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CMS moves forward on capitated "Direct Provider Contracting" for primary care

CMS has published feedback and issued a new request for information (RFI) on proposed "Direct Provider Contracting Models" — which sound a lot like direct primary care, but with CMS paying the bills.

In an announcement released April 23, CMS says it had reviewed over 1,000 comments received on its September 2017 RFI on the New Directions initiative of its Center for Medicare and Medicaid Innovation (CMMI). “The responses from this RFI will help inform and drive our initiatives to transform the health care delivery system with the goal of improving quality of care while reducing unnecessary cost," says CMS Administrator Seema Verma in the announcement. Current comments can be viewed via Excel file or pdf

Many comments from major stakeholders were focused on a particular concept — "allowing Medicare beneficiaries to contract directly with healthcare providers" — and, apparently inspired, CMS has issued a "follow up RFI" for further comments, which will remain open until May 25.

As described in the new RFI, the models would be primary care-focused and have two-sided risk, as in the more advanced accountable care organizations (ACOs). Beneficiaries would elect to be aligned with the practice, and CMS would pay the practice a capitated per beneficiary, per month fee for "primary care services… which may include office visits, certain office-based procedures, and other non-visit-based services covered under the Physician Fee Schedule, and flexibility in how otherwise billable services are delivered." Practices would also be eligible for "performance-based incentives for total cost of care and quality."

"A direct provider contract model would allow providers to take further accountability for the cost and quality of a designated population in order to drive better beneficiary outcomes," says the announcement. "Such a model would have the potential to enhance the doctor-patient relationship by eliminating administrative burden for clinicians and providing increased flexibility to provide the high-quality care that is most appropriate for their patients, thus improving quality while reducing expenditures."

Interestingly, CMS said in the RFI that, while these new models are inspired by their Comprehensive Primary Care Plus (CPC+) Model pilot and by the Shared Savings and Next Generation ACOs, they are also interested in "understanding the experience of physicians and practices that are currently entirely dedicated to direct primary care and/or DPC-type arrangements," and asked providers of such services "how you made the transition to solely direct contracting arrangement" and for "key lessons learned in moving away from fee-for-service entirely." 

Direct primary care is a form of concierge service in which provider take a monthly or annual payment from patients to provide and number of primary care services, with the patient or insurance paying above that for non-covered services. 

In their comment to the original RFI, the American Association of Family Physicians (AAFP) said it "actively supports family physicians who choose to practice in a delivery and payment model in which they contract directly with patients, typically referred to as Direct Primary Care (DPC)." AAFP also said it has seen under the DPC model "increased access to a personal physician, extended visits, electronic communications, in some cases home-based medical visits, and highly personalized, coordinated, and comprehensive care administration" and "DPC practices nationwide negotiate substantially lower prices with local imaging and diagnostic centers, because their patients are paying out of pocket for the services."

The American College of Physicians, however, hoped CMS would take care that "any new primary care project should not jeopardize the important research methodology of CPC+," and the Blue Cross Blue Shield Association (BCBSA) warns that "the DPC model involves a significant expansion of the ability of physicians and other providers to contract privately with beneficiaries, which could increase beneficiaries’ financial liability and cause confusion." BCBSA also read MedPAC research to suggest that "retainer-based practices" tend to focus care on "a select group of patients that are not particularly sick," which "does not necessarily advance the health of communities overall."

Blog Tags: CMS, payment models
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