What is the Geographic Model?
Geo will test whether a geographic-based approach to value-based care can improve quality of care and reduce costs from Medicare beneficiaries across the entire region leveraging a set of best practices from prior Innovative models. Geo DCEs will be taking responsibility for the total cost of care for a set of Medicare beneficiaries in an entire region, thereby encouraging DCEs to partner with community organizations in a given region to create the most effective care network. The geo model will be tested over a six-year period with two three-year performance periods in a defined set of regions based on the submissions of letters of interest (LOIs) (due Dec 21, 2020). Fill out the form to understand, at a high level, what the eligible FFS population looks like in the defined 15 Geo regions.
While the global and professional DC models (as well as many other models) require an entity to take financial risk for a set of beneficiaries that see a particular group of providers, this model requires the entity to take financial risk for a portion of those doctors’ beneficiaries who reside in a specific geographic area. It’s clear that CMS is keen to test and understand how a geographic approach may improve value-based care with their release of the geo model as well as the release of the CHART model.
Please note that providers that choose not to enter into value-based arrangements with a Direct Contracting Entity will continue to be reimbursed at full Medicare fee-for-service rates.1
The 15 candidate regions that DCEs are allowed to operate in are as follows:1
Below is a timeline with the critical dates that each Geo DCE needs to keep in mind.1
Why a Geographic Model?
A Geo model offers a variety of options for those considering submitting an LOI. While the Direct Contracting global and professional options allow for a number of valuable benefits, the geo model offers even more. Geo DCEs can lower beneficiaries’ out-of-pocket costs by reducing copayments or by offering a Part B premium subsidy if the beneficiaries voluntarily choose to visit the DCE’s preferred providers, essentially offering yet another option for beneficiaries that don’t enroll in a Medicare Advantage plan.
In addition to lowering beneficiaries’ out-of-pocket costs by visiting a Geo Preferred Provider, DCEs can also offer a variety of Care Coordination and Clinical Management tools, and can perform certain program integrity functions to ensure adherence to original Medicare policies as a means of reducing unnecessary services or payments. These tools are extensions from the existing benefits that are offered under the professional and global Direct Contracting options and are similar in kind to some of the benefits one might expect from a Medicare Advantage, an Individual and Family Plan, or a Managed Medicaid Organization. While the list of tools on the fact sheet is by no means exhaustive, it gives you a sense of what is possible. We’ve highlighted a few examples below.1
Prepaid, non-transferable vouchers for transportation: By nature of having the Geo DCEs operate in major CBSAs, some aligned beneficiaries will undoubtedly face some difficulties making it to their appointment. As a means to curb that difficulty, DCEs are eligible to leverage prepaid vouchers to transport their beneficiaries to and from their appointment with a provider.
Items and services to support management of a chronic disease or condition: While this is traditionally thought of as items like air purifiers, railings to prevent falls, etc., another option might be pest control services, carpet cleaning services, portable air conditioning units, dehumidifiers, or other items to improve the air quality or other management of chronic diseases.
Meal Vouchers: As a means to support beneficiaries with food security and nutritional needs, DCEs can offer vouchers to access meal programs such as Mom’s Meals or Meals on Wheels.
Phone applications for patient adherence to treatment regimens: Probably the most exciting of the bunch, DCEs can officially offer services such as Digital Medication Adherence to ensure adherence to treatment regimens, patient education materials and alerts to ensure compliance to your treatment regimen (i.e., cardiovascular exercise or blood sugar testing for diabetes), or SMART on FHIR apps with phone connectivity to both alert you to take an action (i.e., call your doctor if your blood pressure reading is unusually high) and record the entry into your DCE’s system of record for improved coordination. For more information on how your organization can take advantage of this benefit, please reach out to our Advisory Services team at [email protected].
Vouchers for Vision and Dental Care Services: The most common MA supplemental benefits are dental, vision and hearing with 97% of MA plans offering at least one, and half of all MA plans offering all three in 2019. DCEs can offer dental and vision services and compete with MA plans in a given region.
In addition, similar to the global and professional tracks, Geo DCEs are able to offer a $75 gift card (annual limit) as a means to incentivize participation in a chronic disease management program. Those DCEs who might opt to partner with a non-traditional healthcare provider (i.e., Smart Health Stations) may want to consider providing those gift cards to encourage usage of their services.
While alignment in the global and professional tracks boil down to claims based and voluntary alignment, the Geo Model offers several other steps and requires a larger threshold. Each Geo DCE will be aligned with at least 30,000 beneficiaries with no maximum. Alignment can occur in a variety of ways to ensure you get to that 30,000 beneficiary threshold.1
- Voluntary Alignment: Similar to the Professional and Global options, Voluntary Alignment will be a critical component of the alignment process, giving beneficiaries the option to choose a participating provider as their doctor. Beneficiaries will have the option to voluntarily align both electronically or through paper-based forms. While the electronic interface can be clunky, it behooves DCEs in any track to optimize the workflow for beneficiaries to voluntarily align.
- MCO Based Alignment for Dually Based Beneficiaries: Since DCEs and their affiliates can operate Medicaid Managed Care Organizations, any dually-eligible beneficiaries will be aligned to the particular DCE that operates the Medicaid MCO (unless a beneficiary has voluntarily aligned to another DCE).
- ACO-Based Alignment (Capped): Geo DCEs cannot have more than 50% of their aligned beneficiaries also aligned to an ACO. Since DCEs are allowed to enter into an arrangement with an ACO participating in the Shared Savings Program, some of those beneficiaries could be aligned to the ACO and the DCE if the beneficiary resides in the DCE’s region.
- Claims Based Alignment (Capped): If a beneficiary hasn’t been aligned to one of the previous three methods, they may be aligned based on primary care services received from a DCE’s preferred providers via claims indicating an active relationship.Each DCE will be capped at 50% enrollment between ACO-Based and Claims-Based Alignment.
- Random Alignment: A new concept to the Geo model, any beneficiary that is not aligned in a previous method will be randomly aligned ensuring that each DCE meets the 30,000 beneficiary threshold.
Level of Maturity
It’s important to remember where we came from and to see the progression in shift to value that CMS has supported.2,3