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Pathways to Success and Primary Care First

Pathways to Success and Primary Care First: Ushering in a New Era in Healthcare

Pathways to Success is a bold step towards quality healthcare at a lower cost through competition and beneficiary engagement. The rule strikes a balance between encouraging participation in the ACO program and advancing the transition to value, ultimately protecting taxpayers and patients. Medicare can no longer afford to support programs with weak incentives that do not deliver value. As we structure new payment arrangements, the impact on the overall market will be top of mind.

– CMS Administrator – Seema Verma

Almost ten years ago, accountable care organizations (ACOs) were added as a permanent part of Medicare due to the Affordable Care Act (ACA). As of last year, there were a total of 561 Medicare ACOs serving more than 10 million beneficiaries. More than 377,000 providers provide care for these beneficiaries through the ACO model.

Though the ACO program is the fastest growing in the history of Medicare, it has endured multiple changes. This past December, the Centers for Medicare & Medicaid Services (CMS) finalized an overhaul to Medicare’s value-based payment program, the Shared Savings Program (MSSP). The changes are designed to save approximately $3 billion over ten years by prompting Medicare ACOs to more quickly adopt two-sided risk models and therefore assume downside financial risk sooner.

As you already know the new program is called “Pathways to Success.” It eliminates the three MSSP model tracks and replaces them with the BASIC and ENHANCED tracks through which qualified ACOs must participate for no less than five years. Also, it’s designed to accommodate the following five goals: accountability, competition, engagement, integrity and quality. 

Key Changes

What does this mean for you? Whether or not your practice plans to participate in Pathways to Success, it’s important to know that the new ACO criteria will take effect on July 1. In this blog, we’re going to highlight some of the primary changes the new program introduced:

  • Decreases the time period from six years to two in which new ACOs can continue in an upside-only track.
  • Decreases the time period from six years to three in which new, low-revenue ACOs can stay in one.
  • Expands coverage of high-quality telehealth services.
  • Offers increase flexibility in choice of assignment methodology.
  • Decreases the shared savings rates for upside-only ACOs from 50 to 40 percent.
  • Expands the three-day rule waiver eligibility for skilled nursing facilities.

Primary Care Payment Models

To build on these changes, CMS created its Primary Care Initiative. It’s comprised of a new set of voluntary payment models focused on supporting care for patients who experience chronic conditions or a serious illness. If you work in a primary care practice, you may qualify to participate in one of these five payment options offered in 26 regions beginning next year:

  • Primary Care First
  • Primary Care First – High Need Populations
  • Direct Contracting – Global
  • Direct Contracting – Professional
  • Direct Contracting – Geographic

According to CMS, Primary Care First aims to achieve the following goals:

  • Improve quality and patient experience of care and reduce expenditures.
  • Address the need to preserve and strengthen primary care and support serious illness care services for Medicare beneficiaries.
  • Create a seamless continuum of care and accommodates a continuum of interested providers.
  • Focus on advanced primary care practices ready to assume financial risk in exchange for reduced administrative burdens and performance-based payments.
  • Encourage advanced primary care practices, including providers whose clinicians are enrolled in Medicare who typically provide hospice or palliative care services, to take responsibility for high need, seriously ill beneficiaries who currently lack a primary care practitioner and/or effective care coordination.
  • Prioritize patients by emphasizing the doctor-patient relationship by reducing administrative burdens so practitioners can spend more time with patients.

CMS offers a table outlining the differences between Primary Care First and the Comprehensive Primary Care Plus (CPC+) model Tracks 1 and 2. They also hosted a webinar with more specifics on the model.

If you have any questions on Pathways to Success, Primary Care First or any other recent healthcare industry changes, please contact us to learn more.