AAPS Submits Comments to CMS on New Direction for Innovation Center

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On November 20, 2017, AAPS submitted comments to CMS in response to the agency’s request for ideas to help its efforts to shift its Innovation Center (CMMI) in a more patient and physician friendly direction.

We applaud the new direction CMMI is embarking on to empower patients and the medical professionals treating them. Expanded choice and competition are going to be essential to increasing access to high quality, lower cost medical care.

CMS asks: Do you have comments on the guiding principles or Expanded Opportunities for Participation in Advanced APMs?

Direct Primary Care models should be given consideration for appropriate APM status in relation to MACRA. According to Katherine Restrepo of the John Locke Foundation: “Direct Primary Care (DPC) is the epitome of value-based medicine.” She further states:

The Medicare alternative payment model (APM) under the Primary Care Enhancement Act has good intentions of opening up access to DPC for Medicare patients, but such a move could seriously undermine the main appeal of DPC for many doctors and patients — removing government and middleman intervention so providers can actually practice the art of medicine and spend more time with their patients. If Medicare were to determine a set rate for physicians, it would set a precedent for Medicare to get in the business of dictating the types of services doctors offer their patients to get paid. A better approach would be to have Medicare distribute vouchers to patients and let them decide where to receive DPC services. There is no one- size-fits-all DPC. It’s best to keep it that way to empower patients with more choices to find a practice most suitable for them.”

CMS asks: Do you have comments on the guiding principles or Consumer-Directed Care & Market-Based Innovation Models?

We applaud CMMI’s goals of increasing choice, competition, and meaningful price and quality transparency. However, we hope it will keep in mind the limitations to the quality metrics currently in use and the obstacles, like contracted gag-clauses prohibiting price disclosure, that are blocking meaningful price transparency.

CMS asks: Do you have comments on the guiding principles or Consumer-Directed Care & Market-Based Innovation Models?

We suggest the CMMI consider the following designs to empower patients and the medical professionals treating them:

1) Direct Primary Care (DPC) DPC arrangements are proving their value to patients while decreasing downstream spending too. We would encourage CMMI to consider DPC as the type of innovation that will be needed to modernize and streamline the aging and top-heavy Medicare program on which Americans depend. Key ingredients in the success of DPC are a) the direct connection between the doctor and patient, with as little interference as possible from others; b) the low overhead that is possible due to keeping administrative hassles to a minimum. We urge CMMI to avoid over-burdening DPC practices with unnecessary red tape when developing any DPC models. DPC is proving beneficial especially for patients with chronic conditions or disabilities, as noted in this meticulously documented and data-driven analysis by the John Locke Foundation: https://www.johnlocke.org/app/uploads/2017/03/DirectPrimaryCare.pdf

2) Reference-based Pricing Reference-based pricing is lowering bills and helping patients select the most qualified medical professionals and facilities for their procedures. CMMI should consider models that allocate patients a set dollar amount per procedure and allow providers the freedom to set their own fee. Patients who select a facility offering the service below the set amount would keep the savings. Alternately, the patients would be free to choose a more expensive facility, and pay the difference out-of-pocket. CALPERS, the California pension system is using reference-based pricing effectively and saved $5.5 million over two years: https://www.fiercehealthcare.com/finance/reference-pricing-saves-calpers-5-5-million. Physicians participating in a reference based pricing model would need the flexibility to set fees independent of the physician fee schedule, and collect any fees above the PFS fee through balance billing.

3) Increased flexibility for the provision of care to beneficiaries outside of the Medicare program, e.g. a Pilot Program to Study the Benefits of Disenrollment from Medicare Disenrollment from Medicare has many potential benefits to the program. Under disenrollment, a physician is neither enrolled in Medicare nor opted-out of Medicare, and some of his patients might submit a Form CMS-1490S for reimbursement on covered medical services for which the patient has paid. See https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS1490S-ENGLISH.pdf

This disenrollment option is analogous to the option of homeschooling rather than sending children to public schools. Initially homeschooling was opposed by the government, but over time there was realization that it saves taxpayer money while also giving greater flexibility to citizens. Disenrollment would also save the Medicare program as the government would pay nothing or relatively little in connection with the services provided. There would be no greater expense to the government in paying on CMS-1490S claims with respect to a disenrolled physician than there would be on a physician who is enrolled in Medicare, and there would be fewer claims to process. Because patients pay up-front whenever they see a disenrolled physician, there is less of a risk of overutilization of Medicare services compared with when patients see participating Medicare physicians, surgeons, and other healthcare professionals.

The disenrolled option has the potential to save the government billions of dollars annually, while also providing greater flexibility to patients and physicians. Aside from increased flexibility for disenrolled physicians, another potential model for exploration is greater freedom for physicians with non-par status. For instance, a pilot might exclude non-par physicians from MIPS penalties or incentive payments.

CMS asks: What Prescription Drug Model designs should the Innovation Center consider that are consistent with the guiding principles?

In-office dispensing, particularly in a Direct Primary Care setting, is lowering prescription costs for patients. CMMI, in conjunction with a more general pilot centered around DPC, could facilitate beneficiary utilization of in-office dispensing. Direct payment could be facilitated via a voucher system or HSA-like account for beneficiaries.

CMS asks: What Medicare Advantage (MA) Innovation Model designs should the Innovation Center consider that are consistent with the guiding principles?

MA beneficiaries an option to use a Direct Primary Care arrangement for primary care in lieu of primary care coverage through the Medicare Advantage plan. Let the beneficiary use an HSA-like account to cover the DPC fee. In return, the PMPM paid to the MA plan would be lowered by a corresponding amount.

CMS asks: What State-Based and Local Innovation, including Medicaid-focused Model designs should the Innovation Center consider that are consistent with the guiding principles?

CMMI could encourage states to develop and apply for waivers that incorporate the availability of Direct Primary Care arrangements for Medicaid and CHIP populations. For instance, states could allow vouchers or HSA-like accounts to fund DPC payments for enrollees. DPC provides a low-cost, high-quality option for primary care delivery as well as opportunities for savings on in-office dispensing. Current Medicaid rules and regulations too often improperly block these populations from DPC arrangements. For instance, ACA Section 6401(b) is being used by states to prevent Medicaid patients from using their benefits for prescriptions and tests ordered by their DPC physician. In the long-run such over-regulation is costing the system much- needed funds. In addition, CMMI and CMS should explore needed protections for Medicaid beneficiaries, and their physicians, who wish to privately contract outside of the system. There is currently no safe harbor within Medicaid for direct payment, similar to Medicare opt out status.

CMS asks: Are there payment waivers that CMS should consider as necessary to help healthcare providers innovate care delivery as part of a model test?

Allow greater flexibility for states to waive or comply with requirements related to ACA Section 6401(b) to better serve Medicaid enrollees who choose to pay out of pocket for Direct Primary Care

CMS asks: What Mental and Behavioral Health Model designs should the Innovation Center consider that are consistent with the guiding principles?

DPC-like arrangements are proving beneficial for patients seeking treatment for addiction or other behavioral health challenges. See for instance practices like: http://www.bluegrassfamilywellness.com/home-recovery/ Models might include the ability to use vouchers or an HSA-like account to fund such care.

CMS asks: Are there payment waivers that CMS should consider as necessary to help healthcare providers innovate care delivery as part of a model test?

Allow greater flexibility for states to waive or comply with requirements related to ACA Section 6401(b) to better serve Medicaid enrollees who choose to pay out of pocket for addiction treatment but need assistance covering prescription medication related to their treatment.

CMS asks: What Program Integrity model designs should the Innovation Center consider that are consistent with the guiding principles?

Program integrity will benefit by increased availability of private and direct contracting / payment options for beneficiaries. Increased flexibility for beneficiaries to contract with medical professionals and facilities outside of the Medicare or Medicaid program can have an added benefit of decreasing fraud and overutilization. Because patients pay up-front whenever they see a non-par, opted-out, or disenrolled physician, there is less of a risk of overutilization of Medicare services compared with when patients see participating Medicare physicians, surgeons, and other healthcare professionals.

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