Accountable Care Organization (ACO) Realizing Equity, Access, and Community Health (REACH) Model

Overview

The Centers for Medicare & Medicaid Services (CMS) has redesigned the Global and Professional Direct Contracting Model (GPDC) Model to advance Administration priorities, including our commitment to advancing health equity, and in response to stakeholder feedback and participant experience. The Center for Medicare and Medicaid Innovation (Innovation Center) is releasing a Request for Applications (RFA) to solicit a cohort of participants for the Accountable Care Organization (ACO) Realizing Equity, Access, and Community Health (REACH) Model. The GPDC model will be renamed the ACO REACH model to better align the model’s name with its purpose: to encourage health care providers to coordinate care to improve the care offered to people with Medicare – especially those from underserved communities, a priority of the Biden-Harris Administration.

CMS is also committing to greater transparency by releasing more information on current GPDC model participants and strengthening monitoring to ensure beneficiaries whose providers participate in GPDC and ACO REACH receive high-quality, patient-centered care during 2022 and beyond.

The new cohort will begin participation in the ACO REACH Model on January 1, 2023. Current GPDC Model participants must agree to meet all the ACO REACH Model requirements by January 1, 2023 to continue participating.

Additionally, CMS is announcing the permanent cancelation of the Geographic Direct Contracting (Geo) Model. The Geo Model was announced in December 2020 and paused in March 2021 and is being canceled due to concerns raised by stakeholders. 

A comparison table of ACO REACH and GPDC is available at https://innovation.cms.gov/media/document/gpdc-aco-reach-comparison.

CMS’ Vision and Principles for Accountable Care

In October of 2021, CMS outlined a renewed vision and strategy for how the Innovation Center will drive health system transformation to achieve equitable outcomes through high-quality, affordable, person-centered care for all beneficiaries [link here]. CMS’ ACO models and programs are an important component of achieving this vision.

In ACOs, physicians and other health care providers join together to take responsibility for the quality of care their patients receive and the total costs of that care. These responsibilities encourage providers to coordinate the services across clinicians and care settings. The Affordable Care Act (ACA) created the Medicare Shared Savings Program, CMS’ largest ACO initiative, to provide beneficiaries in Traditional Medicare the opportunity to receive care that meets the full range of their needs. ACOs work to improve chronic disease management, ensure smoother transitions from hospitals to homes, and promote preventive care that keeps patients healthy.

As the Innovation Center makes changes to existing models and launches new ones consistent with this vision, we want to work with partners who share our vision and values for improving patient care. The goals of the redesigned ACO REACH Model are to improve quality of care and care coordination for patients in Traditional Medicare, especially for patients in underserved communities.  The ACO REACH Model provides tools and resources to empower doctors and other health care providers to achieve these goals.  This approach affords patients greater individualized attention to their specific health care needs while preserving choice of providers and all other services and flexibilities in Traditional Medicare.

ACO REACH Model Will Advance Equity, Provider Leadership, and Beneficiary Protections

The redesigned ACO REACH Model reflects the priorities of the Biden-Harris Administration and responds to feedback from stakeholders and participants. ACO REACH will enable CMS to test an ACO model that can inform the Medicare Shared Savings Program and future models by making important changes to the GPDC Model in three areas.

1. Advance Health Equity to Bring the Benefits of Accountable Care to Underserved Communities. The ACO REACH Model promotes health equity and focuses on bringing the benefits of accountable care to Medicare beneficiaries in underserved communities. CMS 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. 
2. Promote Provider Leadership and Governance. The ACO REACH Model includes policies to ensure doctors and other health care providers continue to play a primary role in accountable care. At least 75 percent control of each ACO's governing body must be held by participating providers or their designated representatives, compared to 25 percent in the GPDC Model. In addition, the ACO REACH Model goes beyond prior ACO initiatives by requiring at least two beneficiary advocates on the governing board (at least one Medicare beneficiary and at least one consumer advocate), both of whom must hold voting rights.
3. Protect Beneficiaries and the Model with More Participant Vetting, Monitoring, and Transparency.  CMS will require additional information on applicants’ ownership, leadership, and governing board to gain better visibility into experience in health care delivery, ownership and financial interests, and affiliations to ensure participants’ interests align with CMS’ vision. We will  employ increased up-front screening of applicants, robust monitoring of participants, and greater transparency into the model’s progress during implementation, even before final evaluation results, and will share more information on the participants and their work to improve care. Last, the ACO REACH Model will include stronger protections against inappropriate coding and risk score growth.

The ACO REACH Model will offer two voluntary risk sharing options: (1) Professional Option (‘Professional’), a lower-risk option with 50 percent Shared Savings/Shared Losses and Primary Care Capitation Payment; and (2) Global Option (‘Global’), a full risk option with 100 percent Shared Savings/Shared Losses and either Primary Care Capitation Payment or Total Care Capitation Payment.

The ACO REACH Model will also allow participation by three different participant types: (1) Standard ACOs for organizations with substantial experience serving people with Traditional Medicare; (2) New Entrant ACOs for organizations with less experience serving the Traditional Medicare population; and (3) High Needs Population ACOs, for organizations that serve small Traditional Medicare populations with complex health care needs. 

Current GPDC Model participants must agree to meet requirements for the ACO REACH Model by January 1, 2023 in order to continue their participation.

The Path to Greater Transparency

CMS recognizes that stakeholders are interested in information about Innovation Center models, including greater insights into the participants, what they are doing to improve care, and impacts on quality and costs in advance of evaluation results being published.  CMS recognizes that this transparency not only provides more accountability to the public but can also help inform quality improvement. Today, CMS is reaffirming its commitment to provide greater transparency into the GPDC Model for the remainder of 2022 and pledging to do the same with ACO REACH. For GPDC, CMS is sharing information at the participant level, including:

• Type of entity (Standard, New Entrant, High Needs),
• Risk-sharing arrangement (Global or Professional)
• Payment option (Primary Care Capitation, Total Care Capitation, Advanced Payment),
• Benefit enhancements and beneficiary engagement incentives they have elected to use (e.g., care management home visits to prevent hospitalization, waiver of the Medicare homebound requirement for access to home health services, Part B cost sharing support),
• Organization website, and
• Core service area.

See here for a link to this information: https://innovation.cms.gov/media/document/gpdc-model-participant-summary.

CMS will also share aggregate information for the Model, including the number of aligned beneficiaries, and information on quality and financial performance based on operations and actuarial data, not the model’s evaluation, which will be updated quarterly. It is important to note that the quality information presented is limited to two claims-based measures—All Condition Readmissions and Unplanned Admissions for Patients with Multiple Chronic Conditions. In addition, information will be shared on the payments being made to model participants on a quarterly basis. Data for additional quality measures may be provided when information becomes available. Finally, as with all Innovation Center models, independent evaluation results will be posted when available.

FREQUENTLY ASKED QUESTIONS:

What is the ACO Realizing Equity, Access, and Community Care (REACH) Model?

The ACO REACH Model is the redesigned version of the Global and Professional Direct Contracting Model (GPDC) Model and focuses on promoting health equity and addressing healthcare disparities for underserved communities, continuing the momentum of provider-led organizations participating in risk-based models, and protecting beneficiaries and the model with more participant vetting, monitoring and greater. The ACO REACH Model provides tools and resources to empower doctors and other health care providers to better coordinate and improve the quality of care they provide for patients in Traditional Medicare. This approach affords patients greater individualized attention to their specific health care needs while preserving all services and flexibilities beneficiaries enjoy in Traditional Medicare. The goal of ACO REACH is to provide beneficiaries with access to enhanced benefits and to increase the availability of high quality, coordinated care, including for people in underserved populations. 

The ACO REACH Model takes all the important lessons learned thus far from the Innovation Center’s previous model tests and brings accountable care to Medicare beneficiaries who have previously lacked access in new and exciting ways. Please refer to the table for a comparison of ACO REACH and GPDC at https://innovation.cms.gov/media/document/gpdc-aco-reach-comparison.

Why is CMS making the change from GPDC to ACO REACH?

CMS redesigned and renamed the GPDC Model as the ACO REACH Model to better reflect the priorities of the Biden-Harris Administration, to highlight changes due to feedback received from participants and stakeholders, and to affirm our commitment to health equity as central to improving the quality of care for all beneficiaries. CMS is committed to making sure our nation’s health care system works for everyone and eliminates health disparities. The ACO REACH Model is designed to advance this goal through the following important policies:

• Requiring all participants to have a robust health equity plan describing how they will reach underserved populations; and
• Applying an adjustment to increase the benchmark for ACOs serving higher proportions of underserved beneficiaries, which will be identified using a composite measure that incorporates a combination of the Area Deprivation Index^[1] and Dual Medicaid Status to ensure the benefits of ACOs are available to all Medicare beneficiaries.

How will ACO REACH focus on Health Equity?

The ACO REACH Model seeks to improve quality of care and health outcomes for Traditional Medicare beneficiaries. Research shows that certain underserved communities experience worse health outcomes and lower quality of care than the general population. To improve the quality of care and outcomes for all types of Medicare beneficiaries, the ACO REACH Model will test ways to address these health inequities.

The ACO REACH Model is introducing five new policies to promote health equity starting in PY2023:

1. Health Equity Plan Requirement
2. Health Equity Benchmark Adjustment
3. Health Equity Data Collection Requirement
4. Nurse Practitioner Services Benefit Enhancement
5. Health Equity Questions in Application and Scoring for Health Equity Experience

These updates are expected to reduce disparities in health such that those with the greatest needs and least resources receive the care they need. Each of these new policies is discussed in greater detail in the RFA, and will apply to all REACH ACOs (including PY2021 and PY2022 participants from the GPDC Model interested in continuing in ACO REACH, with the exception of the application questions and scoring). (See the comparison table for more information on the above policies.)

Have other models used Health Equity Plans and if so, what has CMS learned from them?

The Accountable Health Communities (AHC) Model is the only Innovation Center model so far to require a Health Equity Plan. In the ACO REACH Model, each ACO will use a Health Equity Plan to identify underserved communities within its beneficiary population and implement initiatives to measure and reduce health disparities for such populations over the course of the model performance period. CMS continues to learn that while documenting disparities and planned mitigating actions is an important first step, it is critical to track adherence to these plans over time and update them as needed. The Innovation Center will provide ACOs with a template based on the CMS Disparities Impact Statement^[2] created by the CMS Office of Minority Health to identify health disparities, define health equity goals, establish a health equity strategy, and a plan for implementing the health equity strategy and monitoring and evaluating progress to advance health equity for underserved communities.

Future Innovation Center models will also include features, like the requirement of a health equity plan, to reduce health disparities and expand the reach of models intended to improve care and outcomes.

How are current GPDC Model participants affected by the changes to the ACO REACH Model?

Current GPDC participants must maintain a strong compliance record in 2022 and agree to meet all the ACO REACH requirements beginning January 1, 2023 in order to continue participating in the ACO REACH Model. For example, model participants must meet the updated governance standard that Participant Providers or their designated representatives generally hold at least 75 percent control of the ACO's governing body (an increase from 25 percent for PY2021 and PY2022). (See comparison chart for full list of requirements.) Alternatively, model participants may elect to leave the Model.

How are beneficiaries affected by ACO REACH?

Beneficiaries with Traditional Medicare retain all of their rights, coverage, and benefits, including the freedom to see any Medicare provider. Like previous ACO models, the ACO REACH Model prohibits limited networks, prior authorization or any other means of restricting care.  Even if a beneficiary is aligned to a REACH ACO, they always have the freedom to see any Medicare-enrolled provider. CMS expects that beneficiaries whose primary care provider is part of a REACH ACO will see and feel improvements in the quality of health care they are getting because of the ACO REACH Model. For example, they may receive increased access to telehealth, home visits after leaving the hospital, cost sharing support to help with co-pays, or other enhanced services and incentives. Moreover, the new Health Equity provisions are expected to provide greater access for underserved communities, reaching beneficiaries who have not previously received coordinated care.

Starting in PY2023, CMS is requiring each REACH ACO to have both a Medicare beneficiary and consumer advocate serving on the REACH ACO’s governing body who will hold voting rights (the same person is no longer permitted to fill both roles) to ensure beneficiary representation in the REACH ACO’s governance.

In addition, CMS will closely monitor levels of care provided over time and compare care delivery patterns to a reference population to determine if REACH ACOs are stinting on beneficiary care. CMS also will conduct compliance audits throughout the year, investigate beneficiary complaints, and conduct beneficiary experience of care surveys (CAHPS) annually to measure changes in beneficiary satisfaction. Lastly, CMS will monitor whether beneficiaries aligned to the model are being shifted into or out of Medicare Advantage.

If at any time a Medicare beneficiary or their caregiver has concerns about the ACO REACH Model, the Innovation Center has a model liaison that is part of the Medicare Beneficiary Ombudsman team in the Offices of Hearings and Inquiries. The model liaison can be reached thru 1-800 Medicare and will assist in facilitating communications with the Medicare Quality Improvement Organizations (QIOs), the CMS regional offices, and ACO REACH Model team to ensure the beneficiary’s concerns are heard.

What does this mean for health care providers?

CMS encourages health care providers with a strong track record of direct patient care and those who have had success improving the lives of people in underserved populations to apply to be part of this transformative model. Health care providers are taking more responsibility for the care they are giving people with Medicare. In the ACO REACH Model, providers are incentivized to provide high quality, well-coordinated health care to Medicare beneficiaries, including those in underserved communities. ACO REACH places a strong emphasis on provider-led organizations participating in the model including a requirement that participating providers generally hold at least 75 percent of governing board voting rights. This ensures that the care the beneficiaries will receive is driven by quality first.

How do risk adjusted benchmarks and payments work in the model?

Risk adjustment has been a critical component of all ACO-based models dating back to the creation of Medicare ACOs with the ACA. Without the ability to adjust benchmarks and payments based on how sick a given beneficiary is, participants are incentivized only to treat healthy beneficiaries, and the sickest, most vulnerable populations are left out. However, including risk adjustment also introduces potential for over-coding, so it is important to have strong protections against such over-coding.

The ACO REACH Model improves upon the GPDC Model’s approach to risk adjustment, which already offered the strongest risk adjustment protection to date compared to other ACO initiatives and MA by ensuring 100 percent protection to Medicare against inflated payments. The ACO REACH Model takes a two-fold approach: First, the model caps the risk score growth of each individual model participant at +/- 3 percent over a two-year period (this is called the ‘risk score cap’). Some fluctuation in risk scores is natural and should be allowed, but the risk score cap ensures that no single participant’s risk scores grow too fast (which would be to the detriment of other model participants, given the second component). Second, it locks in the average risk score across the entire model from before the model began, to ensure that risk scores within the model do not grow faster than risk scores in all of Traditional Medicare (this is called the ‘Coding Intensity Factor’ or ‘CIF’). The CIF essentially creates a ‘zero-sum’ environment and is the mechanism that provides 100 percent protection to Medicare against inflated payments.

The ACO REACH Model improves upon how the risk score cap works in two ways. First, it locks the reference year for the risk score cap, so that the capped risk scores of a single model participant are not able to grow greater than 3 percent every two years in the later years of the model. Second, it takes into account how the underlying demographics of a model participant’s aligned population change over time when determining whether the risk score hits the risk score cap. Importantly, the CIF remains in effect, so Medicare remains fully protected from risk score upcoding.

What is the model timeline?

The redesign of the GPDC Model, now called the ACO REACH Model, starts on January 1, 2023 and will span four Performance Years, ending on December 31, 2026. This Request for Applications (RFA) is for interested provider-led organizations to apply and begin participation in PY2023 with an optional Implementation Period (IP) to run from August 1, 2022 through December 31, 2022. 

Who can apply to join the ACO REACH Model?

The ACO REACH Model is designed to attract a range of providers and suppliers operating under a common legal structure, with attention given to advancing primary care as a means to better manage Medicare beneficiaries’ health. We believe this model is well-suited to provider-led organizations, including those with prior experience participating in the Next Generation ACO Model or the Medicare Shared Savings Program that are interested in continuing and deepening their participation in Medicare shared risk arrangements. We are particularly interested in providers with direct patient care experience and a strong track record serving underserved populations.

When can organizations apply to participate in the ACO REACH Model?

The application period for ACO REACH opens on March 7, 2022 and closes on April 22, 2022 at 11:59 PM ET. CMS is not soliciting Letters of Intent (LOIs) for PY2023 starters, therefore submitting an LOI is not required to apply in response to this RFA.

What changes are being made to the applicant screening process? 

The RFA for ACO REACH requests additional information on applicants’ ownership, leadership, and governing board to gain better visibility into ownership interests and affiliations, and information regarding their direct patient care experience, as well as experience serving underserved communities. This information will help CMS determine if the applicant's interests align with CMS’ vision for a health care system that achieves equitable outcomes through high quality, affordable, person-centered care. 

What changes are being made to monitoring and compliance under the Model?

CMS will strengthen its current set of compliance and monitoring activities to ensure beneficiaries are protected and ACOs are adhering to the requirements of their Participation Agreement with CMS. These activities will include increased use of data analytics to monitor use of services over time and compared to a reference population to assess changes in beneficiaries’ access to care, including stinting on care; assessing annually whether beneficiaries are being shifted into or out of Medicare Advantage; continuation of audits of contracts ACOs have with providers to learn more about their downstream arrangements and identify any concerns; examining ACOs’ risk score growth to identify inappropriate coding behaviors; monitoring for noncompliance with prohibitions against anti-competitive behavior and misuse of beneficiary data; reviewing marketing materials and websites to ensure information on the Model is accurate and beneficiaries understand their rights and freedom of choice; and investigating beneficiary complaints and grievances in coordination with 1-800-Medicare, the Innovation Center liaison on models in the office of the Medicare Beneficiary Ombudsman, CMS regional offices, and others as appropriate.

What is the status of the Geographic Direct Contracting Model?

The Innovation Center is canceling the Geographic Direct Contracting Model, which was announced in December 2020 and paused in March 2021, because it does not align with CMS’ vision for accountable care and due to concerns raised by stakeholders. 

For more information on the ACO REACH Model, visit: https://innovation.cms.gov/innovation-models/aco-reach

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