CMS Value Based Approach to Primary Care

Wednesday, November 11, 2020

As highlighted in a Might 2020 Milbank Memorial Fund white paper titled, “How Fee Reform May Allow Main Care to Reply to COVID-19,” the COVID-19 public well being emergency has pushed transformation within the provision of major care providers throughout the nation. Whether or not it’s the usage of telehealth expertise to facilitate “digital visits” or the event of latest therapy protocols to establish and deal with sufferers who want behavioral well being assist to handle the emotional challenges endemic to the general public well being emergency, modifications in major care supply have drawn elevated consideration to the necessity for concomitant modifications in the best way major care is financed.

As evidenced by our April 23, 2019 weblog put up, “CMS Broadcasts New Initiative for Worth-Based mostly Transformation of Main Care,” effectively earlier than the emergence of the coronavirus and COVID-19, the Facilities for Medicare and Medicaid Companies (“CMS”) and the Middle for Medicare and Medicaid Innovation (“CMMI”) had already turned its consideration to major care and the necessity for cost transformation as a method to facilitate and assist transformation within the provision of major care to advertise high quality, cut back supplier administrative burdens, and “empower major care suppliers to spend extra time caring for sufferers whereas decreasing general well being care prices.”[1] As introduced in its April 22, 2019 Press Launch, CMS’s Main Cares Initiative contains 5 different major care cost fashions designed to, “remodel major care to ship higher worth for sufferers all through the healthcare system.”[2]

Of the 5 different cost fashions, the 2 Main Care First (“PCF”) cost fashions are risk-based/pay-for-performance cost choices designed to, “take a look at whether or not monetary danger and performance-based funds that reward major care practitioners and different clinicians for simply understood, actionable outcomes will cut back whole Medicare expenditures, protect or improve high quality of care, and enhance affected person well being outcomes.” Practitioners who elect to take part within the PCF cost fashions are obligated to make a five-year dedication to start on both January 1, 2021 or April 1, 2021, relying upon which PCF mannequin is chosen.

With the brand new yr quick approaching, it’s a good time to overview the varied options of the PCF fashions.

Tracks. The PCF fashions supply two completely different cost tracks — a Normal Monitor and a Significantly In poor health Inhabitants (“SIP”) Monitor. The Normal Monitor is for major care practices with superior major care capabilities which can be ready to simply accept elevated monetary danger. The SIP Monitor is for practices searching for to deal with excessive want, excessive danger sufferers who at present lack a major care practitioner or care coordination that particularly choose to take part within the cost mannequin possibility. Practices could take part in each tracks.

Eligibility. With the intention to be eligible to take part in both monitor, a participant should (i) have a apply that’s positioned in one of many 26 areas[3] the place the PCF possibility is being supplied by CMS and (ii) have earlier expertise with value-based cost preparations. The participant’s apply wants to incorporate major care practitioners who’re licensed in inner drugs, normal drugs, geriatric drugs, household drugs, and hospice and palliative drugs. As well as, the apply should meet sure information necessities, together with: (i) Use 2015 Version Licensed Digital Well being File Expertise (CEHRT); (ii) Use Software Programming Interface (API); and (iii) Connect with their regional well being data alternate (HIE). The apply should even have sure enumerated superior major care supply capabilities together with 24/7 entry to a practitioner or nurse name line and empanelment of sufferers to a practitioner or care crew.[4]

To take part within the Normal Monitor, major care providers should (i) account for not less than 70% of the practices’ collective billing based mostly on income and (ii) the apply should deal with not less than 125 Medicare beneficiaries yearly. To take part within the SIP Monitor, the apply solely wants to supply major care providers to 20 Medicare sufferers, and the apply doesn’t must have major care providers account for 70% of collective income. SIP practices have till 2022 to fulfill information necessities.

Reimbursement. PCF features a two-tiered cost construction that consists of (1) a Whole Main Care Fee and (2) a Efficiency Based mostly Adjustment.

Whole Main Care Fee: The Whole Main Care Fee (“TPCP”) is set based mostly on two sub-components: (i) a flat care go to payment, which incorporates telehealth and annual wellness exams, and (ii) knowledgeable population-based cost. The skilled population-based cost is paid on a quarterly, potential foundation based mostly on the variety of assigned sufferers. The speed is calculated by averaging the hierarchical situation classes (HCCs) scores of the taking part sufferers. The HCC scores put practices in one among 4 danger teams. There may be an adjustment mechanism to account for sufferers who obtain major care outdoors of the apply.

Efficiency Based mostly Adjustment: The Efficiency Based mostly Adjustment gives the potential for practices to extend their income by as much as 50% of their TPCP or lower income within the occasion of poor efficiency. The Efficiency Based mostly Adjustment considers two components: (i) regional efficiency and (ii) steady enchancment. To measure regional efficiency, the apply’s acute hospital utilization (AHU) charge is in comparison with an AHU minimal benchmark based mostly on the apply’s regional reference group. To measure steady enchancment, the apply’s AHU efficiency is in comparison with the apply’s efficiency for the earlier yr.[5]

High quality. CMS has additionally established sure measures so as to be certain that practices will not be decreasing high quality in an effort to scale back hospitalization. In 12 months 1, taking part practices must exceed the 50th percentile of a nationally constructed AHU charge. For Years 2-5, taking part practices must go a “High quality Gateway,” which shall be based mostly on 5 high quality measures whose information CMS will gather in 12 months 1. Failure to fulfill high quality benchmarks impacts the Efficiency Based mostly Adjustment.[6]

The appliance interval for practices making use of to start participation in Main Care First is now closed. Practices taking part within the Normal Monitor will start in January 2021 whereas practices taking part within the SIP Monitor will start in April 2021.[7]

Solely time will inform if the PCF fashions are profitable at decreasing Medicare spending and growing general high quality of affected person care. We shall be watching.

FOOTNOTES

[1] CMS Press Launch, April 22, 2019, “HHS NEWS: HHS To Ship Worth-Based mostly Transformation in Main Care.”

[2] Id.

[3] The areas are: Alaska (statewide), Arkansas (statewide), California (statewide), Colorado (statewide), Delaware (statewide), Florida (statewide), Larger Buffalo area (New York), Larger Kansas Metropolis area (Kansas and Missouri), Larger Philadelphia area (Pennsylvania), Hawaii (statewide), Louisiana (statewide), Maine (statewide), Massachusetts (statewide), Michigan (statewide), Montana (statewide), Nebraska (statewide), New Hampshire (statewide), New Jersey (statewide), North Dakota (statewide), North Hudson-Capital area (New York), Ohio and Northern Kentucky area (statewide in Ohio and partial state in Kentucky), Oklahoma (statewide), Oregon (statewide), Rhode Island (statewide), Tennessee (statewide), and Virginia (statewide).

[4] CMS webpage, “Main Care First Mannequin Choices.”

[5] Jim Thompson, MD and Amy Loriaux, Clever Medical Objects Webinar titled “What to find out about reimbursement below the Main Care First Act,” at 2:00 pm EST on October 28, 2020.

[6] Id.

[7] As described by CMS in its June 30, 2020 announcement, “CMS Innovation Middle Fashions COVID-19 Associated Changes,” the implementation date for the SIP Monitor was delayed to April 1, 2021 as a part of CMS’ efforts to accommodate the exigencies of the present public well being emergency.