Who is eligible to participate in Primary Care First?

Who is eligible to participate in Primary Care First?

This post is part of a series of posts that aim to educate independent primary care practices about CMS’ recently announced Primary Cares Initiative.

Click here to read our overview of Primary Care First.

As policy programs continue to center around value-based care, Elation is here to ensure that independent practices and innovative organizations like ACOs and IPAs are at the forefront of this new healthcare landscape. By keeping you informed, we’re committed to supporting small practices’ participating in programs that focus on prioritizing high-quality, patient-centered care.

The Centers for Medicare & Medicaid Services (CMS) Innovation Center is opening up applications for primary care practices that want to participate in the Primary Care First initiative beginning in January 2020. Primary care physicians must be willing to accept a certain amount of financial risk in exchange for the benefits of participation in Primary Care First. Those benefits include a reduced administrative burden, predictable monthly payments (replacing per-visit and per-service payments), and possible additional financial incentives for high quality healthcare outcomes.

Primary care practices located in 26 regions across the country will be eligible to participate in Primary Care First in 2020: Alaska (statewide), Arkansas (statewide), California (statewide), Colorado (statewide), Delaware (statewide), Florida (statewide), Greater Buffalo region (New York), Greater Kansas City region (Kansas and Missouri), Greater Philadelphia region (Pennsylvania), Hawaii (statewide), Louisiana (statewide), Maine (statewide), Massachusetts (statewide), Michigan (statewide), Montana (statewide), Nebraska (statewide), New Hampshire (statewide), New Jersey (statewide), North Dakota (statewide), North Hudson-Capital region (New York), Ohio and Northern Kentucky region (statewide in Ohio and partial state in Kentucky), Oklahoma (statewide), Oregon (statewide), Rhode Island (statewide), Tennessee (statewide), and Virginia (statewide).

In addition, CMS has mandated that primary care practices meet certain other requirements, including advanced primary care capabilities, in order to participate in Primary Care First. Primary care practices must:

  • Include primary care practitioners (MD, DO, CNS, NP, and PA), certified in internal medicine, general medicine, geriatric medicine, family medicine, and hospice and palliative medicine.
  • Provide primary care health services to a minimum of 125 attributed Medicare beneficiaries at a particular location.
  • Have primary care services account for at least 70% of the practices’ collective billing based on revenue. In the case of a multi-specialty practice, 70% of the practice’s eligible primary care practitioners’ combined revenue must come from primary care services.
  • Have experience with value-based payment arrangements or payments based on cost, quality, and/or utilization performance such as shared savings, performance-based incentive payments, and episode-based payments, and/or alternative to fee-for-service payments such as full or partial capitation.
  • Use 2015 Edition Certified Electronic Health Record Technology (CEHRT), support data exchange with other providers and health systems via Application Programming Interface (API), and connect to their regional health information exchange (HIE).
  • Attest via questions in the Practice Application to a limited set of advanced primary care delivery capabilities, such as 24/7 access to a practitioner or nurse call line and empanelment of patients to a practitioner or care team.

Those primary care practices that opt to participate in the Primary Care First – High Need Population model must demonstrate relevant capabilities and care experience in their application. These practices will have the option when they apply to agree to be attributed and furnish services to the Seriously Ill Population (SIP) patients that CMS identifies in their service area who express interest in the model.