On April 23, 2018, the Centers for Medicare and Medicaid Services (CMS) released a Request for Information (RFI) seeking input on opportunities to create Direct Primary Care (DPC) arrangements between traditional fee-for-service Medicare, Medicaid, and Medicare Advantage (MA) plans and primary care or multi-specialty group practices. In addition to potential roles for DPC in CMS programs, CMS also requested comment on how DPC can be a part of current Accountable Care Organization (ACO) initiatives like the Medicare Shared Savings Program.
The RFI also refers to Direct Primary Care as “Direct Provider Contracting.”
Comments are due on May 25, 2018.
In the RFI, CMS notes that the Center for Medicare and Medicaid Innovation (CMMI) currently is testing several initiatives that have unique opportunities for primary care and physician group practices, such as the Comprehensive Primary Care Plus (CPC+) model, and various ACO models that typically rely on primary care physicians as the basis for patient attribution and coordination of care.
CMS is interested in expanding the role of primary care by direct contracting for services with two-sided risk, while also placing a larger emphasis on beneficiaries’ role in selecting a primary care provider, and in encouraging more active beneficiary engagement in their own health. CMS seeks information on models that involve voluntary beneficiary enrollment in a DPC practice with enhanced access to services, reductions in administrative burden for billing, and a dedicated revenue stream that allows for “more flexibility in how and where they care for their patients.” The RFI seeks responses to 6 categories of questions, outlined below.
1. Provider and state participation
Under the section on participation, the RFI asks respondents to describe how a DPC model could attract a wide variety of practices at a range of scales, and whether such a model would necessarily operate under a convening organization like an ACO or other network arrangement. CMS also seeks information on what qualifications a provider would need to participate in a given model, such as certified electronic health record technology (CEHRT), specific staff competencies, or experience with other risk arrangements.
Additionally, CMS asks for information on how the agency could support practices in establishing a DPC model, as well as necessary state authorities under Medicaid State Plans and state-level technical assistance needs.
CMS requests information on practice experiences with DPC arrangements, including instances where a practice is exclusively dedicated to DPC.
2. Beneficiary participation
CMS seeks comments on whether there should be limitations on enrollment or disenrollment into a DPC program, and how costs are assessed if a beneficiary leaves the DPC arrangement. The RFI also asks what practices would need in order to conduct outreach to potential beneficiaries, and what sorts of incentives would be included to do so. As Medicare Part B has beneficiary cost-sharing requirements, CMS seeks information on whether or how cost-sharing could be waived or altered, and how a DPC arrangement would interact with Medigap or other supplemental coverage.
While CMS is considering Per-Beneficiary-Per-Month (PBPM) payments as the basis for a DPC model, the agency seeks information on what services would be covered under a model’s PBPM payment, how this is coded, and in what ways a PBPM rate would be risk-adjusted or geographically adjusted. CMS also states that it remains open to other payment structures aside from a PBPM model.
Other payment-related questions in the RFI address how payments could differ for practices of varying sizes and scopes, and what proportion of the total cost of care for a Medicare beneficiary would play into a DPC program’s risk calculations.
4. Model design
In this section, CMS highlights its interest in administrative burden reduction for clinicians, while also recognizing that any model would have significant data collection requirements. CMS requests information on what information would be necessary, how it could be collected with minimal additional burden on providers and beneficiaries alike, and whether an existing model could be adapted to meet the goals of a DPC program.
Aside from information collection, the RFI seeks information on how quality or performance data might differ from existing ACO models, or CPC+, and how such data would relate to any performance incentives.
CMS seeks input on existing commercial models for DPC that could be readily adapted to the Medicare or Medicaid programs, including considerations for dual-eligibles and differences in beneficiary characteristics.
5. Program integrity and beneficiary protections
As an extension of questions on data collection, the RFI seeks comments on how beneficiaries could be assured of comprehensive and high quality care under a DPC arrangement, including monitoring methods CMS could deploy. The RFI also seeks comments on how beneficiaries might be given an equal opportunity to enroll in a DPC practice as a safeguard against adverse selection for healthier beneficiaries, as well as how a model would address incentives for higher-risk patients to disenroll.
6. How DPC relates to existing ACO initiatives
Pursuant to questions in the model design section of the RFI, CMS seeks comment from stakeholders that have worked with a CMS ACO initiative related to how greater numbers of providers could be incented to join two-sided risk arrangements, how DPC can play a role in that effort, and whether a separate DPC model is needed, or whether any changes to existing ACO models could achieve the same goals.
How DPC differs from other models
CMS acknowledges that there are several current payment arrangements that may already operate with some level of DPC, but that this initiative would differ in being expressly focused on DPC while being iterative, adding services or practices to a DPC arrangement over time. For example, a DPC model might begin as a straightforward contract with a primary care practice, but expand to encompass specialists or other aspects of care delivery based on prior experience.
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