ACO REACH Model
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Overview of the ACO REACH Model announced by Medicare for 2023 start date.
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ACO REACH Model
- 2. ACO Reach Participation 31 Dec. 2022 The GPDC Model will continue until December 31, 2022 and then transition to the ACO REACH Model. 1 Jan. 2023 Current participants in the GPDC Model must agree to meet all the ACO REACH Model requirements by January 1, 2023 in order to participate.
- 3. ACO Reach Participation Mar 7 2022 The application portal will be available beginning on March 7, 2022 and will close at 11:59 PM Eastern Time (E.T.) on April 22, 2022. June 2022 REACH ACO Selection Aug 1 2022 Implementation Period until 12/31/2022 to conduct voluntary alignment Jan 1 2023 The first performance year of the redesigned ACO REACH Model will start on January 1, 2023, and the model performance period will run through 2026. Dec 31 2026 ACO Reach End CMS is not soliciting Letters of Intent (LOIs) for PY2023 starters, therefore submitting an LOI is not required to submit an application in response to this RFA. Nor do current GPDC participants need to complete an application.
- 4. Reach ACO Key Differences to Traditional ACO Eligibility for those with insufficient number of aligned beneficiaries (5,000) Two risk sharing and capitation options with participation options for participants and preferred providers •Global or Professional risk sharing model •Total Care Capitation (TCC) or Primary Care Capitation (PCC) Claims-based quality performance Health Equity Requirements Split the TIN for participants (NPI participation) •Splitting the TIN will be permitted, which will allow Participant Providers with separate NPIs who bill through the same TIN to join separate models. In addition, a Participant Provider may participate in another model using another TIN that is not being used for the ACO REACH Model. Does not apply to preferred providers
- 5. Minimum Number of Aligned Beneficiaries Required at the Start of Each Performance Year Standard: Minimum of 5,000 aligned beneficiaries prior to the start of each performance year. Minimum of 3,000 beneficiaries that would have been aligned during at least one base year (CY2017, CY2018, or CY2019). New Entrant: Minimum number of aligned beneficiaries prior to the start of each performance year under the “glide path”: Beneficiaries aligned via claims must not exceed 3,000 in any base year (2017-2019 • PY2021 (April-December 2021): 1,000 beneficiaries • PY2022: 1,000 beneficiaries • PY2023: 2,000 beneficiaries • PY2024: 3,000 beneficiaries • PY2025: 5,000 beneficiaries • PY2026: 5,000 beneficiaries High-Needs: Minimum number of aligned beneficiaries prior to the start of each performance year under the “glide path”: • PY2021 (April-December 2021): 250 beneficiaries • PY2022: 250 beneficiaries • PY2023: 500 beneficiaries • PY2024: 750 beneficiaries • PY2025: 1,200 beneficiaries • PY2026: 1,400 beneficiaries ACO Type Standard Experience with beneficiaries New Entrant Limited historical experience delivering care to Medicare FFS beneficiaries. High Needs Very high-risk patients
- 6. CMS Reach ACO Global 100% (Full Risk subject to risk corridors) Primary or Total Care Capitation Participants ACO Participant Providers for alignment of beneficiaries and mandatory capitation Preferred Providers Preferred Providers optional capitation arrangements Professional 50% (Partial Risk subject to risk corridors) Primary Care Capitation Participants ACO Participant Providers for alignment of beneficiaries and mandatory capitation Preferred Providers Preferred Providers optional capitation arrangements Participant Provider claims reduction: PY2021: 1-100% PY2022: 5-100% PY2023: 10- 100% PY2024: 20-100% PY2025: 100% PY2026: 100% Participant Providers must participate in 100% claims reduction Preferred Providers elect 1- 100% claims reduction Primary Care Capitation (PCC) equal to 7% of the PY Benchmark for enhance primary care services (4% recoup) subject to a quality withhold Choice between PCC or Total Care Capitation (TCC) equal to 100% of the cost of care for aligned beneficiaries subject to a discount and quality withhold
- 7. Gross Savings/Losses as a % of Final PY Benchmark (Professional ACO Shared Savings/Losses Cap CMS Shared Savings Losses Cap Risk Band 1: Gross Savings/Losses Less than 5% 50% savings/losses 50% savings/losses Risk Band 2: Gross Savings/Losses Between 5% and 10% 35% savings/losses 65% savings/losses Risk Band 3: Gross Savings/Losses Between 10% and 15% 15% savings/losses 85% savings/losses Risk Band 4: Gross Savings/Losses Greater than 15% 5% savings/losses 95% savings/losses Gross Savings/Losses as a % of Final PY Benchmark (Global) ACO Shared Savings/Losses Cap CMS Shared Savings Losses Cap Risk Band 1: Gross Savings/Losses Less than 25% 100% savings/losses 0% savings/losses Risk Band 2: Gross Savings/Losses Between 25% and 35% 50% savings/losses 50% savings/losses Risk Band 3: Gross Savings/Losses Between 35% and 50% 25% savings/losses 75% savings/losses Risk Band 4: Gross Savings/Losses Greater than 50% 10% savings/losses 90% savings/losses
- 9. Five new policies to promote Health Equity starting in PY2023 •Health Equity Plan Requirement • REACH ACOs will be required to develop and implement a Health Equity Plan starting in 2023 to identify underserved patients within their beneficiary population and implement initiatives to measurably reduce health disparities • Disparities impact statement as a guide •Health Equity Benchmark Adjustment • A beneficiary-level adjustment will be applied to increase the benchmark for those REACH ACOs serving higher proportions of underserved beneficiaries in order to mitigate the disincentive for ACOs to serve underserved patients by accounting for historically suppressed spending levels for these populations • Atlas map •Health Equity Data Collection Requirement •Nurse Practitioner Services Benefit Enhancement • Nurse Practitioners will be able to assume certain responsibilities or furnish certain services without physician supervision that they typically could not under current Medicare law, to the extent permitted under applicable state law Health Equity Questions in Application and Scoring for Health Equity Experience
- 10. ACO Reach Benchmarking Methodology • BY1, 2 & 3 will be 2017, 2018 & 2019 for all REACH ACOs including existing DCEs • Benchmark includes a mix of historical claims experience and a regional rate book • Trending, geographic adjustments, risk adjustments, discounts and incentives • New- Health Equity Benchmark Adjustment – Area Deprivation Index – Dual Medicaid Status – Top 10% receives a $30 PMPM positive adjustment – Bottom 50% receive a $6 PMPM negative adjustment
- 11. Demographic and SDOH Data Reporting and Bonus Demographic and SDOH Data Reporting and Bonus REACH ACOs will be required to collect and report certain beneficiary-reported demographic data and social determinants of health data on their aligned beneficiaries for purposes of Model monitoring and evaluation. In PY2023, completing the requirement to collect and report beneficiary-reported demographic information will result in a bonus to the ACO’s quality score, but there will be no downward adjustment for the failure to report this information. In PY2024 and beyond, CMS may impose a requirement on ACOs to collect and report demographic and social determinants of health data on their aligned beneficiaries that results in a downward adjustment to the ACO’s quality score if not completed.
- 12. Discount PY2023 PY2024 PY2025 PY2026 Professional N/A N/A N/A N/A Global (GPDC) 3% 4% 5% 5% Global (ACO Reach) 3% 3% 3.5% 3.5% Quality Withhold PY2023 PY2024 PY2025 PY2026 Professional and Global (ACO Reach 2% 2% 2% 2% Global (GPDC) 5% 5% 5% 5%
- 13. ACO Reach Changes to Original GPDC PY 2023 - Providers will have to control at least 75% of REACH ACO governing boards, compared to 25% in GPDC and Medicare beneficiary and the consumer advocate serving on the ACO’s governing body are not permitted to be the same individual and both must hold voting rights The ACO REACH Model employs the ACO- specific symmetric 3% risk score cap. To further deter coding intensity, starting in PY2024, the application of the symmetric 3% risk score cap will be modified to: 1) adopt a static reference year population, and 2) cap the ACO’s risk score growth relative to the ACO’s demographic risk score growth in determining the ACO-specific 3% risk score cap thresholds
- 14. Why consider ACO Reach Model? Options that offer flexibility • PCC vs. TCC capitation • Global vs. Professional risk • Participant Provider selection at NPI level • More effectively control spend using preferred provider arrangements Benchmarking methodology may be more favorable to your organization 5% APM bonus for claims-based quality reporting Claims-based quality reporting and performance assessment reduces provider reporting burden
- 15. Tasks next week Benchmark analysis for ACO Reach Important to complete ACO Reach benchmark analysis using ACO data to determine if ACO Reach methodology is favorable for organization Retain application preparation assistance and preferred provider contracting assistance Greg Shockey, greg@nationalendeavors.com