CMS给组织第二次机会申请成为直接签约实体(dce)。. On June 18, 2020, CMS宣布,它将重新开放DCE申请周期,允许选择4月1日的开始日期, 2021, or January 1, 2022. Before the announcement, 只有在2019年底提交意向书的实体才有资格参与, and there was no indication that there would be any future opportunities. This follows on the heels of the notification by CMS that, because of the COVID-19 public health emergency, CMS已经放弃了2021年开始的新医疗保险共享储蓄计划(MSSP)的申请. To help you decide if your organization should apply to be a DCE, this blog compares the DCE and MSSP models, considers strategic opportunities, and explains the differences in the financial arrangements between the two models.
What is the Direct Contracting Model?
CMS直接承包模式允许医疗bet8娱乐提供者接受传统医疗保险受益人50%到100%的上行和下行风险. The model incorporates features of the MSSP, the Next Generation ACO Model, Medicare Advantage, and commercial plans, including capitation.
How is a DCE Different from the MSSP?
While there are many differences between the DCE and MSSP ACO, as shown in table 1, the major differences are the payment methodology and levels of risk.
Other significant differences include:
Capitation
在MSSP ACO模型中,CMS根据正常的医疗保险方法向所有提供者支付费用. In the DCE, 初级保健bet8娱乐是资本化的,DCE可以选择(但不是必需的)为其首选提供者协商其他支付方式.
全球期权基本上提供了100%的上行和下行风险,并允许DCE选择初级保健资本化(包括基础设施的强化资本化)或TCOC资本化(包括参与和首选提供者的专业和设施费用).
A lower level of risk is possible with the professional option, which only includes primary care capitation.
Levels of Risk
At its highest level of risk, 成功之路MSSP模型滑动路径将总上升潜力限制在节约的75%. DCE, on the other hand, allows up to 100% upside potential, 尽管CMS已经建立了2%-5%的累进折扣,以保证它从成功的dce中实现一些节省.
为了帮助降低风险,CMS还将以尚未确定的费率提供dce止损保险.
Split Tax Identification Numbers (TINs)
DCE参与者提供者在TIN和单个国家提供者标识符级别定义. By contrast, the MSSP model is an all-or-none model; all providers within a TIN must participate. 这意味着拥有大量初级保健或专业成分的医疗集团可以根据其地理位置或其他原因定制其提供者补充.
Additional Options and Waivers
DCE模型中的提供者将拥有额外的工具来帮助管理其人口. dce将能够提供福利增强或患者参与激励,旨在通过减少护理障碍使患者群体管理更容易. In addition to the SNF 3-Day Rule waiver offered to two-sided MSSPs, dce将能够使用异步远程保健,并将放宽关于出院后和护理管理家访的规定. Even more aggressive enhancements and incentives are proposed or under consideration.
Patient Engagement
dce将被允许为受益人提供患者参与激励,这在MSSP中是不允许的. Some examples include:
- Over-the-counter medication vouchers.
- Transportation vouchers.
- 改善家庭条件,以支持慢性病的管理或防止再受伤(e).g., air filtering, railings).
- Waiving some or all of patient out-of-pocket expenses for Medicare Part B services.
- Gift cards (up to $75) for participation in chronic disease management programs.
What Organizations Should Consider Applying?
对于希望积极进入基于绩效的安排的组织来说,DCE机会是总体付款人战略的一个有吸引力的组成部分. The types of organizations likely to be successful as a DCE include health systems, medical groups, ACOs, or clinically integrated networks (CINs) that:
- 已证明有能力成功管理MSSP和Medicare Advantage(或商业)安排的财务风险.
- Can report excellent quality scores.
What Are the Strategic Implications?
Organizations contemplating applying to a DCE have important strategic opportunities to consider; DCEs can be a strong tool to create alignment between independent medical groups, health systems, other ACOs, or CINs and other providers or suppliers. 它还可能提供与医疗保险优势计划保持一致的机会,这些计划可以提供重要的基础设施来支持该计划.
Additionally, the DCE model can support the creation of CINs. 联邦贸易委员会指出,MSSP ACOs符合临床整合的标准.[1] 因为DCE增加了额外的财务整合,并包括许多定义临床整合的相同特征, it is expected that the statement would also apply to DCEs. Thus, 成为与CMS签约的经批准的DCE也将允许实体成为CIN, 使其参与供应商能够与医疗保险优势和商业保险公司共同协商安排.
增加的规模经济将有利于投资支持人口健康的组织. The investments and ongoing operating costs could be spread over a larger population. 按人头支付方法将提供可预测的现金流来支持基础设施.
[1] http://www.ftc.gov /政策/ federal-register-notices / ftc-doj-enforcement-policy-statement-regarding-accountable-care.
What Are the Financial Opportunities?
In addition to strategic considerations, it is critical to understand the financial implications; the upside can be considerable, but that comes with comparable downside risk.
Shared Savings and Losses
机会(和风险)的范围取决于DCE是否参与专业期权(部分风险为50%,风险走廊窄)或全球期权(100%风险,风险走廊宽).
Organizations that can provide care management, successfully reduce inpatient admissions and emergency department utilization, and move care to lower cost settings may be able to realize significant savings. Careful analysis is important to understand the range of likely outcomes.
Predictable Cash Flow (capitation)
One hard lesson learned from the COVID-19 crisis is that when patients stay away, so does the fee for service revenue. With a capitated model, revenue is predictable and not tied to volume. With the enhanced capitation, DCEs would still have cash flow to fund their operations.
与MSSP模式不同,当ACO降低利用率时,医院会损失收入, in the DCE under the global option (after the CMS discount), 第一笔美元盈余将缓解收入的减少,同时可变成本也会减少.
How Do Organizations Apply?
The time to apply is limited. A letter of intent must be submitted for the April 2021 performance year, and the application must be completed by July 6, 2020. 除非法律实体已经满足成为DCE的要求,否则这是一个令人生畏的时间框架. For organizations that need time to develop DCEs, there will be a second application cycle in 2021 for the January 2022 start.
In either case, submitting the application is nonbinding. If the organization is approved as a DCE, the actual decision to participate can wait until just before the start date, 让DCE有时间在CMS发布有关基准的更新信息后完成任何精算或其他分析. ECG can help organizations evaluate the strategic opportunities, model the range of performance and expenses, facilitate the agreements among potential participating providers, and generally shepherd the organization through the application process.
Published June 24, 2020