CMS Value-Based Payment Goals

In April of 2019, the Centers for Medicare and Medicaid Services (CMS) announced it is rolling out a new set of CMS value-based payment goals. It’s called the CMS Primary Cares Initiative, and its goals are to shift providers away from fee-based programs and into value-based reimbursement. CMS is hoping to shift the focus of physicians to preventive care by incentivizing patient outcomes as opposed to the typical fee-based structure.


What is value-based reimbursement?

Value-based reimbursement is defined as a payment model in which providers are paid based on patient improvements as opposed to individual treatments. The shift to value-based care has been growing over the last decade. The federal government has been introducing various value-based care models for the past ten years beginning in 2008 with the Patients & Providers Act (MIPPA).


What’s the future of value-based payment?

The current Merit-based Incentive Payment System (MIPS) has more changes in store with the CMS Primary Cares Initiative for 2020. This model is made up of five payment models broken down into two separate paths, Direct Contracting (DC) and Primary Care First (PCF). CMS has released fact sheets detailing the DC and PCF plans.

DC contains three voluntary payment models spanning five years. CMS indicated that the DC payment models are geared to reward providers with the ability to offer improved efficiency and quality of care.

  • Professional (DC). This model reduces risk by enabling providers to share 50% of the financial risk with CMS. It offers providers a fixed monthly payment.
  • Global (DC). The Global model offers two payment options, a monthly payment for services that are adjusted for risk or a total care capitation.
  • Geographic (DC). This payment model offers a similar payment structure to the Professional payment model; however, it differs as the financial risk is at 100% for providers.

The PCF path is intended for primary care practices, and it is made up of two payment models.

  • General (PCF). This model is intended for primary care providers that are willing to accept a large financial risk in exchange for performance-based reimbursement and a reduced administrative burden.
  • High Need Population (PCF). In this model, the CMS value-based payment goals are to encourage primary care providers, including those enrolled in Medicare and/or providing hospice services, to assume financial responsibility for high-need patients that are lacking primary care practitioners.


Benefits of participating in the CMS Primary Care Initiative?

  • Financial. Providers that opt-in to these plans will receive monthly payments that are tied to patient outcomes such as lowering blood pressure and getting cancer screenings. Additionally, high-need providers can receive additional rewards-based payments.
  • Increased flexibility. Clinicians will be rewarded for patient outcomes, as opposed to receiving payments per each individual test or treatment. Providers will have the freedom to use these pay models as it best serves them.
  • Improved feedback systems. In order to help providers move toward value-based care systems, CMS is improving feedback systems that will, in turn, give clinicians more insight into their monthly performance.
  • A wide range of providers can participate. Primary care practices and large health providers are able to take advantage of these payment plans.


The bottom line

CMS value-based payment goals allow primary care providers to have more time to care for their patients while reducing health costs. CMS is looking to expand CMS value-based payment programs and goals. There are some big financial incentives for participating in these plans.

However, it’s a lot to keep straight, and transitioning from fee-for-service to value-based care is a complicated process.  Value-based reimbursement – are you prepared?

Often a medical billing audit and review your processes can get you ready for the coming changes.

Engaging outside experts may be the best next step that can walk you through regulatory compliance steps and ensure your organization can benefit fully from these new plans.

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