The U.S. Center for Medicare & Medicaid Services (CMS) will not move forward with the Seriously Ill Population (SIP) component of the Primary Care First initiative. The move follows the Biden Administration’s ongoing review of Trump-era policies.
CMS announced Primary Care First in April 2019 and is implementing the models in phases, 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. The general primary care component launched in January.
In canceling the SIP payment option, CMS cited potential challenges in identifying and aligning these beneficiaries with the right providers.
“After careful review, the agency has determined that the proposed outreach method in the Primary Care First Seriously Ill Population (SIP) Model, which was designed to comply with statutory privacy protections for Medicare patients, is unlikely to result in sufficient beneficiary uptake to allow for model evaluation,” a CMS spokesperson told Hospice News.
According to CMMI, the objective of SIP was 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.
CMS had planned to identify eligible patients according to three criteria as reflected in Medicare claims data. Eligible patients would have multiple co-morbid conditions or high disease burden as well as two or more unplanned hospitalizations within the previous 12 months, or evidence of frailty.
Second, the claims data would have to show evidence of care fragmentation based on utilization patterns during the prior year. Finally, the model would have excluded beneficiaries already attributed to providers operating within a value-based arrangement.
After CMS or their designated agent identified and validated that patients were eligible, they would conduct outreach to solicit their interest in participating. If the patient opted in, CMS would notify the health care organization, which would have been charged with contacting the patient as soon as possible, within a maximum of 60 days.
A third component of Primary Care First is a set of direct contracting models. The first year of the program launched in April, following a delay prompted by the COVID-19 pandemic, but CMS announced early in 2021 that the geographic direct contracting option would also be subject to review. The agency suspended the application process for the 2022 participation year. Thus far, CMS hasn’t announced a decision on the future of that model.
While the SIP is not going forward, CMS has not ruled out retooling or redesigning aspects of the program for a future demonstration.
“CMS is exploring the development of additional models that complement the existing portfolio, with the goal of filling gaps that are not addressed by current models,” the agency’s spokesperson said. “As part of the Innovation Center’s strategy refresh announced in October, CMS is re-examining our approach to addressing the needs of the seriously ill population and soliciting stakeholder perspectives on ways that future models could effectively improve the quality of care for this vulnerable group.”
