The Centers for Medicare and Medicaid Services (CMS) has introduced the Guiding an Improved Dementia Experience (GUIDE) model, aiming to test an alternative payment methodology for supporting and treating Medicare fee-for-service (FFS) beneficiaries with dementia. The model's goals include reducing the total cost of care (TCC), enhancing quality of care, improving quality of life, reducing caregiver strain, and enabling beneficiaries to remain at home.
GUIDE Model Mechanics:
- Participants must be Medicare Part B-enrolled providers or suppliers, excluding DME and lab, and establish Dementia Care Programs (DCPs).
- Participants must maintain a list of providers and have beneficiaries attest to their dementia status.
- Beneficiaries must opt into the program.
- Participants receive a monthly per beneficiary per month (PBPM) capitation payment—the dementia care management payment (DCMP)—replacing various FFS billings.
- DCMP varies based on caregiver status, complexity tier, and duration in the model.
- Performance and health equity adjustments can be applied to the DCMP.
Participant Requirements:
- Maintain interdisciplinary teams, including a care navigator and a clinician with dementia proficiency.
- Complete comprehensive training programs for care navigators.
- Conduct comprehensive assessments and develop person-centered care plans.
- Provide 24/7 access to care teams, ongoing monitoring and support, care coordination, and referral to services.
- Manage medications and provide caregiver education and support.
- Refer and coordinate respite care.
Analysis of Beneficiary Experience:
- beneficiaries with dementia have significantly higher TCC claims than other Medicare FFS beneficiaries.
- The potential medical savings estimates for the GUIDE model range from nearly $0 to over $500 PBPM.
Financial Implications for Providers:
- The DCMP is intended to cover a broader range of services than current Medicare FFS payments.
- Current care management costs are relatively small compared to the expected DCMP.
- The gap between expected revenues and potential expenses suggests that GUIDE could be profitable for efficient providers with significant dementia populations.
- ACOs must consider the impact of GUIDE on their shared savings and losses, as the program's costs and potential savings could significantly affect their financial performance.
Opportunities for Other Stakeholders:
- Long-term care insurers (LTCIs) have a strong financial interest in the success of GUIDE, as it could reduce nursing home stays for their policyholders.
- State Medicaid agencies may benefit from reduced nursing home expenditures and could potentially partner with GUIDE Participants.
- Medicare Advantage (MA) plans may consider mimicking aspects of GUIDE through supplemental benefits via SSBCI or VBID programs.
Key Deadlines and Termination Policies:
- Applications are due on January 30, 2024.
- Participants may terminate participation with at least 180 days' notice.
- CMS may terminate participation for reasons such as poor performance or noncompliance.
- Participants must repay infrastructure payments if they withdraw or are terminated.
Conclusion:
The GUIDE model presents a new opportunity for providers to better manage dementia care while potentially reducing costs. However, it also involves significant risks, particularly for providers in risk-sharing arrangements. ACOs and other stakeholders should carefully evaluate the potential financial and operational impacts of the model before deciding whether to participate.
