Hospices to Adapt to Primary Care Role Under Direct Contracting

Hospices nationwide have been diversifying their services in recent years to capitalize on value-based payment models and to establish relationships with patients further upstream in the course of their illnesses. An increasing number of hospice providers are offering PACE, home-based primary care, and palliative care, among others. These programs will be essential for those considering direct contracting.

As the April 1 implementation date for the direct contracting models approaches, participating hospices are gearing up to take total responsibility for a patient’s care potentially long before they enter the last six months of life.

“What direct contracting offers is the chance to serve as the main point of contact and the main primary care provider for those patients, and also to take on the total cost of care responsibility for those patients,” Jacqueline Kimmell, director of population health strategy Capital Caring Health “This is the future. It’s seeing that patient day after day after day, caring for them over the course of their lifetime.”


Direct contracting includes three payment model options that are designed to help the U.S. Centers for Medicare & Medicaid Services (CMS) and health care providers reduce the cost of care and improve quality. The models incorporate lessons learned from other programs such as Accountable Care Organizations, the Medicare Shared Savings Program, and Medicare Advantage.

The direct contracting models, announced in conjunction with the Primary Cares initiative, were initially slated for a Jan. 1 implementation date but were delayed until April 1 due to the coronavirus pandemic. An additional program under Primary Cares is the Serious Illness Population model, which CMS recently postponed indefinitely.

Direct contracting as it was first designed was only available to large practices caring for more than 5,000 patients. Later, the Center for Medicare and Medicaid Innovation (CMMI) created a pathway in the first year for smaller organizations with a threshold of 250 patients. This is designed to address a high-needs population, which the agency defines as patients with a hierarchical condition category (HCC) score greater than 3, or a lower HCC score with multiple unplanned hospital admissions and demonstrated frailty or disability.


Empath Health and Stratum Health, parent companies of Suncoast Hospice and Tidewell hospice, respectively, are considering applying to the high-needs direct contracting program. Empath and Stratum are in the last phases of completing a merger. The combined organization will provide hospice, private duty, skilled home health care, physician services, palliative care, primary care, a PACE program and an HIV medical clinic.

As Empath-Stratum mull their options related to high-needs direct contracting, they are focusing a lot of attention on their PACE program as a cornerstone for their participation in that model.

“When you look at the tenets of a model like direct contracting, you look at that emphasis on the chronic, the frail, and those with advanced illness,” Rafael Sciullo, president and CEO of Empath Health, told Hospice News. “You have the [patient] population fit for us. Then you look at the focus on primary care, and certainly Stratum has been a leader in that. PACE has really prepared us in many ways for that whole element of risk management and providing the best care at a contained price.”

PACE programs represent a comprehensive approach to care for participants who meet certain eligibility criteria, generally those who have significant medical and non-medical needs to help them age in place and avoid hospitalizations or nursing facilities.

PACE program staff assess each patient upon admission and develop a care plan. Services available at the joint venture’s center will include primary care from a physician, social work and nursing support, occupational and other therapies, as well as homemaking, transportation, home modification and other services.

The very nature of the direct contracting models requires care to move further upstream.

“This is a home-based primary care program. This is not a palliative care program. You are providing, like in a PACE model, comprehensive care to these patients,” Bob Tavares, chief strategy officer for the health care analytics firm Cyft, said. “A lot of [hospice] organizations don’t have that today, but recognize that it is in their best interest to start moving in that direction.”

Within the direct contracting models, providers bear 100% of the risk associated with eligible patients for the global option or 50% risk with the professional option. Contracted agencies would have to choose between a Total Care Capitation option or a Primary Care Capitation option. This would be a capitated, risk-adjusted monthly payment for enhanced primary care services equal to 7% of the total cost of care.

Taking on this role may require some retooling for hospice providers. Clinical staff must understand how to manage patients with serious illness across health care settings, and business staff must know how to operate and bill for primary care programs. Negotiation with payers to develop value-based contracts is also an essential skill that hospices must develop in order to be successful in the program.

One key advantage that hospice providers have is expertise in treating seriously ill patients in the home setting.

“This model really speaks to them leveraging their expertise and then leveraging on the opportunity to innovate,” Carole Fisher, president of the National Partnership for Hospice Innovation, told Hospice News. “Providing care in the home sounds simple, but it’s not. There’s a lot of variables.”

In addition to leveraging existing skillsets and developing new capabilities, a shift in perspective may also be necessary for hospice providers.

Historically some providers have seen new service lines such as palliative care as a potential source of referrals for their legacy hospice business. They engage the patient further upstream in their illness trajectory and eventually transition them to hospice when they become eligible. This may not be the case for direct contracting-oriented programs. Some, perhaps many patients, would not be moving into hospice when they reach the last six months of life.

“It’s a unique and time-limited opportunity to go after this large pool of patients to provide upstream care,” said Leonard D’Avolio, CEO and co-founder of Cyft. “But it reduces the incentive for them to send people over to hospice if they believe they can provide adequate care with the existing care team and and maintain those revenues and control.”

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