newly announced cms payment models - microsoft · 7/16/2019 · payment amounts for sip patients...
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Newly Announced CMS
Payment ModelsJuly 16, 2019
Lisa Benton
Jenna Vonaa, MS
Agenda
Provide a high-level overview of the
Direct Contracting Payment Model
Outline the eligibility requirements
Describe the timeline and application
deadlines
Provide a high-level overview of the
Primary Care First Payment Model
Outline the eligibility requirements
Describe the timeline and application
deadlines
Helpful resources
Acronyms
ACO – Accountable Care Organization LOI – Letter of Intent
AHU – Acute Hospitalization Utilization MIPS – Merit Based Incentive Program
CMS – Centers for Medicare and Medicaid
Services
PBP - Population Based Payment
CMMI – Centers for Medicare and
Medicaid Innovation
PCF – Primary Care First Model
CPC+ - Comprehensive Primary Care Plus RFI – Request for Information
DCM – Direct Contacting Model SIP – Seriously Ill Populations
FFS – Fee for Service
CMS Primary Cares Initiative
Administered through the CMS Innovation Center, the CMS Primary Cares
Initiative will provide primary care practices and other providers with five
new payment model options under two paths:
Primary Care First (PCF):
PCF - General
PCF – Seriously Ill Populations (SIP)
Direct Contracting (DC):
Professional PBP
Global PBP
Geographic PBP
Direct Contracting
Payment Model
Direct Contracting Model Options
Professional Population-Based Option (PBP)
• ACO structure with Participants and Preferred Providers defined at the TIN/NPI level
• 50% shared savings/ shared losses with CMS
• Primary Care Capitation equal to 7% of total cost of care for enhanced primary care services
Global PBP
• ACO structure with Participants and Preferred Providers defined at the TIN/NPI level
• 100% risk
• Choice between Total Care Capitation or Primary Care Capitation
Geographic PBP*
• Would be open to entities interested in taking on regional risk and entering into arrangements with clinicians in the region
• 100% risk
• Would offer a choice between Full Financial Risk with FFS claims and reconciliation and Total Care Capitation
CMS will test three voluntary risk-sharing payment model options under Direct Contracting:
*CMS sought public input on
model design elements
Lowest Risk Highest Risk
Themes for Professional and Global PBP
Model Goals
Goal: Examples of how Direct Contracting will achieve these goals
DC Risk Sharing Arrangement
Option Risk Arrangement
Professional PBP 50% Savings/Losses
Global PBP 100% Savings/Losses
Geographic PBP
(proposed)100% Savings/Losses
DC Payment Model Options
Full Financial Risk
with FFS claims
processing
Primary Care
Capitation
Total Care
Capitation
Professional PBP
Global PBP
Geographic PBP
(Proposed)
Direct Contracting Entities - Eligibility
• Generally, must have at least 5,000 aligned Medicare FFS beneficiaries
• “On ramp” for organizations new to Medicare FFS
• Added flexibility for organizations serving dually eligible, chronically
ill populations
• Core providers and suppliers
• Used to align beneficiaries to
the Direct Contracting entity
• Responsible for reporting quality
through the Direct Contracting
Entity and improving the quality
of care for aligned beneficiaries
• Not used to align beneficiaries
to the Direct Contracting Entity
• Participate in downstream
arrangements, certain benefit
enhancements or payment rule
waivers, and contribute to
Direct Contracting Entity goals
DC Participants Preferred Providers
Timeline for Direct Contracting Model
Direct Contracting Model will begin in January 2021 and end December 2025
While submitting a LOI (letter of intent) is required in order to apply, a LOI will not bind an interested organization to participate in the model.
❑ Failure to submit an LOI during the allowed timeframe will result in the organization being ineligible to apply during the initial application period.
The LOI for the Global and Professional DC Options is available and must be received by Friday, August 2, 2019 at 11:59 pm EDT.
❑ https://innovation.cms.gov/initiatives/direct-contracting-model-options/
Currently pending, CMS will release a Request for Applications (RFA) for organizations interested in applying who have submitted an LOI
Primary Care First (PCF)
Payment Model
PCF Model Options
• Focuses on advanced primary care practices ready to assume financial risk in exchange for reduced administrative burdens and performance-based payments. Introduces new, higher payments for practices caring for complex, chronically ill patients
PCF Payment Model Option
• Promotes care for high need, seriously ill population (SIP) beneficiaries who lack a primary care practitioner and/or effective care coordination
PCF Seriously Ill Populations
Payment Model Option
* Clinicians can participate in both the PCF and the SIP Payment Model options
PCF Model Design
5 year alternative payment model adapted
from CPC+
Offers greater flexibility, increased transparency, and performance-based payments to participants
Fosters multi-payer alignment to provide
practices with resources and incentives to enhance
care for all patients, regardless of insurer
Rewards participants with additional revenue for taking on limited risk,
based on easily understood, actionable
outcomes
Payment options for practices that specialize in patients with complex chronic conditions and high need, seriously ill
populations
Primary Care First: Quality of Care
Measures were selected to be actionable and clinically meaningful, including:
patient experience of care survey
controlling high blood pressure
diabetes hemoglobin A1c
poor control
colorectal cancer screening
advance care planning
CMS will assess quality of care based on a focused set of measures that are clinically meaningful for patients with complex, chronic needs and the
serious illness population.
PCF Payment Structure:
Two Major Components
PCF – Seriously Ill Populations Option
PCF includes unique aspects for practices electing to serve seriously ill
populations (SIP) to increase access to high-quality, advanced primary care.
Payment amounts for SIP patients will be set to reflect the high need, high
risk nature of the population.
Payments in the first 12 months include:
▪ One-time first visit payment
▪ Monthly SIP payments
▪ Flat visit fees
▪ Quality payment
Eligibility for PCF
Primary care practitioners (MD, DO, CNS, NP, PA) in good standing with CMS
Provide health services to a minimum of 125 attributed Medicare beneficiaries*
Primary care services account for at least 70% of the practices’ collective billing*
Experience with value-based payment arrangement
Use 2015 Edition CEHRT, support data exchange, and connect to a regional HIE
Attest to a limited set of advanced primary care delivery capabilities in the Practice Application
*Note: Practices participating only in the SIP option are not subject to these specific requirements.
Additional Eligibility for PCF – Seriously Ill
Populations Option
Meet basic competencies to successfully manage complex patients and
demonstrate relevant clinical capabilities
Have a network of providers in the community to meet patients’ long-term
care needs for those only participating in the SIP option
Practices receiving SIP-Identified patients (identified based on risk score) need to:
PCF Eligible Regions
26 Regions for the 2020 start date:
Alaska (statewide), Arkansas (statewide), California (statewide), Colorado (statewide), Delaware (statewide), Florida (statewide), Greater Buffalo region (New York), Greater Kansas City region (Kansas and Missouri), Greater Philadelphia region (Pennsylvania), Hawaii (statewide), Louisiana (statewide), Maine (statewide), Massachusetts (statewide), Michigan (statewide), Montana (statewide), Nebraska (statewide), New Hampshire (statewide), New Jersey (statewide), North Dakota (statewide), North Hudson-Capital region (New York), Ohio and Northern Kentucky region (statewide in Ohio and partial state in Kentucky), Oklahoma (statewide), Oregon (statewide), Rhode Island (statewide), Tennessee (statewide), and Virginia (statewide).
*Note: Connecticut and Vermont are not eligible
Timeline for Primary Care First
Spring 2019 Summer 2019 Fall/Winter 2019 January 2020 April 2020
Practice
application
period
Practice and
payer
solicitation
period
Practices
and payers
selected
Model
Launch
Payment
Changes
Begin
Helpful Resources
Qualidigm Payment Model Homepage
https://www.qualidigm.org/payment-models/
CMMI - Primary Care First Model
https://innovation.cms.gov/initiatives/primary-care-first-model-options/
CMMI - Direct Contracting Model
https://innovation.cms.gov/initiatives/direct-contracting-model-options/
Questions
Join Us:
Open Call for Q&A : Tuesday, July 30, 2019 – 12 – 12:30 pm
Contact Us
Lisa Benton
Jenna Vonaa, MS