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April 26, 2018

CMS eyes test that would let providers contract directly with patients

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    CMS on Monday released a request for information (RFI) seeking "broad input" on ways to allow primary care providers to contract directly with patients, noting that the agency plans to test a direct provider contracting model in Medicare Parts A and B, Medicare Advantage, and Medicaid.

    Medicare 101: Cheat sheets for Parts A through D


    CMS said it released the request based on responses it received to a separate RFI that asked for input on how the Trump administration could use CMS' Center for Medicare and Medicaid Innovation to make it easier for the health care industry to work with Medicare.

    According to CMS, comments on that request "focused on a number of areas that are critical to enhancing quality of care for beneficiaries and decreasing unnecessary cost, such as increased physician accountability for patient outcomes, improved patient choice and transparency, realigned incentives for the benefit of the patient, and a focus on chronically ill patients." The responses also "reflected broad support for reducing burdensome requirements and unnecessary regulations," CMS said.

    CMS announces plans to test direct provider contracting model

    In response to the comments, CMS said it is looking to test a direct provider contracting (DPC) model in Medicare Parts A and B, Medicare Advantage, and Medicaid. CMS said, "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."

    CMS said the test would be informed by comments it receives on the new RFI, which seeks "broad input on [DPC] between payers and primary care or multi-specialty groups." CMS encouraged "the public … to provide feedback on their experiences with, and perspectives on, DPC and how CMS can use DPC models to reduce expenditures and preserve or enhance the quality of care for Medicare, Medicaid, and [CHIP] beneficiaries." CMS also asked commenters to address certain potential design features of a DPC model, such as:

    • Beneficiary participation;
    • Existing CMS initiatives;
    • General model design;
    • Payment;
    • Program integrity and beneficiary protections; and
    • Providers/state participation.

    CMS is accepting public comments on RFI through May 25.

    How a DCP model might work

    According to Modern Healthcare, a DPC model could allow physicians to bill beneficiaries directly for services and charge them higher rates than what providers currently are paid under Medicare, Medicaid, and CHIP.

    Alternatively, a DPC model also could allow providers to receive lump sums from the programs to cover basic primary care services for each beneficiary, instead of requiring the providers to submit claims for each service provided. Under such a model, providers could have the opportunity to receive bonuses for providing additional or high-quality care, Politico's "Pulse" reports.

    Stakeholders voice support—and concerns

    Some providers groups in comments submitted on CMS' CMMI RFI expressed support for DPC.

    For instance, Dennis Holtschneider, chief operations officer at Ascension, wrote that a DPC model could make more funding available to beneficiaries upfront, and allow them to use those funds to pay for services that typically are not covered by Medicare. "This aspect of such a model would allow both a beneficiary and provider, in partnership, to define what has value and create competition for such services," Holtschneider wrote.

    The American Association of Neurological Surgeons in its comments also backed a DPC model, saying it could increase beneficiaries' access to care.

    However, some consumer advocates have criticized DPC models. For example, AARP in comments on the original RFI said a DPC model could allow physicians to choose which services they will bill to Medicare or which patients they will treat. "(Current) rules prevent doctors from choosing patients based on the severity of their illness or other characteristics or charging different patients different amounts," AARP wrote, adding, "These rules also reduce the likelihood of fraudulent billing, help maintain access to care for Medicare beneficiaries, and protect patients from high out-of-pocket costs" (Dickson, Modern Healthcare, 4/23; CMS release, 4/23; CMS request for information, 4/23; Clason, CQ Health, 4/23 [subscription required]; Diamond, "Pulse," Politico, 4/24).

    Medicare 101: Cheat sheets for Parts A through D

    Through the years Medicare has grown more complicated, including private supplemental insurance and prescription drug coverage. Download our cheat sheets to learn how each of the four parts of Medicare works, and why they’re so important for provider organizations:

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