CMMI's Direct Contracting Models: Key Issues and Opportunities

The Center for Medicare and Medicaid Innovation’s (CMMI’s) Direct Contracting (DC) Model is being implemented during a key time. We’re emerging from a pandemic that demonstrated the important role such advanced alternative payment models (APMs) have in ensuring the resilience of our health care system during times of crisis. We’re entering CMMI’s second decade of operation and examining how the next generation of APMs, including the DC Models, can leverage lessons learned during CMMI’s first decade of APM implementation. We’re also in the early stages of a new Administration at the start of implementing its vision for continuing our health care system’s transition to value-based care. The DC Model represents a model that has generated substantial interest at this important time, with many stakeholders seeing the DC Model as a harbinger of what the future may hold for value-based care.

In March 2021, the Duke-Margolis Center convened a group of stakeholders, including providers, payers, consumer representatives, and others, to discuss the DC Model and its implications for value-base payment. The goals of the meeting were to (1) discuss key issues, opportunities, and challenges involving the DC Models and (2) explore potential approaches to advance DC program goals in the context of (a) implementing the DC Global and Professional Options and (b)addressing key concerns as CMMI reviews the Geographic DC Model. This meeting summary reflects the key strategic and technical issues discussed during and in follow-up to the meeting. Detailed description of these issues follows, but key messages that emerged from the discussion included:

• The DC Model has considerable potential to meet the health needs of beneficiaries, particularly those without a usual source of care and whose care experiences are usually uncoordinated and therefore at risk for being inefficient and ineffective. Certain strategic and technical issues could be addressed to enhance the likelihood the DC Model is more effective in identifying and connecting these beneficiaries to providers, and in serving as a comprehensive, capitated payment alternative to Medicare Advantage. 
• Interest in participating in the DC Model is high among providers and other groups, particularly those with a long history of participating in CMMI models (e.g., many Next Generation ACO participants and advanced physician group practices).
• Given the interest in the DC Model and the general desire in the health care community for information and reassurance regarding CMMI’s plans for value-based payment (VBP), it is important for CMMI to publicly state its support for VBP, identify a path forward for continuing the transition to VBP, and continue to provide opportunities for participation in CMMI models in 2022 and beyond.