On December 8, the Center for Medicare and Medicaid Innovation (CMMI) announced two new models to increase patient engagement in care decisions by putting more information in the hands of Medicare beneficiaries. Under one of these models, the Shared Decision Making (SDM) Model, CMMI will pay ACOs participating in the Medicare Shared Savings Program or the Next Generation ACO Model to provide information regarding treatment options to Medicare beneficiaries with specified diagnoses, described below.
CMMI will select 50 ACOs to implement the SDM Model and 50 ACOs to serve as the control group. Those ACOs selected to implement the model will receive $50 each time an ACO practitioner provides the specified services for a Medicare beneficiary. An ACO may elect to share a portion of the payment it receives from CMMI with its participating providers.
To pursue this opportunity, an ACO must submit to CMMI its completed letter of intent and application by March 5, 2017. In addition to general information, the application requires the ACO to explain its goals for participating in the SDM Model, describe its organization and leadership capacity, and present an implementation plan.
CMMI will notify successful applications in June 2017, with a go-live date of January 1, 2018. CMMI promises to provide ACOs with technical assistance to ensure smooth implementation of the SDM Model.
So what will an ACO and its participating providers be required to do to earn the $50 payment? Briefly summarized, the SDM Model involves a specific, structured 4-step process:
- Identify SDM-eligible beneficiaries
- Distribute the Patient Decision Aid (PDA) to eligible beneficiaries
- Furnish the SDM service
- Track and report data
Steps 1, 2, and 4 can be completed by ACO staff, the practice’s administrative or clinical staff, or a physician or non-physician practitioner. Step 3—which includes having a face-to-face discussion with the beneficiary, assisting the beneficiary with the decision, and then documenting that this step took place—must be completed by a physician or non-physician practitioner.
Step 1: Identify Eligible Beneficiaries
Each participating practice will flag in its electronic health record those Medicare fee-for-service beneficiaries diagnosed with one of the following conditions: (1) stable ischemic heart disease, (2) hip osteoarthritis, (3) knee osteoarthritis, (4) back pain from a herniated disk or spinal stenosis, (5) early stage prostate cancer, or (5) benign prostate hyperplasia.
These six medical conditions are ones for which the clinical evidence does not clearly support one treatment option, and the appropriate course of treatment depends on the values or preferences of the beneficiary regarding the relative benefits and harms associated with each treatment option.
Step 2: Distribute Patient Decision Aids
A patient decision aid, or PDA, is an evidence-based educational tool to assist beneficiaries in communicating their values, beliefs, and preferences for purposes of making treatment decisions. A CMMI contractor will work with each ACO to select the PDAs for use across the participating practices, and the ACO and its participants will determine to whom, and the manner in which, PDAs will be distributed.
Step 3: Furnish Shared Decision Making Service
After receiving the PDA, the beneficiary will meet with his or her physician or non-physician practitioner to consider available options and develop a treatment plan based on the beneficiary’s identified preferences. The physician or non-physician practitioner documents the discussion and the resulting plan in the beneficiary’s record. In most cases, this discussion will occur in the course of an E/M service, which may be billed by the physician or non-physician practitioner accordingly.
Step 4: Track and Report Data
Participating practices will compile and submit to the ACO relevant data regarding those beneficiaries who receive SDM services. The ACO, in turn, will be responsible for submitting required data to the CMS contractor for purposes of payment and program evaluation.
Participation in the SDM Model offers ACOs the opportunity to generate revenue to support a key component of clinical integration: adoption and adherence to evidence-based clinical guidelines. PYA can assist your organization in evaluating this opportunity and completing and submitting your application. For more information, contact Martie Ross at (800) 270-9629.