Improved care coordination is an underlying goal of the Primary Care First payment structures recently unveiled by the U.S. Centers for Medicare & Medicaid Services (CMS). Strategic partnerships with primary care providers could be the key for hospice and palliative care providers seeking to capitalize on the emerging payment models.
The U.S. Centers for Medicare & Medicaid Services (CMS) unveiled Primary Care First in April. Hospices and palliative care organizations are eligible to participate in the payment models provided they meet the program’s criteria. The program will be implemented in phases beginning in January of 2020, initially in 26 regions around the country, though CMS eventually expects to expand the program.
Eligible providers have two payment options under the program: A general payment option and a Seriously Ill Population payment option designed to serve patients with complex, chronic needs, for which providers would receive increased payments. Eligible providers, including hospice and palliative care practitioners, can choose to participate in one of those options or both simultaneously.
Hospice and palliative care practitioners may be particularly interested in the Serious Illness Population Model as it aligns with their primary mission of providing person-centered, interdisciplinary care to patients suffering from advanced or terminal illness.
“Care coordination is a real buzzword in primary care first. The health care system is really fragmented, and there are all kinds of cracks for people to fall through,” Brad Stuart the chief medical officer at the Coalition to Transform Advanced Care, in Washington, D.C., and co-author of a Health Affairs study that helped inform the new payment models, told Hospice News. “That’s why I think primary care first is very interesting, because they are promising primary care practices performance bonuses for coordinating care and preventing hospitalization.”
Among the goals of Primary Care First is to create a seamless continuum of care, according to CMS. The payment options also are designed to test whether delivery of advanced primary care can reduce health care costs, asking eligible primary care practices to assume financial risk in exchange for reduced administrative burdens and performance-based payments.
Performance-based payments are a double-edged sword. Health care provider can receive a bonus of as much as 50% of their Primary Care First revenues for strong performance on quality metrics designated by CMS. They can also be penalized as much as 10% of their revenues from the program if they fail to hit those metrics.
The program is oriented around functions of comprehensive primary care, including care management, patient access and continuity of care, comprehensiveness and coordination, patient and caregiver engagement, and planned care and population health.
“Based on the eligibility criteria [CMS] is going to be looking at Medicare beneficiaries who are not experiencing coordinated care,” Allison Silvers, vice president of payment and policy for the Center to Advance Palliative Care. “They are going to be looking for evidence of coordinated care by looking through claims to find beneficiaries who have less than 50% of their visits with a single practice.”
While direct participation in Primary Care First is an option, hospice and palliative care organizations can also partner with participating primary care practices to provide interdisciplinary care and support the practice’s efforts to reduce hospitalizations, while sharing in the payments.
“You can apply independently, but with the way this model is set up it will help to have strong relationships with other practices and providers in your community,” Silvers said. “In particular if you can find a primary care practice to partner with on the application, that might be a great opportunity. To get smart about the model, make sure you have a plan to operate on slim revenues, and know how to be efficient and build relationships with primary care practices in your area.
The focus on care coordination could be a step towards an ultimate goal of system integration, in which health care providers work in close concert, share information and resources, coordinate care and share accountability for patient outcomes.
“The more we get to system integration as the Emerald City on the yellow brick road of care coordination, I think the better of we will be,” Stuart said. “Primary Care First is a step in the right direction to incentivize care providers to do what they know is the right thing and help them to not lose money. They don’t need to have a huge margin, but they have to do well.”