April 30, 2018

CMMI’s Next Big Thing: Direct Provider Contracting

Last fall, the Center for Medicare and Medicaid Innovation (CMMI) asked the public to submit recommendations on the agency’s future direction.  On April 23, CMMI made public a 4,643-page document and a 6,380-line Excel spreadsheet containing the responses it received from approximately 1,000 individuals and organizations.  Stay tuned for our high-level summary of these comments.

At the same time, CMMI published a new request for information (RFI) on primary-care-focused direct provider contracting (DPC) models.  Under the model, “CMS could contract directly with participating practices, such as primary care practices or larger multi-specialty groups, to establish the practice as the main source of care for services ranging from solely primary care to a wide range of professional services for beneficiaries that voluntarily elect to enroll with the practice.”

In the RFI, CMMI suggests that a participating practice would receive a fixed per-beneficiary-per-month (PBPM) payment to furnish a defined scope of primary care services for its enrolled beneficiaries.  The practice also would be eligible for performance-based incentives determined by quality and total cost of care.

Of course, the devil is in the details, and CMMI poses several questions for which it seeks the public’s input:

  • What minimum requirements must a practice meet to participate in DPC?
  • What technical assistance would DPC practices require?
  • How should beneficiaries be incentivized to enroll? How should the enrollment and dis-enrollment process work?  What’s needed to prevent lemon-dropping and cherry-picking?
  • What services should be included in the PBPM payment? How should that payment be calculated?  What financial safeguards are needed to protect practices from higher-than-anticipated utilization?
  • How should the practice’s performance on quality measures and/or enrolled beneficiaries’ total cost of care impact the practice’s payments?
  • What safeguards are needed to protect beneficiaries?
  • How should accountable care organization (ACO) models be adapted to support DPC?

Interestingly, CMMI did not address whether the DPC model would qualify as an advanced alternative payment model for participating physicians.  Nor did the agency indicate whether federally qualified health centers and rural health clinics may have an opportunity to participate.

CMMI will accept comments on the DPC model at DPC@cms.hhs.gov through May 25, 2018.

Previously, CMMI has relied on RFI responses to inform new initiatives.   For example, the agency solicited comments on new ACO and specialist payment models in 2014, and then announced the NextGen ACO and Oncology Care Models the following year.  It published an RFI on advanced primary care models in 2015, and then announced the Comprehensive Primary Care Plus program in 2016.  It is likely, therefore, CMMI will announce a DPC opportunity later this year or early next.

For providers who may be interested in DPC, there’s more to do than sit and wait.  Explore how  provider groups are implementing DPC now.   Deepen relationships with Medicare beneficiaries; for example, encourage them to designate their primary care providers through the CMS on-line Voluntary Alignment program.

If you have further questions about DPC, this new RFI, or how your practice might consider this opportunity, contact Martie Ross at PYA (mross@pyapc.com), or at (800) 270-9629.

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