The CMS is trying to create a Medicare Advantage-like alternative payment model that bypasses insurers, but it’s an uphill battle because the agency is hemmed in by Medicare’s benefit structure.
As a part of that, the Center for Medicare and Medicaid Innovation is prioritizing voluntary alignment—its term for when a Medicare beneficiary chooses a primary-care provider for attribution in a risk-based payment model—above claims-based, prospective assignment in its new Direct Contracting Model. The Innovation Center is doing that in an attempt to increase beneficiary engagement and help providers better manage risk through their relationships with patients.
The Innovation Center has “been interested in trying to get some of the outcomes of Medicare Advantage but not have the insurance company as the primary entity that they’re working with,” said Michael Hales, senior director of government healthcare programs for University of Utah Health. “They’re trying to work directly with provider communities.”
But without considerable prodding from providers, the vast majority of fee-for-service Medicare beneficiaries won’t voluntarily align themselves with a primary-care provider under direct contracting because there’s nothing in it for them, since they don’t get additional benefits or reduced cost-sharing.
There aren’t even any concrete negative implications for beneficiaries, like the need to get a referral from their primary-care physician to see a specialist, said Dr. Amol Navathe, a Medicare Payment Advisory Commission member and associate director of the Center for Health Incentives & Behavioral Economics at the University of Pennsylvania.
“It’s pretty well-accepted at this point that patients have to have some incentives and disincentives in order to change behavior,” said Dr. Nirav Vakharia, associate chief of value-based operations at the Cleveland Clinic. Voluntary alignment has been part of the CMS’ Medicare Shared Savings Program since 2018, and the Innovation Center included it in the Pioneer and Next Generation ACO models. But in each instance, “uptake has been disappointingly low,” the National Association of ACOs said.
“A tiny fraction of ACO-assigned patients actually go online to MyMedicare.gov to select their primary provider,” according to an email from NAACOS.