Should you Consider Primary Care Flex?

Hi friends!

Did you know CMMI has been working on a hybrid prospective payment model for primary care providers in MSSP ACOs? It’s a collaborative effort between the Center for Medicare and the Innovation Center, and they announced it for a one-time, 2025 start date.

Many stakeholder groups have provided input like the Primary Care Collaborative (PCC) and the National Association of Accountable Care Organizations (NAACOS). Until the announcement last week, we didn’t know if it would make it through the necessary approval processes to be available for the MSSP 2025 Performance Year. But it did!

CMMI will provide more details in a webinar on April 4, 2024, and then in the RFA later this Spring.

And if you like to listen to webinars or podcasts while you do busy work around the house like I do, here’s a recording of Liz Fowler with the Primary Care Collaborative, followed by a discussion with thought leaders who contributed to the model concepts and development at different stages:

Below are highlights and some early thoughts:

Key Highlights of “Flex”

• Only for new and renewing ACOs who sign 2025 MSSP Participation Agreements

• Only for “low revenue” ACOs

• “About 130” ACOs will be be invited to participate in this CMMI model

• ACOs may be able to receive up-front advanced shared savings of $250,000, similar to the Advance Investment Payment (AIP) option in MSSP, which is new in 2024. An ACO may not choose AIP and apply for Flex

• Payments for a set of primary care services and an “enhanced payment” will be provided prospectively to ACOs, who must distribute those payments to primary care practices

• Overall, most primary care providers will see a revenue increase

• The “enhanced payment” component of the prospective payment will not be used for calculating ACO spend or for reconciling shared savings and losses

• New and renewing ACOs must submit their MSSP application for 2025 in the window ending June 17, 2024, and indicate their intent to apply for “Flex”

CMMI Has Released Several Primary Care Models Over the Last Year

There are now several model options to choose from

On March 14, 2024, the Innovation Center released an update to their Value-Based Care Strategy in Health Affairs, reiterating their commitments to alignment, growth, and health equity. They have been diligently developing models that test concepts they hope will, in part or whole, meet the requirements to build on the accountable chassis that is the MSSP.

As I’ve shared with you, primary care investments are needed to improve the United States’ health care system. Only then can it live up to its potential of supporting the health of the nation’s population.

Prevention, early disease detection, engaged patients with chronic illness(es), addressing SDOH and non-medical drivers of health, patient navigation, caregiver support….all start with advanced primary care teams. We have shown what’s possible in a re-imagined, patient-centric primary care structure, but scaling it and moving through the culture change needed for wide adoption will take more time.

Other Primary Care Models have been Announced by the Innovation Center in the Past Year

CMS has a number of priorities they touch on in these new models:

• Accountable Care for Medicaid beneficiaries, including for dual-eligible beneficiaries

• Multi-payer alignment

• Aligning acute care hospital and community-based care incentives

• Up-front financing (via loans and investments)

• Prospective, enhanced primary care payments

• Participation options that may appeal to underserved providers

• “No-wrong door” approach to primary care for those accessing behavioral health as primary setting of care

Then there’s the Medicare Shared Savings Program Basic and Enhanced Track options as well as the ACO REACH Model.

After an RFI in the 2024 Physician Fee Schedule about an “Enhanced Plus” Track, CMS provided detailed feedback in the final rule last November on comments and on what they are taking into consideration as they work on this hypothetical new option. We could see that proposed this year or next.

CMS Also Continues to Improve the Medicare Shared Savings Program

MSSP is the “chassis” upon which accountable care infrastructure for Medicare beneficiaries is built. CMMI models are tested to find successful features that can be added to MSSP and other CMS programs. Examples of this are the ACO Investment Model (AIM), now re-tooled as the statutory MSSP option called Advance Investment Payments (AIP), and the expanded home health value-based purchasing program, which was tested first and then expanded to all home health agencies when its success was evident.

Here’s my Two Cents:

CMS is trying to achieve many different goals.

For multi-payer alignment goals, they need to incorporate Medicaid, and, therefore, states.

MCP and AHEAD check those boxes.

Access to primary care for Medicaid beneficiaries (and, optionally, Medicare/Duals) gave us:

IBH

Incentivizing hospitals to reduce unnecessary hospitalizations and post-acute care?

AHEAD (global budgets)

Enhanced, prospective primary care payments for MSSP participating PCPs?

ACO Primary Care Flex

Then we have MSSP Participants in all Tracks, Global and Professional participants in ACO REACH, Primary Care First,

Oh, and don’t forget the Dementia Model to address those administration goals, the GUIDE Model.

Then there are overlap considerations:

GUIDE overlaps both patients and providers of all other models.

MCP participants may not participate in MSSP or with REACH.

AHEAD states (up to eight of them) may not overlap with the prescribed eight MCP states.

Except for NY, where upstate NY is an MCP state but NYC is not. So they are eligible to participate in AHEAD.

Primary Care AHEAD and MSSP may overlap. We don’t yet know about MSSP with Flex and AHEAD.

Hospitals in AHEAD may not be receiving prospective payment as part of a REACH ACO.

Primary Care First overlaps with MSSP but not REACH.

Flex and AIP offer some providers up-front shared savings. MCP offers investments to inexperienced providers in Track 1.

One more thing—

In my opinion, the release of Flex was important for this reason: MSSP ACOs in MCP states have a prospective payment option for participation while remaining in MSSP (rather than exiting MSSP to enter MCP). MCP and Flex aren’t the same, but there are enough similarities.

Benchmarking methodologies, risk, quality, and payment structures vary throughout options.

My top take is that evaluating all of the primary care participation options is a monumental feat for primary care practices and providers. Even those with experience in accountable care can feel overwhelmed by the choices.

Not to mention there is more in the pipeline (still waiting on the anticipated mandatory episodes of care program), there’s an election coming up, new benchmarking in MSSP to consider when an ACO renews, and uncertainty about what comes next after the most advanced model, using capitation, is scheduled to end at the end of 2026. That’s basically right around the corner.

AND…

A developing specialty and episodic care strategy (MSSP and REACH entities recently received “shadow bundle” data—here’s a good recent Milliman article about it. Also, Premier was writing and speaking about this concept in 2019. Shout-out to my friend Justin Rock, one of the early thought leaders on this subject.).

AND potentially

MACRA reform.

To name a few other things going on.

What I’m confident about:

Primary care providers caring for Medicare populations should make a model choice and jump in for 2025.

Now or yesterday is when you should be thinking about it.

If the options are too much to evaluate, simplify.

There’s one statutory model, MSSP.

It’s not going anywhere.

It can’t be changed without the notice and comment rulemaking process or eliminated without legislation. And that’s not going to happen.

CMMI tests out models concepts so they practice and learn outside of the MSSP. MSSP is not a testing ground.

Maybe learn more about Flex, which will provide up-front payments and enhanced primary care payments. This could potentially go a long way in transitioning a practice from FFS primary care to team-based, advanced primary care.

It’s time to move to advanced, team-based primary care. No matter what happens in upcoming elections, this is where primary care is going.

And if you don’t know much about value-based care, now is a perfect time to learn!

Talk to you all soon. And remember, write back to me anytime by just hitting reply!

All the best,

Dana