The Biden administration has pulled the seriously ill population component of the Primary Care First model due to concerns it won't get enough beneficiaries to participate.
The Center for Medicare and Medicaid Innovation (CMMI) announced the withdrawal of the population component on Tuesday. The center had frozen that part of the primary care model in the spring, part of a larger review of all its models.
“We don’t think it can be implemented because we cannot get enough beneficiaries to participate in the way we anticipated,” CMMI Director Liz Fowler told Fierce Healthcare in an interview.
The Primary Care First model had contained two components: a general one and one focused on seriously ill beneficiaries that don’t have a primary care doctor or effective care coordination. Primary care practices can choose to apply to both components, or they could choose one.
The general component enables advanced primary care practices to take on financial risk and get performance-based payments. The seriously ill population component called on physicians to assess the social needs of identified patients and address other social determinants of health as well as to create a healthcare and wellness plan for such beneficiaries.
But CMMI found it difficult to create an outreach method to seriously ill population beneficiaries that met with HIPAA requirements .
“The first thought was we would connect providers to these beneficiaries and providers do the outreach, but if those providers don’t have a relationship with the beneficiary, that is where the privacy concerns come in,” Fowler said.
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The next approach was to have CMMI perform the outreach, and the center was trying to figure out how to send a letter to the population of beneficiaries. However, there was a concern about fraudulent outreach to beneficiaries.
“We were careful in designing the approach that it would look official,” Fowler said. “We didn’t want to open the door to the perception of any malfeasance or bad actors. We just couldn’t figure out a way to make that work.”
Fowler added that CMMI is open to hearing any ideas on how such an approach could work as coordinating care for this population is a major priority. CMMI released a strategic refresh this past fall that made health equity a major pillar of all models going forward.
“I think this leaves a gap in our portfolio so we are of course open to ideas and approaches even though we couldn’t make this part of Primary Care First work,” she said.
CMMI did take applications for the seriously ill component, but it never officially launched. Any applicants for both the general and seriously ill components will remain in just the general component.
However, any providers that applied for just seriously ill will not be able to apply for the general component.
The decision to withdraw the component came as part of a comprehensive review of all of CMMI’s models. The center has chosen to pull other models due to the review. CMMI walked back several changes in its Part D modernization model that gave insurers more flexibility over their formularies for certain classes of drugs.