Making Care Primary Model Details
Today’s blog is written by Rebecca Rye
CMS has released a Request for Applications (RFA) for its new payment model, Making Care Primary (MCP). CLA took a look at the initial details of the program in a blog post when the model was announced, but the RFA provides an opportunity for a deeper dive into the requirements and prepare for submitting an application. The model is only available in the following eight states: Colorado, Massachusetts, Minnesota, New Mexico, New Jersey, upstate New York, North Carolina, and Washington. Applications are currently being accepted through November 30, 2023, with participants selected in early 2024.
Overview
The MCP model will run for 10.5 years, from July 2025 to December 2034, and focuses on primary care delivery, which can be summarized into one of three categories: care management, care integration, and community connection.
Care management initiatives focus on incorporating payment for chronic condition management into prospective population-based payments, emphasizing improvement in outcomes in for beneficiaries with diabetes and hypertension and decreasing emergency department use and hospitalization. Care integration goals center connections between primary care providers and high-quality behavioral health and specialty care physicians to improve support to patients. Finally, participants will be encouraged to strengthen community connection to address health-related social needs and help patients navigate available community support.
Participants will be in one of three model tracks, each with its own set of requirements and payment methodologies, for their initial entry into MCP. Track 1 focuses on infrastructure building, Track 2 is focused on improving efficiency, and Track 3 centers optimizing care for beneficiaries. There are six payment mechanisms, a required MCP performance measure set among other requirements.
Additional information is provided below.
Eligible Applicants
Eligible applicants for MCP are Medicare-enrolled organizations–like solo primary care practices, group practices, health systems, FQHCs, eligible Indian Health Programs–that provide primary care services to beneficiaries located in Colorado, Massachusetts, Minnesota, New Mexico, New Jersey, upstate New York, North Carolina, and Washington. Applicants can operate in other states, but the majority (at least 51%) of primary care sites must be located in an MCP state. Applicants must serve as the source of regular primary care for at least 125 Medicare beneficiaries. There are some specific eligibility requirements for non-FQHC applicants.
Applicants will be accepted for participation based on whether they meet all eligibility requirements for the model as well as requirements for the specific track applied to, and the results of a program integrity screening.
Current participant providers in the Primary Care First and ACO REACH models are ineligible for MCP along with grandfathered tribal FQHCs, rural health clinics and practices that provide concierge care.
Three Track Approach
The MCP uses three tracks to provide opportunities for participants with varying levels of familiarity with value-based payment to participate. Track 1 requires that applicants have no value-based care experience, while applicants to Tracks 2 and 3 may but are not required to have value-based care experience. Tracks 1 and 2 are progressive, so participants will spend at least 2 years in each before progressing to the next track. The six-month Performance Year (PY) 1 will not be included in these two years, meaning that participants will spend 2.5 years in their entry track. Detailed track requirements are in the RFA.
In addition, applicants should be prepared to comply with or implement a variety of IT requirements by certain dates. For example, MCP participants must provide patients access to their health information via an application based programming interface and use certified health IT. Full details on these requirements are also included in the RFA.
Payment Mechanisms
The MCP model will use six payment types to support care delivery and advance the model’s goals. Five of these payments will be made to primary care participants, while the last is a payment to specialty care partners to encourage collaboration and communication unique to the MCP model.
Upfront Infrastructure Payments (UIP) will be available to eligible Track 1 participants only. These payments are designed to assist participants with no experience in value-based care to implement required infrastructure changes to meet MCP goals. CMS will make two lump sum payments of $72,500—the first in month one of the model and the second in month 13. UIP funds are restricted to specific allowable uses.
CMS will make per beneficiary, per month Enhanced Services Payments (ESP) on a quarterly prospective basis to support ongoing model requirements. ESPs are risk-adjusted based on a beneficiary’s HCC risk score, Area Deprivation Index score, and low-income subsidy (LIS) enrollment status. Beneficiaries are tiered into four categories. The highest needs beneficiaries would receive the largest payments. If beneficiaries are enrolled in a low-income subsidy, they are not included in tiers and will instead receive $25 payments to encourage model participants to include high-needs beneficiaries in their aligned population. As participants progress through MCP tracks, ESP payments decrease as potential performance incentive payments increase.
As MCP participants move through tracks, primary care service payments will move from FFS to quarterly Prospective Primary Care Payments (PPCP) based on historical billing. Track 1 participants will remain 100% FFS, Track 2 participants will receive 50% FFS and 50% PPCP payments, and Track 3 will receive 100% PPCP, but still be required to submit no-pay claims. For participants entering in Track 2 or 3, PPCP will be based on claims period April 1, 22-March 31, 2024. When participants entering in Track 1 progress to Track 2, their PPCP will be based on claims period October 1, 2024-September 30, 2026.
Performance Incentive Payments (PIP) are upside-only and will begin in PY 2 the model. PIP will be made in two lump sums. Potential PIP increase as participants progress through MCP tracks:
- Track 1 is eligible for up to 3% of FFS
- Track 2 is eligible for up to 45% of FFS+PPCP
- Track 3 is eligible for up to 60% of PPCP
Reporting of all MCP Performance Measure Set measures is required for PIP eligibility. In addition, Track 2 and 3 participants must achieve the national 30th percentile on a total cost of care metric.
To encourage use of e-consults by primary care clinicians in the model, participants will be able to bill a MCP E-Consult Code (MEC) beginning in Track 2. The MEC code will be paid at $40/service. It is not billable by specialty care partners.
To reflect the increased care coordination requirements of the model specialists in a Track 3 participant’s Specialty Care Partner List, there is a new Ambulatory Co-Management (ACM) code that can be billed. To bill the ACM Code, the specialty care provider must identify as taking a “co-management” role with the MCP participant. The ACM code will be priced at $50 before a geographic adjustment is applied and will be billable monthly for up to three months after the initial co-management code is billed.
How can CLA help?
Are you interested in exploring the Making Care Primary model more? Wondering what its impact could look like on your organization? CLA can help you navigate the program’s requirements and model the financial implications for your organization. Reach out to an advisor today!
Jennifer Boese is the Director of Health Care Policy at CLA. She is a highly successful public policy, legislative, advocacy and political affairs leader, including working in both the state and federal government as well as the private sector. She brings over 20 years of government relations and public policy knowledge with her to CLA. Well over half of her career has been spent dedicated to health care policy and the health care industry, affording her a deep understanding of the health care market and environment, health care organizations and health care stakeholders. Her role at CLA is to provide thought leadership, policy analysis and strategic insights to health care providers across the continuum related to the industry's ongoing transformation towards value. A key focus of that work is on market innovations and emerging payment models. Her goal is to help CLA clients navigate and thrive in an increasingly dynamic health care environment.
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