One of the questions surrounding the Center for Medicare and Medicaid Innovation’s ambitious Primary Care First (PCF) initiative is how many commercial insurers would participate in the multi-payer program. CMS recently released a list of participants, and it appears that payer partners have signed up in every region except Hawaii.
In PCF, CMS is encouraging other payers — including Medicare Advantage plans, commercial health insurers (including their self-insured business), Medicaid managed care plans (to the extent permitted and consistent with the Medicaid managed care plan’s contract with the state), and state Medicaid agencies —to offer participating practices similar financial support and incentives. CMS believes that value-based payment is far more impactful when it applies across the majority of a practice’s patient population, rather than its Medicare Fee-For-Service (FFS) population alone. It adds that payers working together to offer aligned payment models may be more likely to realize quality improvements and cost reductions.
Starting in 2021, PCF model options will be offered in 26 regions. The practices in regions that can participate starting in 2021 include practices in the existing 18 CPC+ regions as well as eight additional regions (Alaska, California, Florida, New Hampshire, Virginia, Delaware, Maine, and Massachusetts).
Here are a few examples of multi-payer partners. In the Kansas City region, Humana and Blue Cross and Blue Shield of Kansas City are participating. In Louisiana, Aetna, AmeriHealth Caritas Louisiana, Humana and Louisiana Medicaid have signaled they will join CMS.
PCF takes a regionally based, multi-payer approach to care delivery and payment. CMS has said that one goal is to increase flexibility for primary care, providing participating practitioners with the freedom to innovate their care delivery approach based on their patient population and resources. Primary Care First rewards participants with additional revenue for taking on limited risk based on particular outcomes. Measures include a patient experience-of-care survey, controlling high blood pressure, diabetes hemoglobin A1c control, colorectal cancer screening, and advance care planning.
In a December 2019 blog post, Lisa Dulsky Watkins, M.D., of the Milbank Memorial Fund, explained that “evidence that supports investment in multi-payer primary care transformation—in which different insurers set a common set of standards and expectations in order to strengthen primary care — is slowly emerging. But it is not yet certain that current programs are proving their value by improving quality while lowering costs. Despite that ambiguity, CMMI is underscoring its commitment to large-scale innovation by expanding the size and scope of these initiatives with the introduction of the ambitious PCF.”
Dulsky Watkins also noted that PCF implementation will look different in each state or region, and success is not guaranteed. “But the enthusiasm for improving the way primary care is paid for and delivered, on the part of CMMI and many committed payers and practices nationwide, is solid. With growing evidence that multi-payer initiatives lower costs and improve quality over the long term, alignment is essential despite its inherent challenges. We are in this together: no stakeholder can succeed in isolation.”
There are some technology requirements for participating practices. For instance, Primary Care First practices will be expected to support data exchange with other providers and health systems via application programming interface (API) to eliminate the use of faxes for health information exchange (HIE). Connecting to a regional, national, or vendor-mediated HIE using an API would meet both the API data exchange and HIE requirements.
