What is the difference between ACO and DCE?
ACOs are rewarded or penalized based on the service and performance they provide. They are paid or penalized depending on the total cost for a given payment year while DCEs come to terms with the Centers for Medicare & Medicaid Services (CMS) for an agreed-upon monthly payment.
What is a DCE patient?
“Direct Contracting” is a new Medicare program aimed at enabling providers to improve the healthcare outcomes of patients enrolled in traditional Medicare. It allows for the forming of “Direct Contracting Entities” (DCEs), which contract directly with Medicare in the way a health plan does.Jul 26, 2021
What is direct contracting with CMS?
The new Direct Contracting program, a demonstration program that began under the Trump administration, allows "a broad range of organizations to participate with the Centers for Medicare & Medicaid Services (CMS) in testing the next evolution of risk-sharing arrangements," according to a CMS fact sheet.Feb 4, 2022
How is direct contracting different from Medicare Advantage?
Unlike Medicare Advantage, Direct Contracting empowers providers to take on the risk of providing high quality, efficient care to Medicare beneficiaries, obviating the need for a health plan to sit in the middle of Medicare, providers and patients.
What is voluntary alignment?
Voluntary alignment is the process that lets Medicare FFS beneficiaries select, or “voluntarily align” with, a primary clinician. ACOs must notify beneficiaries of their ability to, and the process by which, he or she may identify or change the person he or she chose for the purposes of voluntary alignment.Dec 1, 2021
What does direct contracting mean?
Direct contracting is a strategy that some, typically large, self-funded employers and other health care purchasers use when they believe it will be advantageous to buy health care services directly from a facility, group of physicians, and/or integrated health care system on behalf of their covered population.
What is direct provider contracting?
In “direct contracting” arrangements, a self-insured employer and a provider organization—typically a large health system or provider network (accountable care organization or clini- cally integrated network)—directly negotiate key terms on which the provider will provide and manage the provision of care to the ...
What is DCE program?
A Direct Contracting Entity model framework is the performing entity comprised of strategic healthcare providers and suppliers, referred to as “Participating” and “Preferred” Providers, that operate in the program under a common legal structure.
How many direct Contracting entities are there?
99 direct-contracting entitiesWithin the announcement, CMS acknowledged that there are currently 99 direct-contracting entities (DCEs).Feb 24, 2022
What is the goal of a DCE?
The goals of the MCO-based DCE type include aligning Medicaid MCOs’ financial incentives with whole-person care, empowering beneficiaries, and reducing overall spending across the Medicare and Medicaid programs.
What is direct contracting?
Direct Contracting offers a variety of pathways for health care providers and suppliers to take on financial risk while being supported by enhanced flexibilities. In December 2020, the Innovation Center introduced a new type of Direct Contracting Entity (DCE) to better serve the needs of individuals dually eligible for Medicare and Medicaid.
What is CMS innovation model?
Innovation models. The Centers for Medicare & Medicaid Services (CMS) Center for Medicare and Medicaid Innovation (Innovation Center) developed the Direct Contracting Model Professional and Global Options to test financial risk-sharing arrangements to reduce Medicare expenditures while preserving or enhancing the quality ...
When will the second round of DCE applications be available?
The second round of applications is currently in the process through the end of March 2021and will have an effective beginning date in January 2022.
What is Direct Contracting Model?
CMS designed the Direct Contracting model options to accommodate the variety of provider organizations that may apply. Each DCE model type has unique features that are intended to attract a broader range of participants, such as different risk models, beneficiary alignment requirements, and payment mechanisms. In CMS’ consideration of qualified applicants, applicants must demonstrate an organizational structure that promotes the goals of the models. It will include a diverse set of providers and suppliers who can exhibit a commitment to high-quality care. CMS will assess applications according to the specific criteria in five key domains:
What is QC7 alert?
QC7 controls and sets periodic alerts according to a flexible rules-based engine. This allows organizations to monitor and remain ahead of the curve in population health management and mitigating potential risk.
What is embedded communication module?
Provides embedded communication modules that support instant chat, text, screen share, or video exchange to internal and external care teams within the networked organization and across stakeholders, streamlining access for care, and business operations teams.
What is a robust rules engine?
A robust rules engine that can ingest authorization and claim data whether direct from CMS or other contracted entities, including clearinghouse, HIE, or direct trading partners with auto-adjudication and care coordination functions to streamline line end-to-end processes through payments and electronic distribution of EOBs.
Background
Earlier this year, the Center for Medicare and Medicaid (CMS) announced five new payment models designed to transform primary care by paying providers for outcomes rather than services.
What is Direct Contracting?
Direct Contracting is a voluntary, five-year (plus an optional implementation year) alternative payment model (APM) which leverages components from the Next Generation ACO Model (NGACO), Medicare Advantage (MA), and the private sector and will be the focus of today’s write-up.
Why DC?
CMS believes that DCEs having control of funds with their downstream providers will enable them to improve care coordination and delivery and to better manage the health needs of their aligned beneficiary population, resulting in reduced costs and better outcomes. As such, the proposed payment mechanism will be paid out monthly directly to the DCE.
What are we hearing from members?
After speaking with our members, it’s clear several are interested in better understanding the payment model and whether it’s the right decision for them. Although not all of our members are planning to participate in Direct Contracting, a large number are.
Key Decision Points
There are a number of key decision points that will need to be made prior to the implementation and/or performance period. Several of the key decisions are listed below. The CareJourney Direct Contracting Analysis will provide the key analytics needed to make an informed decision.
Common Approaches to the Implementation Period
The implementation period is intended to help New Entrants DCEs build an aligned FFS population by testing enhanced opportunities for voluntary alignment. This period provides DCEs with additional time to engage in alignment activities and plan their care coordination with management strategies prior to the first performance year. 6
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