New Care Models: Primary Care First & Direct Contracting
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New Care Models: Primary Care First & Direct Contracting Virtual Town Hall May 14, 2019 Leading Person-Centered Care 1
Transcript of New Care Models: Primary Care First & Direct Contracting
New Care Models: Primary Care First & Direct Contracting Virtual Town Hall
May 14, 2019
Leading Person-Centered Care1
Polling Question
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➢Are you providing community-based palliative care?
Definition of Palliative Care:
Beneficial at any stage of a serious illness, palliative care is an interdisciplinary care delivery system designed to anticipate, prevent, and manage physical, psychological, social, and spiritual suffering to optimize quality of life for patients, their families and caregivers. Palliative care can be delivered in any care setting through the collaboration of many types of care providers. Through early integration into the care plan of seriously ill people, palliative care improves quality of life for both the patient and the family.
National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines for Quality Palliative Care, 4th edition. Richmond, VA: National Coalition for Hospice and Palliative Care; 2018. https://www. nationalcoalitionhpc.org/ncp.
Two Model Types and Five Models
Primary Care First
Primary Care First
PCF High Needs Population
Direct Contracting
Professional Care
Global
Geographic
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Geographic Locations for Primary Care First Participation
The Purpose of the Primary Care First Model
➢Rewards outcomes
➢Increases transparency
➢Enhances care for high needs populations
➢Reduces administrative burden
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Goals of the Primary Care
First
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Primary Care First Overview
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Three OptionsTo accommodate providers that specialize in care for different populations
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Practice Eligibility Requirements for the Primary Care First Model Option
✓ Include primary care practitioners (MD, DO, CNS, NP, PA), certified in internal medicine, general medicine, geriatric medicine, family medicine, and hospice and palliative medicine in good standing with CMS
✓ Provide health services to a minimum of 125 attributed Medicare beneficiaries*
✓ Have primary care services account for the predominant share (e.g. 70 to 80 %) of the practices’ collective billing based on revenue*
✓ Demonstrate experience with value-based payment arrangements✓ Use 2015 Edition Certified Electronic Health Record Technology (CEHRT),
support data exchange with other providers and health systems via Applicable Programming Interface (API), and connect to their regional health information exchange (HIE)
✓ Attest via questions in the Practice Application to a limited set of advanced primary care delivery capabilities, including 24/7 access to a practitioner or nurse call line, and empanelment of patients to a primary care practitioner or care team
*Not applicable to the High Need Population/SIP Option)
9Note: Attributed lives requirement is at the practice level, not the individual provider level (the collective NPIs)
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Eligibility Requirements for the PCF High Need Population Model Option
✓ Include practitioners serving seriously ill populations (MD, DO,
CNS, NP, PA) in good standing with CMS
✓ Meet basic competencies to successfully manage complex patients
and demonstrate relevant clinical capabilities (e.g. interdisciplinary
teams, comprehensive care, person-centered care, family and
caregiver engagement, 24/7 access to a practitioner or nurse call
line)
✓ Have a network of providers in the community to meet patients’
long-term care needs for those only participating in the SIP option
✓ Use 2015 Edition Certified Electronic Health Record Technology
(CEHRT), support data exchange with other providers and health
systems via Applicable Programming Interface (API), and connect
to their regional health information exchange (HIE)
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Practices receiving SIP-identified patients (identification is based on risk score) must:
PCF Comprehensive
Primary Care Interventions
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Hybrid Total Primary Care Payments replace Medicare FFS
Practice Risk Group
Group 1 (lowest risk)
Group 2
Group 3
Group 4
Group 5 (highest risk)
Payment PBPM
$24
$28
$45
$100
$175
$50.00
Per face-to-face patient encounter
(Regardless of practitioner type: MD, DO, CNS, NP, PA)
These payments allow practices to:
✓ Easily predict payments
✓ Decrease time spent on claims processing and increase time with patients
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Professional Population-Based Payment (PBP) Flat Primary Care Visit Fee
Payment adjusted to account for beneficiaries seeking services outside the practice
PCF: High Need Population Payment Model Option
❖ Practices demonstrating relevant capabilities can opt in to be assigned SIP patients or beneficiaries who lack a primary care practitioner or care coordination.
❖ Medicare-enrolled clinicians who provide hospice or palliative care can partner with participating practitioners.
Payments for practices serving seriously ill populations
First 12 Months
✓ One-time payment for first visit with SIP patient: $325.00
✓ Monthly SIP payments up to 12 months: $275.00 PBPM
✓ Flat visit fees: $50.00
✓ Quality payment up to $50
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PCF incorporates the following unique aspects for practices electing to serve seriously ill populations (SIP) to increase access to high-quality, advanced primary care
Eligibility and Beneficiary Attribution Payments
The following measures will inform the performance-based adjustments and assessment of model impact
Measure Type
➢Utilization Measure for Performance-Based Adjustment Calculation (Year 1-5)
➢Quality Gateway (starts in Year 2)
•Quality Gateway for practices serving the high-risk and seriously ill populations*
Measure Title
➢Acute hospitalization Utilization (AHU) (HEDIS measure)
➢CPC+ Patient Experience of Care Survey (modernized version of CAHPS)
➢Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) (eCQM)
➢Controlling High Blood Pressure (eCQM)
➢Care Plan (registry measure)
➢Colorectal Cancer Screening (eCQM)
•To be developed during model: domains could include 24/7 patient access and days at home
Benchmark
➢Non-CPC+ reference population
➢MIPS
➢MIPS
➢MIPS
➢MIPS
➢MIPS
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PCF Quality Measures
The following measures will NOT apply to practices in Practice Risk Groups 4 or 5 and for the practices receiving SIP identified patients: a) Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) (eCQM) and b) Colorectal Cancer Screening (eCQM)
Spring 2019
Practice applications open
Summer 2019
Practice applications due; Payer solicitation
Fall 2019
Practices and payers selected
January 2020
Model launch
April 2020
Payment changes begin
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Timeline for PCF Launch
To prepare for model application release: confirm your organization’s eligibility and willingness to participate. Join the CMS listserv for updates on application release and webinar registration to learn more. Read NHPCO NewsBriefs and Alerts and join myNHPCO communities to stay informed of resources to support your participation.
Learn More About PCF
Visit https://innovation.cms.gov/initiatives/primary-care-first-model-options/
Call 1-833-226-7278
Email [email protected]
Follow @CMSinnovates
Webinars:
Thursday, May 16, 12 p.m. EDT Register here
Thursday, May 16, 3 p.m. EDT Register here
Other Resources/Articles:
Medscape: CMS Offers New Risk-Based Payment Methods to PCPs
MedPage Today: New Primary Care Pay Models Put Emphasis on Outcomes
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Polling Questions
➢Are you considering applying for the Primary Care First High Needs Population/Seriously Ill Population?
➢Are you considering contracting with a Primary Care First participant to help with high risk population?
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New Direct Contracting Models
High level themes of the Professional and Global DC Models:
➢ Prospective benchmarking that aligns with Medicare Advantage
➢ Multiple-risk sharing arrangements
➢ Flexible beneficiary alignment options
➢ Move toward capitation
➢ Benefit enhancements and payment rule waivers to improve care coordination and service delivery
➢ Options for organizations that have not participated in Medicare FFS previously
➢ Focus on complex chronic, seriously ill, and dually eligible beneficiaries
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Background
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Background
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Design Approach in Brief – Global and Professional Population-Based Payment (PBP)
➢ Build off the Next Generation Accountable Care Organization Model to offer new forms of capitated PBPs, enhanced payment options, and flexibilities to increase the number of tools providers must meet beneficiaries’ medical and non-medical (e.g. social determinants of health) needs
➢ Expand emphasis on voluntary alignment and beneficiary choice, while retaining claims-based alignment approaches
➢ Reduce burden by focusing quality reporting on select measures
➢ Create a more predictable prospective spending target by capitalizing on Medicare Advantage rate calculations for various benchmarking steps
➢ Focus on dually eligible, complex chronic and seriously ill patients
➢ Create participation opportunities for organizations new to Medicare FFS, and Medicare Managed Care Organizations interested in taking accountability for Medicare cost and quality where already accountable for Medicaid spending
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Payment Model Options Details
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Direct Contracting Entities
➢ Generally, must have a minimum of 5,000 aligned Medicare FFS beneficiaries
➢ “On ramp” for organizations new to Medicare FFS
➢ Added flexibility for organizations serving dually eligible, chronically ill populations
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Prospective Alignment Options
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Prospective Alignment Options
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Considerations for High Need Populations
➢ Complex chronic and seriously ill patients and DCEs focused on those populations
➢ Dually eligible for Medicare and Medicaid with complex needs:
➢ PACE-like populations and PACE-like clinical approach with focus on interdisciplinary team
➢ Allowance with minimum alignment thresholds
➢ Experience in providing a range of Medicaid-covered services and Medicaid coordination
➢ Dually eligible enrolled in Medicaid Managed Care and FFS Medicare
➢ DCEs convened by or affiliated with Medicaid MCOs draw on dually eligible population experience and take accountability for Medicare costs and quality in addition to Medicaid spending under existing arrangements
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Risk-Sharing Arrangement
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Risk-Sharing Arrangement
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Benchmarking Methodology
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Professional PBP and Global PBP
• A blend of historical spending and adjusted MA regional expenditures and used to develop the benchmark (segmented by Aged & Disabled and ESRD)
• Benchmarking will be adjusted to reflect factors, such as, the risk of the population
• Payments will be subject to quality performance
• CMS is considering innovative approaches to risk adjustment for complex and chronically ill populations
Geographic PBP (proposed)
• Would be based on a one-year historical per capita Parts A/B FFS spend in the target region trended forward (no historical/regional blend) with negotiated discounts
• Final methodology would be informed by the Request for Information (RFI) responses
Payment Model Options
DCEs in the Professional and Global options must participate in a capitation arrangement
Total Care Capitation: Monthly capitation payments for all services furnished by Participants and optionally Preferred Providers
Primary Care Capitation: Monthly capitation payments for enhanced primary care services furnished by Participants and optionally Preferred Providers
All Participants and Preferred Providers must continue to submit claims to CMS. CMS is exploring ways to simplify administrative claims submission for primary care services included under a capitated arrangement
CMS will continue to pay claims for services made outside the DCE (non-associated providers)
Organizations will have added flexibility to reduce the FFS payments not covered under the capitation arrangements. DCE and providers must agree in writing to the percentage of reduction
CMS will provide benchmark reports on a regular basis to enable DCEs to maintain a national accounting system similar to private sector arrangements
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Reconciliation
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Quality Performance
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Quality Performance
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Benefit Enhancements and Payment Rule Waivers
DC is considering the same benefit enhancements and payment rule waivers offered in Next Generation Accountable Care Organizations (NGACO) such as
➢ 3-day SNF Rule Waiver
➢ Telehealth Expansion Waiver
➢ Post-Discharge Home Visits Rule Waiver
➢ Care Management Home Visits Rule Waiver
DC also intends to build upon those offerings and explore additional enhancements and payment rule waivers such as
➢ Allowing Nurse Practitioners to certify that a patient is eligible for home health services
➢ Allowing the provision of home health services to beneficiaries who are not “homebound”
*These benefit enhancements and payment rule waivers are still in development and not finalized. The DC Team will release more information, as it becomes available
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Timeline and Next Steps
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Polling Questions
➢ Are you considering contracting with a Direct Contract Entity to provide hospice care for their population?
➢ Are you considering contracting with a Direct Contract Entity to provide palliative care for their population?
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Geographic PBP Option: Request for Information (RFI)
➢ CMS posted an RFI to gather additional input from the public about their perspective on design parameters for the Geographic PBP model option
➢ Responses to the RFI are now being accepted and can be submitted electronically to [email protected]. Responses must be received by Thursday, May 23, 2019 11:59 pm.
➢ The Geographic PBP model option will have a separate application process
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We want to hear from you➢ For Geographic model comments:
➢ Social determinants of health?
➢ Comparison group considerations?
➢ Criteria for selecting target regions?
➢ What are the benefits and/or risks to access, quality, or cost in rural areas?
➢ Beneficiary alignment – random or risk adjusted?
➢ How can CMS ensure beneficiary access to the right care at the right time?
➢ What waivers might CMS consider?
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We want to hear from you➢ Are you interested in applying for the Primary
Care First Seriously Illness Population model?
➢ What resources and support can NHPCO provide to assist members that apply?
➢ Data and analytics?
➢ Consultants for program development and sustainability?
➢ Contracting with health plans, provider groups, Accountable Care Organizations, Direct Contracting Entities?
➢ Other?
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Learn More
➢ Letter of Intent➢ Geographic PBP RFI➢ Direct Contracting Website➢ Submit questions electronically for Direct Contracting
Model: [email protected]➢ Informational Webinar slides➢ Future Webinar Topics:
o Payment Methodologyo Alignment and Overlapo Benefit Enhancements and Payment Rule Waiverso Special needs populations and Medicaid MCOs
➢ Subscribeo CMS Listserv
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What should I be doing?➢ Determine your interest in participating – do the new care models align
with your program’s mission, vision and values?
➢ Determine the level of participation – contract with a participating entity or apply for the SIP option?
➢ Know your current program costs –
➢ Do you have the right team mix to operate cost effectively? (more nurses and social workers / less physicians)
➢ Do you utilize virtual visits to supplement care? (phone and telehealth and 24/7 response)
➢ What about non-clinical staff? (community health workers and trained volunteers)
➢ Does your electronic medical record comply with 2015 CEHRT?
➢ Know your patient population – can you risk stratify by needs?
➢ Know your data – do you track utilization metrics, quality of care, patient/family satisfaction, discharge disposition?
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