The connection between behavioral health and physical health is well-documented. Physical health is greatly affected by such behaviors as smoking, substance abuse, poor diet, lack of exercise, insufficient sleep, etc. In addition, mental health issues and social determinants of health (SDoH), such as lack of housing and/or transportation, language barriers and food insecurity, impact health.
In an effort to more closely integrate behavioral health into primary care for these populations, the Centers for Medicare and Medicaid Services (CMS) has created a primary care reimbursement model to promote a more equitable, innovative, and team-based approach. Launching Jan. 1, 2025, the voluntary ACO Primary Care (PC) Flex Model aims to address health equity and drive better outcomes for underserved populations by increasing access to higher-quality primary care, including unique services, such as behavioral health integration. CMS hopes it will grow participation in ACOs and the Medicare Shared Savings Program.
The model’s new Prospective Primary Care Payment (PPCP) option will shift reimbursement for primary care away from the fee-for-service, visit-based payment model, which should be attractive to low-revenue ACOs with Federally Qualified Health Center and Rural Health Clinic participants.
Here’s how it works: An ACO’s PPCP rate won’t be based on the ACO’s historical spending, but on the average primary care spending in the county in which it’s located. This allows the model to pay an ACO the same rate for a specific patient in a region, before considering social and clinical risk factors. As a result, providers with patterns of inappropriately low spending for underserved areas and populations can be paid more. The PPCP also includes payment enhancements and adjustments to the county rate, providing additional resources to providers caring for underserved populations.
