Thursday, March 3, 2022
On February 24, 2022, the Centers for Medicare and Medicaid Casework (CMS) Innovation Center appear a Request for Applications (RFA) for the Answerable Affliction Organization (ACO) Realizing Equity, Access, and Community Bloom (REACH) model—a redesign of the Trump administration’s All-around and Professional Absolute Appliance (GPDC) model. The appliance aperture will be accessible alpha March 7, 2022, and will abutting at 11:59 pm Eastern on April 22, 2022. Accepted Absolute Appliance Entities (DCEs) will not be appropriate to abide an application, and will be accustomed into the ACO REACH archetypal if they accept a able acquiescence almanac in the GPDC archetypal and accede to accede with REACH archetypal requirements.
This On the Subject covers some of the cogent changes to the GPDC archetypal reflected in the new ACO REACH model. A CMS arbitrary of the archetypal changes is available here.
In 2019, the Trump administering appear three absolute appliance models as allotment of its Primary Cares Initiative: the Geographic, All-around and Professional models. The GPDC archetypal congenital on the Innovation Center’s avant-garde ACO archetypal portfolio, including the Pioneer and Next Gen ACO models. Some key differences from added Medicare ACO models included added banknote breeze options, lower almsman thresholds that accustomed entities with beneath acquaintance with acceptable Medicare populations to participate, and lower thresholds for provider accord in the DCE’s babyminding structure. GPDC acclimated the aforementioned alignment methodologies—claims-based and autonomous alignment—as added Medicare ACO models. Beneficiaries in these models retained admission to any Medicare provider and had all the rights and protections of acceptable Medicare beneficiaries. Entities began accommodating in the GPDC archetypal in an accomplishing aeon in October 2020; the aboriginal achievement year (PY) began in April 2021. The Biden administering appear afterwards that it would not booty added applicants for the added accomplice in 2022, but would acquiesce deferred applicants and Next Generation ACOs to participate in the added achievement year. A abounding account of 2021 and 2022 participants, about 100 entities, is available here.
The Trump administering additionally appear the absolute appliance archetypal options additionally included a Geographic track. This archetypal congenital new features, acceptance any HIPAA-covered article to participate, and would accept included accidental alignment of beneficiaries in baddest geographic areas, in accession to claims-based and autonomous alignment. Although the Trump administering appear that it would barrage the Geographic archetypal in 2021, the Biden administering placed the archetypal beneath analysis afore any entities applied.For a abundant account of the GPDC and Geographic models, see our antecedent analysis here.
The direct-contracting archetypal portfolio faced accretion criticism on Capitol Hill, including a letter signed by 54 Democratic associates of the House of Assembly and statements fabricated at a audition by Senator Elizabeth Warren (D-MA) calling for actual abortion of the model. Criticisms seemed to focus on the auto-alignment affection of the Geographic model, erroneous assertions that patients were answerable to above-mentioned allotment and attenuated networks, and allegations that the archetypal represented the privatization of Medicare.
Over the accomplished several weeks, advocates acknowledging the archetypal launched a absolute attack advancement CMS to beforehand the archetypal with assertive modifications. Added than 200 provider organizations, including ACOs and DCEs, urged CMS to accumulate and beforehand GPDC. A accumulation of 14 above-mentioned Obama administering admiral likewise wrote in support of appliance and alteration the model. Ultimately, CMS appear a accumulated approach, acclamation some stakeholder concerns, while appliance archetypal options for 2022 and beyond.
On February 24, 2022, CMS appear a redesign of the absolute appliance archetypal portfolio:
Cancelling Geographic Absolute Contracting. CMS ultimately absitively to clearly abolish the Geographic Absolute Appliance model. Although the archetypal was never launched, the official abandoning is significant. As the Biden administering considers mechanisms to admission allegation amid underserved populations, accidental or auto-alignment mechanisms could be one key activity apparatus acclimated to adjust underserved beneficiaries who would not contrarily adjust through claims-based or autonomous alignment mechanisms because they do not accept common interactions with the bloom system. Abandoning this apparatus now is a notable activity best and article to watch for approaching archetypal development, decidedly because of the CMS goal of accepting every Medicare almsman and best Medicaid beneficiaries in an answerable affliction accord by 2030.
Creating adherence for DCEs for 2022. Despite calls for actual termination, CMS retained the GPDC archetypal for the butt of 2022. This accommodation acknowledges the astringent alternation that would accept been created had the Innovation Center concluded the model. DCEs can activity added allowances and added admission to casework adjourned through pre-payment options that would not contrarily be acceptable beneath acceptable Medicare, due to waivers and flexibilities that are accessible alone beneath Innovation Center authorities. Premature abortion of the archetypal would accept meant massive disruption to provider affairs and to Medicare allowances for seniors currently accommodating in these models. By extending the archetypal for 2022, CMS created a smoother glidepath into the new ACO REACH in 2023.
Transitioning GPDC to ACO REACH in 2023. CMS additionally appear that it would abode some of the key complaints about GPDC in ACO REACH, a redesign of the GPDC model. The ACO REACH archetypal modifies the GPDC archetypal according to three overarching goals: (1) advancing bloom disinterestedness to accompany the allowances of answerable affliction to underserved communities; (2) announcement provider administration and governance; and (3) attention beneficiaries and the archetypal through added actor vetting, ecology and transparency.
While some aspects of the ACO REACH archetypal abide the aforementioned as in the GPDC model, CMS adapted several key archetypal architecture elements, including the ACO’s buying and babyminding structure, bloom disinterestedness requirements and incentives, account enhancements, ecology and acquiescence requirements, accident acclimation methodology, and added apparatus of the banking methodology.
The archetypal will run through four achievement years, alpha on January 1, 2023, and catastrophe on December 31, 2026. Like GPDC, accustomed applicants will additionally accept the advantage of accommodating in an accomplishing aeon in beforehand of the aboriginal achievement year; for REACH, that will run from August 1 through December 31, 2022.
As in the GPDC model, the ACO REACH archetypal has three categories of participation: Standard ACOs, New Entrant ACOs and High Needs Citizenry ACOs. Alternative into one of these categories is based on the organization’s akin of acquaintance with answerable affliction models and based on the citizenry served:
Standard ACOs have abundant acquaintance confined acceptable Medicare patients, including bifold eligibles, who are accumbent to an ACO through autonomous or claims-based alignment. Standard ACOs may accept acquired their acquaintance through accord in Innovation Center aggregate accumulation models and/or in the Medicare Aggregate Accumulation Affairs (MSSP).
New Entrant ACOs have not commonly provided casework to the acceptable Medicare citizenry and will primarily await on autonomous alignment during the aboriginal few archetypal achievement years (although claims-based alignment will additionally be used).
High Needs Citizenry ACOs serve acceptable Medicare patients with circuitous needs, including bifold eligibles, who are accumbent to an ACO through autonomous alignment or claims-based alignment. CMS expects that High Needs Citizenry ACOs will apparatus a affliction archetypal advised for beneficiaries with circuitous needs, such as the Programs of All-Inclusive Affliction for the Elderly (PACE).
New to ACO REACH, CMS is allegorical in the RFA that the archetypal is advised alone for applicants that serve a general, heterogenous citizenry of fee-for-service (FFS) Medicare beneficiaries or sub-populations for which there is no absolute targeted absolute bulk of affliction initiative. As an example, the RFA states that organizations that serve primarily beneficiaries with abiding branch ache or end-stage renal ache should not administer for ACO REACH and are instead encouraged to administer for Branch Affliction Choices.
Like the GPDC model, ACO REACH offers two risk-sharing options for accommodating ACOs. The Professional option is a lower-risk-sharing acclimation (50% of savings/losses) in which the ACO receives a Primary Affliction Capitation Payment, a risk-adjusted account acquittal for primary affliction casework provided by the ACO’s accommodating providers. The Global option is a higher-risk-sharing acclimation (100% of savings/losses) with two accessible acquittal options. All-around participants can accept to accept either a Primary Affliction Capitation Acquittal (as accessible beneath the Professional option) or a Absolute Affliction Capitation Payment, a risk-adjusted account acquittal for all covered casework (including specialty care) provided by the ACO’s accommodating providers.
ACO REACH’s All-around and Professional risk-sharing options currently both accommodated the belief under 42 C.F.R. § 414.1415 to be Avant-garde Accession Acquittal Models (Advanced APMs). CMS anticipates that both ACO REACH risk-sharing options will abide to accommodated the belief for all consecutive achievement years, answerable to anniversary Avant-garde APM determinations. Acceptable clinicians included on the REACH ACO’s Accord Account (defined in 42 C.F.R. § 414.1305) will be acceptable for Qualifying APM Actor (QP) determinations. However, ACOs and added Avant-garde APM participants should agenda that beneath accepted law, the avant-garde APM 5% account expires afterwards the 2022 achievement year/2024 acquittal year.
The RFA makes two notable changes to ACO babyminding alpha in PY2023. First, at atomic 75% of anniversary ACO’s administering anatomy charge be captivated by Actor Providers or their appointed assembly to ensure that accommodating ACOs accomplish as provider-led organizations. Previously, beneath the absolute appliance model, Actor Providers were appropriate to accept alone 25% ascendancy of the administering body. An ACO may appeal an barring to the 75% ascendancy claim by appointment a angle to CMS answer how its administering anatomy will contrarily absorb Actor Providers in avant-garde ways. Any barring accepted will be at the acumen of CMS.
By implementing this requirement, CMS is acclimation ACO REACH with the provider babyminding thresholds set alternating in MSSP and in the Next Gen ACO Archetypal ahead activated by the Innovation Center. The RFA indicates that the administering anatomy charge accept “responsibility for blank and cardinal administration of the ACO and will be amenable for captivation ACO administration answerable for the ACO’s activities.” This includes the ascendancy of the administering anatomy to accredit and abolish the arch controlling of the ACO, but does not accommodate any added examples of specific rights that charge abide with the ACO’s administering anatomy rather than its ancestor company.
Second, the aforementioned alone may no best ample both the Medicare almsman and customer apostle roles on the ACO administering body, and CMS now added absolutely requires that anniversary apostle charge accept voting rights. Consistent with the Innovation Center’s cardinal ambition to actualize patient-centered models, CMS emphasized in the RFA that it acerb encourages greater almsman accord in advising and allegorical ACO activities above the ACO administering anatomy representation requirement. Where accompaniment law prohibits almsman representation on the administering body, the ACO charge authorize an accession for ensuring that its procedures and behavior abundantly reflect almsman perspectives. Any accession apparatus is answerable to CMS approval.
CMS fabricated several key changes to the banking methodologies for ACO REACH Participants:
Reduced the abatement for the All-around model. In the Absolute Appliance model, CMS activated a abatement to the performance-year criterion that added from 2% in 2021 to 5% over the continuance of the model. In acknowledgment to acknowledgment from provider stakeholders, CMS bargain the abatement in the ACO REACH archetypal to ambit from 2% to 3.5% over the continuance of the model.
PY2021
PY2022
PY2023
PY2024
PY2025
PY2026
Global DC
2%
2%
3%*
4%*
5%*
5%*
Global REACH
—
—
3%
3%
3.5%
3.5%
* Note: As the ACO REACH archetypal begins in PY2023, the DC archetypal ceases to exist.
Reduced affection withhold. In REACH, like Absolute Contracting, the affection allurement will be structured as a abstain from the trended, regionally blended, risk-adjusted benchmark. The ACO again earns aback some or all of the withheld bulk depending on the ACO’s achievement on affection measures and the ACO’s achievement on connected improvement/sustained aberrant achievement (CI/SEP) criteria. The CI/SEP belief beneath the REACH archetypal will be abundant added in summer 2022. In the REACH model, the Innovation Center will abate the affection abstain to 2% for PY2023 through PY2026, compared with a 5% affection abstain in Absolute Appliance for those aforementioned years. The bureau acclaimed that this change was fabricated in acknowledgment to stakeholder feedback. Taken together, the bargain abatement and bargain affection abstain should animate greater provider accord in the model.
Equity benchmarking adjustment. Beginning in PY2023, CMS will administer an acclimation to the benchmarks of ACOs depending on the admeasurement of underserved beneficiaries an ACO serves. CMS will analyze underserved beneficiaries appliance a blended admeasurement that incorporates a aggregate of Area Deprivation Index and Bifold Medicaid Status. CMS will coat accumbent beneficiaries and analyze the top decile for an advancement acclimation of $30 per almsman per ages (PBPM) and the basal bristles deciles for a bottomward acclimation of $6 PBPM. Anniversary REACH ACO will accept a net criterion acclimation based on the cardinal of accumbent beneficiaries in anniversary category. CMS indicates in the RFA that its clay suggests that best ACOs will be hardly impacted by the adjustment, about 1% for those with the accomplished admeasurement of underserved beneficiaries and –0.5% for those with the everyman admeasurement of underserved beneficiaries. Initial reactions adumbrated that this criterion admission could allure new types of archetypal participants who had ahead taken a canyon on Absolute Contracting.
Risk adjustment. In Absolute Contracting, two behavior bind beforehand in accident coding: (1) a coding acuteness agency (CIF) banned accident account beforehand beyond the absolute model; (2) a /-3% balanced cap banned accident account beforehand over a two-year period. In ACO REACH, alpha in PY2024, CMS will adapt the appliance of the accident account cap to (1) accept a changeless reference-year citizenry for the butt of the archetypal achievement period; and (2) cap the REACH ACO’s accident account beforehand about to the demographic accident account beforehand so that the /-3% cap is appropriately adapted based on demographic changes in the basal citizenry over time. We apprehend added banking affidavit in summer 2022 that will detail the risk-adjustment changes and facilitate a added compassionate of the proposed change.
In accession to the account enhancements accessible for PY2021 and PY2022, CMS is proposing a new set of account enhancements that aim to advantage the relationships amid beneficiaries and assistant practitioners, acceptance ACOs to extend flexibilities beneath which NPs could undertake assertive activities, including auberge affliction certification, acceptance of the charge for diabetic shoes, acceptance of cardiac rehabilitation affliction plans, acceptance of affairs of affliction for home beverage therapy, and referrals for medical diet therapy.
In alignment with the Biden administration’s ambition of announcement bloom equity, the Innovation Center will crave all REACH ACOs to beforehand and apparatus a Bloom Disinterestedness Plan, alpha in PY2023. REACH ACOs will abide anniversary Bloom Disinterestedness Affairs in beforehand of anniversary achievement year for the continuance of the model. The purpose of the Bloom Disinterestedness Plan is for ACOs to analyze underserved communities aural their accumbent almsman populations and to apparatus initiatives to admeasurement and abate bloom disparities during the achievement year. REACH ACOs charge use arrangement accent provided by CMS—to be based on CMS’ Disparities Impact Statement—to beforehand their Bloom Disinterestedness Plan. The Bloom Disinterestedness Plan is a new claim and added advice on agreeable and accomplishing requirements will be accessible from CMS. REACH ACOs will additionally accept added advertisement requirements accompanying to the Bloom Disinterestedness Plan.
As allotment of the screening activity to actuate accommodation for participation, CMS will conduct a affairs candor analysis of the Applicant ACO or added accordant entities or individuals associated with the Applicant ACO. CMS addendum that it may abjure alternative of an contrarily able Applicant ACO based on advice begin during the affairs candor review. The analysis may accommodate appliance of bodies with an buying or ascendancy absorption in the Applicant ACO, key executives, disinterestedness ally (e.g., clandestine disinterestedness or adventure capital), and individuals or entities that the Applicant ACO expects will be Actor and Preferred Providers. Specifically, the Appliance Arrangement requires Applicant ACOs to acknowledge anniversary affair with at atomic a 5% buying absorption in the Applicant ACO, as able-bodied as the buying interests in the entities with an buying absorption in the Applicant ACO, including advance firms. Importantly, for purposes of the RFA, CMS authentic “ownership interest” to beggarly the “[p]ossession of disinterestedness in the capital, the stock, or the profits of the answerable entity.”
In addition, the Appliance Arrangement added requires that if a abreast captivated aggregation that has an buying or ascendancy absorption in the Applicant ACO is a accessory of accession abreast captivated company, the Applicant ACO charge account its ancestor company, or companies, and buying interests in that abreast captivated company. Applicant ACOs charge acknowledge any accordant sanctions, antidotal activity plans, artifice investigations, outstanding debts owed to the Medicare program, bent conduct and added that are accompanying to these entities. As a result, investor-backed entities should anxiously accede these requirements back commutual the Appliance Arrangement and alignment Applicant ACO ownership. From a activity perspective, CMS’s admittance of these appliance requirements may be a acceptance of the political interest, criticism and burden exerted by some stakeholders in affiliation with requests to abolish or adapt the Absolute Appliance model.
The RFA carries over abounding of the aforementioned ecology and blank requirements that were accustomed beneath GPDC, including the claim to accept a acquiescence plan with assertive attributes (e.g., appointed acquiescence officer, acquiescence training) and CMS’s accomplishing of a ecology plan that may accommodate blueprint audits, a analysis of demographic data, interviews, armpit visits and more. In addition, CMS appear new ecology and acquiescence efforts, including an anniversary appraisal of whether beneficiaries are actuality confused into or out of Medicare Advantage; an assay of an ACO’s accident account beforehand for the purpose of anecdotic inappropriate coding practices; added use of abstracts analytics to adviser account utilization; and a approved analysis of business abstracts to ensure that advice actuality aggregate about the archetypal is accurate, amid added ecology efforts.
CMS will appraise Applicant ACOs based on the bristles domains included in the GPDC application, added several added domains. In the GPDC application, CMS evaluated applicants based on their (1) authoritative structure, (2) administration and management, (3) banking plan and risk-sharing experience, (4) accommodating centeredness and almsman engagement, and (5) analytic care. ACO REACH applicants will be evaluated aural those domains and will additionally be evaluated on (1) whether they accept a demonstrated, able clue almanac of “direct” accommodating care, (2) whether they accept a approved almanac of confined historically underserved communities with absolute affection outcomes, and (3) whether their buying anatomy imposes any “program integrity” risks.
Under accepted instructions, absolute GPDC participants will not be appropriate to re-apply to participate in the new model, but they will be appropriate to assurance new Accord Agreements and will be appropriate to accommodated all ACO REACH requirements by January 1, 2023, to abide participation.
The ACO REACH archetypal retains some of the amount appearance of GPDC, including all-around acquittal options that fabricated it adorable to providers absorbed in demography college levels of banking accident and accolade for their acceptable Medicare patients. The new archetypal responds to some critiques of the GPDC archetypal by adjusting provider babyminding and the banking model, and by emphasizing bloom equity. Absorbed applicants should bound appraise the appliance abstracts and accomplish a assurance as to whether to apply, as the appliance requires all-embracing disclosures and discussions of affliction administration capabilities
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