The CMS Center for Medicare & Medicaid Innovation (CMMI) continues to launch initiatives to test ways to improve the quality of health care while controlling cost, despite an uncertain fate under the future Trump Administration and Republican-controlled Congress.
Specifically, two new CMMI Beneficiary Engagement and Incentives (BEI) Models seek to promote “shared decision making,” which CMS describes as a process of physician-patient communication and deliberation regarding treatment options in light of best medical evidence, tailored to support the beneficiary’s values and preferences. The first BEI model, the Shared Decision Making Model (SDM Model), will test the use of decision aids and the integration of a structured Four Step shared decision making process into the clinical practice of practitioners participating accountable care organizations (ACOs). The SDM Model will focus on six conditions: stable ischemic heart disease, hip osteoarthritis, knee osteoarthritis, herniated disk and spinal stenosis, clinically localized prostate cancer, and benign prostate hyperplasia. The SDM Model will pay participating ACOs $50 for each SDM service furnished if all required SDM Activities are completed. In the second BEI model, the Direct Decision Support (DDS) Model, CMS will partner with a maximum of seven Decision Support Organizations (DSOs), organizations that provide health management and decision support services, to test shared decision making provided outside of the clinical delivery system. The DSOs will receive a fixed per beneficiary per month payment for each beneficiary in the geographic region assigned to them. CMS expects the DSOs to provide direct decision support to about 700,000 beneficiaries annually, focusing on the same medical conditions as under the SDM Model.
CMS has also launched a new Medicare-Medicaid ACO Model, under which CMS will partner with up to six states to use ACOs to improve quality of care and lower costs for beneficiaries enrolled in both Medicare and Medicaid (dual-eligible beneficiaries). In these states, new and existing Medicare Shared Savings Program ACOs will have the opportunity to be held accountable for Medicaid costs and quality of care for their assigned Medicare-Medicaid enrollees in addition to Medicare costs and quality. If Medicare-Medicaid ACOs generate Medicare savings, states and the ACO may be eligible to share in those savings. Medicare-Medicaid ACOs that qualify as “Safety-Net ACOs” may receive pre-payment of Medicare shared savings to support investment in their care coordination infrastructure.