The Centers for Medicare and Medicaid Services (CMS) have set forth an ambitious roadmap for the transformation of healthcare payment systems. By 2030, the aim is for 100% of Medicare payments to be tied to quality and value, facilitated through two-sided risk Alternative Payment Models (APMs). Achieving this monumental goal hinges on the development of versatile reimbursement models that can be adopted by healthcare practices of varying sizes and specialties.
Primary care has emerged as a critical focal point in the journey towards value-based healthcare. While CMS and its Center for Medicare & Medicaid Innovation (CMMI) have rolled out several value-based reimbursement models, these often require a level of infrastructure that may not be feasible for all primary care organizations. This is particularly true for those treating a diverse patient population covered by different types of insurance.
Understanding the challenges and lessons learned from previous models like Comprehensive Primary Care Plus and Primary Care First, CMMI has introduced the Making Care Primary Model (MCP). This innovative model aims to amalgamate the best features of earlier primary care models while ensuring inclusivity for healthcare practices at various stages of value-based care adoption. MCP focuses on three core objectives:
- Comprehensive primary care that promotes health equity.
- Coordinated care that eases care transitions and specialist consultations.
- A flexible value-based reimbursement structure to aid practices in transitioning to capitation payments.
MCP offers a structured pathway for primary care organizations to transition from traditional fee-for-service (FFS) to a capitated per beneficiary per month (PBPM) reimbursement model. To support this transition, MCP provides up-front financial incentives, including quality bonuses that increase as organizations take on more risk. The model operates on three distinct "Tracks," allowing practices to enter at a level that matches their readiness for risk-based reimbursement. Over time, organizations can progress to higher Tracks, each offering a different degree of at-risk reimbursement.
In Track 1, organizations with limited revenue and telehealth capabilities can still retain traditional FFS reimbursement. However, starting from Track 2, a Prospective Primary Care Payment (PPCP) is introduced, which is a defined PBPM payment per attributed patient. By Track 3, nearly all professional services are reimbursed through the PPCP PBPM model, calculated based on an organization's historical spending.
The graph below from CMS’s overview webinar presentation of the MCP provides example payment calculations by track:
MCP also introduces two supplementary payment types: the Enhanced Services Payment (ESP) and the Performance Incentive Payment (PIP). ESP is designed to fund care management and patient navigation, while PIP serves as a quality incentive bonus. These payments are calculated based on various factors, including clinical and social risk scores, and they evolve as organizations move up the Tracks.
The table below from CMS’s overview webinar presentation of the MCP presents how the ESP is calculated by Track:
To address the gap in coordination between primary care providers and specialists, MCP includes the MCP E-Consult (MEC) payment starting in Track 2. This payment encourages electronic consultations with specialists, further integrating care and improving patient outcomes.
The MCP model is open to primary care organizations in eight specific states and excludes certain types of practices. However, it offers significant benefits to organizations that meet specific criteria, such as those with a high proportion of patients with chronic conditions or those that have strong relationships with community specialists.
The Making Care Primary Model (MCP) by CMS is a groundbreaking initiative that promises to redefine the landscape of value-based healthcare. It offers a flexible, inclusive approach that accommodates healthcare practices at different stages of value-based care adoption. With its multifaceted reimbursement structure and focus on coordinated, quality care, MCP is poised to be a game-changer in the healthcare industry.
For healthcare organizations looking to navigate the complexities of MCP and value-based care, Diagnostic Robotics offers unparalleled solutions. Our services not only recommend optimal care path steps to reduce preventable costs but also streamline patient triage and navigation. Furthermore, we can assist you in the application process for MCP, ensuring a smoother transition to value-based care.
By embracing models like MCP and leveraging advanced solutions like those offered by Diagnostic Robotics, healthcare providers can look forward to a future where quality care is accessible, equitable, and financially sustainable.
Lorem ipsum about this text that we will decide later on.
