On July 1, 2024 the Center for Medicare and Medicaid Innovation (“CMMI”) will be inaugurating a new value-based payment model designed specifically to address the devastating impacts that a diagnosis of dementia[1] or Alzheimer’s Disease[2] can have on a patient, their family, friends, and other caregivers who make up the patient’s circle of support. The Centers for Medicare and Medicaid Services (“CMS”) designed the Guiding an Improved Dementia Experience (“GUIDE”) model (the “Model”) for health care providers enrolled in Medicare Part B and that treat Medicare fee-for-service beneficiaries and dual eligibles diagnosed with dementia or Alzheimer’s Disease. CMS accepted letters of interest for the GUIDE Model through September 15, 2023, and a GUIDE Request for Applications (“RFA”) will be released shortly. The Model is unique in that non-clinical caregivers, community-based organizations, and family members are part of the care team included in calculating the per beneficiary per month (“PBPM”) allocation of resources.

The crisis of dementia and Alzheimer’s Disease was forecasted by scientists and physicians for decades.[3] In 1994, President Reagan announced his diagnosis of Alzheimer’s Disease, in an open letter to all Americans, recognizing that the family often bears a heavy burden. As people grow older, it is common to notice some forgetfulness as the brain, like the rest of the body, deteriorates as a person grows older. Some people age normally and other do not; the result can be dementia or Alzheimer’s Disease. With the population in the U.S. living longer and aging, the number of people diagnosed with dementia or dementia caused by Alzheimer’s Disease has increased markedly.[4]

A 2009 bipartisan Report to Congress: A National Alzheimer’s Strategic Plan: The Report of the Alzheimer’s Study Group, began: “Alzheimer’s disease poses a grave and growing challenge to our Nation.” The numbers of persons affected and the costs of their care told a very different story than can be used to describe the trajectory of other diseases. Along with the 5 million people diagnosed with Alzheimer’s disease, 10 million caregivers were providing 94 billion hours of care, and the cost of care for dementia patients was estimated to be $100 billion per year. Yet, there are no expensive tests or medical equipment used to diagnose Alzheimer’s disease, there are not many effective medications used to treat the disease, and yet while the patient deteriorates, the treatments that could help, including social, environmental, and psychological interventions, Medicare would traditionally not cover.

Even though the Model is based on a familiar framework where patients are risk stratified and a national benchmark is applied, there are some interesting new features to the GUIDE model. GUIDE begins with a comprehensive health risk assessment that informs care plan development, care coordination and transitions planning, medication management and ongoing monitoring, assigning patients to one of five-tiers based on care intensity criteria, and a payment methodology based on a PBPM rate that gradually increases as the intensity criteria increase, and then, adjusted +/- for performance and meeting certain health equity quality measures.

What differentiates the GUIDE model from other CMMI models is, this model will run for 8 years, beginning in July 2024, and is heavily focused on care coordination designed to improve the quality of life, reduce strain on unpaid caregivers, and enable people living with dementia to remain in their homes and communities. The longer duration that the Model will run gives participants the opportunity to follow patients through the various stages of the disease and can provide insight into the way care evolves as the disease progresses. Another unique feature of this Model is there is a role for what is referred to as a “care navigator”, that offers support to caregivers, so they are not “left alone” in the process as the dementia / disease progresses. A care navigator is envisioned to provide long-term help to beneficiaries/patients and their caregivers to reevaluate and revise their goals and needs at any time during the course of treatment. In addition, care navigators will connect beneficiaries and their caregivers to community-based services and supports, such as home delivered meals and transportation. Caregivers can take educational classes and beneficiaries will also receive respite services, which ultimately helps to relieve the burden on caregiving duties. CMS has begun to recognize the need for caregiver support, especially when non-clinical caregivers and traditionally uncompensated care is often used to treat patients in the home.

The GUIDE model also has an Established Program Track for organizations that are already in existence and providing care to dementia patients, and a New Program Track for organizations that wish to start provision of dementia care or expand into dementia care. Established Track participants must submit an eligible billing tax-identification number (“TIN”) and a list of proposed GUIDE practitioners that includes physicians and other practitioners (with National Provider Identification numbers (“NPIs”)) and other non-clinical practitioners who will provide services under the model as part of their application. New Program Track participants must have an eligible billing TIN and at least one practitioner with an NPI prior to executing a Participation Agreement in Spring 2024. New Program Track applicants must submit a dementia care program plan for CMS to approve.  In addition, participants in the New Program Track that are classified as safety net providers will be eligible to receive a one-time infrastructure payment of $75,000 to cover some of the upfront costs of establishing a new dementia care program, to be paid at the beginning of the pre-implementation period. The infrastructure payment is intended for providers who want to develop new dementia care programs to serve underserved beneficiaries but need resources to get started. Whether a provider is considered a safety net provider will be determined based on the proportion of patients the provider treats that are dual eligible for Medicare and Medicaid or that receive the Part D low-income subsidy (“LIS”) benefit. The RFA will include the specific thresholds and methodology that will be used for identifying safety net provider eligibility. 

Notably, the GUIDE model is designed to be compatible with other CMMI models and programs. Meaning that providers that participate in ACO Realizing Equity, Access, and Community Health (“REACH”) Model and Medicare Shared Savings Program (“MSSP”) are eligible to participate in the GUIDE model and beneficiaries in those programs are also eligible to voluntarily align to a GUIDE participant while remaining aligned to ACO REACH, MSSP and other total cost of care CMMI models. This new model design might still have some of the financial and benchmark underpinnings of previous models, but the Model is unique. It represents an important step for CMS because it highlights patient-centered care in a way that quality reporting cannot capture, and enhanced reimbursements cannot reward. To date, participation in one ACO program foreclosed the opportunity for providers to participate in any other models at the same time. So, if a provider participating in MSSP recognized that a significant portion of his/her patients would benefit from another care model’s programming, e.g., the Medicare Diabetes Prevention Program, it was not possible to participate in both. From the provider’s perspective, having the opportunity to learn with and from their patients and use data and knowledge gained from treating them to do more and better with them may finally be the turning point where patients and their caregivers can make the choices that are right for them while getting the support and care they need. Providers should seize this opportunity to define this program to work for their patients with dementia.  

EBG’s Value Based Contracting and CMMI Innovation Models team has extensive experience in assisting with RFAs for participation in CMMI model programs, providing regulatory support to existing participants in CMMI model programs, and advising on the data that drives value based contracting models. For questions concerning the GUIDE Model, please contact any of the authors of this post or the EBG attorneys with whom you typically work.

[1] “Dementia” is a general term for loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life. See Alzheimer’s Association, What is Dementia? at: https://www.alz.org/alzheimers-dementia/what-is-dementia.

[2] Alzheimer's Disease is the most common cause of dementia and is characterized by two abnormalities in the brain: amyloid plaques and neurofibrillary tangles. See Alzheimer’s Disease, Stanford University Spotlight, at: https://stanfordhealthcare.org/medical-conditions/brain-and-nerves/dementia/types/alzheimers-disease.html#:~:text=Nearly%20all%20brain%20functions%2C%20including,amyloid%20plaques%20and%20neurofibrillary%20tangles

[3] See “The Problem of Dementia”, Thomas, Lewis, Discover 

[4] See Alzheimer’s Disease Facts and Figures describing the prevalence of Alzheimer’s disease in the US. “More than 6 million Americans are living with Alzheimer's. By 2050, this number is projected to rise to nearly 13 million. 1 in 3 seniors dies with Alzheimer's or another dementia.” https://www.alz.org/alzheimers-dementia/facts-figures#:~:text=More%20than%206%20million%20Americans,with%20Alzheimer's%20or%20another%20dementia.

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