Primary Care First is on its way to opening doors for hospice providers to reach patients and their families further upstream in their health care trajectories. While the implementation of some aspects of the initiative have been delayed, the application period for the program’s second year is underway. Tracking patient outcomes through data and workflow processes will be crucial for hospices looking to participate in this bundle of payment models, which could offer new revenue streams and referral relationships.
The U.S. Centers for Medicare & Medicaid Services (CMS) announced in April 2019 plans to begin Primary Care First, a program designed to control costs, reduce avoidable hospitalizations and improve care coordination for patients and their families. CMS is accepting applications for Cohort 2 until April 30, which are now available on its website.
Hospices and palliative care organizations are eligible to participate in the payment models provided they meet the program’s criteria. Primary Care First payment models are anticipated to make waves throughout the health care system.
“Primary Care First should have huge impacts and be a huge opportunity for hospice,” said Jeremy Powell, CEO of Acclivity Health Solutions. “Hospices should really see an impact because they can partner with the traditional primary care practices within their market. The practices are on the hook for total cost of care, but hospice agencies are the ones that are already really good at leveraging the hospice benefit. Their patients are so often right at the precipice of hospice, and providers get time to build trust and rapport in that program.”
Strategic partnerships with primary care providers could be the key for hospice and palliative care providers seeking to capitalize on the emerging payment models.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.
Primary Care First is being offered in 26 regions across the country and includes two cohorts of participating practices. Cohort 1 began in January, and Cohort 2 will start in January 2022. According to recent data from CMS, more than 800 practices and 14 payer partners are currently participating in Cohort 1, including Medicare Advantage plans, state Medicaid agencies and Medicaid managed care plans, as well as private health insurers.
To be eligible to participate in this payment model, providers must be located within one of the 26 regions included in the demonstration, as well as meet quality of care standards reflecting positive performance-based outcomes. They must provide primary care services to a minimum of 125 attributed Medicare beneficiaries, with those services accounting for at least 50% of the practices’ combined overall revenue. Providers must have experience working within value-based payment arrangements.
CMS has delayed implementation of two components of Primary Care First, the Serious Illness Population and direct contracting options. The Biden Administration has suspended those programs, indicating that they are under review. The future of those models is uncertain, but the general Primary Care First option is proceeding into its second year.
“When providers join Primary Care First, one of the first things that happens is CMS assigns you to a risk group, and most people that are doing home-based palliative or home-based primary care are already taking care of pretty seriously ill people,” Julie Sacks, president and chief operating officer of the Home Centered Care Institute (HCCI), told Hospice News. “Even taking away that track, it doesn’t take away your ability to provide care well and to get paid for taking care of that very seriously ill population.”
CMS uses a focused set of clinically meaningful and patient outcome data measures to assess quality of care received by patients with complex, chronic and serious illnesses. Quality measures can include survey data of patient and family experiences, medical and clinical patient data and advance care planning rates.
The number of days spent at home during the last six months of life can represent a significant quality measure for hospice providers looking to participate in value-based models, according to a 2019 study from The New England Journal of Medicine
Participating providers commit to data sharing and collection to align their resources, with built-in incentives for those with positive quality outcomes, which CMS believes will increase patient access to advanced primary care services.
“If you’re able to demonstrate positive results on patient experience metrics, you can earn up to 50% more in revenue in a bonus potential,” Sacks said. “Every one of your patients gets tied to rates. A lot of practices will find that just with those first two components, they will be able to earn more than they did in a traditional fee-for-service arrangement.”
In contrast to traditional fee-for-service models, hospices have the potential to receive quarterly performance bonuses in the form of pre-payments after submitting claims data under the Primary Care First payment model. This can help providers better manage patient care and caseloads for staff as well, according to Sacks.
Primary Care First can be game changing for serious illness and end-of-life care, according to Powell.
“There is definitely a fever pitch, excitement in Primary Care First. The number of patients that are getting attributed —the number of dollars that are incrementally to the good for these organizations — is game changing, especially after a COVID impact on revenue,” Powell told Hospice News. “The bonus is about 50% of the revenue that you can select in this program from both capitation and your visits. You could use hospice to the full cap and literally turn everyone onto it that you can; you could save tons of money.”
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