On April 22, 2019, the CMS Innovation Center announced two new Medicare payment models that will launch in 2020: the Primary Care First (PCF) model; and the Direct Contracting (DC) model.

The PCF model builds upon the Comprehensive Primary Care Plus (CPC+) model rolled out in 2018. It is designed to determine whether advanced primary care services coupled with providers’ assumption of financial risk can reduce overall care costs, improve quality/outcomes/patient experience, and ensure clinical accountability. In short, the PCF model allows eligible providers to select one or more participation options. The first option requires eligible advanced primary care practices to assume some downside financial risk (10% of revenue) for care provided to attributed patients. In return, those practices would be eligible to receive a share of savings of up to 50% of revenue in addition to a “risk-adjusted professional population-based payment (PBP) with a flat primary care visit fee.” The second option targets Seriously Ill Population (SIP) patients who do not have a primary care provider or care coordination and assigns interested SIP patients in the service area to practices that have elected this second option. Participating providers will be paid for care provided to SIP patients based on the high complexity and need of such patients, with further adjustments based on quality metrics. Providers may elect to participate in both PCF options.

As with the CPC+ model, CMS is seeking to align commercial payors, Medicare Advantage plans, Medicaid managed care plans and state Medicaid plans with the PCF model payment structure (as well as quality measurement and data-sharing processes).

For 2020 commencement, the PCF model will be available in the following states/regions:

Professional Population-Based Payment – 50% risk-sharing (savings and losses) on top of monthly risk-based capitation payments for enhanced primary care servicesThe DC model expands upon prior innovation models for accountable care organizations (ACOs) and similar organizations, such as the Next Generation ACO model, by appealing to a broader range of larger provider organizations with the experience and/or ability to enter into risk-based contracts for Medicare fee-for-service patients. The DC model offers three reimbursement tracks:

  1. Global Population-Based Payment – 100% risk-sharing (savings and losses) on top of either monthly risk-based capitation payments for enhanced primary care services or for all services provided by participants/preferred providers
  2. Geographic Population-Based Payment – this track is pending public comment, but it is expected to allow certain providers, selected through a competitive process, to assume financial risk for all care provided to all Medicare fee-for-service patients within a specified region

For more information on the PCF model, visit the CMS Primary Care First Model homepage at https://innovation.cms.gov/initiatives/primary-care-first-model-options/.

For more information on the DC model, visit the CMS Direct Contracting Model homepage at https://innovation.cms.gov/initiatives/direct-contracting-model-options/.