CMS’s latest offering provides a significant opportunity for payers and providers, but those that can’t crack interoperability will struggle.
On April 1, 2021, the first 53 organizations selected by CMS as Direct Contracting Entities (DCEs) kicked off their initial performance period. The second batch of DCEs will enter the model beginning their performance period in January 2022.
“Direct Contracting is CMS’ most advanced risk-sharing program to date,” says Mike Rawaan, Chief Strategy Officer at Post Acute Analytics, a company that helps health systems and providers monitor their patients in real-time outside their four walls. “A DCE operates by entering into agreements with Medicare primary care providers and partnering with other providers, such as specialists and suppliers. That’s the ‘direct contracting’ part. The DCE receives monthly capitated payments from CMS and uses the funds to reimburse their participating and partner organizations as well as investing in technology and resources that will help improve quality of care and drive down cost. At the end of each performance year, CMS reconciles DCE’s spending against a benchmark, similar to an ACO, to determine if money was saved or lost.”
Types of Direct Contracting Entities (DCEs)
There are two risk-sharing models for DCEs: global and professional. The global model has the highest risk and highest reward where the DCE is fully capitated similar to a Medicare Advantage plan and they retain any savings they’ve earned. However, if the DCE ends up losing money, they are responsible for all the losses. The professional model delivers a lower risk share since a DCE is only eligible for up to 50% of savings and only at risk for up to 50% of losses.
From a cost of care standpoint, acute admissions, post-acute care utilization, and hospital readmissions are the most significant cost drivers for payers and risk-bearing providers. However, tracking patients through acute and post-acute care in real-time has been nearly impossible. DCEs have a couple of options to address this challenge: invest in resources to help navigate care – which is expensive and inefficient or align with a partner that can provide real-time, clinical insights on individual patients as they move through their acute and post-acute care journey.
Solving Interoperability in DCEs
“Primary care has a pretty significant blind spot when their patients leave their office; especially when the patients are admitted to an acute hospital,” says Rawaan. “That is the very challenge Anna, our post-acute care management platform, is designed to address. Anna can alert the DCE in real-time when their patient is admitted or discharged from an acute or post-acute care setting, but that’s just the tip of the iceberg. Anna™ uses proprietary technology to connect to hospital, skilled nursing facility, and home health agency electronic medical records systems and leverages artificial intelligence to inform care teams how patients are progressing along their care journey. Anna™ immediately alerts a care team when a patient deviates from their care path, ensuring that the patients who need the most attention receive it.
“The AI system also locates the best provider in the patient’s local market and identify how long a patient should stay in their care.”
To deliver these insights, Anna™ utilizes over 3.2 million unique patient records, including lab values, progress notes, medication lists, and clinical documents. Anna™ also has several modules, such as telehealth, remote patient monitoring, and quality reporting.
“Anna™ delivers a comprehensive solution that helps providers succeed in value-based care arrangements,” said Rawaan “To date, by reducing avoidable readmissions, streamlining utilization of post-acute care, and optimizing collaboration of acute and post-acute care providers, Anna™ has been able to reduce total cost of care by $27 PBPM. That’s nearly a 13% reduction in total cost of care compared to baseline spending.
“As providers shift toward alternative payment models and take on more risk, the need for real-time actionable insights is critical. Post Acute Analytics’ goals and values perfectly align with payers and providers in value-based payment arrangements. In fact, we put 100% of our fees at risk. When our partners in value-based care models succeed, we succeed.”
Implementing a post-acute care management platform like Anna™ allows DCE physicians to keep a finger on the pulse of patients outside of their four walls wherever they are along their healthcare journey. Two other areas that deliver high return on investment for both payers and providers are optimization of their provider networks and streamlining care transitions, which we’ll cover in future articles.
For more information on Post Acute Analytics and their comprehensive solution, Anna™, schedule your demo today!