Health Experts Propose Alternatives to Using Claims Data for Primary Care First Eligibility

As the U.S. Centers for Medicare & Medicare Services (CMS) prepares to launch the Primary Care First Seriously Ill Population payment model in 2020, the agency should consider mining data from the home health care population to identify eligible patients rather than claims data, a group of physicians argue in a recent editorial in Health Affairs. 

Hospice providers and palliative care clinicians are eligible to participate in Primary Care First, which in addition to the Seriously Ill Population model includes a general primary care model. CMS in April announced that they would implement the new models in phases beginning in Jan. 2020, initially in 26 regions throughout the United States. The agency designed the program to reduce costs, avoid hospitalizations and improve care coordination.

Hospices can participate in the program directly or they can partner with other providers, such as primary care physicians, to support their seriously ill patients and share in the payments. The models present an opportunity for hospices to engage with patients earlier in the care continuum, and some have posited that it could be a pathway towards making palliative care profitable.


“The intention is to try to improve the coordination of care in the hopes that this leads to improved quality of care overall for these patients,” said Pedro Gozalo, professor of health systems, practice and policy at Brown University. “They are trying to bring down the cost and improve the quality of care for these participants by offering a value-based payment system as well as requiring a little bit less administrative burden so providers can devote more time to actual patient care.” 

CMS has indicated that it would identify patients who can benefit from the Seriously Ill Population model by analyzing claims data. The agency will be seeking Medicare beneficiaries suffering from late-stage chronic illness that threatens health and impairs the patient’s ability to function. These patients represent an estimated 4% of beneficiaries but account for 25% of Medicare costs, research indicates.

“CMS will be looking through claims looking for beneficiaries who have less than 50% of their visits with a single practice, and then on top of that they will be screening for certain diagnoses or indicators of frailty, which is not ideal,” Allison Silvers, vice president of payment and policy for the Center to Advance Palliative Care, told Hospice News. 


However, better methods may exist, Gozalo and his co-authors argue. They proposed that CMS mine data from the comprehensive assessments that home health care patients receive at admission, which would provide clearer details of the patients’ conditions among a population that has a higher proportion of seriously ill individuals. The assessments contain details such as identified co-morbidities, pain levels and indicators of physical and cognitive functioning. 

“Those sorts of information are missing from claims. When starting something like this it would be helpful if they tried to be more careful in targeting the population, increasing the chances that the model will succeed,” Gozalo said. “By the fact that these people that require home health, that’s already indicating that this is a population that is at risk for poor outcomes and potentially avoidable hospitalizations and would likely benefit from improved care coordination.”

The authors further proposed that CMS consider lessons learned through the establishment and evolution of the Medicare Hospice Benefit, a model designed in the early 1980s, also to improve care and reduce hospitalizations and other aggressive, more expensive treatments. At the time, more than 90% of hospice patients suffered from cancer, and according to Gozalo the benefit was designed around care for that population.

“When they rolled out the hospice benefit, cancer patients were the ones they primarily targeted, but now we all recognize that hospice has a role in types of care that is delivered to patients suffering from all kinds of diseases, and the benefit is still in line with the cancer patient trajectory of care,” Gozalo said. “We are trying to bring up some of these lessons so that when they roll out these alternative payment models they are careful that they don’t target the payment to patients experiencing a particular condition.”

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