CMS Primary Cares to Include New Track for High-Cost Patients

The U.S. Centers for Medicare & Medicaid Services (CMS) is planning to implement a payment model within its Primary Cares Initiative that would address the needs of patients associated with the highest health care costs. Few details about the model are available as the agency has not yet publicly announced the program.

The program would fall under the direct contracting component of the Primary Cares Initiative, which CMS unveiled in April. Primary Cares consists of five payment models, three associated with direct contracting as well as the Primary Care First model and the Seriously Ill Population Model. CMS has indicated that hospices and palliative care providers that meet certain eligibility criteria will be able to participate in the program.

Primary Cares will launch in January, initially in 26 regions throughout the United States. The program is designed to control costs, reduce avoidable hospitalizations and improve care coordination.

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“The [Center for Medicare & Medicaid Innovation] are talking about having a complex direct contracting track, and it would identify high-cost patients which would be like [patients who are eligible for CMS’ Independence at Home demonstration project] that would have a primary care capitation and greater potential shared savings than there is in the Primary Care First program,” Tom Cornwell, M.D., executive officer for the Home Centered Care Institute, said in a session at the Coalition to Transform Advanced Care (C-TAC) National Summit in Minneapolis.

Under the Primary Cares Direct Contracting option CMS designed three voluntary payment model options intended to reduce dollars spent on health care while promoting quality improvement. The agency has called the models “the next evolution of risk-sharing arrangements.”

Three tracks are available through direct contracting: Professional, Global, and Geographic.

In the Professional track, health care providers would bear 50% of the risk of shared savings or losses on the total cost of care and receive a capitated risk-adjusted monthly payment equal to 7% of the total cost of care.

Participants in the Global track would bear 100% of the risk and will be able to choose between a primary care capitation or a total care capitation model. Participants in the Geographic program would also bear 100% of the risk for eligible patients in a target region. CMS would select these providers via a competitive application process and would provide CMS with a specified discount off the total cost of care.

Details of the risk sharing and payment process for the as-of-yet unannounced fourth track designed for the patients with the highest cost of care are not yet available.

To participate in the direct contracting models, a health care provider must have at least 5,000 eligible Medicare fee-for-service beneficiaries. However, the forthcoming model is expected to open the door for smaller organizations that do not meet that threshold.

“The big difference is that it would be a much smaller number than the 5,000 patients that you would need under direct contracting,” Cornwell said. “They haven’t said the number, and part of this is to include home-based primary care and perhaps home-based palliative care but to allow smaller organizations to really make a difference with these patients.”

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