Primary Care-focused APM Checks AAFP Advocacy Boxes
New Model, Senate Testimony Coalesce Around Academy’s Policy Goals
June 8, 2023, News Staff — CMS’ Center for Medicare and Medicaid Innovation announced this morning it will launch a state-based, primary care-focused alternative payment model, Making Care Primary, in July 2024. Although the AAFP is still digging into the details, preliminary information from CMMI indicates the new model encompasses numerous Academy recommendations advancing value-based primary care.
And that’s not the only high-profile win the AAFP scored today: Barely an hour before CMMI’s announcement, Academy EVP and CEO Shawn Martin testified before the Senate Finance Committee, laying out how today’s growing wave of health care consolidation, combined with decades of underinvestment in primary care, has undermined access to and delivery of comprehensive, longitudinal primary care.
Highlighting Primary Care’s Role in Value-based Payment
Based on what is known about Making Care Primary to date, it’s clear that the Academy’s longstanding advocacy to bring primary care out from under the shadow of fee-for-service has commanded respect from the nation’s top regulators.
“While details of the model are still forthcoming, family physicians are pleased to see that many aspects of CMMI’s new model reflect several of the recommendations for value-based primary care that the AAFP has been sharing with CMMI for several years,” Martin said in a news release. “It’s important to recognize that these efforts reflect increased investment in primary care and value-based care, which ultimately enables practices to innovate and improve patient and population outcomes.”
The agency will pilot the multipayer model in eight states — Colorado, Massachusetts, Minnesota, New Jersey, New Mexico, New York, North Carolina and Washington — which have been chosen based on agreements with state Medicaid agencies regarding alignment around program principles and model dimensions that matter for physicians (e.g., quality measurement, moving from FFS to prospective payment, provision of learning resources) to ease the burden of participating. This and other aspects of the new model build on learnings gleaned from a number of previous transformation models, including Comprehensive Primary Care and Comprehensive Primary Care Plus.
Story Highlights
Incorporating Medicaid beneficiaries in APMs represents a significant step forward in advancing health equity by facilitating equitable access to high-quality primary care. Moreover, aligning models across payers and embedding equity as a shared aim independent of patient population can be expected to foster physician participation and resource practices more efficiently. That, in turn, helps ensure that all patients receive high-quality, affordable, patient-centered care.
In a nod to the AAFP’s longstanding position that payment rates must ensure that practices caring for high-risk patients are supported — not penalized — for providing added services needed to facilitate addressing social determinants of health, behavioral health concerns or environmental factors, CMMI has said that Making Care Primary payments will be risk-adjusted to reflect patients’ clinical and social needs in alignment with the Academy’s Guiding Principles for Value-based Payment.
CMMI’s model addresses another issue family medicine has for years worked to change — namely, that APM options suitable for small and independent practices that have no previous value-based payment experience are limited, leaving many such practices effectively stuck in FFS.
By acknowledging that primary care physicians need payment model options that span the value spectrum and are aligned across payers, including models that provide an on-ramp to participation and practice transformation, Making Care Primary promises to support and preserve independent primary care by providing the ability to gradually progress to higher levels of capitation. In addition, the model includes no downside risk and may feature a new primary care-focused patient-reported outcome measure.
Making Care Primary Tracks Aim to Build Practice Capabilities
The model includes three tracks that each focus on specific goals:
- Building Infrastructure: Participants work to establish a foundation for implementing advanced primary care services such as patient risk-stratification, data review, workflow development, chronic disease management, and SDOH screening and referral. Payment for primary care will remain FFS-based while CMS provides financial support to help participants develop care transformation infrastructure and build advanced care delivery capabilities. Participants begin earning financial rewards for improving patient health outcomes.
- Implementing Advanced Primary Care: Participants build on Track 1 requirements by partnering with social service professionals and specialists, implementing care management services, and screening for behavioral health conditions. Payment for primary care will shift to a 50/50 blend of prospective, population-based payments and FFS payments. CMS will continue some financial support for building advanced care delivery capabilities, even as participants are able to earn increased financial rewards for improving outcomes.
- Optimizing Care and Partnerships: Participants begin using quality improvement frameworks to optimize and improve workflows, address silos to improve care integration, develop social services and specialty care partnerships, and deepen connections to community resources. Payment for primary care will shift to fully prospective, population-based payment while CMS continues minimal financial support to sustain care delivery activities. Participants can earn even greater financial rewards for improving patient health outcomes.
Making Care Primary demonstrates CMMI’s recognition that meaningful practice transformation takes time, is dynamic in nature, and is characterized by considerable variations in quality, cost and utilization outcomes. The model’s 10-year timetable for fundamental primary care delivery and payment transformation allows the agency ample time to examine results and determine its impact on long-term sustainability of value-based payment for primary care.
The window to apply to participate in Making Care Primary is expected to open later this summer and will likely run through late fall. Further information on the model, including eligibility criteria, is available from CMS.