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May 24, 2018: MGMA comments in response to the Center for Medicare and Medicaid Innovation Request for Information on Direct Provider Contracting Models

Advocacy Letter - May 24, 2018

May 24, 2018 
Mr. Adam Boehler  
Deputy Administrator for Innovation and Quality
Director, Center for Medicare & Medicaid Innovation
Centers for Medicare & Medicaid Services  
U.S. Department of Health and Human Services  
7500 Security Boulevard
Baltimore, MD 21244 
Submitted via email at 
Re: Center for Medicare and Medicaid Innovation Request for Information on Direct Provider Contracting 
Dear Deputy Administrator Boehler: 
The Medical Group Management Association (MGMA) appreciates this opportunity to provide feedback regarding the draft direct provider contracting (DPC) model. We support the Center for Medicare and Medicaid Innovation’s goal of increasing participation in Advanced Alternative Payment Models (APMs) by creating additional opportunities that encourage provider flexibility and choice and reduce burdensome regulations and one-size-fits-all requirements. MGMA commends the Innovation Center for seeking stakeholder input at the outset of DPC model development, and we look forward to an ongoing, constructive dialogue as model details are refined.  
Since 1926, MGMA has been the premier association for professionals who lead medical practices. With a membership of more than 40,000 medical practice administrators, executives, and leaders, MGMA represents more than 12,500 organizations of all sizes, types, structures, and specialties that deliver almost half of the healthcare in the United States. 
Before commenting specifically on the proposed DPC model, the Association wishes to emphasize our support for the Innovation Center’s recent actions to reduce or eliminate mandatory participation requirements in several bundled payment models and to develop the voluntary Bundled Payments for Care Improvement (BPCI) Advanced APM. Despite general support for APMs, a large majority of physician group practices oppose government-mandated participation due to a lack of evidence that joining an APM leads directly to more efficiently delivered care and better patient outcomes, significant diversity among group practices, and the potential negative impact on practice innovation. Physician group practices overwhelmingly prefer flexibility and financial incentives over mandates when considering participation in an Advanced APM. While offering Advanced APM opportunities on a voluntary basis may lead to self-selection by participants that expect to do well on performance metrics, these industry leaders can establish the value proposition and thereby encourage other organizations to move to Advanced APMs.  

MGMA continues to support the clear objective of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) of incentivizing physician group practices to embrace alternatives to fee-forservice and to incur greater performance risk for clinical outcomes and the cost of care. Unfortunately, physician group practices have limited opportunities to move into an Advanced APM. Current regulations establish a restrictive risk standard and the Innovation Center previously took a top-down, government driven approach to testing APMs. According to estimates in the 2018 Quality Payment Program final rule, less than 71,000 clinicians are expected to participate in Advanced APMs, compared to 621,700 clinicians who will participate in the Merit-based Incentive Payment System (MIPS) in 2018. 
The proposed DPC model, if implemented appropriately, could be a catalyst to increasing opportunities for physician group practices to participate in Advanced APMs by recognizing innovative care delivery and payment reforms happening in the marketplace today and encouraging physician-led, value-based transformation. We are encouraged by the potential of this model to support specialty and independent physician group practices that currently have few APM opportunities. MGMA seeks assurances regarding the Innovation Center’s commitment to involving physician group practices of all sizes and specialties through attainable benchmarks, robust incentives, upfront investment support, data sharing, and tools for patient engagement. Without this commitment, the DPC model could drive further consolidation among healthcare providers while forcing independent practices out of business–actions which restrict patients’ access to care.  
MGMA urges the Innovation Center to consider the following principles for encouraging physician practice participation and allowing for their success in a DPC model: 
• Patients over paperwork – Burden reduction must be a priority for the Innovation Center when implementing the DPC model. Collecting and reporting quality metrics remain technically challenging, data intensive, and administratively burdensome. Bureaucratic barriers to care, including prior authorization and appropriate use criteria, are at odds with care delivery and financial models in which participants are accountable for care outcomes.  
• Alignment of patient incentives – DPC participants should be provided the authority to revise beneficiary cost-sharing and other out-of-pocket expenses to encourage Medicare beneficiaries to actively engage in their care and seek high-value care providers.  
• Access to data – Data sharing will be of the utmost importance for participants in a DPC model. The Innovation Center should devote significant resources to providing timely and actionable analyses of patient care trends, including gaps in care and cost drivers, to DPC participants. To the extent possible, these reports should be customized according to the specific DPC arrangement and regularly updated, preferably in real time.  
• Choice of payment models – Physician group practices of all specialties, practice settings, and geographic areas should have the opportunity to participate in a DPC model, based on what best accommodates their practice and the needs of their patients. We encourage CMS to adopt physician-led APMs recommended by the Physician-Focused Payment Model Technical Advisory committee (PTAC) that are based on the DPC approach by using different types of payment during different phases of care and stratifying the risk based on a physician’s patients and their medical conditions.   
• Upfront investment support – The Innovation Center should account for investment risk in the DPC model and assist interested physician group practices through direct investment support. Success in risk-bearing payment models requires practices to make significant infrastructure investments, furnish uncompensated care, and forego guaranteed performancebased payments if the clinical transformation efforts are not sufficient to reduce waste or improve outcomes.   
• Evolution of risk – The Innovation Center should explore multiple tracks for DPC arrangements with physician group practices based on their experience in pay-forperformance programs and value-based models. We recommend the Innovation Center appropriately qualify risk for group practices based on the care and costs within their control.  
• Care coordination – Modernization of fraud and abuse rules is needed to better support care coordination in innovative payment arrangements, such as the DPC. Working in concert with the relevant federal agencies, CMS should develop a standard waiver of certain otherwise applicable Medicare fee-for-service rules to allow DPC participants to effectively coordinate and assume accountability for beneficiary care.  
In addition, MGMA urges CMS to consider our specific feedback that follows. Because there remain many unanswered questions about the proposed DPC model, we urge the agency to develop the model as transparently as possible so that potential participants can make fully informed decisions about participation. CMS should release detailed model information and seek comments about the model refinements prior to accepting model applications.
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