Primary Care First: Opportunities and Challenges for Multipayer Collaboration

We were listening to an update on Primary Care First (PCF), the latest innovative payment and delivery model from the Center for Medicare and Medicaid Innovation (CMMI), when my colleague leaned across the table and whispered insistently, “I just don’t know how, but we are going to make this work. We have to!”

What struck me was that this seasoned regional nonprofit health insurance executive wasn’t wondering whether to jump into the risky fray of multipayer collaboration again, but how to jump in and succeed.

An Opportunity to Advance Primary Care Practice

Evidence that supports investment in multipayer primary care transformation—in which different insurers set a common set of standards and expectations in order to strengthen primary care is slowly—emerging. But it is not yet certain that current programs are proving their value by improving quality while lowering costs. Despite that ambiguity, CMMI is underscoring its commitment to large-scale innovation by expanding the size and scope of these initiatives with the introduction of the ambitious PCF.

Since 2011, CMMI has launched four national primary care programs, including the ongoing Comprehensive Primary Care Plus (CPC+) program, which the new initiative builds upon. A regional multipayer five-year program slated to begin in 26 regions in January 2021, PCF will reward participating primary care practices with additional revenue if they meet clear and timely outcomes; for the first time, the practices will also face some downside financial risk if they don’t meet those goals. CMMI will allow primary care practices to tailor their care delivery approach based on their unique patient population and resources. Practices will also enjoy fewer administrative burdens given that payment will be coordinated across regional payers.

Responsibility and Risk

Still, health care payment and delivery innovation of this magnitude involves a significant degree of responsibility and risk for both clinicians and payers. CMMI is expecting that the participating practices will have already achieved a high level of care delivery and financial capability. And payers, including Medicaid, that wish to be a part of the multipayer regional groups must be willing to devote time and resources to align their payment methodologies with CMS and with each other. Navigating the complex requirements of federal programs can be onerous and working with competitors, tricky.

Time to Apply

Applications are currently open to non-CPC+ practices in CPC+ regions, and to any practice in the newly designated PCF states, until January 22, 2020. (Currently participating CPC+ practices have to wait an additional year to apply.) Payers can apply between December 9, 2019 and March 13, 2020.

The Milbank Memorial Fund has long supported multipayer primary care transformation and will continue to do so as the PCF gets underway. We recognize that hurdles for participation are still in place. For example, interested Medicaid agencies need to apply to CMS for complicated and time-consuming waivers in order to join PCF. Yet there is no question that value-based payment needs to be in Medicaid’s arsenal given that it’s serving the state’s most vulnerable populations — and that Medicaid’s participation may make a state’s primary care transformation efforts more stable. To that end, Milbank’s Multipayer Primary Care Network will host an informational webinar about Medicaid participation in PCF in January in partnership with the PCF team at CMMI, the Center for Health Care Strategies, and experts at the Center for Medicaid and CHIP Services.

PCF implementation will look different in each state or region, and success is not guaranteed. But the enthusiasm for improving the way primary care is paid for and delivered, on the part of CMMI and many committed payers and practices nationwide, is solid. With growing evidence that multipayer initiatives lower costs and improve quality over the long term, alignment is essential despite its inherent challenges. We are in this together: no stakeholder can succeed in isolation.