To meet ACO REACH requirements, a PCP practice must “meet standards that reflect quality care in order to be eligible for a positive performance-based adjustment to their primary care model payments. Here's what you need to know.
When the Centers for Medicare and Medicaid Services (CMS) announced a complete and systematic restructuring of its Global Professional Direct Contracting (GPDC) model in February 2022, the goal was to renew a vision of more equitable care and access for patients who most need it. The program they introduced—The Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) model—is a comprehensive approach to patient-centered, affordable, high-quality care for everyone.
The program supports primary care physicians (PCPs) and medical specialists in moving away from traditional fee-for-service models to value-based care (VBC) and payment systems. Beginning January 2023, hundreds of REACH ACOs accepted into the program will be responsible for collaborating with a network of providers to improve individualized attention and care for aligned beneficiaries.
GPDC redesign with a purpose
GPDC—the predecessor to ACO REACH—took steps to better align payments with risk and empower beneficiaries to better control their health and care quality. But that program was also criticized for not addressing growing disparities in access and care quality. ACO REACH aims to remedy these issues by emphasizing health equity, access for underserved communities, and provider leadership and governance within ACO entities. It also increases beneficiary protections with better participant vetting, monitoring, and transparency.
The primary care transformation
Primary care providers are critical to the care quality and access puzzle. There are just under 500,000 PCPs practicing in the United States, and on average, each one provides care for 2,300 patients each year (an average of about six patients per day). CMS has clearly intended to focus on primary care with ACO REACH, which is central to a high-functioning value-based care system. PCPs are essential for coordinating individual patients’ care across multiple specialties and touchpoints.
To meet ACO REACH requirements, a PCP practice must “meet standards that reflect quality care in order to be eligible for a positive performance-based adjustment to their primary care model payments. These measures were selected to be actionable, clinically meaningful, and aligned with CMS’s broader quality measurement strategy.”
The need for new and innovative technology
The demands for the new REACH ACOs go well beyond the capabilities of legacy technology designed for current care delivery and payment models, including current VBC models. To succeed in ACO REACH, organizations must have the full spectrum of value-based care technology—including advanced data management capabilities, in-depth analytics, population health and care management, and payment technology.
Antiquated legacy systems will struggle to keep up with the new CMS requirements. Some view restructuring as burdensome because it requires significant changes in how organizations collect, track, and analyze data for assigned beneficiaries. Without a doubt, the model will require planning and preparation. For many, that will mean putting new technology in place that is purpose-built to support forward-looking VBC models and is fully integrated to seamlessly share information across the entire organization.
Enterprise data management (EDM)
A comprehensive data management system is at the heart of effective health care software platforms. EDM systems pull in data from multiple sources and make it available for analysis, care management and delivery, and reporting. But most data management systems struggle to provide meaningful, usable data when it comes from so many disparate sources.
An integrated EDM allows ACOs to leverage consistent data in any application. But first, it must map standard file formats from CMS, Area Deprivation Index (ADI) and social determinants of health (SDoH), EHRs, laboratories and other ancillary services, and third-party care entities into a clean dataset that can be used throughout the enterprise. This is beneficial because a file mapping engine works well with all different types of data. Tailoring how CMS data comes into the system and is handled means teams won’t have to completely rewrite the implementation and manually adjust, field by field, how data is handled for different clients in different use cases.
An integrated data warehouse also means normalized data is shared across the entire platform with population health, analytics, care management, and payment modules. Care teams, administrators, and other stakeholders can quickly access the same information, providing everyone with a comprehensive view of a beneficiary’s health experience.
ACO REACH requires a significant change in model administration and care administration. Analytics power the ability to surface insights into everything, from health equity data to identify and target underserved populations, high-performing providers within a network, and precise fund flow analysis.
Most health care organizations today don’t suffer from a lack of data. Instead, they struggle with using all the data they have to make meaningful decisions that improve clinical and financial operations. As CMS requires more information from sources like the ADI (a multi-dimensional evaluation of a region’s socioeconomic conditions linked to health outcomes) and SDoH surveys, REACH ACOs must be prepared to report on these metrics and incorporate them into care decisions. This information is central to an organization’s ability to identify health equity gaps and create a health equity plan.
REACH ACOs are also responsible for reducing care costs for aligned beneficiaries, which requires a network of primary and specialty care providers, hospitals, long-term and skilled nursing care facilities, home health, and more. Identifying high-performing providers and facilities within the network is essential to minimize the total cost of care and maximize patient health outcomes. Advanced software tools that perform these analyses could make the difference between success and failure in ACO REACH.
Finally, analytics tools that offer critical insights into capitated payment and funds flow will improve financial success for REACH ACOs. The ability to analyze claims paid to network providers and compare them to reimbursements from CMS can improve profitability management to ensure steady cash flow in a dramatically different system from fee-for-service models. Getting the same information from an analytics system not built for funds flow analysis in capitated payment arrangements is difficult (and may not be possible at all).
Population health and care management
Health equity plans are central to CMS goals of increasing access to high-quality care for underserved populations. Once identified (using in-depth analytics tools), care teams need access to information on health equity opportunities and care gaps within the context of their workflows. REACH ACOs must also collect data on patient demographics to report on SDoH. Without care management and population health tools designed to consistently capture and aggregate this information for CMS reporting, participating ACOs will waste resources to manually compile the data to meet program requirements. These manual workarounds are no longer acceptable as organizations face inflation and staff shortages.
Care management software for REACH ACOs should also include chronic care management and clinical decision support tools. That includes the ability to surface HCC risk scores and coding opportunities for aligned beneficiaries. Since HCCs must be captured at the point of care, effective care management software must also alert providers to these opportunities before or during patient encounters.
Capitated payments are a dramatic shift for most health care organizations—even existing GPDC participants moving into ACO REACH may not have a lot of capitation experience – 32% of DCEs in 2021 opted out of capitated payments, which is no longer an option in the REACH program. The advantage of this alternative payment model (APM) is more cash flow predictability. Unfortunately, most payment technology is still built for a fee-for-service system. Administering full capitation or sub-capitation agreements within these platforms requires significant time and manual effort to properly adjudicate claims and reconcile payments, mitigating the financial benefits.
With payment technology designed for APMs, organizations can accept and properly administer capitated payments both internally and for downstream providers participating in care for aligned beneficiaries. In a platform architecture with integrated analytics, administrators can conduct funds flow analysis and payment reconciliation for a beneficiary population that is always changing. This can help forecast profitability and avoid over- or underpayment that could significantly impact revenue cycles and care delivery.
A composable solution
Most REACH ACOs have some of these tools in place, but almost none have a platform that can deliver in all four critical areas. Thus, organizations must look for modular solutions—or, as Gartner calls it, “composable” technology—that fills technology gaps and creates an effective ecosystem for administering ACO REACH.
Transitioning with ease
An efficient end-to-end software platform that is purpose-built for ACO REACH gives providers unique data management, analytics, care management, and payment technology tools. Users get a 360-degree shareable view of patients’ or beneficiaries’ needs that seamlessly performs the tasks necessary to succeed in CMS models designed to move health care forward.
David L. Morris is the EVP and Chief Commercial Officer of Cedar Gate Technologies.