CMS’ new model to advance regional value-based care in Medicare

Dec. 4, 2020

The Centers for Medicare & Medicaid Services (CMS) announced a new voluntary payment model that builds on CMS’ focus to deliver Medicare beneficiaries value through better care and improved quality. The Geographic Direct Contracting Model (the “Model”) will test an approach to improving health outcomes and reducing the cost of care for Medicare beneficiaries in multiple regions and communities across the country. 

Through the model, participants will take responsibility for beneficiaries’ health outcomes, giving participants a direct incentive to improve care across entire geographic regions. Within each region, organizations with experience in risk-sharing arrangements and population health will partner with healthcare providers and community organizations to better coordinate care. 

Beneficiaries in the model will maintain all of their existing Original Medicare benefits, including the ability to see any provider they choose. Beneficiaries may also receive enhanced benefits, including additional telehealth services, easier access to home care, access to skilled nursing care without having to stay in a hospital for three days, and concurrent hospice and curative care. Participants will also have the ability to reduce beneficiary cost sharing for Medicare Part A and Part B services as well as offer beneficiaries a Part B premium subsidy. Lower out-of-pocket costs will allow participants to encourage beneficiaries to seek high-value care while maintaining the freedom and choice beneficiaries have in the Original Medicare program. While providers and participants may choose to voluntarily enter into value-based arrangements, the Model will not change how Medicare-enrolled providers care for beneficiaries in Original Medicare today. 

Participants will work within defined geographic regions to maintain and improve care coordination, leveraging beneficiaries’ existing provider relationships as well as developing innovative care delivery solutions that take into account a region’s unique, local needs. 

Specifically, Model participants will coordinate care and clinical management for beneficiaries in Original Medicare in their region. This coordination may include care management services, telemedicine, as well as help for beneficiaries to understand which providers have a history of delivering better results and lower costs over the long-term. Beneficiaries in the model will remain in Original Medicare and maintain all of their benefits and coverage rights. Beneficiaries will also keep all of the protections of Original Medicare, including access to all Medicare providers and suppliers, the freedom to choose and change providers at any time, and a strong appeals and Ombudsman system. 

To help with delivering improved outcomes, participants may create a network of preferred providers, armed with the Model’s enhanced flexibilities to provide the right care for beneficiaries at a lower cost. Participants and preferred providers may choose to enter into alternative payment arrangements, including prospective capitation and other value-based arrangements. Participants will also work to augment Medicare’s current program integrity efforts, reducing fraud, waste, and abuse in their region and decreasing costs for beneficiaries and taxpayers. 

CMS has the release