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STATE | ASPS on the Direct Provider Contracting Payment Initiative

In response to a request from the CMS Innovation Center for input on direct provider contracting (DPC), ASPS encouraged the Agency to focus on better ways to ensure that physicians are able to provide services efficiently and in a manner that allows a specialist to exercise a meaningful level of influence on patient care.

Under current law, physicians who treat Medicare patients can choose to be paid under a fee schedule that limits the amount they can bill the patient, or they can "opt-out" of the Medicare program. Medicare does not consider "opt-out" services to be eligible for reimbursement, which requires the patient to cover the full cost of care. This policy can limit access to specialty care providers.

ASPS has long advocated for patients with complex medical needs to be able to seek and receive the best care possible, regardless of a provider's Medicare status, and was cautiously optimistic when the Agency signaled it was willing to look at direct provider contracting as a new payment initiative. Unfortunately, the plan unveiled by the Agency appears to be based on a formula that places primary care as the "gatekeeper" for specialty services, with a focus of payment reform based on "resource use measurements" rather than increasing flexibility and the quality of care for Medicare beneficiaries.

ASPS offered several DPC considerations to the Agency, as well as a promise to work with the Agency to help shape this and other payment programs into meaningful initiatives.

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