The Global and Professional Direct Contracting Model will phase out December 31, 2022.
One model will be in and another two out as CMS and the Biden-Harris Administration seek to shape a health-equity-informed model of accountable care.
On February 24, CMS announced ACO REACH—Accountable Care Organization Realizing Equity, Access, and Community Health—as the federal agency designs a new decade of value-based innovation. CMS Administrator Chiquita Brooks-LaSure states that "CMS, through the Innovation Center, is testing new models of health care service delivery and payment to improve the quality of care that people receive, including those in underserved communities."
The existing Global and Professional Direct Contracting Model (GPDC) will phase out December 31, 2022, redesigned to create ACO REACH. A similarly named program, the Geographic Direct Contracting ("Geo") Model, was immediately terminated as part of the ACO REACH announcement.
In a Fact Sheet describing ACO REACH, CMS states it will use "an innovative payment approach to better support care delivery and coordination for patients in underserved communities and will require that all model participants develop and implement a robust health equity plan to identify underserved communities and implement initiatives to measurably reduce health disparities within their beneficiary populations."
Better for beneficiaries
CMS' Fact sheet on the new model outlines multiple beneficiary and provider benefits, in addition to stricter requirements. ACO REACH is designed to extend Medicare accountable care to more underserved beneficiaries while giving them a greater voice in their care and in ACO governance as well as possible expanded benefits—including but not limited to telehealth, post-discharge home visits, and lower cost-sharing.
A larger focus on health equity is designed to benefit Medicare members, in quality and in number. ACO REACH will include five new policies:
- Health Equity Plan Requirement
- Health Equity Benchmark Adjustment
- Health Equity Data Collection Requirement
- Nurse Practitioner Services Benefit Enhancement
- Health Equity Questions in Application and Scoring for Health Equity Experience
Of note, the benchmark adjustment will include whether a person has Dual Medicaid Status, bridging additional gaps for Medicare beneficiaries who also qualify for Medicaid. In addition, REACH ACOs must create Health Equity Plans to identify and address disparity risks.
Greater provider privileges and responsibilities
Providers will also play an enhanced role but with more stringent requirements for ACO REACH entry, monitoring, performance, and transparency. This includes current GPDC participants, who must apply for, but are not guaranteed, a spot in the new program. For each ACO chosen, providers must have at least a 75% controlling interest.
For all providers, ACO REACH will require downside risk: 50% or 100%, associated with partial or global capitation. Three types of groups may participate: Standard ACOs with Medicare experience, New Entrant ACOs to allow for new but less-experienced players (like GPDC), and High Needs Population ACOs to ensure groups caring for smaller but more complex populations are included.
Providers are also subject to new risk-adjustment requirements, which expand beyond the GPDC's already stringent model. (CMS published a model comparison as part of its announcement.) To control risk-coding manipulation and payment inflation, CMS is creating a "zero-sum environment" that caps risk score growth at +/- 3% while locking in average scores. Higher payments due to coding manipulation have long been an issue of the Medicare Advantage program, with CMS also looking at risk-adjustment within the marketplace. For ACO REACH, CMS believes that its Coding Intensity Factor approach will provide "100 percent protection to Medicare against inflated payments."
To balance these new requirements, CMS states that it will provide improved "tools and resources." ACO REACH will "empower doctors and other health care providers to better coordinate and improve the quality of care they provide for patients," who will receive "greater individualized attention."
What's next for current GPDC participants?
GPDC's phase-out gives current participants the opportunity to apply for ACO REACH. But will they be eligible, or chosen? There are 53 plan year 2021 GPDC participants—called Direct Contracting Entities (DCE)— including 16 new entrants ranging from single- to multi-state entities. There are also at least two health-plan-led participants: Clover Health Partners and the Humana DCE.
Both Clover and Humana are currently participating in GPDC under the Primary Care Capitation and Advanced Payment Option risk-sharing options and are offering all eight possible Beneficiary Engagement Incentives (BEI), including skilled nursing and home health waivers, post-discharge and care management home visits, telehealth, hospice, and affordability support through Part B cost sharing and chronic disease management rewards.
This information is part of CMS' promised increased transparency, which will begin with current GPDC participants and continue and expand with ACO REACH.
Of these plans, Clover tweeted support for the announcement, indicating ACO REACH will make "VBC [value-based care] accessible to more physicians."
CMMI's next decade has begun
ACO REACH represents one of the first major accountable care changes since CMS' CMMI announced a strategy refresh in October 2021. The refresh includes five objectives, which all appear to components of ACO REACH:
- Drive Accountable Care
- Advance Health Equity
- Support Care Innovations
- Improve Access by Addressing Affordability
- Partner to Achieve Health System Transformation
To some degree, ACO REACH is an example of what all new administrations seek to do: create distance from their predecessors while defining new footprints that don't disrupt what is currently working. But can that be said for CMS and CMMI ACOs and other advanced payment models?
CMMI reports that of the 50-plus models it has tested, only six "generated statistically significant savings to Medicare and to taxpayers." In June 2021, MedPAC reported similar results, including for CMS' first ACO model, the Medicare Shared Savings Program. All eyes will be on CMMI and CMS as to whether the refresh and ACO REACH can achieve what prior models have not.
“CMS, through the Innovation Center, is testing new models of health care service delivery and payment to improve the quality of care that people receive.”
CMS Administrator Chiquita Brooks-LaSure
Laura Beerman is a contributing writer for HealthLeaders.
Photo credit: New York, USA - 15 February 2021: CMS Centers for Medicare website in browser with company logo, Illustrative Editorial. Postmodern Studio / Shutterstock
KEY TAKEAWAYS
CMS and its Center for Medicare & Medicaid Innovation (CMMI) have announced a new equity-based alternative payment model called ACO REACH.
ACO REACH will continue the framework of a prior model, while increasing the federal government's focus on the underserved, provider leadership and accountability, and benefit enhancement.
ACO REACH has followed quickly on the heels of CMMI's strategy refresh, which is designed to achieve similar aims by applying learnings from a decade of value-based design.