CMS Announces New Value-Based Primary Care Model for 2024: Making Care Primary

Jun 9

Post Written by Juliette Price, Chief Solutions Officer

A new value-based model from CMMI underscores continued federal priorities around health equity, health-related social needs, and alternative payment models for primary care providers in an effort to shore up the nation’s primary care system.

In CMS’ introduction of Making Care Primary, the role of primary care clinicians as the “first line of defense for prevention, screening, management of chronic conditions, and overall wellness” is centered as the reason why CMS is rolling out this model–reinvesting in the nation’s primary care system is a top priority and policy goal of this model.

Exactly what problems is this model seeking to solve? CMS points to a few things: first, that primary care has become far more complex to deliver in today’s world, citing a statistic that between 2000 to 2019, the percent of Medicare beneficiaries that receive care from 5 or more providers annually increased from 18 to 30 percent. Second, CMS points out that the COVID-19 pandemic had an outsized impact on primary care–driving patients towards telehealth options to keep individuals safe from in-person visits, and now some of those visits have never come back, leaving patients uncared for or under-surveilled, while others embraced digital options, which also strained providers to deliver care between both modalities. Third, primary care providers who were in value-based arrangements during the pandemic experienced the benefits of prospective payment in the form of more predictable cash flow at the practice–HSG itself has worked with providers who will attest that they were able to keep staff members on payroll due to these payments that were de-linked from Fee-For-Service reimbursement. Even though the mechanisms of value based payments have tremendous up-sides, CMS notes that less than half of primary care practices are engaged in any form of value-based payment. This runs against CMS’ goal of having 100% of Medicare beneficiaries and most Medicaid beneficiaries in accountable care relationships by 2030. Therefore, offering a model that targets primary care providers–especially those who have not been in any value based arrangements before–is a way for CMS to make progress against these goals.

On the whole, CMMI is looking to expand the access that Medicare beneficiaries have to “advanced primary care” through this model. To do so, CMMI proposes to help primary care providers build their internal infrastructure and help reduce provider reliance on Fee-For-Service payments. In addition, CMMI seeks to provide risk-adjusted enhanced service payments to allow providers to invest in care management, screen for health-related social needs, and integrate with specialty care providers.

Interestingly, this will be the first time CMMI directly involves Federally Qualified Health Centers (FQHCs) in an advanced primary care model. This comes amongst significant feedback from FQHCs that they are being left behind when it comes to value-based models. Due to their status, FQHCs will be placed in upside-risk only arrangements.

What are the Core Components of the Model?

The devil is always in the details when it comes to value-based payment models, and the details here are scarce until CMS releases the RFA (Request for Applications) later this summer. On the whole, it looks like this model will offer providers three tracks of payment options, some flexibilities in beneficiary enhancements and engagement options, a focus on health equity and health-related social needs activities, as well as care management and integration.

First, the care model of Making Care Primary relies heavily on the following three components:

Care Management: focusing on building/expanding a provider’s ability to offer care management and chronic condition self-management programs, specifically focused on chronic diseases like diabetes and hypertension and reducing total cost of care and emergency department utilization.
Care Integration: focusing on building stronger relationships with specialty care providers, especially as it relates to behavioral health.
Community Connection: focusing on identifying health-related social needs and connecting patients to social care providers in the community who can provide relevant services.

Next, the financial model breaks itself into three progressive tracks, designed to give providers choice and move them towards prospective payments as it relates to their previous experience in value-based arrangements. CMS also notes that providers will accept greater accountability for quality as they advance amongst the tracks.

Track 1: Named “Building Infrastructure,” this track is carved out for the provider who hasn’t had any/much experience in value-based care. Participants will focus on gaining experience in risk-stratification of their patient population, building out workflows, identifying staff for chronic disease management, and conducting health-related social needs screenings and referrals. This track will continue to pay providers under Fee-For-Service billing, with CMS providing upfront infrastructure payment. Providers in this track can earn financial rewards for improving patient health outcomes.
Track 2: “Implementing Advanced Primary Care” seems to imply that the provider has had some experience in building the infrastructure needed for at-risk contracting and providers in this track will layer on deeper relationships with social care providers, implementing care management services, and screening all patients for behavioral health conditions. Payment in this track will shift to a 50/50 blend of Fee-For-Service and prospective payment. CMS continues to provide “financial support” on top of these payments, and providers are able to earn increased financial performance-based payments, but will see a reduction in care management payments. Importantly, in this track providers will be able to implement new e-consult codes to support electronic consultations or interprofessional consults between primary care providers and speciality providers–this is a new payment concept and clearly seeks to pay for better coordination amongst providers.
Track 3: “Optimizing Care and Partnerships” seems to be where the most advanced providers will fall, building on the activities outlined in Tracks 1 & 2 by additionally engaging in quality improvement work, improving workflows, creating care integration, and deepening community partnerships. Payments in Track 3 shift to a fully prospective model, still with some “financial support” from CMS, though expect to see reduced care management payments, and a greater opportunity for performance-based payments. New to track 3 will be an ambulatory co-management payment for patients with either new diagnoses or conditions that require coordination between a primary care provider and a specialty provider.

Lastly, health equity plays a big role in this model, unsurprising if you’ve followed CMS’s health equity strategy and investments. Included in this model are:

Payments adjusted for risk by both clinical data and social risk data (let’s hope CMMI doesn’t replicate the ADI issues it created in ACO REACH as it looks to broaden the use of social risk adjustment).
Health equity plans created by the participating providers that outline how they will identify and reduce disparities (required).
Providers will have to commit to screening patients for health-related social needs and implement referrals to the appropriate social care providers (required).
Providers will have the option to reduce cost-sharing for patients who would benefit from such interventions.
CMS is committed to measuring the percentage of patients who get the above-mentioned health-related social needs screening and referrals in order to evaluate health disparities in participating communities.

Who can participate in the model?

Primary care providers who operate at least 51% of their physical primary care locations in Colorado, Massachusetts, Minnesota, New Mexico, New Jersey, New York, North Carolina, and Washington are part of the lucky group who will be able to participate in this model. CMS says they selected these states after a review of key attributes, including current Innovation Center footprint, how similar the Medicare population in these states is to the rest of the Medicare population, and the ability to align with the respective state Medicaid agency. On that last point, you will notice no red states were included on this list, only states with currently-held Democratic governorships.

CMMI is opening the door for smaller providers to participate in this model, with the minimum number of attributed Medicare beneficiaries sitting at a wildly low 125 beneficiaries. This addresses some criticisms about other CMMI models – consider ACO REACH - where the minimum number of beneficiaries for new entrant ACOs was set at 1,000.

Who can’t participate? Rural Health Clinics (this is a specific CMS designation), concierge practices, practices currently in the Primary Care First model, practices participating in the ACO REACH model, and grandfathered Tribal FQHCs are not eligible. Interestingly, CMS will allow practices that are currently in the Medicare Shared Savings Program (MSSP) to participate in both models for the first 6 months; acknowledging a timing discrepancy they’ve created by launching this model mid-year in 2024. After Jan 1, 2025, providers will have to choose between MSSP and this new model.

What’s the overlap with Medicaid?

To be honest, CMS is pretty nondescript about what they hope the Medicaid-Medicare collaboration in this model will be. While they reference “multi-payer alignment” there are no other details on how they expect Medicaid agencies to collaborate with CMMI or participating providers on this model. Perhaps we will see more details about this in the RFA or we’ll see state-specific collaborations bloom.

What Does This Model Tell us About the Direction CMS is Taking Primary Care?

In a long-form blog article published on the same day as the model release, CMS/CMMI team members opine not just on the Making Care Primary model, but on what CMS sees as key problems in primary care and what they might do in the near future to further support their vision of primary care in the future.

Fiscally, it seems like CMS is hinting towards other new primary-care models that may be offered to or specifically tailored to primary care practices that are involved in the Medicare Shared Savings Program (MSSP). This would allow CMMI to test providing increased investments through prospective payments, something that isn’t a part of the MSSP program today. Additionally, CMMI hints that it is working on a state-based model that would be based around total-cost-of-care approaches in an attempt to move spending away from acute care into primary care.

On the issue of health equity, it is clear that CMS has been disappointed that alternative payment model participation has an overrepresentation of White beneficiaries, as compared to Black and Hispanic beneficiaries. In order to see more diversity in beneficiary participation, CMS points towards Maryland’s Total Cost of Care Model’s Maryland Primary Care Program, which included a HEAT payment (Health Equity Advancement Resource and Transformation); targeted payments to providers for patients with high social risk.

Lastly, there’s a lot of talk of payer alignment in the blog post from CMS. Clearly, they are wanting there to be Medicaid-Medicare alignment; what CMS is lacking is a clear path forward (at least in this piece) for how they plan to do so. The only hint CMS lays in this direction is a brief passing mention towards a “state-based total cost of care model” that would have a “major” emphasis on primary care with “Medicare fee-for-service supporting Medicaid advanced primary care efforts.”

What’s Next?

Next, we wait. The RFA (Request for Applications) will be a large, CMS-jargon-filled document that will truly provide the details providers will need to evaluate whether this program is a good fit for their patient population and strategic goals as an organization.

Be warned; the last time CMMI released an RFA, organizations were given just 7 weeks to decide if the model was right for them, compose a proficient application, and submit all documentation to CMS. CMMI identifies “later this summer” as their timeline, so go ahead and move up your summer pool party to make time for this late summer arrival which is sure to cause a…splash.

Are you interested in learning more about the Making Care Primary model or how to apply for a CMMI value based model? HSG routinely leads clients through successful CMMI program applications. Reach out to learn more about how we can help your organization be successful in this or other CMMI programs.

About the Author: Juliette Price is the Chief Solutions Officer at Helgerson Solutions Group. Follow her on Twitter and connect with her on LinkedIn.