Thread by @Farzad_MD

It's going to be fun meeting old friends at the @CMSinnovates launch of new primary care models.

Will let y'all know what's new in this string

1/n

2/ here with the usual advanced primary care superheroes
@iorahealth @rushika1
@ChenMed Chris Chen

3/ scuttlebutt in the room on what's coming:

1) "Direct Contracting" - the Next Generation of the Next Gen Program
2) A New Primary Care program, maybe modeled after @aafp @PFPMTAC proposal
3) A CPC Track 3, focused on multichronic beneficiaries with severe illness burden

4/ Things I'm listening for:

A) what's geographic or other availability/ limitations

B) Any mandatory models or all voluntary

C) what's the extent of total cost of care incentives/ accountability (IMO without this won't see savings

D) for risk models, WHATS THE BENCHMARK?

5/

E) how these models handle overlap with existing models and with each other.

F) whether attribution is opt-in only or includes claims-based attribution with opt-out

6/ we are underway

With @SecAzar to speak first for the administration on one of his top priorities ("changing how we pay for care to be more value-based")

7/ "culmination of years of work"

(Yes, not just acknowledging that it takes a long time to get a model through clearance, but also long bipartisan history)

8/ Primary Care First

for small practices
payment components:

1) prospective, risk-adjusted, primary care global payment

2) bonus if risk adjusted hospitalizations are reduced

3) downside risk

9/ Direct Contracting- for larger organizations that can take global risk

...and surprising to me-
What sounds like an alternative to MA for Traditional Medicare beneficiaries that opt-in to an entity that does value-based purchasing, negotiate prices, etc?

10/ @SeemaCMS next, touches on admin burden and healthcare affordability, before switching to "choice, competition, and innovation" as ways to "transform FFS system".

PCPs are at the center (nodding heads here, but I think "gatekeeper" is not as popular)

11/ one question answered:

Models will be VOLUNTARY.

2 new tracks:
1) Direct Contracting (at least 5k lives)- looking for MA plans and providers with experience in full risk. Open network.

2) Primary Care First

In all, 5 new options with choices on the road to value.

12/ Press release and summary for both models: go.cms.gov/2VZa0v9and bit.ly/2VYIfmA

 Primary Care First go.cms.gov/2W0AlZU
Home Page: bit.ly/2W1EnBd

Direct Contracting
go.cms.gov/2W1EvAH
Home Page: bit.ly/2VZaod5

13/ Primary Care First
2020 start
RFP in next month
Flat visit fee
Downside risk 10% of revenue
Upside 50% OF REVENUE
Based on risk adjusted hospitalizations

14/ Direct Contracting with monthly prospective payments
2020 start, RFA June
A) 50% total cost of care up/down
B) Global 100% cap model

And seeking comment on a potential geographic model (hospice, palliative care, hotspotting) to potentially start June 2020 ("Big MAC"?)

15/ so, are these Direct Contracting options better than existing 2-sided MSSP (ENHANCED) options??

Pure economic terms not as good, although Prospective payments help with cash flow, and real draw will have to be BENCHMARKS.

Are they using MA benchmarks? Full risk adjustment?

16/ other sweeteners-

Reduced # quality measures

Benefit enhancements ("while maintaining all Original Medicare benefits.")

Ability to negotiate prices (significant for DME/Labs, but less so for players with market power)

17/ there's a fair amount of expectations on these prospective payments reducing admin burden for small practices, but
A) if I still bill commercial plans and submit encounters, not that helpful
B) the feedback on the E&M proposal showed the burden of CHANGING anything in billing

18/ @SeemaCMS hopes that Medicaid programs will follow suit. @AdamCMMi has been working with commercial payers too

But there aren't many levers on Medicaid Managed Care Organizations today and commercial payers still very stuck on their own flavors, sadly.

I hope they are right

19/ I will give a shout-out to the first person to locate how the benchmark will work for Direct Contracting

20/ DC Benchmark:
Historical and Regional components- the regional benchmark and trend components will "capitalize on MA rate calculations"!!!

I love this idea

catalyst.nejm.org/medicare-advan…

21/ hmm- "will be AAPMs for 2021 performance period"??

I thought @AdamCMMi said 2020 start

21/ more details

Historic benchmark trends forward with national inflation (IMO introduces too much variability due to regional trends)

Quality bonus reduces amount of discount taken by CMS (like nextgen)

"Innovative approach" to risk adjustment- not MA-like free-floating HCC?

22/ expanding PACE like programs for dually eligible, but through the Medicare lever?

Not sure how this is supposed to happen, but I guess the Medicaid MCO would take accountability for the Medicare side too?

23/ here's the explanation of the 2020 start (performance year zero), but payments and AAPM designation really start 2021

24/ always important to acknowledge the hard working and creative civil servants who are behind these efforts and will help them work

25/ Q&A
a) Benchmark for DC will blend regional and historic, will increase up to 50% regional by y5
b) not clear how to handle overlap, but individual patient will be in either DC or ACO, not both (CPC3 though?)
c) claims-based default, with voluntary like today, but enhanced?

26/

It
Is
All
About
The
Benchmark

This is an article from @Travis_Broome and @bobkocher on why the NextGen program didn't work for us

ajmc.com/contributor/tr…

27/ Reminder, you can have preferred providers and incentives, but beneficiaries retain full rights of Traditional Medicare with total choice.

28/ Without the ability to create narrow networks, there will not be much ability to get cost concessions from suppliers I don't think, but could allow hospitals eg to lay claim to a geography, as in Maryland global budget program.

I worry about the consolidation risks of that

29/ cost-sharing: beneficiaries still pay their 20% for what the claim would have been, ie you still have to submit a 99214. (And for attribution)

Again, don't count on huge savings from admin simp, even under primary care cap.

30/Primary Care First, at first blush
A) better QM structure (gate, few measures)
B) smarter payment structure (fewer guaranteed cost-increasing pmpms)
C) more aligned w total cost of care (focus on hospitalization)
D) still can do concurrent w MSSP

Sounds good in my book
@aafp

31/ I do worry about the serious illness model shoehorned into PC1st, with really high pmpm for seriously Ill patients that could be abused I'm afraid.

32/ In my mind Direct Contracting is supposed to be the bridge we lack between MSSP and MA.

The construct here comes close, but there are a few key unanswered Qs:

A) can we pay for services not covered by trad Medicare out of total budget without taking over claims processing?

33/

B) Can we have predictable Benchmark? Using Medicare ratebook for regional cost and trend is good, but trending historic on national inflation is a step backwards.

MSSP fixed this defect, and yet the CMMI model perpetuates it. Why add variability and uncertainty?

34/
C) another key contributor to uncertainty in MSSP is non-standard approach to risk adjustment. I'm hopeful that we won't see cliff effects and one sided caps, but testing an "innovative approach" could bite people taking serious downside risk. Why not do HCC with an adjuster?

35/ As MA becomes more prevalent, docs doing a better job with risk adjustment in traditional Medicare will seriously help reduce MA trend, nothing wrong with reducing the gap between MA and FFS coding.

(I think we will soon learn the extent to which this is already working)

36/ and finally (I think)

D) MA is long-term sustainable because it's 100% regional benchmark, 0% historic.

MSSP used to gradually rise to 75% but new rule capped it at 50%. I was/am hoping the DC model provides a pathway to 100% and is not also capped at 50%
#RewardEfficiency