Many hospices during the past two years have been preparing for participation in the Center for Medicare & Medicaid Innovation’s (CMMI) Primary Care First Serious Illness Population payment model. Now that the U.S. Centers for Medicare & Medicaid Services (CMS) has delayed the program indefinitely, providers are assessing the impact of late implementation on their business.
CMS has not announced a new start date for the program, leaving some doubt as to whether it will move forward at all. The agency indicated the delay in a note on its Primary Care First website, promising more information in the near future. CMS has not made any statement as to the reason for the new delay, whether the decision is due to the pandemic or whether it represents a policy change under the new Biden Administration.
“The Primary Care First Model’s Seriously Ill Population component is currently under review, and will not begin on the previously announced April 1, 2021 start date. CMS looks forward to sharing additional information when available,” CMS noted on its website.
The model had previously been delayed from Jan. 1, 2021 to April 1, on the grounds that providers have not had sufficient time to prepare due to the need to focus on the COVID-19 pandemic.
The Serious Illness Population model is aimed at promoting care for high need seriously ill beneficiaries, who lack a primary care practitioner and receive fragmented care coordination. CMS anticipates that this would account for roughly 2% to 3% of Medicare beneficiaries. The program is designed to control costs, reduce avoidable hospitalizations and improve care coordination.
Hospice providers have been re-examining their business and clinical operations to gear up for the Serious Illness Population model, which many believed to be the most promising for hospices among the new payment models that come with Primary Care First and direct contracting.
“Too many patients with serious illness also suffer the added burden of fragmented care. We believe that programs like SIP take a step in the right direction to provide improved access to the benefits of coordinated, patient-focused care,”said Mary Ann Boccolini, president and CEO of the hospice and palliative care provider Samaritan. “Advancing towards more value-based care and reimbursement models is essential to providing high-quality, cost-effective care for our growing aging population.”
To prepare for SIP, hospice providers have invested in new technologies, including interoperable electronic health record systems and predictive analytics platforms. In some cases they have launched new lines of business such as palliative care or home-based primary care.
Despite these efforts, hospice leaders are taking the delay in stride, as they are able to leverage those same investments to support other aspects of their businesses. For now, many believe that the delay will not ultimately lead to the complete cancellation of the program.
“Hospice of the Piedmont is continuing to work with local providersin preparation for the demonstration,” Mike Smith, CFO of Hospice of the Piedmont, told Hospice News. “Even if [the model] doesn’t come to fruition, which I hope it does, we’re going to continue to serve or work with our community partners and better serve those in need in our area.”
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.
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.
“We believe these models will benefit patients with advanced illness through improved access to high-quality, cost-effective and coordinated care, including primary care at home, palliative and hospice services,” Boccolini said. “We appreciate the work of CMS and the opportunity to participate in validating these new models that support the care our patients need.”
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