What is the Primary Care First (PCF) Program?
Launched by the Centers for Medicare & Medicaid Services (CMS) Innovation Center, the Primary Care First (PCF) model was a voluntary five-year program that ran in several phases between 2021 and 2024. It was an advanced payment model (APM) designed to promote better health outcomes and lower costs for Medicare beneficiaries by transforming the primary care landscape. The program incentivized primary care practices to provide more advanced, coordinated, and patient-centered care, especially for those with complex chronic conditions or serious illnesses.
The Core Goals of PCF
The PCF model had three main objectives that guided its design and implementation:
- Improve quality of care: By rewarding practices for achieving specific quality metrics, PCF encouraged a higher standard of care.
- Enhance patient experience: The model aimed to foster stronger, more patient-focused relationships between primary care providers and their patients, ultimately improving satisfaction.
- Reduce expenditures: A central goal was to lower overall healthcare costs, primarily by reducing avoidable hospitalizations and emergency room visits for beneficiaries.
How the PCF Payment Model Worked
Unlike the traditional fee-for-service (FFS) model, where providers are paid for each individual service they provide, PCF used a hybrid payment structure. This created a more predictable revenue stream for practices and empowered them to innovate care delivery.
The payment structure consisted of three main components:
- Professional Population-Based Payment (PBP): A quarterly lump sum payment for each attributed patient, adjusted based on the patient's health risk (determined by their Hierarchical Condition Category, or HCC, score). This provided practices with a steady, risk-adjusted payment to cover care management services.
- Flat Primary Care Visit Fee (FVF): A flat, per-visit fee for face-to-face primary care encounters. The patient would still be responsible for the standard 20% coinsurance on the traditional Medicare fee-for-service amount, not the flat fee itself.
- Performance-Based Adjustment (PBA): A quarterly incentive payment, or potential penalty, based on a practice's performance. For most practices, this adjustment was linked to a single utilization measure, Acute Hospital Utilization (AHU), and a set of quality metrics, such as patient experience and management of chronic conditions like high blood pressure and diabetes. Practices that performed well could earn an upside bonus, while those that performed poorly could receive a penalty.
How Patients Were Attributed to PCF Practices
Patient attribution, or the process of assigning beneficiaries to a specific PCF practice, was primarily based on a patient's choice through voluntary alignment using their MyMedicare.gov account. If a patient did not voluntarily align with a practice, CMS used claims data, prioritizing recent Annual Wellness Visits, to determine attribution. It is important to note that beneficiaries whose primary care providers participated in PCF did not see changes to their Medicare benefits, and their ability to choose any Medicare provider was not affected.
The Legacy and Outcome of PCF
While the Primary Care First model has concluded, its evaluation and findings continue to inform future healthcare models. Initial evaluations by independent contractors showed mixed results. While many participating practices made significant changes to care delivery, including expanding care management and integrating behavioral health, the model did not immediately achieve its cost-saving goals. Some evaluations showed an initial increase in Medicare expenditures and high practice attrition rates, primarily due to financial concerns. The PCF model, along with others, has since been succeeded by new initiatives from CMS, such as the Making Care Primary (MCP) model.
Read more about the official evaluation of the Primary Care First model on the CMS website.
Comparison: PCF vs. Traditional Medicare (Fee-for-Service)
| Feature | PCF Program (Primary Care First) | Traditional Fee-for-Service (FFS) |
|---|---|---|
| Payment Structure | Hybrid model with population-based payments and flat visit fees. | Payments for each individual service performed. |
| Financial Incentives | Rewards for positive patient outcomes and reduced avoidable hospitalizations. Potential penalties for poor performance. | Volume-based incentives, rewarding the quantity of services provided. |
| Focus of Care | Proactive, coordinated, and patient-centered care, especially for high-need patients. | Reactive care, typically in response to specific medical issues. |
| Care Coordination | Strong emphasis on comprehensive care management and coordination, often with a dedicated care team. | Less emphasis on coordinated care across different providers and settings. |
| Patient Experience | Includes performance metrics tied to patient experience to drive better service. | Patient experience is not directly tied to provider reimbursement in the same way. |
| Flexibility | Greater flexibility for practices to innovate care delivery, like 24/7 access and enhanced care management. | Limited flexibility; care delivery is dictated by specific, billable services. |
Conclusion
Although the Primary Care First (PCF) program has officially concluded, it was a pivotal step in Medicare's journey toward value-based care. The model's goals of enhancing care quality, improving patient experience, and reducing costs through a hybrid payment system represent a blueprint for future initiatives. For seniors, PCF helped demonstrate the benefits of more proactive and coordinated primary care, a key element of healthy aging. The lessons learned from PCF are instrumental in shaping new models that continue to prioritize patient outcomes and move the healthcare system forward.
