CMS Revamps Direct Contracting Model

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In response to suggestions from stakeholders, the Facilities for Medicare & Medicaid Companies (CMS) announced on Thursday that it’s going to cancel one direct contracting accountable care group (ACO) mannequin and change a second direct contacting mannequin with a redesigned model centered on bettering well being fairness for sufferers.
Stakeholder teams shared clashing responses to the brand new bulletins, with one doctor group arguing that the redesign repeats the “deadly flaws” of the unique mannequin.
The Heart for Medicare and Medicaid Innovation (CMMI) has determined to cancel the Geographic Direct Contracting mannequin and change the International and Skilled Direct Contracting (GPDC) mannequin with the redesigned ACO Realizing Fairness, Entry, and Neighborhood Well being (REACH) mannequin.
“The Biden-Harris Administration stays dedicated to selling value-based care that improves the well being care expertise of individuals with Medicare, Medicaid and Market protection,” mentioned CMS Administrator Chiquita Brooks-LaSure in a press assertion.
As a part of that dedication, she said, CMMI is making modifications to present fashions and launching new ones and testing all of them, with the aim of accelerating high quality of care — notably sufferers in underserved communities, she said.
The sufferers who’ve suffered probably the most during the last 2 years have been these with continual diseases who transition out and in of their properties or nursing properties to hospitals, mentioned a senior CMS official throughout a press name on Thursday.
With that in thoughts, CMMI is targeted on advancing care fashions centered on making care extra accountable for sufferers with continual ailments, as a result of higher fee fashions can translate to higher affected person care and if performed proper, higher value outcomes, the official mentioned.
All GPDC contributors who want to proceed within the Direct Contracting program should agree to fulfill the ACO REACH mannequin necessities by January 1, 2023, famous a CMS fact sheet.
“The GPDC mannequin shall be renamed the ACO REACH mannequin to higher align the mannequin’s identify with its goal: to encourage well being care suppliers to coordinate care to enhance the care supplied to folks with Medicare – particularly these from underserved communities, a precedence of the Biden-Harris Administration,” the press launch famous.
“CMS can also be committing to higher transparency by releasing extra info on present GPDC mannequin contributors and strengthening monitoring to make sure beneficiaries whose suppliers take part in GPDC and ACO REACH obtain high-quality, patient-centered care throughout 2022 and past,” in response to the company’s reality sheet.
There are just a few marked variations between the unique GPDC mannequin and ACO REACH, senior CMS officers famous throughout Thursday’s press name, which was held on background. Officers additionally shared a side-by-side comparison table of the unique mannequin and the redesign.
First, the REACH mannequin requires 4 key modifications associated to well being fairness, that every one contributors should do the next:Develop a Well being Fairness Plan that identifies disparities and concrete actions to handle themIncorporate a well being fairness benchmark adjustment for underserved communitiesCollect beneficiary-reported knowledge associated to social wants and demographicsAdopt a Profit Enhancement to develop the varieties of providers that nurse practitioners can present to beneficiaries with the purpose of bettering accessSecond, whereas the unique GPDC mannequin suppliers had been required to carry a minimum of 25% of a governing board’s voting rights within the REACH mannequin, taking part suppliers should maintain 75% of these rights. As well as, every governing board underneath the ACO REACH mannequin will need to have a separate beneficiary and client advocate, which underneath the GPDC mannequin may need been the identical particular person. Underneath the ACO REACH mannequin, the beneficiary consultant and client advocate should even have voting rights.
Third, the brand new mannequin will embrace higher beneficiary protections reminiscent of “enhanced vetting, compliance and monitoring actions,” famous senior company officers. Contributors within the ACO REACH mannequin may even be audited to make sure they’re clearly speaking info relating to beneficiary participation within the fashions, and contributors shall be watched intently to “determine inappropriate coding practices,” in response to the company’s comparability desk.
One vital ingredient of the brand new mannequin is that it goals to restrict code development, which has been a “nice concern” in Medicare Benefit plans, famous a senior company official on Thursday.
“And so we see this as not creating the identical vulnerabilities that now we have to the statutory development on to the [Medicare Advantage] facet, however [an] alternative for us to check methods to proceed to threat modify,” mentioned a senior CMS official.
“Right now’s announcement we expect reaffirms CMS’ total dedication in the direction of Accountable Care and reaffirms the aim of the Innovation Heart, to proceed to check and assist to tell higher coverage going forth,” added the official.
Susan Rogers, MD, an inner medication doctor and president of Physicians for a Nationwide Well being Program (PNHP), slammed the company’s announcement.
“ACO REACH is Direct Contracting in disguise … This new mannequin doubles down on Direct Contracting’s deadly flaws, inserting a profit-seeking intermediary between beneficiaries and their suppliers,” Rogers mentioned in a press release. “The ACO REACH fee mannequin establishes a harmful incentive for middlemen to limit affected person care, an incentive that has by no means beforehand existed in Conventional Medicare.”
PNHP argued that the brand new mannequin offers “middlemen” a flat payment to supervise seniors’ care, after which lets them maintain 40% of no matter is not spent on care as revenue and overhead. The mannequin routinely enrolls seniors with out their understanding or consent, and as soon as enrolled, seniors can’t choose out with out altering major care suppliers, the group said.
And like the unique direct contracting mannequin, the ACO REACH mannequin locations “just about no limits” on the varieties of corporations that may take part — “entities may be owned by business insurers, non-public fairness buyers, and different profit-seeking companies, together with present Direct Contracting entities,” famous PNHP.
Whereas new necessities improve supplier governance from 25% to 75%, Rogers said, “Buyers desire a return on their funding, making a harmful incentive for ACO REACH middlemen to each maximize revenues by way of upcoding, and decrease expenditures by limiting affected person care.”
Clif Gaus, ScD, president and CEO of the Nationwide Affiliation of ACOs, strongly disagreed, calling the company’s modifications “the fitting choice for each conventional Medicare sufferers and the way forward for value-based care. Most of the criticisms in opposition to Direct Contracting had been a product of nice misunderstanding in regards to the mannequin and the general shift to value-based fee. As a substitute, conserving the mannequin with further deal with fairness, elevated supplier governance, enhancements to threat adjustment, and different modifications is finest shifting ahead.”
“Despite the rhetoric getting used, conventional Medicare sufferers want extra entry to coordinated care and suppliers who’re accountable for his or her high quality and complete value of care,” Gaus mentioned in a press launch. “When a affected person’s physician is accountable for his or her outcomes, sufferers usually tend to have team-based care, care coordinators serving to their transitions out of hospitals, an emphasis on prevention and continual illness administration, and extra environment friendly care by way of telehealth or dwelling visits, all of which ends up in larger high quality care and decrease out of pocket prices for sufferers. ACO fashions are serving to enhance our healthcare system and produce higher outcomes for sufferers.”
The unique GPDC mannequin will proceed as is till Dec. 31, 2022, with the ACO REACH mannequin slated to start Jan. 1, 2023, mentioned CMS officers.
CMMI has issued a request for purposes for contributors within the ACO REACH mannequin and can start accepting candidates this spring, officers added.

Shannon Firth has been reporting on well being coverage as MedPage Right now’s Washington correspondent since 2014. She can also be a member of the location’s Enterprise & Investigative Reporting group. Follow



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