The following comments were submitted by Richard Besser, MD, Robert Wood Johnson Foundation (RWJF) President and CEO, in response to the Center for Medicare and Medicaid Innovation's (CMMI's) Request for Information (RFI) on Direct Provider Contracting (DPC) Models.
RWJF is working alongside others to build a Culture of Health that ensures everyone in America has a fair and just opportunity to live as healthy as possible. When it comes to the health care system, we expect that anyone, no matter where they live in the United States, will have access to health care providers who give care with respect and dignity, and who acknowledge and address both health and well-being. As CMMI has acknowledged with the launch of many of its initiatives, getting to that future will require a sea change. Health and health care systems will need to be aligned around the people and communities they serve. Health care, public health, and social services partners must work hand-in-hand to address both a person’s acute medical needs and the underlying community and social conditions contributing to health. And all of this must be done with a clear commitment to advancing health equity and eliminating health disparities.
We, along with leaders at CMMI, know from our decades of work in health care that one of the severely limiting factors in changing the direction of the health care system and how providers practice within it is the way in which the system is financed, and subsequently, delivered. For that reason, to achieve our vision of a Culture of Health, RWJF is focusing on advancing payment and care models that not only try to reconcile perverse incentives for care, but at their core explicitly promote and facilitate the kind of alignment across sectors that helps meet patients’ broad sets of health needs. It is from that perspective that we submit these comments to you.
Aspirations for DPC
RWJF applauds CMMI’s creativity in considering how to bring an emergent approach to care, DPC, to Medicare and Medicaid populations. DPC models are intriguing because they operate outside of traditional insurance and financing systems—in theory affording the providers who practice in those environments maximum flexibility to deliver care in a way that comes much closer to our vision of a Culture of Health, and of CMMI’s vision of a flexible, accessible, market-driven, and high quality health care system that promotes person-centered care.
We understand that DPC models vary considerably, but would point to especially innovative models such as Iora Health, which uses an integrated, team-based approach to care that adopts a coaching relationship with patients. Iora’s mission is to help people live their “happiest, healthiest lives.” This kind of orientation should serve as an example for CMMI to strive for with contracted DPC practices. Our worry is that if DPC simply becomes a way for doctors to practice “business as usual” without insurance, CMMI would miss a significant opportunity to lead the way for reimagining primary care such that it addresses both health and social needs. Absent a clear directive and vision from CMMI, DPC could go the way of delivering suboptimal care in parallel with the traditional health care system—offering marginally more convenience for patients but likely adding to the total cost of care.
The RFI asks: “What features should CMS require a practice to demonstrate in order for practices to be able to participate in the DPC model?” and “How can a DPC model be designed to attract a wide variety of practices, including small, independent practices and/or physicians?”
Our hope is that CMMI will articulate a bold vision for which DPC practices ought to strive. CMMI should use its leverage to challenge DPC practices to use their flexibility to hire differently: to bring in social workers, coaches, community health workers, and use inter-professional, integrated care teams. Approaches to care that include inter-professional and integrated teams have demonstrated promising results for patients with complex care needs, exposure to traumatic stress, behavioral health needs, chronic conditions, and people with underlying social needs that contribute to poor health outcomes.
One of the major concerns about the DPC model is its potential to exacerbate the primary care physician shortage. RWJF would point to the use of interprofessional care teams and non-physicians as a way to alleviate that concern. From that perspective, we encourage CMMI to consider DPC arrangements with nurse- and physician assistant-centered practices. This approach may also address CMMI’s concern of attracting small, independent practices to DPC.
DPC practices should also prioritize collaboration outside of the clinical setting. CMMI has the opportunity, for example, to encourage DPC practices to establish partnerships with community services that address social needs in the same way that DPC practices engage in partnerships with phlebotomy labs and imaging services. We have seen powerful examples of what community connections can do through our investments in initiatives such as Medical-Legal Partnerships, Health Leads, and the Y’s Diabetes Prevention Program. CMMI has been a leader in encouraging that kind of paradigm shift, and can continue that leadership here.
Concerns about DPC and CMMI’s Potential Approach
While CMMI’s interest in expanding access to DPC is encouraging, RWJF also has a number of concerns and reservations about whether and how to do so.
We were encouraged to see the RFI ask: “How can CMS ensure that a DPC-participating practice does not engage in activities that would attract primarily healthy beneficiaries (‘cherry picking’) or discourage enrollment by beneficiaries that have complex medical needs or would otherwise be considered high risk (‘lemon dropping’)?” RWJF shares this concern, and we strongly encourage CMMI to prioritize resolving this question ahead of issuing any future DPC rules.
It will be critical for CMMI to ensure that DPC practices cannot turn away a patient because of their health status, complexity, or perceived risk to the provider. We would especially underscore this in the case of Medicaid beneficiary access to DPC practices. CMMI should work with providers and managed care organizations to determine a satisfactory patient panel size, and consider employing ongoing, rigorous efforts such as “secret shopper” programs to ensure that participating practices are complying with access requirements. Those efforts should be attached to clear consequences (e.g., terminating a DPC contract with a provider). CMMI should also commit to monitoring beneficiary uptake of DPC practices across various demographic dimensions (including across age, gender, racial, ethnic, and geographic lines). If it appears that only certain populations are benefitting from DPC, CMMI should plan for an ability to make nimble and quick adjustments.
Finally, the RFI asks: “What monitoring methods can CMS employ to determine if beneficiaries are receiving the care that they need at the right time? What data or methods would be needed to support these efforts?”
RWJF is committed to ensuring that health and health care systems can meet the diverse goals and needs of the people they serve. When it comes to what people want and need from their relationship with a primary care provider, in addition to access and professional skill, people are looking for a provider who treats them with trust and respect and a provider that shares in decision-making. This is important not only because treating people well is the right thing to do and what patients want, but also because of the impact of not doing so on care outcomes and costs. Research we have funded has shown that people who feel disrespected by their providers are unlikely to trust them, and are twice as likely to not be adherent to their medication protocols. They are also a third less likely to manage their chronic conditions.
From that perspective, we encourage CMS to directly survey patients about the degree to which their DPC practice fosters a trusting, respectful care relationship as a point of accountability. Additionally, CMS should collect information from patients about how their sense of holistic health and wellbeing has improved to gauge the effectiveness of DPC. For example, CMS could consider adhering to the principles of patient-centered measurement.
We appreciate the RFI questions about the level of information to collect from DPC practices via claims submission and reporting requirements. We worry that approach does not address the underlying reason many providers move into DPC models in the first place: to operate outside of the administrative complexity of insurance. Along with surveying patients about their health and experience (rather than collecting that information from practices), CMS ought to consider assessing and reconciling evidence of DPC effectiveness on the “back end” by examining the impact on total cost of care and outcomes pre- and post-DPC introduction. It may be unworkable to recruit providers into a DPC model if they are expected to directly engage in detailed reporting. Of course, as CMS monitors effectiveness it will be important to conduct this assessment across different patient demographic groups and geographies.
In conclusion, we appreciate the opportunity to comment on the new directions that the Innovation Center is considering. Innovation and learning are significant to our work at RWJF and we are happy to continue conversations with CMS about what we are doing to help improve the health and well-being of individuals, families, communities, and the nation.