Hospice and palliative care providers who opt to participate in Medicare’s new Primary Care First Models would have to apply to Medicare Part B in order to receive reimbursement, the agency announced in a webinar providing new details on the program’s Seriously Ill Population (SIP) payment option. A participating hospice would be considered a physician practice under the model.
The U.S. Centers for Medicare & Medicaid Services (CMS) in April announced that they would implement Primary Care First in phases beginning in Jan. 2020, initially in 26 regions throughout the United States. Hospices and palliative care organizations are eligible to participate in the payment models provided they meet the program’s criteria. The program is designed to control costs, reduce avoidable hospitalizations and improve care coordination.
Eligible providers can choose to participate in one or both of two payment options under the program: A general payment option and the SIP payment option designed to serve patients with complex, chronic needs, through which providers focused on caring for that population would receive increased payments.
“SIP aims to fill gaps in care for patients that are complex and chronic or are otherwise seriously ill or in decline,” said Gary Bacher, chief strategy officer for CMS Center for Medicare & Medicaid Innovation (CMMI), in the webinar. “It’s aimed at people who seem to be in need of these services in terms of having a care pattern that suggest fragmentation, and who are not otherwise aligned or enrolled in a different organized system of care or model where the incentives to provide the kind of care we aim for in SIP are already present.”
To determine which patients are eligible, CMS will use claims data to identify beneficiaries in designated service areas who meet one of these criteria: They exhibit a fragmented pattern of care in which no single practice accounts for half or more of the patients’ visits, high rates of hospitalization or emergency department visits, and the patients’ conditions must meet the agency’s definition of serious illness.
To be classified as a patient with a serious illness under the Primary Care First Model, the patient’s health status must be medically complex, have high rates of hospital utilization or show signs of frailty as indicated by medical equipment usage claims such as the use of transfer equipment or a hospital bed.
Improved care coordination is a key goal of Primary Care First. The program is transitional, and providers can receive payments through SIP for a particular patient for a maximum of 12 months. Participating health care organizations are expected to clinically stabilize patients and then transition them into a more longitudinal care setting, be it a primary care practice, an accountable care organization, a participant in CMS new direct contracting model, a Medicare Advantage plan, or to a hospice if the patient’s life expectancy is six months or less.
“SIP hopes to address fractured, siloed care which often leads to a patient experience of poor coordination, difficulty for patients to navigate the care plan — if they have a care plan — and patients that often undergo care they don’t want or receive unnecessary treatments,” said CMMI Chief Medical Officer Michael Lipp in the webinar. “This offers patients a high-touch intensive intervention to coordinate and stabilize the patients, helps manage their symptoms, helps develop care plans and ultimately transitions them to a practice and provider than can take responsibility for their longer term care needs.”
Among the program’s goals are reducing hospitalizations, emergency department visits and specialist visits as well as associated costs and increased patient satisfaction.
If a hospice can navigate the program’s eligibility requirements, such organizations would be well-suited to provide the type of care the SIP model is designed to promote, as the criteria for care align well with the hospice model.
The program requires participating health care organizations to provide an interdisciplinary care team that includes a physician or nurse practitioner, care manager, nurses, and social workers, with the option to include chaplains and other professionals. Participating organizations must be capable of providing comprehensive person-centered care management that includes the ability to assess the patient’s social needs. They must also display relationships with community resources to address social determinants of health, ensure patients and families have 24/7 access to providers, promote high levels of patient and family engagement, and complete advance care planning.
The payment structure includes a $325 flat fee for the initial visit with the patient, which will not be geographically adjusted. Following that, the provider would receive $275 per patient per month, with a portion withheld for quality purposes. Patient visits would be reimbursed at a base rate of $50.52. CMS would also apply a quality adjustment, adding or subtracting $50 to or from payments based on performance on certain quality measures.
CMS indicated that it would provide more details on the quality withholding in coming weeks.
The agency will identify eligible patients through analyzing claims data against the three criteria: hospital utilization, fragmented care, or frailty. This method could come with complications.
“There’s limitations to what claims can tell you. They are going to miss a lot of people who could benefit from this, and there are going to be delays,” Allison Silvers, vice president of payment and policy for the Center to Transform Advanced Care told Hospice News. “I do understand why they are doing this. They are taking the claims and identifying eligible beneficiaries because they need a control group in order to evaluate the program, and if they accept patients through physician referrals they are not going to be able to get a control group.”
After identifying patients via claims data, CMS would send providers a list of SIP-eligible patients within their geographic service area. The provider would make contact with the patient, ideally within 24 hours, but no longer than 60 days, according to CMS. The agency would confirm timing of first contact through claims for initial face-to-face visits.
Providers, including hospices and palliative care organizations, will be able to apply to the Primary Care First program for a two-month period expected to begin later this summer. The program will launch on Jan. 1, 2020. The focus will be on provider and patient onboarding for the first quarter, with the new payment system becoming effective in April 2020.
“CMS wants to strengthen primary care. There is no one move that would create savings more quickly than incentivizing primary care practices to share in more of the responsibility and share in more of the payment for taking care of patients within the practice,” Brad Stuart, M.D., chief medical officer at the Coalition to Transform Advanced Care, told Hospice News. “What they haven’t said out loud yet is that they would love to see primary care do more and not refer every single patient with heart failure to a cardiologist, for instance.”
