Benefit Enhancements in Direct Contracting

Pearl Health


Direct Contracting Model’s Benefit Enhancements

Direct Contracting strives to create high-value patient care by empowering providers to better serve patients. By changing reimbursement models and encouraging risk-sharing, the CMMI Direct Contracting model focuses attention on results rather than the volume of services. Direct Contracting Entities (DCEs), and participating and preferred providers aligned to these DCEs, can thus explore innovative ways to provide higher-value care. The benefit enhancements CMMI has made available to DCEs participating in the current Direct Contracting models pave the way for creativity and innovation.

In an effort to safeguard beneficiaries’ rights, several current rules and requirements in Medicare nonetheless limit providers’ abilities to explore lower-cost, higher-value care. Adjustments to these rules and requirements, made available by the Direct Contracting model’s option benefit enhancements, will allow DCEs to deploy novel care management approaches. DCEs can choose to apply for all, some, or none of these enhancements, depending on their unique goals and strategies.

Benefit Enhancements Available Immediately

Medicare is introducing a handful of benefit enhancements that DCEs can immediately choose to implement. If a DCE chooses to do so, they are required to submit an implementation plan for the specific benefit enhancements selected. These plans serve as a way to ensure the DCE has the appropriate procedures in place to avoid issues in implementing the benefit. The following are benefit enhancements that DCEs currently have the option of electing:

  • Skilled Nursing Facility 3-Day Rule Waiver – Under traditional Medicare rules, patients aren’t eligible for admission to a skilled nursing facility (SNF) without a 3-day hospital admission. This requirement has the potential to add excessive hospitalization costs to a patient’s care, or delay needed care assistance until a patient worsens to a point requiring hospitalization. Neither of these situations are geared to innovation, therefore, one of the direct contracting changes involves a waiver of this 3-day requirement. Thus, DCEs that choose this as one of its benefit enhancements could potentially save significant costs and offer better care more consistent with the needs of a given patient.
  • Asynchronous Telehealth Permissions – Unlike synchronous telehealth where real-time interactions occur, asynchronous telehealth allows for delayed communications, where providers can engage with their patients on an ad hoc basis. Using store and forward technologies, patient images can be sent to referral providers for diagnosis and assessment. This benefit enhancement allows for the introduction of this model of care delivery only in dermatology and ophthalmology. Previously, Medicare did not allow asynchronous telehealth transmissions. But as one of its direct contracting changes, it is doing so for these specialty areas. This benefit enhancement can therefore make dermatology and ophthalmology consultations more efficient and less costly. As part of these changes, Medicare also added new billing codes that allow providers to receive reimbursement for these services.
  • Post-Discharge Home Visit Allowances – Attentive, responsive care in the right care setting is critical to preventing avoidable readmissions. One area where this can be accomplished relates to home visits after a hospital discharge. In the past, these types of home visits required that patients either qualify for home healthcare services or be homebound. This naturally limits the ability of providers to address patient issues that could lead to complications or readmissions. Therefore, Direct Contracting allows auxiliary personnel to perform these post-discharge home visits. In total, these benefit enhancements permit up to 9 home visits in the first 90 days after a discharge.
  • Care Management Home Visit Allowances – Medicare limitations also restricted the ability of personnel to perform home visits for chronic care as well, limiting the ability for providers to shift from reactive to proactive, preventive care. In patients who have higher risks for complications and hospitalization, home visits can preempt problems. This naturally saves money and improves quality of care. Therefore, as part of its benefits enhancements, Medicare is allowing such home visits by DCEs. Patients with qualifying medical conditions can receive up to 12 home visits each year under these benefit enhancement. These visits are intended to supplement primary care visits rather than replace them.

Other Benefit Enhancements Proposed

While the above benefit enhancements for DCEs can be selected immediately, others are still being evaluated. Of these, three are most likely to be offered by Medicare in the coming years. These include: mechanisms that allow nurse providers to approve patient home health services instead of physicians, waiving homebound requirements for ongoing home health services, and the allowance of concurrent care for Medicare Hospice patients. In each case, these expanded opportunities offer more creative ways to create value in healthcare.

Other potential Direct Contracting changes are under consideration for later performance years. Several of these will require analysis of data from early direct contracting program results. Some of the possibilities that are being considered include: tiered cost-sharing reductions among DCEs and providers, alternative sites of care and cost-sharing supports for SNFs, and waivers for existing limits involving long-term care hospital services.

DCE Requirements Using Benefit Enhancements

As noted, DCEs may choose to implement all of the benefit enhancements, or none of them. However, DCEs that choose to implement any of them must submit a plan to Medicare. This plan not only details strategic uses of the benefit enhancements but also self-monitoring efforts and documented authorization from the governing body overseeing the DCE. Those strategies that work the best may well serve as models for future programs from CMMI.