Primary Care First: Why CMS’ Latest Program Truly Matters

The Centers for Medicaid and Medicare Services (CMS) released yet another voluntary payment model intended on restructuring financial reimbursement for primary care services. At face value, Primary Care First furthers many of the underlying concepts utilized in CPC+ by generally offering upfront Per-Member-Per-Month (PMPM) payments to providers while theoretically undercutting the financial pressure for primary care physicians to push volume of appointments over meaningful time spent with patients. Primary Care First intends to upend market realities that straightforward Fee-For-Service reimbursement pressures put on providers to drive focus towards patient outcomes.

Just another CMS pilot? Maybe. It’s worth looking into this long stream of programs and initiatives CMS has unveiled aimed at re-prioritizing primary care, to clear up time for patients with complex chronic ailments. This simultaneous effort to increase patient health outcomes and reduce total costs of care may seem like just another theoretic framework doomed, waiting to face harsh practical realities to an untrained eye.  Though this multiprong effort intending to liberate a primary care office from the many inefficient entanglements’ providers face, simply trying to get paid for providing care, there is a more impactful lesson here. So, what makes Primary Care First different than any other lofty so-called “Re-design”? Nothing.

Nothing except for a potentially brand new medical framework to prove your ability to offer effective care coordination that actually reduces readmissions, unnecessary ED utilization, and simply shows your personalized care plans works better for your patients than your competitor down the street. Nothing except for the capability to pivot PMPM success from CMS to your local employer and payors, with data, infrastructure, and legal means to do so. Nothing except for a temporary breath of financial fresh air to contemplate your own practices to see how you can meet patients on their terms, rather than in the terms of a Medicare Fee Schedule. Nothing except another source of profitable information your Clinical Integration Network can bring to the negotiating table. How so?

In order to change our current circumstances, we need to change the conversation. So, how can we change the conversation? Easy, develop something new to talk about, that is worth talking about, and then talk about it, a lot.

Something new to conversate with your local self-insured employer groups may be your recent successes in reducing avoidable admissions amongst your highest acuity patients. Something new to conversate with a large local employer may be your home-grown lower-back pain “clinic” that you integrated into your practice that created a pathway toward therapeutic rather than surgical care, when appropriate.

See a trend here?

Something new to conversate with your regional Medicare Advantage payors may be your successful annual wellness visit in which an NP captures over 80% of your patients on a yearly basis, funneling them to their PCP when necessary with a practical team-based care model. They’d certainly be interested in hearing how you developed a pathway to document HCC coding for 80% of your eligible patients. The thinking is simple, do not undervalue how swiftly you can position recent action into conversation, and bring that conversation to those that need it most. With a bit of disciplined strategic discussion and transparent action, primary care practices are perfectly positioned to dovetail any population health success in quality, clinical outcomes, and financial savings with CMS to interested parties down the street. Those who struggle to see this, will likely continue to face new disrupting competitors showing up unannounced with proven evidence at succeeding in reducing non-value adding health costs by providing technologically-advanced personalized team-based care that patients, employers, and providers all desire.

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