Primary Care First and the SIP Option

Primary Care First (PCF) is an alternative new payment model that was first announced by the Centers for Medicare & Medicaid Services (CMS) on April 22nd of this year. The original January 1, 2020 start date has been delayed, and PCF will now launch in 26 regions beginning in 2021.

PCF is a voluntary, regionally-based, five-year demonstration program designed to enhance care for patients with serious illnesses. It is based on the existing Comprehensive Primary Care Plus (CPC+) model and prioritizes the doctor-patient relationship, helps practices focus on patient outcomes, and incentivizes better care at lower costs. According to CMS, the new program aims to create a “seamless continuum of care” that will “improve quality, improve patient experience of care, and reduce expenditures.” 

Primary Care First consists of two payment options which theoretically will increase patient access to advanced primary care services and test whether the delivery of such services can reduce the total cost of health care. Eligible providers can choose to participate in either one or both of these options.

  • The first “General” option introduces higher payment for primary care practices caring for complex, chronically ill patients. 
  • The second “High Need Population” option encourages advanced primary care practices that typically provide hospice or palliative care services to take responsibility for high-need, seriously ill population (SIP) beneficiaries. On the PCF application, practices must specifically opt to participate in the SIP option.

The PCF program was developed by the CMS Innovation Center (CMMI), with input from a few primary care stakeholders. CMMI supports the development and testing of innovative health care payment and service delivery models. The Innovation Center will test the PCF model with two groups of participants for five years each. The first cohort will start in 2021, and the second in 2022. Current CPC+ practices will not be able to participate in PCF until 2022.

How Does It Work?

Primary Care First will help move practices away from a fee-for-service structure by introducing monthly risk-adjusted, population-based payments and simple flat rate fees for primary care visits. In addition, PCF will reward practices that provide quality care for patients with complex chronic needs or serious illnesses. It will assess and incentivize quality of care based on “a focused set of measures that are clinically meaningful” for these patients, including a patient experience-of-care survey, controlling high blood pressure, diabetes hemoglobin A1c poor control, colorectal cancer screening, and advance care planning. Practices also will be incentivized to better manage chronic or serious illnesses and to reduce acute hospital utilization. 

Performance-based adjustments will be calculated and applied on a quarterly basis. Practices that participate in PCF must be willing to assume limited risk (10% of revenue) if quality care outcomes are not met, in exchange for significant rewards (up to 50% of revenue) if they are. The PBS will reward practices that:

  • exhibit a high standard of performance and quality
  • excel compared to peer practices and improve over time
  • improve or maintain high quality outcomes 

CMS anticipates that as many as 25% of primary care practitioners nationwide may opt in to the new program and that more than 6 million Medicare fee-for-service beneficiaries ultimately will be enrolled. 

What Practices Are Eligible for PCF?

According to CMS, in order to be eligible for the Primary Care First program, practices must be located in one of the PCF regions and include primary care practitioners certified in general medicine, internal medicine, family medicine, geriatric medicine, palliative medicine, and hospice. Additional eligibility requirements:

  • Practices provide primary care health services to at least 125 attributed Medicare beneficiaries at a particular location.
  • Primary care services must account for at least 70% of the practice’s collective billing based on revenue. In the case of multi-specialty practices, 70% of the combined revenue of all eligible practitioners must come from primary care services. Note: This is NOT a requirement for SIP-only practices.
  • Practices must have experience with value-based payment arrangements or payments based on cost, quality, and/or utilization performance such as shared savings, performance-based incentive payments, and episode-based payments, and/or alternative to fee-for-service payments such as full or partial capitation.
  • Practices must use 2015 Edition Certified Electronic Health Record Technology (CEHRT), support data exchange with other providers and health systems via Application Programming Interface (API), and connect to their regional health information exchange (HIE). Note: SIP-only practices must attest in the PCF application that these conditions will be met by January 1, 2022.
  • Practices must attest via questions in the Practice Application to a limited set of advanced primary care delivery capabilities, such as 24/7 access to a practitioner or nurse call line and empanelment of patients to a practitioner or care team.
  • Practices must meet the requirements of the PCF Participation Agreement.

The Seriously Ill Population Model (SIP) Option

The SIP option seeks to identify high-need, high-risk beneficiaries who are experiencing fragmented, uncoordinated care under Medicare fee-for-service (FFS). The program targets patients who typically lack a primary care practitioner and effective care coordination. Through SIP, CMS seeks to better coordinate their care and avoid hospitalizations.

CMS will identify and attribute SIP patients to PCF practices that have opted to participate in the SIP model option. This population is expected to account for about 2-3% of Medicare beneficiaries. The SIP option will not require participating providers, including hospices, to obtain referrals.

SIP Practice Eligibility

There are some additional eligibility requirements for practices that opt in to the SIP option instead of–or in addition to–the general PCF option. Practices receiving SIP patients must provide:

  • An interdisciplinary care team that includes a physician or nurse practitioner, care manager, RN, and social worker
  • Comprehensive, person-centered care management ability, including ability to assess social needs of patients
  • Relationships with community and medical resources and supports to help address social determinants of health, medical, and behavioral health issues
  • Wellness and healthcare planning as part of care management
  • Family and caregiver engagement
  • 24/7 access to a care team member

How will CMS identify eligible SIP beneficiaries? 

SIP beneficiaries can not be already attributed to CPC+ or Accountable Care Organization providers. SIP beneficiaries MUST meet both of the following criteria:

  1. Serious illness (at least one of the following):
    • significant chronic or other serious illness, defined as a Hierarchical Condition Category (HCC) risk score ≥ 3.0
    • HCC risk score greater than 2.0 and with two or more unplanned hospital admissions in the past 12 months
    • signs of frailty, as evidenced by a durable medical equipment claim submitted to Medicare for a hospital bed or transfer equipment 

  2. Fragmented pattern of care defined by (at least one of the following):

    • proportion of  evaluation and management visit by varying practices/providers
    • Emergency Department visits and hospital utilization patterns over the past 12 months

How Will SIP Beneficiaries Be Attributed?

Once identified, potential SIP beneficiaries will be contacted to solicit their interest in SIP model participation. According to many in the primary health care industry, CMS has not provided enough details about SIP outreach. Providers have expressed concern about who—or what entity—will be identifying and contacting potential SIP beneficiaries. The initial outreach to these patients will be crucial to the success of the SIP model.

Patients who opt in to SIP will be assigned to a participating SIP practice. Practices will be encouraged to contact assigned beneficiaries as soon as possible, ideally within 24 hours. They must make contact within 60 days. Attribution will begin after the first face-to-face visit and the patient’s expressed interest in receiving services under SIP.

There is no limit to the number of SIP beneficiaries that can be attributed to any given practice, but practices will be asked to specify a target number of SIP beneficiaries they prefer to accept. CMS will take this number into account when attributing.

Transitioning Patients Out of SIP

The SIP option is an intensive, time-limited intervention intended to help stabilize SIP patients and develop a comprehensive care plan for their long-term needs. Practices are expected to transition patients out of SIP in a timely manner. CMS anticipates the average SIP episode to last approximately eight months; payment for SIP participation beyond 12 months will be subject to CMS approval. SIP-only practices may continue to provide care for transitioned patients, to be reimbursed through Medicare FFS.

What Does the SIP Option Mean for Hospice Providers?

Hospice providers can apply for Primary Care First’s general model option, but the SIP option seems to be a natural fit. Many hospices already offer care coordination for their patients, and many have expanded their services to include palliative care or home-based primary care to pre-end-of-life patients. Data suggests that a combination of palliative care and hospice can reduce health care costs by helping patients avoid unnecessary hospital utilization. Together, these factors mean that hospice providers are uniquely qualified to meet the challenges and requirements of SIP’s quality bonus.

The Benefits of SIP

  • SIP hospice providers will be paid for the care management and palliative care services they already offer—services that may currently be unbillable and unreimbursed.
  • SIP patients will have longer lengths of stay on average than traditional hospice patients.
  • SIP hospices will be forming relationships with attributed SIP beneficiaries: when traditional hospice care is required, these patients will be much more likely to select the SIP organization that is already caring for them.
  • SIP hospices will be forming new relationships with community providers: hospices that have looked to community providers as referral sources will now be referral sources for those providers.

The CEHRT Requirement

As noted above, SIP-only practices must meet the Certified Electronic Health Record Technology (CEHRT) requirement by January 1, 2022. This date represents a one-year grace period offered by CMS to SIP-only practices, in recognition of the fact that hospice and palliative care practitioners and practices may lack the necessary resources to meet CEHRT requirements in year one of the PCF model. 

Very few hospice providers currently use CEHRT systems, and most EMR vendors do not currently offer CEHRT for their hospice clients. Hospice EMR vendors will be working to ensure SIP compliance within the required timeframe.

PCF Timelines

The application period for January 2021 participation in the Primary Care First model opened on October 24, 2019 and will close on January 22, 2020. 

During the first six weeks of this application period (to December 6, 2019), primary care practices may submit a non-binding Statement of Interest form (PDF) signaling their interest in partnering in Primary Care First. Those that do will receive information from CMS about how many practices submitted applications, by region and county, at the end of the practice application period.

PCF practice selection will take place in Winter-Spring 2020 and the model will begin in January 2021.

Interested practices should start thinking now about how PCF and/or the SIP option will impact their organization and their bottom line. 

  • What new staffing will be necessary to accommodate all PCF requirements? Hospices that currently employ a multidisciplinary staff are in a good position to meet these challenges.
  • What new technologies will be necessary to comply with PCF and SIP requirements? Make sure your organization is on track for CEHRT and HIE compliance.

Additional Resources

CMS Newsroom “Primary Care First: Foster Independence, Reward Outcomes”: https://www.cms.gov/newsroom/fact-sheets/primary-care-first-foster-independence-reward-outcomes

CMS Primary Care First Model Options: https://innovation.cms.gov/initiatives/primary-care-first-model-options/

CMS Primary Care First Request for Applications: https://innovation.cms.gov/Files/x/pcf-rfa.pdf

CMS Webinar: PCF Model Options – Seriously Ill Population (7/24/19):
https://innovation.cms.gov/Files/slides/pcf-sip-slides.pdf

CMS Webinar: PCF Model Options – Seriously Ill Population (SIP) Part II (10/31/19):  https://innovation.cms.gov/Files/slides/pcf-sidii-slides.pdf