CMMI Strategy Officer: Private Sector Will Emulate Primary Care First

A key goal of the Center for Medicare & Medicaid Innovation’s (CMMI) Primary Care First payment models is to create a “spectrum of models” to support patients suffering from serious illness from diagnosis through end of life. In addition to these government programs, the agency foresees that health care providers — including hospice and palliative care organizations — will work with payers to develop similar programs in the private sector, CMMI’s Chief Strategy Officer Gary Bacher told the attendees of the Coalition to Transform Advanced Care (C-TAC) National Summit on Advanced Illness Care in Minneapolis. 

Bacher made the comments in response to a question from C-TAC co-founder Tom Koutsoumpas.

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.

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Ultimately, CMMI anticipates that private sector payers as well as health care providers will begin to develop their own payment models designed around patients who suffer from chronic, serious or advanced illness.

“There is a recognition of this model of care as well as the need to support this population, and so we would expect that there will be many arrangements between organizations that increasingly specialize in this population to work with other private sector organizations, to work with the Medicare Advantage organizations, or by working with [accountable care organizations],” Bacher said. “It’s not all just about the models; it’s also about how we catalyze the work of people and providers who specialize in this kind of care.”

Under Primary Care First, eligible providers can choose to participate in one or both of 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, through which providers focused on caring for that population would receive increased payments.

The Seriously Ill Population option is designed to promote coordinated, patient-centered interdisciplinary care, very similar to the hospice care model. Hospices who have diversified their services to include pre-end-of-life care such as palliative care programs or home-based primary care have the experience and expertise to provide this kind of care

An estimated 4% to 6% of the combined Medicare and Medicare population will be eligible to receive care via Primary Care First programs, which is comparable to the Medicare decedent rate. The program will not require participating providers, including hospices, to obtain a referral. Nor will it require a six-month terminal prognosis.

“The needs and preferences for those with advanced or serious illness will be met in the place and in the manner that is comfortable for each person. That’s likely in most cases — but not all cases — going to be the home, and it’s very important that we and the care models that we are developing recognize the special needs of people suffering from advanced illness,” Bacher said. “There is no single model, no single provider, no single site of care that can do it all … We envision this as a spectrum. We don’t want model silos. We want to make sure there is a connection point between these models, but that all of them reflect how we can best meet the needs of people with advanced and serious illness, how do we make sure that the models can help provide the right incentives and the right support in order to support that population.”

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