In April 2019, the U.S. Centers for Medicare & Medicaid Services (CMS) rolled out a new suite of direct-contracting payment models, with the goal of accelerating the shift to value-based care.
Since then, exactly 51 direct-contracting entities (DCEs) have signed up for either the ”global” or “professional” options. Among them is Huntington Beach, California-based Landmark Health, an in-home medical care provider that cares for tens of thousands of complex patients each year.
“We, as an organization, have been interested in a model like this for traditional Medicare beneficiaries for a long time,” Chris Johnson, vice president of corporate strategy and development for Landmark, told Home Health Care News.
Founded in 2014, Landmark has built its business model on delivering comprehensive in-home medical care to chronically ill older adults. Today, its physician-led multidisciplinary teams work alongside patients’ existing health care providers in 16 states and dozens of metropolitan areas.
Traditionally, Landmark has operated within the Medicare Advantage (MA) landscape, helping health plans bend the cost curve by reducing avoidable ER visits and hospitalizations. But thanks to the new direct-contracting model from CMS and its CMS Innovation Center, the company will soon be able to expand its reach to also care for fee-for-service Medicare beneficiaries.
And that will fundamentally transform Landmark, according to Johnson.
“We see this as something that allows legacy health systems and medical groups, as well as newer entrants like Landmark, to be able to bring new innovative models of care to the market,” he said. “We see it as something that will measure us and reward us on our ability to improve outcomes and reduce the overall cost of care for patient populations, without being beholden to the traditional fee-for-service payment system.”
Landmark officially announced its participation in the direct-contracting model on Nov. 23. Other DCEs, according to CMS records, include home-based care pioneers like Lifesprk, Oak Street Health, VillageMD and more.
“We’ve always been very interested in exploring ways that we can move from serving what today is traditionally a Medicare Advantage population into traditional Medicare as well,” Johnson emphasized.
‘A really big contract’
Since launching, Landmark has gained backing from General Atlantic and Oxeon Partners. It has similarly secured several prominent partnerships, including ones with Aetna, Blue Shield of California and Harvard Pilgrim Health Care.
The care provider’s foray into the direct-contracting model shouldn’t come as a surprise to those who are familiar with the company. In fact, innovation and alternative payment models are actually part of Landmark’s DNA.
Before current CEO Nick Loporcaro took over as CEO in September 2018, Landmark was led by founder Adam Boehler. In April of that year, Boehler left Landmark to run the CMS Innovation Center, a tenure that ultimately ended this year.
Overall, the implementation period for the global and professional direct-contracting options runs from Oct. 1 of this year through March 31, 2021.
Of CMS’s direct-contracting pathways, the professional option offers a lower risk-sharing arrangement, with participants being exposed to 50% upside and downside risk. It comes with “primary care capitation,” a capitated, risk-adjusted monthly payment for enhanced primary care services.
Meanwhile, the global option offers the highest risk-sharing arrangement, with participants on the hook for 100% savings and losses. It comes with two payment options: Primary care capitation or “total care capitation,” a capitated, risk-adjusted monthly payment for all services provided by participants plus the preferred providers they work with.
“You have full upside and downside risk for the total cost of care of the beneficiaries that you’re seeing,” Johnson said.
In some ways, direct-contracting is similar to how MA plans operate.
Broadly, CMS sets a base rate at the county level for different patient populations. Each DCE then has to work against the base rate, figuring out where they can improve patient care and curb overall spending.
“We almost think of this as just adding a new contract,” Johnson said. “It’s just that this is a really big contract.”
Landmark will start caring for patients under the direct-contracting model in April. When that time comes, it will have an opportunity to profoundly expand its business.
Currently, Landmark has about 12 million Medicare beneficiaries across its national footprint. Of those, more than 7 million are in traditional Medicare — people Landmark wouldn’t be able to reach without direct contracting.
“The reason we get really excited about it is, you know, part of our mission is to transform the care in the communities that we serve,” Johnson said. “As things stand today, we’ve really been limited. We’ve thought about ways that we could participate with traditional Medicare, but we just couldn’t make our business model work in the fee-for-service world.”
On top of the global and professional options, CMS also recently unveiled plans for a geographic direct-contracting model. With the initial performance period slated for January, the geographic option would pay participants for lowering total cost of care for Medicare beneficiaries in a given marketplace.
“The Geographic Direct-Contracting Model is part of the Innovation Center’s suite of Direct-Contracting models and is one of the Center’s largest bets to date on value-based care,” current CMS Innovation Center Director Brad Smith said in a statement.
CMS is considering 15 geographic regions in which to test the model, though ultimately the agency will select only a maximum of 10. The areas under review include: Atlanta, Dallas, Denver, Detroit, Houston, Los Angeles, Miami, Minneapolis, Orlando, Phoenix, Philadelphia, Pittsburgh, Riverside, San Diego and Tampa.
Each of these areas includes 150,000 to 700,000 beneficiaries.