New CMS Payment Options Can Improve a Primary Care Practice

Primary care physicians have been dealing for some time now with fundamental changes in both practice expectations and the financial landscape. Declining reimbursement rates and ever-increasing bureaucracy have made it harder than ever to focus on patient care, and for decades practitioners have felt pressure to focus on billable procedures at the expense of total care.

That’s why it’s encouraging that new reimbursement plans offered by Centers for Medicare and Medicaid Services (CMS) can provide general practitioners ways to generate income and be paid for pro-patient, quality health care.

CMS’ stated goal is to reduce administrative burdens on primary care providers, and allow them to concentrate on patient care while, at the same time, reducing overall health care costs. The programs involve a transition from the old fee for service payment model to a total cost of care and a focus on general patient health and outcomes. But they also provide a path to improving the financial well-being of the health care practice itself by providing Care Management and Performance-Based Incentive payments.

In many ways these programs are essentially rewarding physicians for quality care standards they’re already incorporating into their daily work. Primary care practices have evolved on their own to encompass data management, coordinated care, out-of-office care options, state-of-the-art recording keeping, and holistic examination of life factors impacting a patient’s health. CMS’ programs offer practices that do so both a financial incentive and a way to get data-based feedback that can drive even more improvements.

Under CMS Innovation Center’s new Primary Care Initiative model, announced in April 2019, the new paths for enrollment and reimbursement will consist of five payment models, grouped under two paths, Primary Care First and Direct Contracting. The models, which build upon lessons learned from previous models such as Comprehensive Primary Care Plus (CPC+), are designed to provide a range of options, with gradient levels of risk. The Primary Care First models are likely to be suitable for smaller practices, while the Direct Contracting models might be a better match for large practices that have experience with risk-based contracts. Within each model, there will be options depending on a practice’s overall patient profile and risk tolerance. Participation agreements are expected in fall/winter 2019 with participation to start in early 2020. Based on past experiences with CMS programs, letters of intent are likely to be non-binding, so it may be worth exploring participation even if your practice ends up deferring participation. Previous programs have also allowed for second-wave enrollment.

While application into a program is generally straightforward, and it’s not difficult to qualify, the real investment comes in ensuring your practice has systems in place to be ready for participation, with the appropriate electronic medical reporting systems that will meet the reporting requirements and prompt real time recording of patient information. Upgrading record keeping and reporting systems will not only ensure you’re ready for a program when the time comes but in the process can enhance productivity and revenue generation.

If you have questions about identify CMS models, evaluating options, and making the right choices in entering a program, please contact Houston Harbaugh’s Health Law Practice Chair Jessica A. Ellel at 412-288-2260 (

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