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TWO DAYS ONLY--CMS looking for comments on possible other MCR arrangements they call Direct Provider Contracting (DPC)

  • 1.  TWO DAYS ONLY--CMS looking for comments on possible other MCR arrangements they call Direct Provider Contracting (DPC)

    Posted 05-24-2018 20:00
    Deadline  11:59 EDT on May 25, 2018

    " CMS is seeking input on direct provider contracting between payers and primary care or multi-specialty group practices to inform potential testing of this approach within the Medicare fee-for-service (FFS) program, Medicare Part C program (also known as Medicare Advantage), and Medicaid (for example via State-based approaches)."     Comments should be submitted electronically to

    Jean, you could submit your model, if you haven't already.

    This may be the opportunity we've been looking for.
    All the APM models CMS has proposed assume primary care will take GLOBAL risk  Unless we're in a huge organization, we simply can't.  A statistical anomaly could roll over in its sleep and crush us.  However, somebody seems to have realized primary care is the tail that wags the dog.

    This may be the opportunity we've been looking for.
    It's my personal belief that a primary care monthly payment at 12% of the expected total cost would allow us to provide better care for the MCR population.
    Annual cost per MCR beneficiary runs $8900-11000/year; 12% of that would be $89-110/ month. Current reimbursement is about 4-5%, $30-45/ month and involves enormous billing overhead, about 30%.

    Desirable features, IMO:
    • adjusted for risk using patients' diagnoses, (HCC) recognizing that primary care utilization is about half as skewed as global costs. 
    • prospective enrollment, patients allowed to change monthly.  Binding electronic enrollment confirmation for providers
    • direct thru MCR, not insurance companies
    • for the first few years, no part of the payment at risk
    • only open to primary care specialties  (FP, GP, IM wo other specialty, Geriatrics, (Peds)

    CMS concerns:  --------------------------------------------------------------------------My thoughts-----
    • Provider/State participation  ------------------------------------------  open to primary care practices
    • Beneficiary participation ------------------------------------------------ by electronic enrollment
    • Payment -------------------------------------------------------------------- direct deposit
    • General model design  ---------------------------------------------------as above
    • Program integrity and beneficiary protections --------------------- Same as current program, 
    • ----------------------------------------------------------------------------------Each patient specifically enrolls, using their MCR card
    • Existing CMS initiatives --------------------------------------------------Cumbersome and excessive burden of data gathering

    After 3 years and with more than 100 enrollees, put 10% of the amount at two sided risk through ratings on HYH  (e.g., payments could be increased or decreased by 10%,  so 90-110% of the initial amount)
    Others may have different ideas

    " Direct provider contracting would enhance the beneficiary-physician relationship by providing a
    platform for physician group practices to provide flexible, accessible, and high quality care to
    beneficiaries that have actively chosen this type of care model. CMS seeks input from all
    stakeholders about their experiences with, and perspectives on, direct provider contracting and
    how CMS can use direct provider contracting models to reduce expenditures and preserve or
    enhance the quality of care for Medicare, Medicaid, and Children's Health Insurance Program
    (CHIP) beneficiaries. Additionally, this RFI solicits stakeholder input on how direct provider
    contracting would interact with, enhance, and/or refine current accountable care organization
    (ACO) initiatives, such as the Medicare Shared Savings Program."

    Peter Liepmann MD FAAFP MBA
    My mission is to fix US health care
    Glendale CA

  • 2.  RE: TWO DAYS ONLY--CMS looking for comments on possible other MCR arrangements they call Direct Provider Contracting (DPC)

    Posted 05-25-2018 07:52
    This looks pretty interesting.  I believe global risk is definitely the way to go, but Peter is right about large cases.  My feedback for CMS would be they should arrange a nonprofit reinsurance effort so small practices can join.  A pool of independent practices would be much cheaper to fund than what is currently being charged by the reinsurance industry.  Assuming adequate protection from big cases, a practice with as few as 100 Medicare patients would be viable.  Practices building to 100 would simply stay fee for service.

    The problem with capitation is that is doesn't provide sufficient motivation for the doctor to save money.  For example, given global risk, a doctor who gets a call from a patient on a Friday evening complaining of fever and cough may decide to do a home visit and administer a Rocephin shot if appropriate.  Why?  The potential savings is large, at least $1000 for the ER visit, $5-10K if they get admitted.  The payment for this home visit is big under a global risk arrangement, ie money saved goes to the doctor.  Without that financial incentive, however, we never see this behavior.  CMS understands that pushing us to accept global risk gets us doing this type of work.

  • 3.  RE: TWO DAYS ONLY--CMS looking for comments on possible other MCR arrangements they call Direct Provider Contracting (DPC)

    Posted 05-31-2018 11:34
    For primary care, the problem w taking on global risk is we're the tail wagging the dog. Primary care is 4-5% of MCR spending.  The global cost for a MCR panel could easily vary by 5% in any year.  Assuming a 100% MCR practice, that means the practice would be at risk for 100% of their gross revenues. RUN!!!
    Yes, better primary care (and MORE primary care) can reduce costs but making primary care docs at risk for amounts twice or 5x as great as their annual gross scares them away.  Appropriately.
    Risk of 3% of their MCR gross is bad enough.
    The point is, most primary care docs are NOT primarily motivated by money.  If they were, they'd be dermatologists or anesthesiologists.
    Just doing what we do, guided by our professional goals, we can reduce costs and increase quality.

    Here's what I sent CMS:

    RE:  Direct provider contracting (DPC) between payers and primary care or multi-specialty groups to inform potential testing of a DPC model within the Medicare fee-for-service (FFS) program.

    CMS strategies to improve care and reduce cost should be viewed from the perspective of the whole health 'system.' The most important strategy, shown to have worked in the US and around the world, is access to high quality primary care.  There are two reasons this is lacking in the US-

    • First, there is an increasing shortage of primary care (due to payment policies) and thus Medicare beneficiaries face markedly worsening access to any primary care.  
    • Second, those same payment policies and shortsighted attempts to compel massive collection of minimally useful data has pushed primary care providers away from (uncompensated) activities which add value, improve care and reduce cost, while pushing them toward massive (compelled) data gathering which has consumed much of their time. Thus high quality primary care only exists where providers have left insurance-company-compensated practice, or ignored its influence on practice and made a personal financial sacrifice.

    Thus the primary goal for fixing the US health care system must be to reverse these trends. Current policy (e.g., MACRA) has focused on the micro process ('the trees') rather than the macro environment ('the forest') and because of this has been ineffective.  The proposed DPC model has the potential to achieve this, by solving several large system problems:

    • First, monthly payments based on numbers of Medicare beneficiaries (MBs) and their degree of illness will dramatically reduce the complexity of payment. Direct deposit with a monthly statement will dramatically reduce billing overhead waste vs. present FFS billing, which is estimated to consume 30% of gross receipts in primary care.
    • Secondly, separating payment from a detailed account of FFS activity will allow practitioners to do what MBs need rather than what insurance will pay for.
    • Thirdly, paying for the value of primary care rather than FFS 'production' will improve compensation for primary care, removing some of the disincentives to entering primary care.

    These measures will vastly increase the attractiveness of primary care, and thus increase access to high quality primary care.

    Peter Liepmann MD FAAFP MBA
    My mission is to fix US health care
    Glendale CA