Medicare Compliance & Reimbursement

Recent payment models offer primary care, behavioral health expanded options.

Not only did the pandemic shed light on the healthcare industry’s systemic issues with equity, but it also reminded many how critical a role primary care providers play and how important behavioral healthcare is for patients across all walks of life. Read on for a breakdown on three new payment models that aim to improve care and offer Medicare providers new opportunities.

1. Whole-person care is at the center of the IBH Model. In January, the Centers for Medicare & Medicaid Services (CMS) announced the Innovation in Behavioral Health (IBH) Model. The CMS Innovation Center will test the model, which will focus on gaps between physical and behavioral health and will be facilitated in the field via interprofessional care teams.

“The systems of care to address physical and behavioral health conditions have historically been siloed, but there is a direct correlation between people with mental health conditions or substance use disorder and poor physical health,” asserts CMS Deputy Administrator and Innovation Center Director Liz Fowler in a release. “This model will bring historically siloed parts of the health system together to provide whole-person care – designed to keep people out of the emergency department, ensuring better care management and coordination, and improving their overall health.”

Community-based providers and organizations — both public and private — will be the primary participants in the IBH Model. They will be incentivized “to work collaboratively to screen, assess, and coordinate between individuals’ physical and behavioral health needs,” CMS says.

The agency will build on existing infrastructure, utilize health IT, and align the IBH Model with its “whole-person care” approach outlined in the CMS Behavioral Health Strategy.

“While the IBH Model is limited to Medicaid and Medicare patients, it is likely that commercial payers may follow suit with similar programs, particularly if CMS shows successful outcomes,” predict attorneys Alexandra B. Maulden and Hannah E. Zaitlin with law firm Foley & Lardner LLP in online legal analysis.

The IBH Model is slated for a fall 2024 start date and is scheduled to operate for up to eight years in at least eight states.

2. Competition and quality center around the new ACO PC Flex Model. Since the feds announced the HHS Initiative to Strengthen Primary Care, CMS has issued a plethora of policies and reforms. In March, CMS premiered the ACO Primary Care Flex Model (ACO PC Flex Model), which applies to primary care providers operating via Accountable Care Organizations and will be tested through the CMS Innovation Center within the Medicare Shared Savings Program (MSSP). A key component of the model will include a “a one-time advanced shared savings payment and monthly prospective primary care payments (PPCPs) to ACOs” to help with set up and ongoing resources, CMS says a fact sheet.

“People whose primary care provider participates in the ACO PC Flex Model may get care in more convenient ways, like care based at home or through virtual means, extra help managing chronic diseases, and more preventive health services to keep them healthy,” said CMS Administrator Chiquita Brooks-LaSure in a release. “Not only will people with Medicare receive more coordinated, seamless care that addresses their unique needs, but CMS is supporting primary care clinicians and giving them more flexibility to provide person-centered care.”

Smaller, low-revenues ACOs made up mostly of physicians will be the centerpiece of the new model, CMS indicates. The ACO PC Flex Model is voluntary and will run for five years, and CMS hopes to work with 130 ACOs via the program, which is scheduled to begin on Jan. 1, 2025. Applications for new and/or existing ACOs will be open from May 20, 2024 through June 17, 2024.