Care Model Eligibility – Shared Decision Making Models (CMS-proposed)

Patients with preference-sensitive conditions that have no clearly superior course of treatment.

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Patient Segment Eligibility Description Data Source
Patients with stable ischemic heart disease Patients with a principal diagnosis consistent with stable coronary artery disease (CAD), such as coronary atherosclerosis or ischemic heart disease.

Exclusions: patients who had a revascularization procedure, a diagnosis of prinzmetal angina, or a diagnosis of unstable disease during the previous two years.

 Claims:

  • ICD-9/10 codes to identify beneficiary visits with diagnosis
  • HCPCS codes to identify exclusions
Patients with low back pain Patients with a diagnosis of low back pain, herniated disc or spinal stenosis. Claims:

  • ICD-9/10 codes to identify beneficiary visits with diagnosis
Patients with knee/hip osteoarthritis Patients with a diagnosis of knee and/or hip osteoarthritis. Claims:

  • ICD-9/10 codes to identify beneficiary visits with diagnosis
Patients with benign prostatic hyperplasia Patients with benign prostatic hyperplasia.

Exclusions: patients with a diagnosis of benign neoplasm of prostate

 Claims:

  • ICD-9/10 codes to identify beneficiary visits with diagnosis
  • ICD-9/10 codes to identify exclusions
Patients with localized prostate cancer Patients with early/localized prostate cancer Claims:

  • Clinical data to identify beneficiary cancer stage

Care Model Implementation – Shared Decision Making (CMS-proposed)

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Time Frame Action
Trigger event Patient diagnosed with preference-sensitive condition
Within 30 days of trigger event (flexible) Distribute evidenced-based patient decision aid (PDA)

  • PDAs are educational tools that help beneficiaries to communicate their values, beliefs, and preferences to decide with the health care practitioner what treatments are best for them based on their treatment options, scientific evidence, circumstances, beliefs, and preferences
Within 30 days of PDA distribution (flexible) Furnish SDM service:

  • Practitioner and beneficiary consider available options together
  • Practitioner describes pros and cons of available options in more detail, uses PDAs
  • Practitioner helps beneficiary explore and form their personal preferences
  • Beneficiary makes a decision based on personal preferences (the patient does not need to make a decision the same day in order for the practitioner to document that the SDM service has been furnished)
Within 30 days of SDM service (flexible) Collect beneficiary questionnaire data

Document beneficiary’s decision

Care Model Compliance – Shared Decision Making (CMS-proposed)

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Intervention Intervention Description Data Source
Provide the Four Step Shared Decision Making process Involves the following steps:

  1. Identify SDM eligible beneficiaries
  2. Distribute Patient Decision Aid
  3. Furnish the SDM service
  4. SDM tracking and reporting
 ACO must provide a monthly list of patients where SDM has been furnished, including the following dates:

  • Date of distribution for Patient Decision Aid
  • Date of furnishing the SDM service
  • Date of patient decision