How Primary Care First and the SIP model re-center family physicians in advanced illness care

As 2021 approaches, hospices and other organizations participating in Primary Care First are gearing up to tackle their new patient loads. The Centers for Medicare and Medicaid Services’ (CMS) Primary Care First (PCF) program, which will start enrolling patients in 2021, includes the Seriously Ill Population (SIP) model. The SIP program is designed to improve care for high-need, high-risk patients who are receiving fragmented or inadequate care.

To accomplish this, CMS will assign patients to participating hospice programs, paying them to create coordinated care plans, avoid unnecessary hospitalizations, and ultimately transfer these patients either to a primary care provider or other appropriate care setting for ongoing care and management.

John Mulder, M.D., one of Acclivity Health’s Advisory Board Members and Medical Director of the Trillium Institute, is a palliative doctor who has years of experience as a family physician. He believes primary care should be central to the care of patients with advanced or serious illnesses.

“For decades, we have looked at our family doctors as the ones who take care of us, who know us, who are responsible for managing our illnesses and making us feel well, and helping us figure out how to manage life when we have a serious illness we can’t fix,” he says. “When we look at value-based changes occurring in health care, one of the things that measures successful outcomes — and this has to do with quality care — is how did the patient feel about their experience? Were their values treated as sacred? Primary care providers are poised to meet that need best because they know these patients, their families, their hopes, and what’s important to them.” He notes that primary care physicians can have a pivotal role in helping their patients navigate the health care system in the midst of a serious illness.

So, if primary care physicians’ participation in serious illness care offers so many benefits, why is it so challenging? Dr. Mulder explains that there are both systemic and financial barriers. The first is what he describes as a linear model of care, in which the patient would visit their primary care provider for annual screenings, receive a referral to a surgeon for a biopsy, then to an oncologist for diagnosis, then to a radiation oncologist for treatment options, and so on.

“One of the main barriers is the evolution of a specialty-based medical system that sends people down a linear path,” he says. “We have this chain of other physicians involved in the care of the patient removed from the family physician, who often doesn’t know what is going on with the patient at this point in time. However, the patient still sees them as their doctor, and if they have issues, they’re supposed to ask their primary provider. But he or she doesn’t have all the most up-to-date information they need.” “In this model, patients are treated as the disease that they carry, not as the person they are,” he adds.

And while many physicians do their best to stay abreast of their patients’ specialty care, it can be difficult to accomplish in the current system.

“Historically, we’ve not compensated primary care physicians for management and navigation roles. I believe they need to be empowered to provide ongoing care, and have it incentivized so its financially feasible to do. This keeps people out of ERs and saves significant dollars across the health care system. As payer sources and government quality initiatives ramp up, they need to keep the primary care provider in the center of this process and provide them opportunities to care for their patients.”

One of those initiatives is, of course, the Primary Care First program and SIP model. Dr. Mulder is optimistic that it will help position primary care providers to be more involved in the direct care of their seriously ill patients’ care. 

“I think the SIP program is a fairly novel model that has the opportunity to demonstrate how integrating a palliative mindset within a primary care environment will produce optimal outcomes,” he explains. “The patients in the SIP program will be those with advanced illness who have been disenfranchised from the health care system and don’t identify with a primary care provider. This program will assign them a primary practitioner with palliative expertise, and these providers understand the role they’ll be playing of managing life with disease for these folks.”

Rather than the linear model of specialty care, Dr. Mulder proposes a spoke-and-wheel model where the primary care physician is at the center of all specialty care for their patient, providing referrals as needed. The PCF and SIP programs are a step in the right direction to achieving this objective.

“I believe that in the SIP program specifically, and the Primary Care First model in general, we will see what those of us in the field already know to be true: that when you provide person-centered care, using value-based decision making, and put the responsibility of care in the hands of physicians who know patients best to help them navigate the system and compensate them for that work, we will see significant improvements in outcomes.”

If you have any additional questions related to the Primary Care First or SIP, please feel free to email us at

2 Responses

  1. I like that you mentioned that advances in primary care can help in avoiding hospitalizations as much as possible. I better start looking for a primary care center that my mom could go to regularly from now on. That way, I can ensure that her health will always be in good condition.

  2. My dad has been sick, and we want to make sure that he gets the right care. It makes sense that getting the right primary care would be important. I’ll be sure to look into different physicians to ensure that he gets the help he needs.

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