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Center Comments on Direct Contract || Center for Medicare Advocacy

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30. Might 2019

By way of Electronic Transmission

Adam Boehler
Director, Medicare and Medicaid Innovation Center
Medicare & Medicaid Providers
200 Independence Ave, SW
Washington , DC 20201

Re: Request for Direct Contract Info – Geographic Inhabitants Cost Model

Pricey Boehler:

Center for Medicare Advocacy (Center) is happy to offer Center for Medicare & Medicaid Providers (CMS) feedback for Center for Medicare and Medicaid Innovation (CMMI) Request for Info (RFI) on Direct Contract – Geographic Population Cost Model

Based in 1986, the Center is a national, neutral coaching and help group that strives to ensure truthful access to Medicare and quality healthcare. We practice the middle for the elderly and disabled individuals to assist guarantee truthful access to the required health care providers. We use our direct experience with hundreds of people to train determination makers on how their selections affect the lives of actual individuals. As well as, we offer legal illustration to make sure that individuals receive the well being advantages they’ve a reputable right to, and the standard of health care they want.


In the comments, the Center offered the previous RFI [1] we said:

”Although CMS presents a few of its goals for RFI DPC models and asks for suggestions on most of the issues related to such models, the current proposal is so unclear that it is troublesome to offer meaningful feedback and particular suggestions with out providing more substances. From the buyer's perspective, sure particulars about enrollment, entry, value sharing, and other issues increase different specific points and questions about which shopper agents can present prudent feedback and assist in troubleshooting. The Center has appreciable reservations on this proposal, but when the CMS had to transfer forward, it should a minimum of provide different, more precise iterations that can be commented on earlier than continuing. “

All in all, we repeat our earlier considerations that the shortage of particulars and the presentation of very particular questions in the RFI a few concept that’s still largely abstract. The shortage of element on this proposal makes it troublesome to offer considerate comments and troubleshoot problems. In the absence of a clearer proposal, we offer the following basic and particular comments

Then again, it is encouraged that CMMI investigates ways to cope with health-related social elements (SDOH) outdoors the Medicare Benefit Regulation and advises CMMI and CMS to continue this analysis beyond the direct contract fashions. We also perceive that the current RFI states that conventional Medicare beneficiaries who’re in settlement with DCEs collaborating within the Geographic PBP mannequin choice would retain all the unique Medicare benefits, including the freedom to decide on any Medicare service provider or provider, even if the service supplier or the provider shouldn’t be an arrangement with DCE. "

However, all models with modeling should have strict controls and a robust focus on the results and satisfaction reported by the beneficiaries in order that the beneficiaries obtain the care they want. As we’re concerned concerning the supervision of the Medicare Benefit program, we’re involved about how this proposed model seems to name even much less regulatory oversight. Persevering with remedy can be a continuing menace to recipients with continual or complicated circumstances. It’s unclear how DCE incentives work, how the DCEs might achieve savings, and which authority DCE should control costs (for instance, do they use utilization administration?). Extra broadly, it is unclear what the present issues or problems are when making an attempt to unravel the Gearius program. In other words, there’s vital info that is certainly missing for us and other shopper advisors.

Questions related to the number of goal areas

  1. What are the advantages and / or dangers of accessing, high quality, or prices related to the implementation of a geographical PBP mannequin choice in a rural space? What safeguards might the CMS think about so as to keep the entry and high quality of the beneficiaries of the agricultural areas of the PBP? How do rural market forces (resembling migration, hospital closures and mergers / acquisitions) affect DCE's means to scale back costs and enhance high quality with a cost mannequin?

Making contracts instantly with DCE to account for complete value of care, CMS can encourage quicker pooling of service providers. This is notably problematic in rural areas, where the impression of wage-keeping may cause everlasting financial instability in the space and the place the shortage of selection by the service provider can result in operational problems. More usually, consolidation can also be a harmful development for your complete healthcare system. For example, hospital techniques can achieve effectivity by means of consolidation and could possibly handle costs or even administration prices, which does not necessarily lead to decrease prices or better quality. Approaches that improve the attractiveness of rural areas can merely worsen this development and create new or worsening issues for the communities in the region

DCE eligibility issues

  1. What are the advantages and / or disadvantages of DCE selection The Geographic PBP mannequin, which are described above, the standards? What different selection criteria and core competencies should the CMS think about when making use of? Describe the advantages of including such further choice standards. Which standards are essential and will we get probably the most weight in our choice selections?

CMMI supplies, together with RFI, continue to check with well being plans as potential DCE brokers. Such references ask questions on how the administration of the Geographic PBP model differs from managing the Medicare Advantage plan, and whether the MA plan sponsors involved on this model would have the ability to circumvent present MA tips, reporting and shopper protection. Current Challenges The CMS has the management of MA plans and the mixing of MA's preventive results despite the deliberate funds [2]. We’re concerned that the well being plans are managed or managed by the geographical PBP mannequin. In addition to the above-mentioned criteria, DCEs have to be free from conflicts of curiosity and any vital sanctions, penalties or termination from Medicare, Medicaid, veteran administration, professional licenses or comparable authorities. , obligations, rules or legal guidelines. DCEs should each be financially strong enough to face up to double-sided danger and haven’t any excessive incentive to abuse, reporting or remedy distortion. As well as, they need to show proven functionality for co-ordinating care for elderly adults or individuals with disabilities and have related beneficiary engagement mechanisms, the power to offer culturally and linguistically competent communications, and privateness protocols that successfully shield beneficiary info.

Points related to Beneficiary Management

  1. Along with or in addition to the necessities described above, are there any transparency / disclosure requirements that the CMS should contemplate protecting the beneficiary's freedom to decide on any Medicare service provider or supplier to the beneficiaries in accordance with the DCE collaborating within the Geographic PBP Model Choice ?

CMS should present shoppers with written written notices clearly informing people that they have the freedom to choose a service provider both within and out of doors their vacation spot space as a way to keep away from attainable confusion or

  1. How can DCEs report recipients of the cost model choice and are they concerned in their care? What obstacles do DCEs should face with beneficiaries of their target space?

Beneficiaries could also be confused about how geographical PBP situations work together with their Medicare coverage, as well as their Medigap, Half D, employer, or other additional coverage. In addition to creating clear guidelines on easy methods to coordinate totally different advantages, the CMS ought to develop and check topical, accurate training and knowledge supplies to mitigate this confusion, even when the interaction would otherwise be utterly invisible to the beneficiary.

Program integrity issues and protection of the beneficiary

  1. What monitoring methods can the CMS use to make sure that beneficiaries receive remedy and that beneficiaries obtain correct care? What info or methods are wanted to help these efforts?

As said above, there isn’t any extra detailed info on how the care of the beneficiary is supervised / managed, so it is troublesome to offer significant suggestions. Generally, the CMS needs to replace present tools and assets to match new models. This consists of custom-made, template-specific scripts for the 1-800-MEDICARE software program so that callers can get the solutions and knowledge they need shortly. One among Medicare's most seen assets is the 1-800-MEDICARE, which is nicely positioned to play an essential position in providing enrollees and potential people with information about the purpose of the model and attainable modifications they will see. In addition to info purposes, this useful resource can serve as a monitoring software. The CMS might create a course of for auditing calls from 1-800-MEDICARE for complaints and creating a standardized process for monitoring such complaints, comparable to Medicare Advantage and Half D plans. 19659003] Equally, the State Health Insurance Packages (SHIP) should obtain training and knowledge on new fashions. SHIPs are absolutely established to help in mannequin registration or different issues, but they need to first perceive the model itself. Importantly, SHIP packages have to be adequately outfitted to satisfy these new special advisory needs, which, in addition to native, unilateral assistance, would assist beneficiaries to navigate their options for Medicare protection and understand their rights. 19659003] The coaching and scripts that CMMI develops for 1-800-MEDICARE and SHIP advisors also needs to be out there to service suppliers so that they will explain a mannequin that’s straightforward to know, in keeping with different CMS assets, and culturally and linguistically competent

] As said within the common comments above, any modeling based mostly on the capital must pay shut attention to the outcomes reported by the beneficiaries and to the satisfaction of the beneficiaries. Remedy is a constant menace to continual or complicated circumstances. The brand new mannequin should anticipate such risks prematurely and be rigorously planned by both the beneficiary and professional suggestions to ensure that the remedy is predicated on medical evidence (which can embrace value) and the wants and needs of the beneficiary.

Robust, easy-to-navigate The attraction and attraction course of have to be included into any mannequin. The contribution of the beneficiary and the lawyer should assist to assess the convenience of navigation in the actual world. Such a course of ought to present protection that’s a minimum of as robust as the current Medicare processes, and the notice of attraction ought to be included in all communications with the beneficiaries.

A strong set of quality actions which are affected person and reported among the affected person is completely very important, including the reported outcomes of sufferers, patient satisfaction measures, and complaints and redress procedures. The mannequin ought to embrace a top quality threshold to be met by service providers earlier than they receive bonuses or different incentives, and supply a clear indication of conflicts of interest between service providers and different entities. Info on qualitative measures have to be readily understood and available to the beneficiaries and their families, carers and advocates.

  1. What regulatory flexibility or operational measures are needed to advertise the success of DCE and how can such flexibility affect program integrity? Medicare Program?

We are against encouraging participation by assuaging present provisions that shield the well being and financial interests of Medicare beneficiaries. Such protective measures are the idea of the Medicare program and should not be waived or in any other case diluted.

  1. Encouraging buyers to positively affect their conduct and healthcare decision-making can lead to fraud and abuse legal guidelines and probably enhance the standard of care. prices or competition considerations, particularly if incentives would permit beneficiaries to adapt to at least one DCE between another DC or another company collaborating within the CMS. What safeguards ought to the CMS take to ensure that beneficiaries don’t adversely have an effect on the standard of care, program costs or competition?

In our comments to the original RFI's feedback relating to the integrity of this system and the protection of the beneficiaries, the CMS properly raised the priority for the required care. We respect this view, nevertheless it doesn’t essentially mean guiding the precept of "reducing the regulatory burden". Typically, service suppliers contemplate it a burden, reminiscent of notification, reporting and different necessities, as essential monitoring instruments for the regulator and shopper protection. This or other fashions shouldn’t start as a place to begin for eradicating present rules to ensure most flexibility for the service provider, and then wanting for methods to satisfy essential shopper safety guesses which safeguards ought to be outlined in an undefined model. 19659003] Most of the protective measures in Medicare have been specifically designed as a kind of coverage (eg MA v. Conventional Medicare), care setting, service, destination, and so forth. As noted above, the shortage of detail in this proposal makes it troublesome to offer info with attentive feedback and troubleshooting for Medicare beneficiaries . For example, protecting a beneficiary who is denied a service requested from a service supplier or apply – wouldn’t it be a corporation definition just like the Medicare Benefit choice? Are promoter notifications (ABN) promoted as a result of they are in conventional Medicare packages in sure situations? If the DPC fashions have been integrated with the Medicaid and / or MA plans, how would the scope of the providers be decided and what discover and proper of attraction would apply in what state of affairs? Questions on co-ordinating different insurances, would such shopper protection legal guidelines be linked to service providers, corresponding to QMB balances, or present restrictions on collaborating Medicare suppliers? These and different issues that might end result from more detailed info on the proposed model must be addressed earlier than proceeding with this proposal.

Cost Issues

  1. If DCEs would organize their own down cost with healthcare providers, how will the price allocation be decided and picked up from the beneficiaries?

For every mannequin by which the beneficiaries pay for something aside from the standard distribution of Medicare costs in follow, we repeat our demand that it shouldn’t improve costs. Beneficiaries should not be subject to sudden billing earlier than or after they receive remedy.

As said within the unique RFI feedback, because the CMS is aware, most conventional Medicare have some kind of supplementary insurance masking no less than a part of value sharing, similar to employer-sponsored protection, Medicaid or Medicare Complementary Insurance coverage (Medigap). Sharing costs for people in MA plans have to be actuarially equal to the cost of traditional Medicare. Within the unique RFI, the CMS appropriately raised the query of how the DPC mannequin would coordinate complementary protection, because it appears to be based mostly on handled care with comparable medical practices. We affirm that no DPC mannequin should reduce, reduce, or invalidate any further coverage that the beneficiary has when it comes to value sharing and availability of further providers.

On the one hand, any mannequin have to be reasonably priced and out there. Individuals with low revenue shouldn’t be excluded from all shows as a result of they are unable to pay the prices. Dual-Eligible Persons must keep the protection of value sharing and ancillary providers in addition to essential hedges, corresponding to Prohibited Invoicing Eligible Medicare beneficiaries (QMB). Allowing such billing might be a backstop to exclude double eligibility necessities for participation.

However, the DPC mannequin should not be the only strategy to broaden the choices of wealthier beneficiaries, for instance to set up boutique medical practices or to offer ways to coordinate health savings accounts (HSA). This or another model shouldn’t help larger revenue recipients or prolong present personal procurement contracts to Medicare.

  1. How ought to the CMS cope with the exploitation and costs of providers for beneficiaries which were aligned with DCE in the DCE's goal space?

Regardless of how the DCE is paid, the beneficiaries should stay unrestricted of their potential to decide on free service providers both inside and out of doors their target space and shouldn’t incur further prices just like those acquired by the service suppliers. DCE Goal Space Not Organized with DCE


We respect the opportunity to present these feedback. For extra info, please contact David Lipschutz, Senior Coverage Lawyer,, at 202-293-5760.

David A. Lipschutz
Deputy Director / Senior Policy Lawyer

Licensed at CA and CT


[1] Comments from Medicare Center Representative Info on Direct Contractor Contract Templates (Might 25 2018), obtainable at:
[2] See p. eg Center for Medicare Advocacy Weekly Alert ”An essential well being article revealed in the New England Journal of Drugs:“ Medicare Advantage Checkup ”(November 2018), out there at -in-new-england-journal-of-medicine-Medicare-advantage-checkup /, and Medicare Advantage plans and raise necessary policy issues ”(M ay 2019), out there at -highlights-overpayments-to-Medicare-Advantage plans-and-raises-notice-policy issues /.