CMS Outlines Patient On-boarding in New Serious Illness Payment Model

The U.S. Centers for Medicare & Medicaid Services (CMS) has unveiled its process for identifying and on-boarding patients who are eligible for coverage under the Seriously Ill Population (SIP) payment model, part of the Primary Care First initiative. However, hospice organizations continue to seek additional answers about the workings of the model.

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.


“[The SIP component] is aimed at promoting care for high need seriously ill population beneficiaries, who lack typically a primary care practitioner and more effective care coordination,” said Gary Bacher, chief strategy officer for the Center for Medicare & Medicaid Innovation, in an Oct. 31 CMS webinar. “We are expecting that [the SIP model patient population] will account for roughly 2% to 3% of Medicare beneficiaries. SIP is aiming to address situations where there’s either fragments that are siloed care, or lack of care management. And then the expectation is as these things are existing, we have higher health care costs, lower quality and lower patient satisfaction than otherwise would be necessary and we are seeking to improve that.”

CMS would identify eligible patients according to three criteria as reflected in Medicare claims data. First, claims data would show that the patient has multiple co-morbid conditions or high disease burden as well as two or more unplanned hospitalizations within the last 12 months, or evidence of frailty.

Second, the patient must show patterns of care fragmentation as evidenced by proportion of the visits without having one practice or 10 that’s providing the majority of patient care or utilization patterns between the past 12 months of either emergency department visits or hospital visits.


Finally the model will exclude beneficiaries already attributed to providers operating within a value based arrangement, like an Accountable Care Organization or organizations that participate in CMS’ Comprehensive Primary Care Plus program.

“We also recognize that there are limits to what we can identify us and claim so we will be allowing referrals on a case-by-case basis for patients that needs certain clinical criteria,” CMMI Chief Medical Officer Michael Lipp said in the webinar. “This may include items such as the presence of clinical deterioration, evidence of frailty using one of the standardized clinical assessment tools, or evidence of social isolation.”

After CMS or their designated agent identifies and validates that patients are eligible, they will conduct outreach to solicit their interest in participating. If the patient opts in, CMS will notify the health care organization, which will be charged with contacting the patient as soon as possible, within a maximum of 60 days. Attribution begins after the patient’s first face-to-face visit with the health care provider.

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.

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.

Though CMS is now accepting applications to participate in the agency’s new Primary Care First payment models, the agency has delayed the program’s launch to 2021, as opposed to the original Jan. 1, 2020 date.

CMS moved the start date to allow stakeholders more time to consider participation, a decision that requires practices to assume risk in exchange for outcomes-based rewards, a CMS spokesperson said in an e-mail to Hospice News. The delay also helps practices prepare for participation by allowing them additional time to move away from a fee-for-services (FFS) structure, according to CMS.

CMS offered up new details in the Oct. 31 webinar, but some say not quite enough. Questions still linger around how the models will work even as hospices and other providers begin applying for the program.

“We continue to be concerned by the scant operational details that have been shared about this important model. CMS noted they would share more details in 2020,” Edo Banach, president of the National Hospice & Palliative Care Organization (NHPCO) told Hospice News. “With the application deadline being Jan. 22, 2020, NHPCO continues to have concerns about information that is needed by the provider community to apply, participate, and succeed.”

One of the key outstanding questions is what entity will actually identify and make first contact with the patients, as it is unlikely that CMS workflows and processes will allow the agency to do this directly. Hospices and other providers are wondering if CMS will contract a third party to fulfill this function and, if so, who that might be.

Much will depend on the initial contact with the patient, because it will involve a sensitive conversation that will include a great deal of education about the patient’s condition, the SIP care model, and the potential benefits to the patients.

“Any process in which there is going to be that many steps between the patient and the people who are ultimately going to be providing care causes a little trepidation about the patient ultimately choosing and getting the care,” Mollie Gurian, director of hospice, palliative and home health policy for LeadingAge, told Hospice News. “It’s still not clear whether they’re planning to hire a contractor or how they’re planning to actually do the initial outreach. It’s going to be really critical that the people who are doing the outreach have the training to conduct those critical conversations that will make or break whether this kind of model can work. That initial conversation and describing the kind of care they would receive will make a huge difference as to whether or not people accept the care.”

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