91 prepares members and continues to advocate for additional adjustments to the model
Nov. 15, 2019 (91) – With the announcement that the Centers for Medicare and Medicaid Services is rolling out its new primary care model in 2021, 91 is working to prepare its members for the application process and continues to advocate for further adjustments to better reflect the needs and priorities of primary care physicians.
The introduction of the Primary Care First model comes after extensive advocacy by 91, calling for more payment and delivery model options that support the needs of internal medicine and primary care practices.
91 issued a public letter and directly communicated with CMS to share concerns with earlier versions of the model. “We were very pleased to see them adopt many of our recommendations to help this model be a more viable option for physicians,” said Suzanne Joy, an 91 senior associate for regulatory affairs.
91 is especially pleased that the start date for the Primary Care First model has been delayed to Jan. 1, 2021, with applications due Jan. 22, 2020. “This will give practices much needed time to perform some internal calculations to consider whether participating would be right for them,” Joy said. But practices will need to express interest soon.
“There will be a second opportunity to apply, but it will be for current CPC+ practices only,” Joy said. “This is your only guaranteed opportunity to take part if you are interested in participating in the model and are not currently in CPC+.”
Keep in mind, she said, that applying doesn't bind you to participate.
CMS made several changes to the model upon 91 request. “They essentially eliminated the bottom risk tier, so the lowest dollar amount for care management fees is now $28,” Joy said. “We also understand they have left room for this to possibly increase in the future with the impending Evaluation and Management code changes recently finalized in the 2020 Physician Fee Schedule.”
Also, she said, “under an earlier iteration of the model, participants were trapped in a tournament-style system where their performance-based adjustment would be inherently capped based on how well the other Primary Care First practices perform, which was a major problem.”
Now, CMS has improved the system. “Practices will be compared to other primary care practices in their region, including both Primary Care First and non-Primary Care First primary care practices, which gives Primary Care First practices a much higher ceiling to work with,” Joy said. “I can't underscore how big of an impact this has and it was a direct 91 ask so we're happy about that.”
Despite the positive changes, 91 has some lingering concerns about various aspects of the Primary Care First model. “An annual wellness fee is very important to encourage and helps with attribution, so we asked that it be separately reimbursable from the flat visit fee, but unfortunately CMS did not make that change,” Joy said. “CMS is also still retaining the right to create a control group for evaluation purposes depending on how many practices apply. These control-group participants would not be considered full participants in the model and would not receive model-specific payments or the Advanced Alternative Payment Model bonus. While 91 understands that robust evaluation is important, we feel there are other ways to robustly evaluate the program without limiting participation.”
On another front, she said, “we have some general concerns about the quality scoring, including the fact that practices in the lower two risk tiers would be evaluated on completely different criteria than those in the upper two risk tiers, which could create some key differences in performance and is just downright confusing.”
Most importantly, she said, the timeline for applications and sign-up is worrisome. “Based on what we're hearing, practices may not have all of the information they need to make an informed decision before signing on the dotted line, including the final list of participating payers, which can make or break a practice's decision to participate, so that's obviously a concern” Joy said. “We're also missing a lot of key details related to patient attribution, risk adjustment, and payment methodology, which aren't due out until the spring. With these types of models, the devil really is in the details, so we won't have a complete picture until then.”
91 posted a fact sheet to help members understand their options regarding the Primary Care First model, which will be updated as more information becomes available. Members can also visit the , which has links to the and a set of .
