• The Centers for Medicare and Medicaid Services (CMS) unveiled a set of five new Medicare alternative payment models that will test two capitation-based approaches for paying for primary care services. All five models are voluntary participation models.
• Two of the models will test a traditional monthly payment system while the other three models will test a “direct contracting” system.
• CMS anticipates as much as 25 percent of Medicare fee-for-service beneficiaries will be cared for under one of these new primary care models.

The Centers for Medicare and Medicaid Services (CMS) unveiled a set of five new Medicare alternative payment models that will test two capitation-based approaches for paying for primary care services. Two of the models will test a traditional monthly payment system while the other three models will test a “direct contracting” system.

All five models are voluntary participation models. They will be tested for five years before CMS decides if they should be expanded. CMS intends to begin paying participating providers under the models in January 2020.

The Primary Care First (PCF) and the Primary Care First – High Need Populations provide a monthly payment to participating primary care providers which can be adjusted to reward reduced spending and hospitalizations. The PCF – High Need Populations provides a higher payment to help participating providers care for more complex patient populations. Providers can earn incentives up to 50 percent of their Medicare revenue for avoiding hospitalizations, reducing costs and improving quality. However, participants can be at risk for up to 10 percent of revenue for higher spending and hospitalizations.

By assessing performance on three simple concepts, cost, hospitalizations and quality, the PCF model is designed for small practices with limited or no experience in risk-bearing payment models.

The three direct contracting models, the Direct Contracting – Professional; Direct Contracting – Global; and Direct Contracting – Geographic, are designed for larger practices. The Geographic iteration is a concept model for which CMS is requesting stakeholder feedback. CMS is not HBMA Washington Report – April 2019 12 Copyright 2019. HBMA. All rights reserved accepting participants in the DC – Geographic nor is it planning to implement this model at this time.

Under the three direct contracting models, participating providers will receive a fixed monthly payment that can range from a portion of anticipated primary care costs to the anticipated total cost of care.

The DC – Professional is a capitated payment with a 50 percent shared risk/savings between the provider and CMS. The DC – Global is a 100 percent risk/savings iteration of this capitated payment.

For the DC – Professional track, CMS will offer primary care capitation equal to seven percent of the total cost of care for enhanced primary care services, along with 50 percent shared savings/shared losses with CMS. For the DC – Global option, participants have the choice of Primary Care Capitation or Total Care Capitation, in addition to 100 percent shared savings/losses.

CMS anticipates as much as 25 percent of Medicare fee-for-service beneficiaries will be cared for under one of these new primary care models.

As always, ADVOCATE will keep you up to date on this and all issues impacting radiology as they become available.

Best regards,

Kirk Reinitz, CPA 

President