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The Primary Care First VBP Model Explained


[12/17/20] The Primary Care First (PCF) model was established by the Centers for Medicare & Medicaid Services (CMS) Innovation Center. It offers a regionally-based, multi-payer approach to primary delivery and payment. By design, PCF allows for increased flexibility and freedom for practitioners to be innovative in their approach to increase quality and reduce costs. 

PCF will be offered in 26 regions in 2021, including many that were covered in our I/DD Managed Care Review blogs.  In those blogs, we covered the ten current programs being offered. Out of those ten, five (New York, Tennessee, Kansas, Arkansas, and Michigan) also have a PCF option.  This leaves us hopeful that PCF programs will start to work with managed care programs and benefit the I/DD community.

primary care

There is another program called the Federally Qualified Health Centers (FQHC) that offers a Medicaid version of the PCF model, which creates opportunities for the underserved population to get quality care. FQHC’s are typically community health centers, public housing health centers, migrant health centers, and the like.

Primary Care First Program

The five-year payment program has some underlying principals including; prioritizing the doctor-patient relationship, enhancing care for patients with complex high-need chronic conditions, treating seriously ill patients, reducing administrative burden, and focusing financial rewards on improved health outcomes. The PCF model incentivizes practices to focus on whole-person care, reducing the need for costly hospital visits.

As of November 2020, 916 primary care practices and 37 regional partnerships were formed and are set to launch in 2021.

Humana's New PCF Model

Humana announced the expansion of its successful value-based payment (VBP) program with a Primary Care First (PCF) model. The new PCF Model will expand the availability to certain Humana Medicare Advantage Plans members throughout the continental United States. As with other value-based models, this will provide high-quality care at a lower cost while boosting overall patient outcomes. With 2020 creating a lot of uncertainty, this model comes at an important time as many U.S. citizens are in need of high-quality primary care.

Humana has experienced success, announcing in October they had saved an estimated $4 billion through the value-based care program last year. In that same report, the health insurer said roughly 67% of its Medicare Advantage (MA) members are treated by primary care physicians enrolled in a value-based model.

As a newly-approved CMS payer partner, Humana is the only insurer to offer their own take on the PCF program. Their model is scheduled to launch on July 1, 2021 and will offer participants a special capitated payment each month with the goal of achieving better outcomes. This type of structure will provide revenue stabilization and help primary care physicians stay afloat through trying times.

The managed care I/DD programs that combine with Humana’s program can be found in Tennessee, parts of New York State, Arkansas, Kansas City, KA, and Michigan.

Advocate's Perspective

The PCF model and FQHC models are both examples of opportunities for value-based care to be brought to the entire population, instead of only episodic care. Humana has taken a huge step forward with this announcement and their move towards an even stronger value-based care model. With their whole-person approach, we are optimistic that extended programs for the I/DD and MLTSS communities are in the near future.

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About the Author

Fady Sahhar brings over 30 years of senior management experience working with major multinational companies including Sara Lee, Mobil Oil, Tenneco Packaging, Pactiv, Progressive Insurance, Transitions Optical, PPG Industries and Essilor (France).

His corporate responsibilities included new product development, strategic planning, marketing management, and global sales. He has developed a number of global communications networks, launched products in over 45 countries, and managed a number of branded patented products.

About the Co-Author

Mandy Sahhar provides experience in digital marketing, event management, and business development. Her background has allowed her to get in on the ground floor of marketing efforts including website design, content marketing, and trade show planning. Through her modern approach, she focuses on bringing businesses into the new digital age of marketing through unique approaches and focused content creation. With a passion for communications, she can bring a fresh perspective to an ever-changing industry. Mandy has an MBA with a marketing concentration from Canisius College.