CMS has issued its first evaluation report for Primary Care First . The report offers a window into: key attributes of advanced primary care practices; strategies for lowering costs and reducing hospitalizations; and new strategies that signal practice transformation. Future PCF program evaluations will include which practice implementations worked and how they improved quality. In the meantime, even if your medical group is not a PCF participant, you can glean insight into what CMS is looking for as it evolves its Alternative Payment Models and how practices committed to value-based care are prioritizing and evolving their practice transformation strategies. First, some background on PCF. PCF: Focus areas, risk models and payments PCF is designed to improve care quality and patient experience, increase access to advanced primary care services and reduce expenditures. PCF builds upon CMS’s Comprehensive Primary Care Initiative (CPC Classic) and Comprehensive Primary Care Plus by adding...

In this edition of DataGen Insights, we look at how alternative payment model participants can ensure their processes and workflows are optimally set up for success. To help, DataGen listed the top three strategies all providers participating in APMs can employ and created a handy checklist to enable maximum returns and reduce financial risk. Please explore our website to learn more about our  products and services .  Download DataGen Insights today .  We hope you enjoy!

Are you up to date with the latest on alternative payment models?  This summer, catch up on all that you might have missed! Check out this list of must-reads from the last few months on APMs like Primary Care First, Kidney Care Choices, and more. Alternative Payment Models (General) Top challenges providers face in alternative payment models [Physician’s Practice] What to expect from CMS’ second decade of APM programs Primary Care First Start the year off right: DataGen answers your Primary Care First questions Three Steps to Successfully Participate in Primary Care First INFOGRAPHIC: 3 Strategies for PCF Success Why you must consider leakage for Primary Care First Kidney Care Choices Crucial rules and deadline guidance for Kidney Care Choices INFOGRAPHIC: 3 Strategies for KCC Success Critical Tools for Kidney Care Choices Success Oncology Care Model Lessons Learned from the Oncology Care Model If you have any questions or would...

Patients' primary care visits outside of their attributed primary care office, also called “leaked” patient visits, can have unintended consequences for Primary Care First participants. Beginning July 2022, PCF Cohort 1 will face a reduction in population-based payments based on their leakage rate. The payment adjustment will be based on their 2021 claims data and will roll forward quarterly. To calculate your leakage rate, divide the number of qualifying visits and services your attributed beneficiaries have made to care centers outside of your practice (for example, visits to urgent care centers) by the total number of qualifying visits and services your attributed beneficiaries have made. Calculating primary care leakage with claims data alone comes with some unintended challenges. Unfortunately, some circumstances can unfairly and negatively impact a practice’s leakage rate: Nuances classifying care delivered by provider team members: It’s di...

The 2022 Primary Care First performance year is underway, does your practice have the necessary steps in place to maximize returns and avoid negative payment adjustments? Participating in the Primary Care First model offers the opportunity to enhance patient care and reimbursement, but it also comes with risk. Practices face negative payment adjustments if they fail to meet certain utilization and quality thresholds. Learn more about the three strategies you can employ for PCF success in our new infographic, and access a checklist of all the steps you can take to enhance outcomes, track requirements, and continuously measure performance.

There is renewed emphasis on advancing primary care. Primary care serves as the front door to the overall healthcare system, and early and accurate diagnosis can lead to fewer hospital admissions – a metric that has become especially important during the pandemic. With the January 2022 launch of Primary Care First Cohort 2, it is important to review how the program works and what steps healthcare organizations should take to ensure the best outcomes. To be successful, PCF participants must pay special attention to three aspects – tracking beneficiary population, obtaining physician buy-in, and ensuring timely access to performance metrics. Tracking Beneficiary Population Tracking patients participating in the PCF program is necessary to build patient navigation processes and monitor care outcomes. However, this can be challenging for many providers as internal EMR solutions do not provide complete data across the entire continuum of care for all providers that a patient may see. Th...

CMS has introduced more than 50 innovative care delivery models designed to drive health system transformation over the last decade. Only six of those produced significant savings; of those, only four met the requirements to be expanded. As the second 10-year period of the program gets underway, which includes $10 billion in new funding, CMS’ Center for Medicare and Medicaid Innovation is considering numerous changes to improve the overall success of these programs and, in turn, drive overall gains in care outcomes and health equity. When evaluating what has worked in the past and what changes are needed moving forward, it is important to review what success looks like for Alternative Payment Model programs.  CMMI relies on three benchmarks to measure levels of success: The gold standard: improving quality of care while simultaneously reducing expenditures. Improving quality of care without impacting expenditures. Reducing expenditures without impacting qual...

The Primary Care First Model , an alternative payment model offering an innovative payment structure for the delivery of advanced primary care, welcomed the involvement of Cohort 2 participants on Jan. 1 . This cohort, which was open to all primary care practices that met the eligibility criteria, will participate from 2022 to 2026. Participants in PCF Cohorts 1 and 2 can expect the following benefits: an opportunity to increase revenue with performance-based payments that reward participants for reducing acute hospital utilization; the ability to assess and improve performance through actionable, timely data; less administrative burden so providers can spend more time focusing on patient needs; and potential to become a Qualifying APM Participant , which includes eligibility for a 5% incentive payment and eliminates Merit-based Incentive Payment System reporting requirements. To ensure that new and prior participants succeed in this model, DataGen has compiled and answered some of t...

Alternative payment programs are critical to payment and care delivery transformation. CMS is introducing new alternative payment models that provide opportunities to deliver better value of care and support healthcare innovation in the years to come. Rising healthcare trends should be taken into consideration when evaluating new APMs. Yet, keeping ahead of which programs offer you the greatest opportunity can be a major challenge. DataGen put together Navigating Alternative Payment Models: A User's Guide , offering insights on the participation categories—and detail on programs within each category—this resource can help you determine the best course for your organization’s future. Download our user's guide to learn about new APMs, implications for providers and data-driven strategies for successful pro gram execution.

The initial cohort of the Primary Care First model went live on Jan. 1.  Cohort 1, represented by 822 practices and 14 payer partners, is offered in 26 regions across the country. Over the six-year PCF demonstration period, CMS will test whether advanced primary care practices can improve patient experience and quality, reduce total cost of care and manage risk through performance-based payments, while decreasing the administrative burdens and increasing financial incentives for a primary care practice. PCF puts particular focus on comprehensive care coordination and the doctor-patient relationship. The Center for Medicare and Medicaid Innovation announced several PCF model updates in the last few weeks: The Seriously Ill Patient component of PCF, which would have gone live on April 1, has been postponed until further notice and is currently under review. The SIP component was established for practices that could focus on patients with complex chronic needs and fragmented care patt...

It’s been a year: a year since the first lockdowns and a year since the landscape of healthcare in the U.S. changed forever. While we’re still evaluating the impacts of the pandemic on healthcare policy, we now have seen enough data to assess the effect of the past year on alternative payments models and how participants are reacting. It’s been reassuring to see the strength of APMs has broadly held steady, as has the resolve of the participants in those programs, despite the impact of the COVID-19 pandemic. Here’s what we’ve learned this year, along with what (we think) those lessons can teach us about the future. COVID-19 has not stopped the progress of APMs — but it is delaying it. COVID-19 has extended the period of some programs, like the Comprehensive Care for Joint Replacement and Oncology Care Model, and delayed the start of others, like Kidney Care First and the Radiation Oncology Model. This is, in part, a function of an overwhelmed system. As policymakers and healthcare org...