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How DPC doctors could start seeing Medicare patients

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Direct primary care (DPC) physicians who see elderly patients may choose to participate in Medicare or may decide to opt out. The decision to accept Medicare for their basic primary care services has typically meant dealing with Medicare regulations that have precluded DPC practices from charging a membership fee for anything except “non-covered services.” As DPC Frontier explains, that requires carefully ensuring that each charge is “for a service that does not appear anywhere on Medicare’s schedule of services.”

A new initiative from the Center for Medicare and Medicaid Innovation (CMMI) may change the way DPC physicians are able to attend to and receive payment for their Medicare patients, a change that may make it more enticing to participate in Medicare. The Centers for Medicare and Medicaid Services (CMS) Primary Cares Initiative, scheduled to launch in January 2020, is designed to pay providers for outcomes rather than services.

The Primary Care First (PCF) models are focused on improving healthcare outcomes, reducing hospitalizations, and reducing the total cost of care. As CMS explains, PCF is “a set of voluntary five-year payment model options that reward value and quality by offering innovative payment model structures to support delivery of advanced primary care.”

Physicians participating in the PCF model may assume some financial risk but might also see additional revenue as a result. With the move away from payment for services, DPC physicians will be able to focus on their primary mission: improving the health of their patients as well as improving the doctor-patient relationship.

Under the Primary Cares Initiative, PCF providers “will be incentivized to deliver patient-centered care that reduces acute hospital utilization. Primary Care First is oriented around comprehensive primary care functions: (1) access and continuity; (2) care management; (3) comprehensiveness and coordination; (4) patient and caregiver engagement; and (5) planned care and population health.”

CMS states that PCF will provide “payment to practices through a simple payment structure, including:

  1. a payment mechanism that allows care to be driven by clinicians rather than administrative requirements and revenue cycle management;
  2. a population-based payment to provide more flexibility in the provision of patient care along with a flat primary care visit fee; and
  3. a performance based adjustment providing an upside of up to 50% of revenue as well as a small downside (10% of revenue) incentive to reduce costs and improve quality, assessed and paid quarterly.