Annie Acs, director of policy and innovation for National Hospice & Palliative Care Organization (NHPCO) recently spoke with Hospice News about the opportunities and challenges for hospice providers navigating towards Primary Care First. Of the payment options that fall under its umbrella, the Serious Illness Population (SIP) model shows potentially the greatest promise for hospice providers. Intended to promote care for high-need, seriously ill Medicare beneficiaries, hospices offering palliative care stand to benefit most from following the SIP model.
Acs will be speaking at the Hospice News Value-Based Care Strategies for Hospice and Palliative Care Summit during the “Navigating the Primary Care First Serious Illness Population Model” session.
With a background in health policy, Acs spent more than eight years at the U.S. Centers for Medicare & Medicaid Services (CMS) working on the Affordable Care Act and health reform provisions, including exchange, eligibility and enrollment. Joining NHPCO roughly a year ago, she serves as the lead for the Center for Medicare & Medicaid Innovation (CMMI) models. As Acs shared with Hospice News, her familiarity with end-of-life care began early on.
What drew you into the hospice and palliative care space?
Hospice holds a special place in my heart — my dad is actually a retired Episcopal priest. Growing up, he was very involved with local hospice organizations. I’ve always really valued that service, and I saw firsthand the importance what an interdisciplinary team looks like for seriously ill individuals.
Among the assortment of models that fall under the auspices of Primary Care First, which do you think holds the greatest opportunity for hospice providers?
It’s important to first differentiate the options provided under the Primary Care First model. Primary Care First model practices have three options that are defined in the request for applications. The first is that providers may choose to purchase a pay-only in the primary care for its general components and not in the SIP component, called Primary Care First general practices. The second is that primary providers may choose to participate only in the SIP component of Primary Care First and not in the general as a SIP-only practice. The third is that providers may choose to participate in both SIP and Primary Care First general components as a hybrid practice.
Hospices providers located in one of the 26 regions eligible for the Primary Care First model can greatly benefit if they chose to participate in the SIP-only practice option or by partnering with a primary care practices to participate under the hybrid practice option. What’s key here is that primary care for SIP and similar models, like direct contracting, are opportunities for hospices to diversify their business relationships with new or different community providers. It also allows hospices to establish relationships with patients suffering from complex illnesses earlier in their disease trajectory.
Can you describe how that model is expected to work?
According to CMMI, the objective of SIP is to identify seriously ill beneficiaries who are experiencing fragmented, uncoordinated care under Medicare fee-for-service, deliver an intensive episodic intervention to stabilize their condition, and then establish a meaningful relationship between the beneficiary and a provider who is accountable for coordinating and managing their care in the long term.
Participating in the Primary Care First general [option] or the SIP program as a hospice provider means that CMS will align chronically-ill and poorly-managed patients directly to you. This could mean that when the patient is ready for hospice, they’ll be much more likely to select the hospice that is already caring for them in these programs.
Providers that are participating in SIP must provide a set of services that are required by the model and includes things like an interdisciplinary care team with a physician, nurse practitioner, care manager, registered nurse, and social worker. It also requires wellness and health care planning, along with family and caregiver engagement with 24/7 access to a member of the care team. There are a lot more details in regards to the complexities of how the model works, but I think the good news here is that hospices already have the proper infrastructure in place to manage seriously ill patients.
Do you think that the Primary Care First models can boost efforts to expand access to financially sustainable palliative care?
It’s a step in the right direction, but SIP doesn’t quite go far enough to boost efforts to expand access to financially sustainable palliative care. To address this, NHPCO, in partnership with the National Coalition for Hospice & Palliative Care, developed a framework to provide community-based palliative care in co-management with other health care providers aimed specifically at improving outcomes and the experience of care and reducing unnecessary or unwanted emergency department visits and hospitalizations for high-risk patients.
Right now, in order to offer community-based palliative care, providers must access this kind of patchwork of limited reimbursement options mostly focused on physician and nurse practitioner visits, which forces many providers to fund the full array of interdisciplinary services. Our proposed model would establish a payment structure to define and pay for a comprehensive community-based palliative care benefit. Amid the current coronavirus pandemic, that type of personalized care in wherever a patient calls home is in greater demand and more critical than ever.
What drawbacks or limitations do you see in these models?
Primary Care First is limited to beneficiaries in 26 regions who show evidence of care fragmentation or high-utilization, and I think COVID-19 has caused massive disruptions to care in all states with a high complication rate for related hospitalizations, so region is definitely a limitation.
Primary Care First is also a transitional model that lacks the interdisciplinary, holistic care. Once transferred to a primary care provider, the sick patient loses 24/7 access to a provider and that interdisciplinary team and palliative care expertise.
Another limitation to highlight is that SIP waits for evidence of emergency department and hospital utilization for management of chronic conditions and it misses a prevention opportunity, creating a missed opportunity for higher-quality care and reduced costs when intervention does not occur until patients are already unnecessarily utilizing the emergency department.
If you would have a wish list, what would you change?
In terms of my wish list, the first change would be to expand the geography to all 50 states. It’s a change to the model that we thought would occur, given the widespread impact of the current pandemic. Particularly since the early hotspots of COVID-19 did not overlap with many of the regions that are included in the Primary Care First SIP model. NHPCO would like to eliminate restrictions based on care fragmentation and create access to SIP co-management support. So, even for patients with a stable primary care physician or other provider, we would like to require that at least one team member has specialty training in hospice and palliative care to better ensure adherence to best practices.
Another wishlist item would be to eliminate the frailty requirement to ensure engagement before use-patterns lapse to a point where the patient is using the hospital and emergency department to manage their chronic progressive condition. Right now, we wait until someone’s drowning until we intervene, and NHPCO would really like to pull those interventions further up the care continuum.
A few more things to eliminate would be the transition requirement to ensure that patients receive appropriate support through the end of life, enhanced telehealth capabilities — especially since this has proven to be effective during the pandemic, and increasing payment amounts to allow for engagement with caregivers and for the delivery of enough service to impact the outcomes.
Have providers had a sufficient opportunity to prepare to participate in these models during the pandemic?
Interest and engagement from providers in preparing for primary care for the seriously ill population predates the pandemic. Many of them have been building upon their previous experience with value-based care, and NHPCO has been in close partnership with those who are choosing to participate and make sure they’re ready. The delayed start of the SIP component until April, 1, 2021, is a helpful and needed flexibility during a time when all hands are on deck to care for seriously ill individuals, including those with COVID-19.
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