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State and Federal Policy Updated State and Federal Policy Update Philip Eskew, DO, JD, MBA Participate in polling questions and submit your questions to https://aafp4.cnf.io Activity Disclaimer The material presented here is being made available by the DPC Summit Co-organizers for educational purposes only. This material is not intended to represent the only, nor necessarily best, methods or processes appropriate for the practice models discussed. Rather, it is intended to present statements and opinions of the faculty that may be helpful to others in similar situations. Any performance data from any direct primary care practices cited herein is intended for purposes of illustration only and should not be viewed as a recommendation of how to conduct your practice. The DPC Summit Co-Organizers disclaim liability for damages or claims that might arise out of the use of the materials presented herein, whether asserted by a physician or any other person. While the DPC Summit Co-Organizers have attempted to ensure the accuracy of the data presented here, these materials may contain information and/or opinions developed by others, and their inclusion here does not necessarily imply endorsement by any of the DPC Summit Co-Organizers. The DPC Summit Co-Organizers are not making any recommendation of how you should conduct your practice or any guarantee regarding the financial viability of DPC conversion or practice. Faculty Disclosure It is the policy of the DPC Summit Co-Organizers that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. All faculty in a position to control content for this session have indicated they have no relevant financial relationships to disclose. The content of this material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices. Learning Objectives 1. Describe recent federal and statewide legislative trends 2. Evaluate the major regulatory hurdles facing new DPC practices. 3. Develop and implement appropriate compliance and mitigation strategies to minimize regulatory risks. 4. Evaluate the existing resources available to support physicians interested in becoming engaged with DPC advocacy efforts Federal HHS Updates 04/22/19 CMS new “Primary Cares Initiative” 1. Primary Care First 1. General 2. High Need Populations 2. Direct Contracting 1. Global 2. Professional 3. Geographic Primary Care First “The general Primary Care First payment model option is designed for primary care practices with advanced primary care capabilities that are prepared to accept increased financial risk in exchange for flexibility and potential rewards based on practice performance.” Primary Care First • Geographic Limitations (next slide) • Include primary care practitioners (IM, GP, Geriatrics, FM, Hospice/Palliative) • Serve as a PCP for at least 125 attributed Medicare beneficiaries at a particular location • Have primary care services account for at least 70% of the practices’ collective billing based on revenue. • Have experience with value-based payment arrangements or payments based on cost, quality, and/or utilization performance such as shared savings, performance-based incentive payments, and episode-based payments, and/or alternative to fee-for-service payments such as full or partial capitation. • Use 2015 Edition Certified Electronic Health Record Technology (CEHRT), support data exchange with other providers and health systems via Application Programming Interface (API), and connect to their regional health information exchange (HIE). • Attest via questions in the Practice Application to a limited set of advanced primary care delivery capabilities, such as 24/7 access to a practitioner or nurse call line and empanelment of patients to a practitioner or care team. • Can meet the requirements of the Primary Care First Participation Agreement (not available yet) https://innovation.cms.gov/initiatives/primary-care-first-model-options/ Primary Care First Application Process and Timeline • Spring 2019 - CMS will release to practices a request for Application • Summer 2019, practice applications will be due and solicitation of payers will take place. • Fall and winter 2019, practices and payers will be selected. • In January 2020, the Primary Care First model will launch and payments will begin in April 2020. Primary Care First Payments • Population rating determines PMPM amount • Risk sharing expected • $50 per visit fee • “Seriously Ill” payments are different • One-time payment for first visit with SIP patient: $325 per beneficiary • Monthly SIP payments for up to 12 months: $275 per beneficiary per month • Flat visit fees: $50 • Quality payment: up to $50 Primary Care First – Seriously Ill Patients CMS will attribute Seriously Ill Population (SIP) patients lacking a primary care practitioner or care coordination to Primary Care First practices that specifically opt to participate in this payment model option. Practices may limit their participation in Primary Care First to exclusively caring for SIP patients, but in order to do so, such practices must demonstrate in their applications that they have a network of relationships with other care organizations in the community to ensure that beneficiaries can access the care best suited to their longer-term needs. Primary Care Plus Quality Markers • CPC+ Patient Experience of Care Survey • Diabetes: Hemoglobin A1c and Poor Control • Controlling High Blood Pressure • Care Plan • Colorectal Cancer Screening CMS “Direct Contracting” • Professional PBP offers the lower risk-sharing arrangement—50% savings/losses—and provides Primary Care Capitation, a capitated, risk-adjusted monthly payment for enhanced primary care services. • Global PBP offers the highest risk sharing arrangement—100% savings/losses—and provides two payment options: Primary Care Capitation (described above) or Total Care Capitation, capitated, risk-adjusted monthly payment for all services provided by DC Participants and preferred providers with whom the DCE has an agreement. • Geographic PBP would offer a similar risk-arrangement as the Global PBP option as potential participants would assume responsibility for the total cost of care for all Medicare FFS beneficiaries in a defined target region. https://caravanhealth.com/thought-leadership/articles/cms-payment-reform-update-recap/ • https://www.kff.org/medicare/fact-sheet/what-is-cmmi- and-11-other-faqs-about-the-cms-innovation-center/ Recommendations • Cannot participate if “Opted Out” of Medicare • Primary Care First = Revised CPC+ • No go, consider using simpler Medicare Chronic Care Management Codes • Direct Contracting = Revised ACOs • No go, consider more DPC-like forms of capitation • PACE – Program for All Inclusive Care of the Elderly • Correctional Medicine Choose Your Location Wisely • Not all states are created equal • A helpful “not insurance” law (half of states) • Medication Dispensing freedom • Pathology restrictions (if procedure heavy) • Certificate of need (if purchasing diagnostics) • CPOM & Fee Splitting (if raising capital) • Other Random Hiccups • Labs (NY & NJ), Medicaid (CO & KY) 2019 DPC Defining “Not Insurance” Efforts • Arizona revision (SB 1105 & HB 2113) – signed into law on 04/17/19 • Georgia – SB 18 – signed on 04/25/19 • Hawaii SB 232 – died in committee • Maryland SB 0315 and HB 0315 – died in committee • Minnesota SF 277 – passed the senate 67-0, currently in the house • New Hampshire HB 508 – on the governor’s desk • South Carolina SB 0445 – died this year • Pennsylvania – discussions only, no bill launched • Wisconsin – SB 28 and AB 26 – stuck in committee 2019 State DPC Pilot Program Discussions • Indiana SB 470 • Missouri HB 233 • Minnesota HF 718 • Oklahoma SB 386 • Tennessee HB 0894 & SB 0696 • Virginia HB 2456 Michigan Medicaid Pilot • Quarterly Performance Metrics Report • Enrollees, DPC rate, claim volume and dollar value • Per-Member-Per-Month “Actual Cost” = DPC fee + insurer allocated overhead • “Total Health Care (THC) has partnered with Department of Health and Human Services (DHHS) and began accepting enrollments into the program on July 1, 2018. As of October 1, 2018 THC has 360 members enrolled in the Direct Primary Care Pilot. THC expects this number to grow over the next few months.” Minnesota – HB 718 • “The commissioner shall pay health care providers directly to provide services for all medical assistance enrollees…” • “The commissioner shall not renew the state’s contracts with managed care plans…” • Primary care providers may be selected by the patient as their “case manager” Minnesota – HB 718 • PCP Case managers “shall also receive a flat per-member, per- month fee for performing care coordination services. The commissioner shall set case management fees to reflect the variation in time and services required for a primary care provider to coordinate care based on the complexity of a patient’s health needs and socioeconomic factors that lead to health disparities.” • “The primary care provider shall provide overall oversight of the enrollee's health and coordinate with any other case manager of the enrollee as well as ensure 24-hour access to
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