Commercial risk will be a critical catalyst of progress – it’s complicated, but is it possible? We think so.


October 28, 2019

CMS delays new primary care, kidney care value-based payment models

Daily Briefing

    CMS on Thursday announced it is delaying the start of several new voluntary value-based payment models, but it continued to encourage Medicare providers to apply to participate in the payment models.

    4 'elephants in the room' hindering health care's drive toward value

    CMS said it is postponing the launch of the payment models until at least 2021. The delay applies to four models. Two of the models are part of CMS' Primary Cares initiative. The other two are part of an executive order to overhaul the U.S. kidney care and donation allocation process.

    Details on the primary care payment models

    CMS in April announced an initiative intended to shift primary care providers and other eligible professionals from fee-for-service (FFS) payments to value-based payments using five new voluntary payment models. The five new payment models—which were developed and will be implemented by CMS' Center for Medicare and Medicaid Innovation—are designed to examine whether performance-based payments paired with providers taking on financial risk will reduce health care costs and maintain or improve health outcomes and quality of care.

    CMS in a fact sheet said the five payment models are divided into two paths:

    • Direct Contracting (DC); and
    • Primary Care First (PCF).

    PCF path

    The PCF path is specifically designed for primary care practices and includes two voluntary, five-year payment models:

    • PCF–General, which CMS said is designed for primary care practices prepared to assume large financial risk in exchange for reduced administrative burden and performance-based payments; and
    • PCF–High Need Populations (HNP), which CMS said is designed to encourage advanced primary care practices, including practices enrolled in Medicare and providing hospice or palliative care services, to assume financial responsibility for high need, seriously ill beneficiaries who lack a primary care practitioner or effective care coordination.

    Under both PCF payment models, participating practices will receive a simplified, total monthly payment, which CMS said will allow clinicians to focus on patient care rather than unpredictable revenue. Practices participating in a PCF payment model will receive payment adjustments based on how they perform on certain clinical quality measures, including controlling high blood pressure, managing diabetes, and screening for colorectal cancer. Practices that specialize in care for patients with complex, chronic, or severe conditions will receive higher monthly payments.

    CMS began accepting applications to participate in the PCF payment models in spring 2019. When the agency announced the models, it said it planned to launch the payment models in 26 regions throughout the United States beginning in 2020. CMS said it would accept a second round of applications for the payment models in January 2020.

    However, CMS in its latest update said the PCF models will not start until 2021.

    Details on the kidney care payment model

    The other models CMS delayed were announced in July as part of an executive order.

    The two voluntary payment models will test alternative Medicare payment options that aim to improve care quality for beneficiaries with kidney disease.

    The Kidney Care First (KCF) model, which is open only to nephrology practices, will tie payments to beneficiaries' health outcomes, the health services used, and quality measures. Participating providers under this model will receive a payment boost over a three-year period for every beneficiary with advanced chronic kidney disease or end-stage renal disease who receives a transplant. In order for providers to receive the full bonus, the transplant must be successful for the full three years.

    The Comprehensive Kidney Care Contracting (CKCC) model consists of three tracks:

    • CKCC Graduated, which begins as a one-sided risk model and slowly phases in additional risks and rewards;
    • CKCC Professional, which gives participating clinicians the option to earn 50% of shared savings and be on the hook for 50% of shared losses based on the total cost of care for Medicare Part A and B services; and
    • Global Models, which requires participating clinicians to take on 100% of the financial risk based on the total cost of care for Part A and B services.

    The deadline to apply to the to the kidney care models is Jan. 22, 2020.

    CKCC will begin in 2021 or 2022, depending on which track providers pursue (Brady, "Transformation Hub," Modern Healthcare, 10/24).

    Have a Question?


    Ask our experts a question on any topic in health care by visiting our member portal, AskAdvisory.