Primary Care First/Seriously Ill Population

Definition: Primary Care First is a set of payment model options that aims to financially incentivize value and quality of care for Medicare beneficiaries seen in the primary care setting, especially those with complex medical conditions.¹ The principles of this model are similar to those of current Comprehensive Primary Care Plus (CPC+) models, especially in terms of prioritizing the primary care provider–patient relationship, financially rewarding improvement in health outcomes, and reducing administrative burden.

Primary Care First has 3 model options:

• Primary Care First Only²
• Seriously Ill Population (SIP) Only²
• A hybrid of both²

Practices that opt into the SIP Only or hybrid models are attributed complex patients with a goal of clinically stabilizing these patients within a limited period of time. A patient is considered for participation in SIP if criteria are met for both complexity of illness (defined by hierarchical condition category coding parameters or use of transfer equipment/hospital bed as a sign of frailty) and care fragmentation (either lack of a consistent primary care provider or frequency of emergency department visits). Practices receive payments dependent on the high-risk nature of the population as well as a performance-based payment.^1,2 The SIP model allows more patients to receive much-needed coordinated care while incentivizing practices to take on the challenge of caring for a complex, high-need patient population.

How it relates to ACO/PCMH: Primary Care First will be offered in 26 regions across the United States starting January 2021 for practices that are not currently participating in CPC+.¹ Existing CPC+ programs will be eligible to participate in 2022. Practices that voluntarily participate in Primary Care First assume some financial risk; however, they have the opportunity to earn rewards through performance-based payments.

Primary Care First incentives are focused on reduction in acute hospital use as a way to reduce costs of care.³ Primary Care First focuses on meeting quality and experience of care standards. There are many opportunities for pharmacists in this model, including being a member of the practice’s care management team and improving quality measure performance (e.g., diabetes and hypertension control).¹

Involved organizations/oversight: CMS oversees and prioritizes Medicare beneficiaries’ preferences to Primary Care First practices. To participate in Primary Care First, eligible practices must meet a list of predefined requirements outlined by CMS.¹ Practices will be allowed to provide services to SIP patients if they demonstrate capabilities and meet specific care experience requirements.¹

Resources:

1. CMS. Primary care model options. Available at: https://innovation.cms.gov/innovation-models/primary-care-first-model-options
2. Sinclair S, Silvers A. FAQs on the new seriously ill population (SIP) alternative payment model option. Available at: capc.org/blog/faqs-new-seriously-ill-population-sip-alternative-payment-model-option/
3. CMS. Primary Care First: Foster independence, reward outcomes. Available at: cms.gov/newsroom/fact-sheets/primary-care-first-foster-independence-reward-outcomes

Contributing authors:

Sara Wettergreen, PharmD, BCACP
University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences

Tracie VanHorn, PharmD candidate 2021
University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences

Last reviewed 9/24/2023 by Amy Thompson, PharmD, BCACP