The AAFP recently took advantage of CMS' invitation to provide feedback on one of five payment models that were unveiled on April 22 as part of CMS' Primary Cares Initiative.(innovation.cms.gov)
Specifically, in a May 20 letter(8 page PDF) to CMS Administrator Seema Verma, M.P.H., that was signed by AAFP Board Chair Michael Munger, M.D., of Overland Park, Kan., the AAFP responded to the agency's request for information on how to refine the Direct Contracting Geographic Population-Based Payment model option.
Participants in this particular model, expected to launch in January 2021, will assume oversight of the health care needs and total cost of care of a population located in a defined target region.
"We appreciate (that) the three DC (direct contracting) models announced recently are part of CMS' strategy to redesign primary care as a pathway to drive broader delivery system reform," said the AAFP, before offering responses to specific questions outlined in the RFI.
- The AAFP recently responded to a CMS request for information with suggestions on how to refine one of the agency's new payment models.
- The AAFP's comments pertained to the Direct Contracting Geographic Population-Based Payment model option that will launch in 2021.
- The Academy's letter focused primarily on how to increase the primary care spend, increase access to primary care physicians, expand participation in advanced alternative payment models, and support the participation of small and independent practices.
The AAFP focused its attention on
- increasing the primary care spend,
- ensuring and supporting increased access to primary care physicians,
- expanding access to participation in advanced alternative payment models, and
- supporting the participation of small and independent practices.
Social Determinants of Health
The AAFP first tackled CMS questions about potential barriers that could prevent direct contracting entities from addressing social determinants of health, such as food, housing and transportation, as well as incentives to promote practice interest in addressing SDOH.
"Social determinants of health have a significant impact on a patient's health and well-being," said the AAFP, and "primary care practices are uniquely positioned to help address these issues but need the support of community resources."
Multiple barriers keep physicians from addressing SDOH, and those same issues likely would apply to direct contracting entities, said the AAFP. For instance, impediments include the fee-for-service payment structure, EHRs that lack interoperability, administrative burden and a lack of available resources.
The letter also called for risk-adjusted payments "to effectively address beneficiaries' health and SDOH needs."
Target Regions, Rural Safeguards
Regarding the design of the Geographic Population-Based Payment model option, the AAFP noted that practice performance across all three models "should be evaluated on the same quality measures at the practice level" and said that CMS should model its evaluation approach to that used in other payment models.
"Comparison groups should be matched to practices outside the selected target regions that have limited penetration of other Medicare advanced alterative payment models," said the AAFP, and they should include practice considerations such as size and location, as well as patient attributes such as average patient risk, age and social need.
The letter urged CMS to monitor the effects of direct contracting models in specific regions to make sure they do not limit competition or encourage consolidation. Direct contracting entities "should be required to provide details on how they will work with small and independent practices in a way that continues to support these practices and promote competition."
Regarding safeguards that would preserve access and quality for patients in rural areas that are part of a geographic population-based payment target region, the AAFP said such regions need to include rural areas to ensure that patients in those areas can enjoy any resulting benefits.
Payment Distribution, Network Adequacy
Direct contracting entities should not systematically pay rural physicians less than their urban and suburban counterparts. "The model should allow primary care practices of all sizes and in any location to participate," said the AAFP.
Addressing the distribution of capitated and shared savings payments to participating primary care providers, the AAFP called on CMS to ensure that primary care spending is increased from the current level of 2% to 5% of total Medicare health care spending to at least 12%.
"Evidence indicates(www.ncbi.nlm.nih.gov) increased spending on primary care will lead to a decrease in overall spending on a per-patient basis," said the letter.
The AAFP also asked CMS to ensure network adequacy in its selection criteria and noted that primary care capacity should be the lead indicator. Additionally, the letter urged CMS to consider only full-time physicians in its calculations and to exclude nonphysician providers such as nurse practitioners and physician assistants "because listing these providers creates the illusion that there is more access to physicians" than is the case.
Beneficiary Alignment, Transparency
The AAFP called the design of the patient attribution methodology "critical" to measuring payment, quality and cost performance, and to defining accountability.
"Accurate attribution may also help patients understand the importance of their relationship with their primary care physician" and the need to include the physician in decisions about health care choices, said the letter.
Therefore, continued the commentary, "the AAFP recommends voluntary alignment through a patient-based, prospective process that includes a 24-month look-back period for attribution in the absence of patient choice."
This process lets physicians know in advance which patients they are responsible for "and facilitates proactive care planning and management while protecting patient choice," said the letter.
The AAFP suggested that beneficiary communications include "bold, plain language informing beneficiaries so that they retain freedom of choice, especially the choice to keep their current family physician or other primary care physician," and asked CMS to ensure that direct contracting entities are prohibited from cherry-picking or aggressively pursuing patients, as well as from discriminating against patient populations.
Program Integrity, Patient Protections
The AAFP urged CMS to assess patients' continuity of care provided by the direct contracting entities before and during the pilot program and advised that any noteworthy changes be reviewed. In addition, high-risk and at-risk patients should be monitored to ensure they are receiving regular care.
Furthermore, CMS should continually monitor network adequacy to ensure patient access to care, said the letter.
The AAFP also encouraged CMS to continue waivers from other programs -- such as waivers that address telehealth and home visits -- because waiving copays would give direct contracting practices "more freedom to invest in primary care."
The letter noted that copays can create obstacles to patient care and add administrative burden to practices who then have to try to collect payment.
"A copay waiver would reduce this administrative burden and encourage beneficiaries to seek the comprehensive and coordinated care provided by primary care physicians," said the AAFP.