Last Updated 7/31/2019
Aligning Payment with Quality
Primary care is the front line of Oregon’s health system, and the Oregon Health Authority (OHA) is working with public and commercial payers across the state on payment reform initiatives that move from volume to value and away from fee-for-service. In 2015 the Oregon Legislature signaled its commitment to primary care payment reform by enacting Senate Bill 231. This legislation mandated the following:
- Primary Care Spending Report: OHA and the Department of Consumer and Business Services (DCBS) report the percent of health care expenditures allocated to primary care by prominent carriers, coordinated care organizations and PEBB/OEBB.
- Primary Care Payment Reform Collaborative: The objective of the collaborative is to allow participants to share best practices that support innovation and improvement in primary care and to work together to seek alignment and agreement around primary care reimbursement to help improve population health, patient care, and control health care costs across Oregon. This collaborative is building on previous consensus-based strategies agreed to by payers and other key partners convened by OHA and the Oregon Health Leadership Council in 2013.
Current Payment Incentive Opportunities for Patient-Centered Primary Care Homes
Public Employees' Benefit Board
The Public Employee's Benefit Board (PEBB) provides an age-adjusted, per-member-per-month incentive payment to recognized primary care homes in the PEBB Statewide plan, administered by Providence Health Plan. In addition, PEBB members in the PEBB Statewide plan have lower cost share for primary care services when they access care through a recognized primary care home - from 15 to 10 percent.
Coordinated Care Organizations
Beginning in 2020, Coordinated Care Organizations (CCO) will be required to provide per-member-per-month (PMPM) payments to PCPCH clinics in their network as a supplement to any other payments made to PCPCHs, such as fee-for-service or VBPs. PMPMs will vary by PCPCH tier level and increase each year over a five-year contract.
Please check with your CCO representative for more information and to inquire about other value-based payments that may be available.
Aetna's Patient Centered Medical Home (PCMH) recognition program offers per-member-per-month payment incentives using the PCPCH tiers, and is available to physician practices in Oregon that meet certain criteria: directly contracted with Aetna; received recognition by the NCQA or by the State of Oregon Patient-Centered Primary Care Home program as a PCPCH; have 10 or more attributed Aetna members; and be reimbursed at 100% of the Aetna Market Fee Schedule. Questions about this program can be directed to Denise Casner, Network Manager, at 503-937-0621, or by email to Denise.Casner@aetna.com.
Federal Payment Initiatives for Primary Care
The Affordable Care Act Section 5501(a) created the Primary Care Incentive Payment program to offer an incentive payment to qualifying primary care physicians and non-physician practitioners who furnish primary care services to Medicare patients. To be eligible for the incentive payment, qualifying services must be rendered between January 1, 2011, and December 31, 2015. Providers in Oregon received approximately $5.1 million under this program in 2012.
Comprehensive Primary Care Plus (CPC+)
Oregon was one of fourteen regions selected by Centers for Medicare and Medicaid Services (CMS) to participate in this multi-payer advanced medical home model offering an innovative payment structure to improve healthcare quality and delivery. This five-year federal program began in January 2017 and ended in in December 2021, building on the Comprehensive Primary Care Initiative (CPC) which ended in December 2016. Please note that no new clinics are eligible to apply for the program at this time.
Nearly 70 primary care clinics in Oregon participated in CPC+. Visit OHA's Transformation Center CPC+ Primary Care Initiative for a list of the public and commercial payers in Oregon that participated and further information about the program.
Primary Care First (PCF)
Primary Care First (PCF) is a six-year program offered by Centers for Medicare & Medicaid Services (CMS) providing an innovative, value-based payment structure that rewards clinics for delivering advanced primary care. It is based on the principles underlying the Comprehensive Primary Care Plus (CPC+) model design.
There are over 100 primary care clinics in Oregon participating in PCF. Practices fall into two cohorts each participating in the model for five years – one from 2021 through 2025 and a second from 2022 through 2026. Visit CMS's Primary Care First webpage for further information about the program and a list of participating practices and payers. Please note that no new clinics are eligible to apply for the program at this time.
The Affordable Care Act also directed a temporary increase for primary care physicians who saw Medicaid patients in 2013 and 2014. The increase in payments brought Medicaid primary care service fees in line with those paid by Medicare. The extra payments were intended to encourage primary care physicians to provide more checkups, preventive screenings, vaccines and other care for Medicaid beneficiaries. States received 100 percent federal matching funds for the increase in payments.
Medicaid Affordable Care Act Section 2703 payments
The time-limited supplemental payments available through the Affordable Care Act Section 2703 for recognized primary care homes ended September 30, 2013. Primary care homes were eligible for enhanced payments under a provision of the ACA from October 2011 through September 2013. Please note that these payments are no longer available and all 2013 patient lists must have been submitted by December 31, 2013.