The Center for Medicare and Medicaid Innovation (CMMI) has hit the pause button and is undergoing a strategic evaluation to determine how its alternative payment models can have a transformative impact on the healthcare delivery system. In a recent interview, François de Brantes senior vice president of commercial business development at Signify Health, spoke about this critical juncture in the value-based care movement, including the start of the Direct Contracting program.
First, here is a little background on de Brantes’ employer, Signify Health: Its platform leverages analytics, technology, and nationwide healthcare provider networks to power value-based payment programs. The Dallas-based company’s goal is to create a suite of clinical, social, and behavioral services to address an individual’s healthcare needs and prevent adverse events that drive excess cost, all while shifting services towards the home.
Signify works with ACOs on the optimization of post-acute care and helps with the transitions of care. “For providers that have accountability in the hospital or health system, once the patient leaves, you really have no idea where they're going. How are you reaching back to their primary care or specialty care provider? This gap exists when patients have an acute event that requires visits in the home,” deBrantes said, “and that's something that we have a lot of experience with.”
De Brantes has spent close to two decades working on healthcare transformation. Prior to joining Signify Health, he served as vice president of Altarum, a national nonprofit. From 2006 to 2016, he was executive director of the Health Care Incentives Improvement Institute (HCI3), a not-for-profit company that designed programs to motivate physicians and hospitals to improve the quality and affordability of healthcare delivery. Prior to HCI3, he was chief operating officer of the eHealth Initiative, which promotes adoption of health information technology in the United States.
I asked de Brantes to describe some of the goals that CMS has for the Direct Contracting program and whether it was based on some lessons learned in the earlier ACO models or other alternative payment models.
“I think it's designed to increase the number of organizations participating in value-based contracts with a clear bias towards primary care practices, as the focus for expansion,” he said, “and if you look at how CMMI developed Direct Contracting, they were probably looking at a fair amount of the work that's being done by Medicare Advantage plans in how they're establishing contracts, with a tight focus on the concept of advanced primary care. These are practices that have made the investment in social care coordinators, mental health providers, behavioral health providers — trying to look at the management of patients in as comprehensive a way as possible.”
The Comprehensive Primary Care program and CPC+ are extensions of what CMS and other purchasers did around Patient Centered Medical Home practices, he added. They wanted to see if they could use that as an investment to do some more care coordination and curating. The ACO program, on the other hand, was very much geared towards hospitals and health systems.
CMS says that 53 Direct Contracting Entities are participating in the first Performance Year of the model, which runs from April 1, 2021, through Dec. 31, 2021. The goals include creating opportunities for a broad range of organizations to participate with CMS in testing the next evolution of risk-sharing arrangements. “The risk-sharing options are anticipated to appeal to a broad range of physician practices and other organizations because they are expected to reduce burden, support a focus on beneficiaries with complex, chronic conditions, and encourage participation from organizations that have not typically participated in Medicare FFS or CMS Innovation Center models,” according to the CMS website.
Direct Contracting is making it the primary care practice’s job to manage the patient and to optimize the patient's care, get the best possible specialist referrals, and engage with community specialists — almost like creating a virtual ACO, de Brantes explained. “I think about it more as the horizontal integration with primary care and specialty care rather than the classic vertical integration through health systems and hospitals,” he said. “That, to me, is the essence of Direct Contracting, as opposed to what has been going on in the ACOs.”
The NextGen ACO program is over, he explained, and ACOs were given a choice or going into Direct Contracting or defaulting back into the Medicare Shared Savings Program. “I do know that there were a substantial number that were really concerned about going into Direct Contracting with the existing baseline.”
So who are the companies involved in Direct Contracting? The Direct Contracting entities tend to be focused on primary care, de Brantes said. “The same ones who take risk in Medicare Advantage felt comfortable that this program was sufficiently close to what they were accustomed to doing in Medicare Advantage that they could step in and try to replicate the same structure and model that they have in MA.”
The first Direct Contracting entities started in January of this year, and the second wave starts in January of next year. Some, including Signify, filed applications this year, but elected to defer participation until next year primarily because when CMMI structured the regulations in designing the program, the financial model wasn't fully fleshed out and finalized, de Brantes said. “So you had to make a decision as to whether or not you wanted to jump in without the full knowledge. Some organizations felt comfortable doing that. I think there's a lot more who felt that they would be better served holding off.”
“We are having lots of discussions with Direct Contracting entities to understand what they are doing today, what their experience in the program is, and where there might be opportunities for improvement,” he said.
Are we likely to see a streamlining or elimination of alternative payment models from CMMI?
De Brantes said the re-evaluation going on now is not uncommon when you have a change in administration. “CMS has been getting feedback that it has so many different value-based payment models, and that it may be time to hit the pause button, and assess what you have,” he said. “Even Direct Contracting had a couple of submodels, and one of them was the geographic model, which would involve assigning all Medicare beneficiaries in a given geographic region to a Direct Contracting Entity. People said you're essentially asking a provider organization to take a risk on Medicare beneficiaries that they may not even be managing at all. That really is what caused CMS to hit the pause button on that.”
I asked de Brantes if there were gaps in the APM models. There are programs for hospitals and health systems and for primary care, but there aren’t APMs for a lot of specialty groups, he noted. “There are ones for oncologists and nephrologists, but what about the cardiologists? What about the neurologists? There's a lack of specialty advanced alternative payment models,” he said.
I used to listen to the hearings of the HHS Physician-Focused Payment Model Technical Advisory Committee (PTAC), where specialty societies and other groups would propose new payment models. Sometimes the advisory committee recommended one go forward to HHS, but they would never be accepted for implementation by the Secretary of HHS, and some of the PTAC members quit because they felt they were wasting their time. I asked de Brantes why that was the case. He said he thought there was a disconnect between how the programs and specialty societies are asked to submit to PTAC and how the models are evaluated. “The deep-dive elements of the design, including how you would attribute patients, how it interacts with the other models, all that hard stuff to engineer, is typically missing because the proposed models tend not to have that depth,” he said.
One thing we've seen during the pandemic is the expansion of the Hospital at Home program. I asked de Brantes if this was something CMS would be likely to continue to encourage beyond the pandemic.
“It's very difficult to do because it requires pretty significant infrastructure,” he said, “but there's no question that for some physicians it's a lot better and for some patients it eases the transitions back into their home. There are a lot of advantages for the individual. Anywhere we can shift the care model to being more patient-centric, and bringing the services to the patient as opposed to bringing the patient to the services, we're doing something right.”