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How Direct Contracting Transforms Home-Based Primary Care

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How Direct Contracting Transforms Home-Based Primary Care

Home-based primary care has historically been a high-value but low-volume service due to logistical hurdles such as drive time and patient complexity. The resulting low fee-for-service revenue made scaling difficult. This year, with the introduction of its direct contracting model—made possible by creating direct contracting entities (DCEs)—CMS has created an economic engine to fuel the expansion of home-based primary care.

Alignment with Value-Base Primary Care

Building on earlier Medicare Advantage Plans and Medicare Shared Savings Programs, including the NextGen Accountable Care Organization (ACO), direct contracting aims to improve outcomes for beneficiaries with chronic health conditions while lowering healthcare costs.

Primary care providers who elect to become participant providers in the program are compensated based on outcomes instead of volume associated fee-for-service revenue. A fixed amount paid monthly per patient gives participant providers a reliable revenue stream that grows with each patient they add under the program.

Beneficiaries who choose direct contracting enjoy greater access to enhanced services, including at-home care, at no additional cost and without losing any of their coverage privileges and benefits.

More Flexibility for Primary Care Providers

DCE lifts restrictions and puts decision-making into the hands of primary care providers, enabling them to optimize treatment plans and decide how and where medical care is provided, including at home. Plus, participant providers can reduce their administrative burden by aligning with DCEs that take this on. This allows them to spend time with patients and develop innovative, individualized treatment plans that help manage disease and improve quality of life.

DCE Benefit: Reduction in Hospital Stays, Increase in DCE Revenue

Home-based primary care providers know the sickest patients benefit from home care. For instance, 65% of patients are hospitalized in the last 90 days of life, and 29% are in the ICU in the last 30 days, which increases risks and costs. With improved access to home care, we have found that only 37% are admitted to the hospital, and 5% are in the ICU, with the rest remaining at home where they most want to be, according to studies.1

For example, in a population of 10,000 DCE lives, 5% (500 patients) of the sickest patients would be targeted for home-based primary care. These 500 patients under Medicare fee-for-service could potentially generate an estimated annual revenue of $1.2 million compared to $16.3 million with direct contracting. The $16.3 million covers all costs, including but not limited to hospital stays, rehab, home health and hospice, primary care, specialists, and ancillaries.

Choosing the Right DCE

The future looks bright for home-based primary care, but participant providers must wisely choose the DCE they align with. Although CMS describes direct contracting as a risk-sharing arrangement, there’s virtually no risk for participant providers aligned with a top-tier DCE such as VillageMD, which assumes up to 100% of the risk and is capable of managing costs within their allotted CMS budget.

When evaluating DCEs, I recommend you look for one experienced in contracting with CMS, and that leverages advanced technology to provide the patient-level data and tools required to successfully meet the needs of medically complex patients. Additionally, a DCE must be knowledgeable about benefit waivers, including waiver of the homebound requirement for home health to preferred networks, and contract with private duty home aid companies and other healthcare specialists to support their participant provider’s decisions for specialized care. Choosing the right DCE will help ensure success for everyone involved.

Village Medical at Home logo

By Thomas Cornwell, MD
Senior Medical Director of Village Medical at Home

1Teno; Site of Death, Place of Care, and Health Care Transitions Among US Medicare Beneficiaries, JAMA 2018

Patient Education: Education for the individual with multiple chronic illnesses on medication adherence and management

It is common for individuals with COPD to have multiple comorbidities. Along with this comes the necessity, in most cases, to see numerous physicians. The opportunity for mismanagement of the individual described here is great. One physician may focus solely on glucose levels and insulin or diabetes medication to prescribe or change. Another physician could be focused on blood pressure and manipulating the dosage of the medication used to treat this disease. This myopic focus can lead to mismanagement of the individual as a whole.

So, what is the solution? Or rather, how can we minimize the risk of such medication errors or mismanagement? We can educate these individuals with best-practice tools and resources. This is a vital part of patient engagement.

doctor and patient reviewing charts

Some of the chronic diseases which are of highest risk for medication error are, but not limited to:

  • COPD
  • Congestive Heart Failure
  • Diabetes
  • Hypertension
  • Depression and/or Anxiety
  • Chronic Kidney Disease
  • Heart Disease
  • Osteoporosis
  • Osteopenia

Educate patients to use these best practices

  • Work with the primary doctor to decide what matters most when it comes to care. Remember that patients can choose which treatments they want and don’t want. Think about these questions and talk to the doctor about:
    • Which health problems are the most bothersome? Which one should be focused on first?
    • What matters most: living a long time, staying independent, or having the least amount of pain or other symptoms?
    • Are any of the treatments causing side effects or problems?

  • Plan for doctor visits ahead of time. When seeing the doctor, make a plan for what to discuss and come prepared with notes or questions. Do not try to do too much at once. If necessary, make more than one appointment.
  • Make sure the primary doctor, and any other doctor or nurse who prescribes medicines, knows about all of the medicines taken. This includes any over-the-counter or herbal medications used on a regular basis. It is helpful to take the actual bottles of pills to each visit, so the doctors or nurses can review them. Ask the main doctor or nurse to go over all medicines at least once a year.
  • Keep a list of all the medicines taken regularly that includes the dose taken, the reason for taking it, and the doctor or nurse who prescribed it. Keep this list on hand and take it to all medical appointments.
  • Ask the doctors and nurses which, if any diet or lifestyle changes would improve your health problems. Some of these changes may reduce the risks and side effects of some medicines or treatments.

There are things that all people can do to improve their health. Here are some examples:

senior man exercising on patio
  • Choose a diet rich in fruits, vegetables, and low-fat dairy products that is low in sweets and processed flours. For example, choose whole-grain bread and whole-grain pasta over white bread or regular pasta.
  • Do some sort of physical activity most days of the week, and build the activity level slowly. Even small amounts of activity done several times a day can help build strength.
  • Try to get enough sleep. For trouble sleeping, talk to the doctor or nurse about possible solutions.
  • For feelings of depression and anxiety, talk to the doctor or nurse. Depression and anxiety can make other health problems hard to manage.
  • Plan activities with other people, to avoid being stuck at home and alone for days. If friends and family are not around, look at the local paper for ways to meet new people through senior centers, religious groups, libraries, garden clubs, or other activity groups.

Patient Education for the Approaching Travel Season

As we approach warmer temperatures and a time when our patients are doing more travel, we can provide some best practice tips to ensure they have the knowledge needed to stay healthy. The following tips may minimize the risk of infections, sickness, and exacerbations while they are trekking through airports, tourist venues, and exposing themselves to unfamiliar airborne germs.

What if I am traveling internationally? Those traveling to Asia, Africa, South America, or Eastern Europe, should make an appointment at a travel clinic. The doctors and nurses there can help prepare for the trip. Depending on the destination, there might be a need to:

  • Have one or more vaccines, weeks, or months before the trip. For example, if traveling to parts of Africa or South America, a vaccine against yellow fever may be indicated.
  • Avoid ice, tap water, and certain foods or parts of foods that can carry germs. Drinking untreated water or eating certain foods may result in an infection that causes diarrhea, vomiting, or other problems.
  • Treat water, to make sure it has no germs that could cause infection. To get rid of bacteria, boil water for three minutes and then let it cool. Another way to eliminate germs is to take two quarts of water, add two drops of 5% bleach, and wait 30 minutes.
  • Use bug spray containing DEET or a chemical called picaridin. Wear clothes that protect from insect bites. Plus, check yourself for insects and remove them if found. Insects carry germs, and may cause infection when they bite or sting.
  • Take medicines before and during the trip to prevent infections such as malaria.
  • Wear shoes that cover the feet entirely if walking anywhere that dog or human waste may be present in the sand or soil. Places that do not have adequate plumbing or that do not treat toilet water before dumping it, result in contaminated soil. If walking barefoot in situations like these, it's possible to acquire a worm infection.

What if I have a health condition, but I want to travel? If you have an ongoing health problem, such as diabetes or heart disease, ask your doctor or nurse how to plan for your trip.

Many people with health concerns can travel without any problems. The key is to form a plan. Make sure to have all the needed medicines and supplies. It is essential to make a list of all the prescribed medications, the doses, and reason or associated diagnosis.

Here are some examples of individual travel needs:

elderly couple dancing on holiday
  • Some people with diabetes must carry pills, insulin, and syringes when they fly. They usually have a letter from their doctor explaining their needs.
  • Some people with lung or heart disease need extra oxygen when they fly. Because oxygen content in a pressurized aircraft contains less oxygen than room air at sea level, supplemental oxygen may be required by those with pulmonary issues. People who need oxygen on the flight must arrange it with the airline before they fly. A copy of the oxygen prescription should be kept on hand while traveling. Also, pre-planning with the HME provider is needed to ensure the availability of the necessary equipment required for travel.
  • Some people with blood clotting problems or bad veins need to stand up and move around if they are on a long flight. Otherwise, they can develop blood clots. They might also need to wear special stockings that improve blood flow in the legs.

Tongue Fat Volume and OSA

Obese patients with obstructive sleep apnea (OSA) are encouraged to lose weight, but the mechanism for improvement in OSA is unknown.

A recent prospective observational study of 67 obese patients with OSA compared the MRI of the upper airway before and after weight loss. The MRI measured airway size and tongue, pterygoid, lateral pharyngeal wall, and abdominal fat volumes. In the study, reduced tongue fat volumes was the primary mediator associated with an improved apnea-hypopnea index leading to the hypothesis that reduction in tongue fat volume may be a potential treatment strategy for patients with obesity and OSA.

Learn more about Incremedical here.

The Necessity of Auditing in Value-Based Care: Ensure Compliance and Optimize Revenue

Who in your organization is responsible for assuring your documentation and submitted codes are correct? Do you have an auditing process in place? If not, you may be assuming that thousands of ICD-10 codes submitted to the Centers for Medicare & Medicaid Services (CMS) are 100% accurate, which may not be the case.

Reimbursement models are changing. Historically, in fee-for-service payment models, the patient assessment in the EHR, coupled with the plan of care, helped identify underlying conditions, the impact of those conditions, necessary treatments, and a patient’s prognoses. In today’s value-based care models, healthcare entities assume financial risk, so the assessment, diagnoses, and ICD-10 codes influence payments, particularly since ICD-10 codes are used to generate a patient’s Hierarchical Condition Category (HCC) risk score. In all primary care models, Current Procedural Terminology (CPT) codes continue to be important, as they reflect the intensity of evaluation and management provided. However, ICD-10 codes, which indicate a patient’s disease state and the severity of such, have assumed center stage. The specificity and accuracy of diagnostic statements, along with assigned ICD-10 codes, directly affect the healthcare entity’s compliance program and revenue.

So, how do you ensure your documentation and codes are correct? Chart auditing:

1. Ensures compliance

Auditing can ensure that diagnoses and accompanying ICD-10 codes are substantiated, meaning there is reasonable evidence that each diagnosis exists, was addressed, and was supported. This is necessary for submission to CMS for risk adjustment purposes. Submitting incorrect codes, particularly if they map to a Hierarchical Condition Category (HCC), violates the False Claims Act. It is important to note that an incorrect code does not necessarily indicate that the provider’s diagnosis was incorrect, but rather the ICD-10 code applied was in error. Additionally, diagnoses cannot be submitted by themselves without demonstrating that they were addressed in some fashion during the encounter. Without proper training in documentation excellence, providers may inadvertently upcode conditions, generating HCCs that are not correct. Therefore, it is important to have consistent auditing practices in place. Identifying and redacting upcoding and incorrect codes demonstrates to CMS that you are looking, and compliance is a priority to your organization.

2. Assists with claims integrity

If claims data and various CMS reports are available, an auditor can ensure that all the ICD-10 codes generated from an encounter are in CMS’s possession for the purpose of an accurate risk score calculation.

3. Can increase revenue
With a comprehensive review of the encounter, an auditor can uncover diagnoses that may exist but were either not captured or only partially captured due to non-specificity. By reviewing labs, diagnostic imaging reports, and specialist consultations, an audit can present potential diagnoses that can be captured during a later encounter with that patient, leading to a more optimal risk score.

Though performing audits internally is acceptable, outsourcing auditing to an independent company improves your organization’s credibility. Capstone Risk Adjustment Services provides auditing solutions for value-based care healthcare entities. Our auditing services, combined with our physician-led Clinical Documentation Excellence (CDE) education, can greatly improve your organization’s compliance and revenue.

We are proud to offer AAHCM members a 5% discount on a 12-month subscription to our on-demand physician-created Clinical Documentation Excellence education course, CDE Online. To find out more about our auditing solutions or CDE Online, email us at [email protected], visit, or call 844-683-5302.



George “Mike” Brett, MD
SVP Consulting Services, Chief Medical Officer
Capstone Risk Adjustment Services

About George W. Brett, MD
Dr. Brett has more than 30 years of experience in geriatric medicine and long-term care. Prior to joining Capstone in 2014, he served as the Medical Director for a PACE (Program for All-Inclusive Care for the Elderly) program in Southwestern Pennsylvania. As a private practitioner for more than three decades, Dr. Brett specialized in internal medicine and geriatrics and served as medical director for several long-term care facilities and hospice organizations, in addition to PACE. His work with PACE led to his interest and eventual expertise in Medicare risk adjustment. He is a frequent presenter on topics including polypharmacy in the elderly and Medicare risk adjustment.

In the move to home-based care, clinician experience matters more than ever


A recent piece published in the Journal of the American Medical Informatics Association discussed the current administration’s efforts to address clinician burnout and improve usability of and satisfaction with healthcare technology. While the article stresses three important areas of focus such as improved health IT system designs, enhanced system configuration decisions, and increased end user training during health IT implementation, it misses the mark on additional challenge areas – particularly as it relates to two significant shifts in how care is delivered.

As more providers and payers make the transition away from offices and hospitals to living rooms, they are increasingly looking to embrace new value-driven approaches to patient care.

The first shift is the move to home-based models of care and the second is the transition to value over volume – both go hand-in-hand to some degree. As more providers and payers make the transition away from offices and hospitals to living rooms , they are increasingly looking to embrace new value-driven approaches to patient care. These new approaches include, but are not limited to, longer visits that prioritize a holistic understanding of the patient while focusing on relationship building – and expanding the type of care team members in the patients’ home.

These changes and others associated with the move to home-based care models mean physicians and care teams need to fundamentally shift their practice of medicine – and in a good way. Still, change is never easy – especially amid a pandemic.

Healthcare organizations looking to adopt at-home, value-driven care models while supporting their clinical staff through this transition should carefully consider the appropriate role technology can play in simplifying these changes. More so, these organizations would be well-served to consider lessons learned from the widespread adoption of healthcare technology over the last decade and move to reduce, not increase, the administrative burden for providers.

If the end goal of value-based care is driving improved outcomes and reducing costs over time, we must “begin at the beginning” – with the doctor and the patient at the point of care.

As part of the strategy to streamline adoption of home-based, value-driven care, healthcare organizations should ensure clinicians have the tools and support to make these efforts successful. If the end goal of value-based care is driving improved outcomes and reducing costs over time, we must “begin at the beginning” – with the doctor and the patient at the point of care. Organizations that are adding new workflows, data and administrative duties to doctors are missing the point and are setting themselves up for failure. As one of my close physician friends recently shared, if it’s not in the current electronic health record workflow, he doesn’t want to have anything to do with it. Doctors simply don’t have additional time and mindshare to offer up to mediocre technology – even if it supports improved patient outcomes.

With much of the healthcare industry focused on bringing at-home models of care to market in support of the transition to value-based care, building on what we have learned from the pandemic, clinician experience matters more than ever. We need to collectively look to adopt technologies and best practices that are provider approved and focused on workflow. Doing so will allow clinicians and care teams to focus on making personalized, holistic, at-home patient care a reality – while reducing the mental drain associated with paperwork and technological challenges.



Curation Health helps providers and health plans navigate and scale from fee-for-service to value-based care. Our advanced clinical decision support platform for value-based care drives more accurate risk adjustment and quality program performance by curating and delivering relevant, real-time insights to the clinician and care team. For more information, visit