initiatives: Potential opportunity but lots of questions

HFMA’s Rich Daly is reporting, “Medicare aims to enroll 11 million Medicare FFS beneficiaries in payment models specifically for primary care providers and practices.”

The full article, “Several new Medicare primary care payment models to launch in 2020,”  describes the five models and provides a list of goals and benefits the administration hopes the models will produce.  

In brief, the models include the following:

• Primary Care First (PCF) model, which is intended for small practices, and includes downside risk of 10% and potential bonuses of up to 50% of total the cost of care.
• A second PCF model focuses on seriously ill populations and offers similar incentives. The Direct Contracting category, includes three models: professional, global and geographic, which, according to a CMS.gov press release, aim to engage a wider variety of organizations that have experience taking on financial risk and serving larger patient populations, such as Accountable Care Organizations (ACOs), Medicare Advantage (MA) plans and Medicaid managed care organizations (MCOs). The Direct Contracting category will allow participants to take on up to 100% downside or upside risk. 

Takeaway

All five models have been generally well received.

However, when it comes to alternative payment models (APMs), like everything else in life, “the large print giveth and the small print taketh away.” And the materials released this week lacked much of both the large and small print. 

Given the paucity of detail, members who are interested should attend the CMMI webinars for the model(s) that most interest them.

The Primary Care First webinars are scheduled for:

• Tuesday, April 30, 12 p.m. EDT  Register here
• Tuesday, April 30, 3 p.m. EDT  Register here
• Thursday, May 16, 12 p.m. EDT  Register here
• Thursday, May 16, 3 p.m. EDT  Register here

The Direct Contracting webinars are scheduled for:

• Thursday, May 2, 3 p.m. EDT  Register here
• Tuesday, May 7, 3 p.m. EDT  Register here

Hopefully, as they have with other APM releases, CMMI will provide answers to some of the questions they’ve received from providers and other stakeholders who are considering participating. And my guess is they have a lot of questions to answer. Based what’s available about the new models so far, CMMI needs to cover relatively basic questions such as:

1. Risk adjustment: For the Direct Contracting models will there be a cap on changes in risk adjustment? 
2. Attribution: Given the emphasis on voluntary attribution, will the attribution model(s) be different than what is currently used?
3. Waivers: Particularly in the Direct Contracting model, will participants have flexibility approaching that of Medicare Advantage plans in terms of providing “innovative care” (e.g. deploy hospital-at-home models, use capitated funds to address select social determinants of health)? Also, in the DC model, will the beneficiary incentive waiver be stronger or more meaningful than what is currently available in Next Gen and under Pathways to Success?
4. Overlap with other models: How will CMS treat savings from (or the cost of) care provided under an episodic-payment model like BPCI-A if the beneficiary is attributed to a DC provider?
5. I’m assuming physicians participating in one of the newly released models will qualify for the 5% advanced alternative payment model bonus payment if they meet the required revenue or patient count thresholds. However, the materials released did not specifically state that.
6. Reserve/Repayment Requirements: What repayment mechanisms will CMS require given the DC model uses partial and full capitation?  Will these start to look more like the reserve requirements that health plans have to meet? 

Related resource: CMMI Primary Care First: HFMA Overview