Beneficiary Engagement and Incentives Models: Direct Decision Support Model
The Centers for Medicare & Medicaid Services (CMS) identifies strengthening beneficiary engagement as one of the agency’s goals to help transform our health care system into one that delivers better care, smarter spending, healthier people, and puts individuals at the center. Specifically, the “CMS Quality Strategy envisions health and care that is person-centered, provides incentives for the right outcomes, is sustainable, emphasizes coordinated care and shared decision making, and relies on transparency of quality and cost information.”
Beneficiary engagement broadly refers to the actions and choices of individuals with regard to their health and health care, and these decisions impact cost, quality, and patient satisfaction outcomes., The Beneficiary Engagement and Incentives (BEI) Models -- the Shared Decision Making Model and the Direct Decision Support Model -- will test different approaches to shared decision making, acknowledging that beneficiaries make decisions regarding treatment options in a variety of ways. The Center for Medicare and Medicaid Innovation is testing the BEI Models under the authority of Section 1115A of the Social Security Act (as added by Section 3021 of the Affordable Care).
The Direct Decision Support Model (DDS Model) will test an approach to shared decision making provided outside of the clinical delivery system by an organization that provides health management and decision support services. The DSO will not interfere with the practitioner-patient relationship, but encourage it.
A Presidential Commission in 1982 first coined the term “shared decision making,” urging adoption of the process to improve physician-patient communication and informed consent in health care. Although it has been 30 years since the Commission urged the adoption of shared decision making, beneficiary preferences and values about medical treatment choices are still routinely left out of important discussions between practitioner and beneficiary. Shared decision making can ensure that treatment decisions, for the many medical conditions that do not have one clearly superior course of treatment, better align with beneficiaries’ preferences and values. One facet of shared decision making is the use of patient decision aids (PDAs)—tools that present information about common medical choices. A 2014 systematic review of PDAs concluded that using PDAs can help patients gain knowledge; have a more accurate understanding of risks, harms, and benefits; feel less conflicted about decisions; and rate themselves as less passive and less often undecided. These tools do not supplant physician-beneficiary conversations about treatment options; instead, they supplement and/or encourage it by better preparing beneficiaries to engage in those conversations.
Despite the inherent value of shared decision making, the literature indicates that practitioners have found it difficult to integrate shared decision making into their routine workflows for various reasons such as overworked physicians, insufficient practitioner training, inadequate clinical information systems, lack of consistent methods to measure that shared decision making is taking place, and uncertainty as to whether, or how, to promote change and invest in the time, tools, and training required to achieve meaningful shared decision making.,,
The DDS Model will test whether engaging beneficiaries about their overall health and specific clinical conditions outside the clinical care setting will enable beneficiaries to become more informed, empowered, and engaged health care consumers and have a positive impact on their health care decision making, utilization patterns, and cost of care. CMS will partner with up to seven Decision Support Organizations (DSOs) to provide direct decision support to approximately 700,000 Medicare beneficiaries annually. Each DSO will provide decision support for a core set of preference-sensitive conditions, in addition to proposing a broader range of acute and chronic conditions. As such, CMS expect the DSO will be able to provide decision support to a significant majority of the Medicare Fee for Service (FFS) population. DSOs will be required to target the following preference-sensitive conditions: stable ischemic heart disease, hip osteoarthritis, knee osteoarthritis, herniated disk or spinal stenosis, clinically localized prostate cancer (cancer that is confined to the prostate gland), and benign prostate hyperplasia. A preference-sensitive condition is a medical condition 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 benefits, harms, and scientific evidence for each treatment option.
DSOs will apply for a geographically based population (e.g., state and/or region). Only one applicant will be awarded to a given geographic area. Each DSO will be assigned a population of not less than 100,000 Medicare beneficiaries to engage in decision support. DSOs will provide information that encourages beneficiaries to take an active role in their own care and also improve the dialogue with their practitioner; the DSO will not interfere with the practitioner-patient relationship, but encourage it. Engaged beneficiaries will interact with decision support mechanisms, such as web-based PDAs and tools, telephonic decision support, and/or mobile e-health applications, throughout the course of the model.
The participating DSOs may be commercial firms that already provide similar health information and decision support services to insured populations, but participating DSOs will not themselves furnish health care services. Participating DSOs will have some discretion under the model in the methods they may use for engaging and supporting beneficiaries in their assigned population. To encourage beneficiary engagement, the model specifies that the DSO will provide a small in-kind incentive and/or store gift card to beneficiaries who complete the decision support process.
Decision support under the DDS Model will be offered to Medicare FFS beneficiaries in predetermined geographic areas who are entitled to Part A and enrolled in Part B, and who are not enrolled in a Medicare Advantage or PACE plan. Medicare must be the primary payer for all beneficiaries under the DDS Model, and the model will permit inclusion of people eligible for both Medicare and Medicaid. There will be no exclusions based on disability status. Beneficiaries may opt out of the DDS model and never be contacted again by the DSO if they desire. They may opt out by either directly contacting the DSO, or by contacting 1-800-Medicare. All beneficiaries assigned to a DSO will receive a letter informing them of the DDS Model and listing options for opting out of the Model. CMS will monitor the DSO’s compliance with opt-out to ensure beneficiaries’ choice whether to participate is respected.
CMS will select DSOs that are willing to commit to an initial period of two years of model participation. CMS plans to offer up to three year-by-year renewals to participating DSOs that meet performance goals and milestones, which will be specified in the Model Participant Agreement. The initial period and all potential renewals amount to up to five years of model operations.
Quality Payment Program:
The DDS Model will be operated by non-providers/suppliers; therefore the Quality Payment Program is not applicable to the DDS Model.
The DDS Model provides a population-based payment to participating DSOs for engaging an assigned population of Medicare FFS beneficiaries in ongoing communications and medical decision support on behalf of CMS. The DSOs will receive a fixed per beneficiary per month (PBPM) payment for each beneficiary in the geographic region assigned to them. Twenty-five percent of this amount will be withheld as a performance incentive, which DSOs will be eligible to receive on an annual basis if they meet performance metrics as specified in their Model Participant Agreements.
Decision Support Organizations that are interested in participating in the DDS Model must submit an electronic, non-binding Letter of Intent (LOI) for consideration for participation in the DDS and SDM Models, the first step of the application process. The LOI submission period begins on December 8, 2016 and closes on March 5, 2017. More information is available on the BEI Models website at https://app1.innovation.cms.gov/beidds/.
For More Information please contact: DDSmodel@cms.hhs.gov or visit the Innovation Center webpage at https://innovation.cms.gov/initiatives/Beneficiary-Engagement/
 Centers for Medicare & Medicare Services. Quality Strategy, pp. 2. (2016). <https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/qualityinitiativesgeninfo/downloads/cms-quality-strategy.pdf>
 Greene J, Hibbard JH, Sacks R, Overton V, Parrotta CD. When patient activation levels change, health outcomes and costs change, too. Health Affairs. 2015; 34(3):431-437.
 Oshima Lee, Emily, and Ezekiel J. Emanuel. “Shared Decision Making to Improve Care and Reduce Costs.” New England Journal of Medicine 368, no. 1 (January 3, 2013): 6–8.
 Alston, C., Berger, Z. D., Brownlee, S., Elwyn, G., Fowler Jr., F. J., Hall, L. K., Montori, V. M., Moulton, B., Paget, L., Shebel, B. H., Singerman, R., Walker, J., Wynia, M. K., & Henderson, D. (2014). Shared Decision-Making Strategies for Best Care: Patient Decision Aids. Institute of Medicine.
 Stacey, D., Légaré, F., Col, N. F., Bennett, C. L., Barry, M. J., Eden, K. B., Holmes-Rovner, M., Llewellyn-Thomas, H., Lyddiatt, A., Thomson, R., Trevena, L., & Wu, J. H. C. (2014). Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev, 1.
 Arterburn, D., Wellman, R., Westbrook, E., Rutter, C., Ross, T., McCulloch, D., Jung, C. (2012). Introducing decision aids at group health was linked to sharply lower hip and knee surgery rates and costs. Health Affairs (Project Hope), 31(9), 2094-2104. doi:10.1377/hlthaff.2011.0686 [doi]
 Agency for Healthcare Research and Quality. (2015). Overcoming Barriers to Shared Decision Making [PowerPoint slides].
 Friedberg, M. W., Busum, K. V., Wexler, R., Bowen, M., & Schneider, E. C. (2013). A Demonstration of Shared Decision Making In Primary Care Highlights Barriers to Adoption and Potential Remedies. Health Affairs, 32 (2), 268-275. doi: 10.1377/hlthaff.2012.1084 [doi]
 Légaré F, Ratté S, Gravel K, Graham ID. Barriers and facilitators to implementing shared decisionâmaking in clinical practice: update of a systematic review of health professionals' perceptions. Patient Educ Couns. 2008 Dec; 73(3):526â35. PMID: 18752915.
 O’Connor AM, Llewellyn-Thomas HA, Flood AB. “Modifying Unwarranted Variations In Health Care: Shared Decision Making Using Patient Decision Aids.“ Health Aff (Millwood). 2004 Suppl. Web Exclusive: VAR63-72. October 7, 2004.