A Renewed Focus on Primary Care – CMS Releases a Request for Applications for the Making Care Primary Model

By John Gibson and Robert Shaw

In its latest initiative to address inefficiencies in primary care, the Centers for Medicare & Medicaid Services (CMS) has announced the Making Care Primary (MCP) model, available to qualified primary care providers seeking to modernize and improve delivery of care. CMS released a Request for Applications (RFA) detailing eligibility and model requirements earlier this summer, and recently opened a web portal where interested providers may submit applications up to November 30, 2023 at 11:59 PM EST. Providers may also submit a non-binding letter of intent to find out more about the model in advance of applying.

What is MCP?

MCP is a new primary care innovative model scheduled to launch July 1, 2024, in eight states, including North Carolina, Colorado, Washington, Massachusetts, Minnesota, New Mexico, New Jersey, and New York. The 10.5-year model is designed to build on successful components of previous CMS primary care models, while also focusing on care management (including an emphasis on managing chronic illnesses), integration with specialty care clinicians (including behavioral health) and connecting primary care to community support services to promote holistic care.

This approach is intended to facilitate preventative care delivery and consequently improve overall health outcomes for metrics including diabetes control, depression, emergency department visits, and total cost of care. The requirements of each program care delivery domain (care management, care integration, and community connection) must be met at the practice level, and participating providers must demonstrate compliance with such requirements after the first twelve-month performance year of the model. Interested providers should review the RFA for additional information about each care delivery domain, including behavioral health and specialty care integration components.

In addition to prioritizing a team-based approach to primary care and care coordination between providers, MCP also promotes health equity by facilitating the highest level of primary care to a wide spectrum of beneficiaries, including traditionally marginalized socioeconomic groups. Examples of program initiatives geared toward equitable care include adjustments to payments based on social risk of beneficiaries, a requirement for participants to develop a strategic plan for how they will identify and reduce social disparities, and collection of data on certain demographic information and HRSNs to measure health disparities in various communities.

There are three available MCP tracks, summarized below, which are designed to encourage participation from a wide variety of providers, including those that have not historically participated in value-based care initiatives, as well as a diverse spectrum of payers. CMS is already working with applicable state Medicaid agencies to implement this model and has indicated plans to engage private payors going forward.

Providers’ initial participation in the tracks varies depending on their respective value-based care experience. Participants that begin in Tracks 1 and 2 eventually progress to Track 3, where they remain for the rest of the program. Participants that begin in Track 3 remain there for the entire program. Track 1, designed for the least experienced providers, focuses on infrastructure building over a 2.5-year period. Track 2 spans 2-2.5 years and is intended to improve efficiency of care. Track 3 features the most robust and comprehensive accountable care deliverables.

Who is Eligible to Participate?

Organizations must satisfy the following criteria to participate in MCP: (1) be a legal entity formed under applicable state, federal, or Tribal law authorized to conduct business in each state in which it operates; (2) be Medicare-enrolled; (3) bill for health services furnished to a minimum of 125 attributed Medicare beneficiaries; and (4) have the majority (at least 51%) of their primary care sites (physical locations where care is delivered) located in an MCP state.

Track 1 is only available for applicants with no experience in value-based care. Track 2 and 3 do not have specific eligibility requirements outside of the elements listed above, but interested providers should review the RFA carefully to understand payment structures, performance measures, IT requirements, and care delivery requirements applicable to each track.

The following entities are not eligible to participate in MCP: (1) Rural Health Clinics; (2) concierge practices; (3) current Primary Care First practices; (4) current ACO REACH participants; and (5) Grandfathered Tribal Federally Qualified Health Centers. Organizations also will not be able to concurrently participate in the Medicare Shared Savings Program and MCP after the first six months of the model.

Reimbursement Structures

MCP will include the following six payment types:

1. Upfront Infrastructure Payment for Infrastructure Building—lump sum payment for Track 1 participants, designed to support IT/technology investments.
2. Enhanced Services Payment—per beneficiary per month (PMPM) payments paid on a quarterly basis, designed to support ongoing care management functions. Available to primary care participants in Tracks 1, 2, and 3.
3. Prospective Primary Care Payment—quarterly payments based on historical primary spending and progressively shifted from fee-for-service to value-based PMPM as participants progress through the tracks. Available to primary care participants in Tracks 2 and 3.
4. Performance Incentive Payment—available adjustments to FFS amounts and Prospective Primary Care Payments (PPCP) based on performance of MCP measures. Available to primary care participants in Tracks 1, 2, and 3.
5. MCP e-Consult—available to Track 2 participants unique to e-consult codes.
6. Ambulatory Co-Management—available to specialty care partners that partner with Track 3 participants.

If you have any questions about MCP, please contact a member of the Health Care practice group or your regular Smith Anderson lawyer.