ALL NEW: CMS PRIMARY CARE FIRST INITIATIVE

READY-OR-NOT: CMS announces Value-Based Primary Care with Downside Risk for 2020. Will you be ready to function, survive and thrive in this model?

Primary Care First will focus on advanced primary care practices deemed ready to assume financial risk in exchange for reduced administrative burdens and performance-based payments. It will also feature a second payment model option, targeted on advanced primary care practices, including providers whose Medicare participating clinicians who typically provide hospice or palliative care services, to assume management of high-need, seriously-ill patients who currently lack a primary care practitioner and/or effective care coordination — referred to under the model as the “Seriously Ill Populations” (SIPs).

KEY TAKEAWAYS

? January 2020 start*

? Aim to reduce hospitalizations

? Aim to reduce overall cost of care

? Pay-for-Performance (P4P) (VBP)

? Voluntary patient opt-in

? Doctors compete for practice loyalty /enrollment/panel growth

? Downside risk 10%

? Upside potential of 50% based on risk-adjusted hospitalizations

? Billing and collections expense reduction - global payment /month

? Prioritizes the doctor-patient relationship

? Enhanced care for SIPs (complex chronic needs / high need, sicker) 

? Reduced administrative burden, and 

? Focusing financial rewards on improved health outcomes through comprehensive care management, don’t worry they’ll have other paperwork /reporting to complete!

WHERE?

*Primary Care First Model Options will be offered in 26 regions for a 2020 start date:

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).

HOW TO PREPARE

? Branding work / re-branding to establish messaging, theme, targeting of ideal patients to choose you

? “Product” creation” vs “appointments”, “prescriptions, and ”tests”

? Think “concierge medicine product development paid by Medicare”

? Patient acquisition costs may outweigh services delivery cost, at first

? Start re-evaluating your key consulting specialists for “alignment” to new objecitves and key results (OKRs) targeted.

? You’ll need a prepared narrative to inform and influence patient behavior, commitment along with contracts for care (clinical care pathways/ patient accountability)

? New patient intake visit to conduct a situation assessment (H&P, ROS, Meds List, Chronic disease management (CDM) review and then as the "plan" (S-O-A-P), to set and inform objectives and key results targeted for each patient in your practice? (Personalized /precision medicine)

? Integrate dietitians, nurse educators, social workers, psych, consulting pharmacists, etc. (seamless continuum of care that leverages a panel of specially-chosen relevant providers)

? How will you manage non-compliant patients? CMS has already cited its rebuke-in-advance for cherry picking.

? Results-oriented social gamification (e.g., “winner’s circle”, book clubs, walking/activity groups, progress charts, badges, etc.) people like to win at something, even if it is only baby-steps in progress, especially in the Medicare demographic. They view it as hope, a goal, an achievement and bragging rights at the restaurant on Friday nights with friends and bridge club, book club, etc. Others who value this bragging right will seek out providers who offer this. One is more than none. Docs who don't do this will remain in commodity category and just collect patients of mixed risk and mixed, uncontrolled outcomes, while doctors with a branding differentiator will attract more patients and will need to have a way to filter out the ones who will not willingly "buy in" and commit to wellness and prevention and CDM or the familiar tendency to head to the ED after hours.

3 DIRECT CONTRACT MODELS for IPAs, PHOs, ACOs, MA Plans and Managed Medicaid

There will be three Direct Contracting payment options: Global, Professional, and Geographic. To be eligible you must demonstrate experience with financial risk and serve larger patient populations. They have this model in mind for IPAs, PHOs, ACOs, Medicare Advantage plans, and Medicaid managed care organizations.

The Direct Contracting participants will get a fixed monthly payment that can range from a portion of anticipated primary care costs to the total cost of care. Participants in the global option will bear full financial risk, while those in the professional payment model will share risk with CMS.

The Direct Contracting payments are intended to support a competitive delivery system that rewards organizations offering greater efficiencies and better care.

The payment model options include a focus on care for SIPs with complex, chronic needs, as well as a voluntary alignment option that allows beneficiaries to align with the health care provider of their choosing. Individual Physician, Practice and Organizational branding, messaging and culture will be of paramount importance in this model as well. While this was always important in the success of shared- and full-risk integrated and aligned groups, it will be more important in this initiative because it will be the differentiator that steers "ideal patients" in by relevant branded, targeted messages that resonate organically with the patients most likely to agree to be managed through more personalized medicine goals and results.

... a hybrid of concierge or direct pay membership practice, with the freedom to practice personalized medicine and be the patients' chosen medical "home" paid, on a value over volume basis, by Medicare.

These options will provide physician participants a range of financial risk arrangements while providing a more predictable revenue stream and reducing healthcare provider burdens commensurate with level of financial risk. Think: a hybrid of concierge or direct pay membership, with the freedom to practice personalized medicine, paid for on a value over volume basis by Medicare.

The professional option offers providers the opportunity to share 50% of the savings and the losses on risk-adjusted total cost of care. Providers in this option will receive predictable, monthly payments for enhanced primary care services. They will be able to manage the patient's care their way - in person, at home, on the phone, via SMS, via synchronous or asynchronous telemedicine, by carrier pigeon or whatever they like as long as high quality and value are the result. This is a triple header in the world series of physician branding, in my professional opinion. It takes what physicians have been running towards in concierge medicine and direct primary care - the freedom to enjoy practicing medicine without interference and pigeon-holed into face-to-face, E/M-constrained billing for services. But it does it through PBPM (a variation of PMPM, where the b = beneficiaries of the Medicare program) whether the patient presents for an in-person office visit or not each month. So those who could not sign up for your concierge membership practice will now be able to afford to enjoy the benefits of your personalized medicine program and product, paid by Medicare, without having to bill for each visit and hope you'll get paid timely and without denied claims and appeals that require follow up.

This is a triple header in the world series of physician branding, in my professional opinion. It takes what physicians have been running towards in concierge medicine and direct primary care - the freedom to enjoy practicing medicine without interference and pigeon-holed into face-to-face, E/M-constrained billing for services.

The global option allows providers to take full 100% accountability for savings and losses. Both the global and professional models will launch in January 2020, with applications reviewed in June 2019.

The geographic option will allow organizations the opportunity to assume responsibility for the total cost of care and health needs of a population in a defined target region, and is expected to launch in January 2021. This provides unprecedented ability for local organizations (IPA, PHO, ACO and maybe something new such as "super groups") to negotiate better rates than Medicare does today, take responsibility for outcomes and provide benefits that work for the local communities' needs. I see this expanding over time to specialty super groups such as pain management, orthopedics, cardiology, gastroenterology, and oncology if the model works.

Practices that choose to care for seriously ill patients will be required to clinically stabilize the patient, and all payment models include enhancements to encourage provider participation for that population.

11 MILLION LIVES

The five payment options could provide better alignment for more than 25% of all Medicare fee-for-service beneficiaries—nearly 11 million people— including the 5 million beneficiaries in the Direct Contracting payment model options.

Primary care services amount to only 2% to 3% of Medicare program spend, and primary care providers can influence downstream costs, but the system has been broken for so long that people now run straight to specialists and skip over primary care and no longer really value relationships with PCPs.

PCPs will need to rebrand their specialty. They will also need to create a professional brand for their individual private practice in terms of brand messaging, "product" creation for personalized medicine, positioning in the patients' minds, reputation, marketing and brand messaging and relevance if they hope to attract the ideal patients to make this model work for them. This requires a little investment but the investment is likely to return an excellent ROI in terms of bonus payments, clinical autonomy, patient outcomes and the delight of practicing medicine your way without interference or payment constraints for the kind of medicine you want to practice. Want to see the patient twice in a day, no problem. Want to call them at home and check on them? No problem. Want to read a two-finger ECG that they do at home four times in a day, no problem. Want to stop by the house and do a house call just to be sure? Not an issue. That's what I mean by "product creation."

You'll get paid by the number of patients you sign up. Sign up the most ideal candidates for this program with brand messaging and product design. Run the practice your way. Offer the services you want to offer. Do what it takes to keep them out of the hospital, out of the ED, and produce value and quality outcomes and you will be golden. This is an entire mindset redesign for primary care, not just a reimbursement redesign.

Those who fail with it will fail because they attracted large numbers of the wrong patients who were wrong for this program, don't follow personalized medical advice, are non-compliant with medication and care management, don't keep appointments, and fail to stop smoking, drinking, won't stay active, won't eat right, and continue to maintain unhealthy habits. That's 100% brand message related. If all you care about is enrolling volumes of patients regardless of risk, you will not like this program. If you don't redesign your practice to create a differentiated product, you will fail in this model.

CMS projects that 25% of primary care practitioners will be drawn into the initiative, which would also create opportunities to coordinate care for Medicaid dual eligibles. The product creation for a personalized medicine program for dual eligibles will be different than for others grouped into different social determinant of health categories. You will have to choose where your passion is strongest and commit to a product design. Try to homogenize it and I don't believe you'll be able to thrive.

Where I believe CMS has its wires crossed is in the statement that revenue cycle and billing will go away. Nobody in this day and age other than a dyed-in-the-wool gerontologist is going to have a practice limited to only Medicare patients and providers won't be allowed to select a subset of patients. Patients will choose the providers. Get the ideal patients to choose your product and practice organically and you'll still have cherry picking by self-selection in a way that Medicare won't punish. That's where a branding expert can bring the most value. A true branding expert will design the product, the message, and work with you to identify the linkage between your style and philosophy of personalized medicine and the right ideal patients who will benefit most from it. They won't sell you a one-size-fits-all cookie cutter solution. The number of consultants ready to do this for you is extremely limited in the USA. There's too much for a johnny-come-lately that doesn't understand capitation and primary care product design to learn overnight.

I also see the eventual irrelevance of Medicare Advantage plans and contracts if they too, refuse to rebrand and redesign their approach, their product, and their contract offers to PCPs. IMHO, it couldn't happen to a more deserving bunch of payers and their executives.

ARE YOU READY

Timelines

CMS anticipates releasing a Request for Application in spring 2019 for the first cohort of payers and practices. Practices and payers will begin participation in the model in January 2020.

Another round of Primary Care First applications is expected to be accepted during 2020. Any practices accepted to participate in Primary Care First during 2020 would begin participation in the model in January 2021.

The SIP payment model option will also follow this timeline.

Additional eligibility details will be available in the forthcoming Primary Care First Request for Applications (RFA) and Solicitation for Payer Partnership. (Not yet released.)

Information for Interested Stakeholders

• Tuesday, April 30, 12 p.m. EDT  Register here
• Tuesday, April 30, 3 p.m. EDT  Register here
• Thursday, May 16, 12 p.m. EDT  Register here
• Thursday, May 16, 3 p.m. EDT  Register here
• For questions about the model or solicitation process, please email [email protected] or call 1-833-226-7278.

Please call on me if I can be of assistance. I offer a complimentary 15-minute chat to any physician who is interested to explore the possibilities. (800) 727.4160 and be sure to download the checklist I shared above so you can tick off the items you already have prepared.