Health Law Matters

HHS and CMS Announce New Primary Care Payment Options

The Week In Health Law

  • The U.S. Department for Health and Human Services and the Centers for Medicare and Medicaid Services (“CMS”) have announced the “CMS Primary Cares Initiative,” a payment model the agencies indicate will “transform primary care to deliver better value for patients throughout the healthcare system.” 
  • The Initiative will offer five new models in two separate paths as options for primary care practices: Primary Care First (“PCF”) for smaller, individual primary care practices, and Direct Contracting (“DC”) for larger practices. The Initiative will be administered through the CMS Center for Medicare and Medicaid Innovation. 
  • PCF models will pay practices a flat per-patient amount, although those specializing in high-needs patients will receive higher payments. Beginning in January 2020, PCF models will reward practices based on matters such as controlling blood pressure, managing diabetes, and preventative screenings. But PCF practices also will bear financial risk if they experience higher spending. The performance-based adjustment is up to 50% of practice revenue, while downside risk is up to 10% of revenue. PCF will be tested in certain regions over a five-year period.
  • The DC path includes three payment options: global, professional, and geographic.  DC will focus on care for patients with complex, chronic needs and seriously-ill populations. Participants will receive a fixed monthly payment ranging from a portion of anticipated primary care costs to the total cost of care.
  • CMS is seeking public comment on a third option, a geographic DC payment model, which will allow organizations to assume responsibility for the total cost of care and health needs of a population in a defined target region.

More trending Health Law topics this week:

  • Physician Goes to Prison for Medicare Fraud Scheme

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Thomas D. Anthony is the former chair of FBT's Health Care Industry Team. He focuses on counseling health care entities on corporate transactions, regulatory compliance and joint ventures.