Medicare Payment and Reimbursement

Providers press CMS for details amid lingering uncertainty about new primary care models

June 20, 2019 6:53 pm

The possibility of conflicts between Medicare payment models joined the customary concern about benchmarking details in provider feedback on coming primary care models, an administration official said.

As details on  the Primary Care First (PCF) and Direct Contracting (DC) models continue to emerge, some of their components remain undecided — even as the Centers for Medicare & Medicaid Services (CMS) aims to garner provider participants this summer.

The models were introduced in the spring as mechanisms to move primary care to an outcomes-based focus, enhance care for high-need patients and reduce physicians’ administrative burdens, among other goals.

Physician responses to the models have been positive but cautious, given the many details that were unknown when CMS announced the models in April, with a goal of launching them in 2020.

Pauline Lapin, MHS, director of the Seamless Care Models Group at the Center for Medicare and Medicaid Innovation (CMMI), described the industry’s response during her address this week at the Bundled Payment and MACRA Summit in Washington, D.C.

Emily DuHamel Brower, senior vice president of clinical integration for Trinity Health, said providers’ shift away from focusing primarily on benchmarking issues is positive. Instead, providers also are seeking information about how Medicare beneficiaries will be selected or opt in to the models, how conflicting model enrollments will be handled, and how the models’ cash flows will function.

“That to me feels like an evolution — that feels like progress, that we’re having those conversations more than whether there is a decedent adjustment in the benchmark,” Brower said.

Emerging details of the models

Based on CMS calls with providers since the models were rolled out, details that will apply to PCF participants include:

  • Participation and credit for those also in bundled payment models will be allowed.
  • Overlap with the Medicare Shared Savings Program — as outlined in future guidelines — will be allowed.
  • Participants will not be able to earn shared savings payments in both PCF and MSSP.

Prospective participants in the DC models likewise have raised questions about conflicts from participation in multiple Medicare models, Lapin said.

“We’re still trying to work through some of those questions,” she said.

Meanwhile, patient-attribution rules for the PCF and Direct Contracting models include:

  • Attribution primarily will be voluntary and take place through the beneficiary portal.
  • Attribution next will be based on which clinician provides the annual wellness visit or “welcome to Medicare” visit.
  • The last criterion will be based on a plurality of primary care visits over the prior two years.

Benchmarking approaches in the different models

Despite the shifting priorities in how providers assess the new models, the still-emerging CMS approach to benchmarking will be critically important to provider organizations that take on two-sided risk in the models.

Benchmark-related approaches in the PCF models include:

  • Establishing a national minimum benchmark, with providers facing a 10% cut if they exceed it
  • Offering a 3.5% bonus for practices that come in under the benchmark — if they improve in cost savings
  • Paying up to a 16% bonus to the top 20% of eligible providers    

Among the two DC models that have made more progress in finalizing details, benchmark approaches include:

  • Creating a prospective blend of historical spending and adjusted Medicare Advantage regional expenditures (segmented by aged/disabled and end-stage renal disease)
  • Using historical baseline expenditures trended forward by U.S. per capita cost growth, with adjustments to account for population risk and geographic price factors
  • Considering innovative approaches to risk adjustment, including for complex and chronically ill populations

“On benchmarking, we’re thinking, ‘How do we leverage the Medicare Advantage rate book more in developing this benchmark?’” Lapin said.

CMS plans a webinar on the DC models’ methodology in late June or early July.

Geographic direct-contracting option

CMS has yet to finalize most aspects of a third DC model that will involve geographic population-based payments, in which an entity would assume risk for all Medicare fee-for-service beneficiaries in a specified geographic area.

Lapin said CMS is still weighing what benchmark methodology to use in the model, factoring in comments it received from the industry.

“We’re thinking it would be based one-year historical per capita spend in the target region,” Lapin said.

That would differ from the approach used in the other two versions of the DC model but might be necessary because the at-risk entity would be accepting accountability for all Medicare FFS beneficiaries in that area, she said.

CMS also continues to develop the model’s risk adjustment — always a controversial issue for providers.

“We’re trying to make sure that what we come up with actually can help us more accurately code for populations that today we are seeing are under-coded, and at the same time protect from over-coding,” Lapin said. “It’s a tricky methodology that we’re trying to get right.”

Next steps for prospective participants

The next steps for the DC models will come this fall, when CMS plans to post a request for applications here, according to a CMS spokesman. However, providers must first submit a nonbinding letter of intent by Aug. 2.

The next steps for the PCF models will be the sending of a solicitation this summer to participate to practices and payers in the selected regions. That solicitation will be posted here.


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