CMS Redesigns Accountable Care Organization Model
According to a Feb. 24 press release, the Centers for Medicare & Medicaid Services (CMS) announced a redesigned Accountable Care Organization (ACO) model “that better reflects the agency’s vision of creating a health system that achieves equitable outcomes through high quality, affordable, person-centered care.”
The release states that “The ACO Realizing Equity, Access, and Community Health (REACH) Model, a redesign of the Global and Professional Direct Contracting (GPDC) Model, addresses stakeholder feedback, participant experience, and Administration priorities, including CMS’ commitment to advancing health equity.”
Further, “As CMS works to achieve the vision outlined for the next decade of the Innovation Center, CMS wants to work with partners who share its vision and values for improving patient care, guided by three key principles. First, any model that CMS tests within Traditional Medicare must ensure that beneficiaries retain all rights that are afforded to them, including freedom of choice of all Medicare-enrolled providers and suppliers. Second, CMS must have confidence that any model it tests works to promote greater equity in the delivery of high-quality services. Third, CMS expects models to extend their reach into underserved communities to improve access to services and quality outcomes. Models that do not meet these core principles will be redesigned or will not move forward.”
“Consistent with these principles, the ACO REACH Model, tested under the CMS Innovation Center’s authority, will adhere to the following priorities: a greater focus on health equity and closing disparities in care; an emphasis on provider-led organizations and strengthening beneficiary voices to guide the work of model participants; stronger beneficiary protections through ensuring robust compliance with model requirements; increased screening of model applicants, and increased monitoring of model participants; greater transparency and data sharing on care quality and financial performance of model participants; and stronger protections against inappropriate coding and risk score growth,” the release adds.
The GPDC Model will continue through the end of this year (Dec. 31, 2022) then will transition into the ACO REACH Model. For the remainder of this year, CMS will use the GPDC Model with stronger and more real-time monitoring of quality and costs for model participants. GPDC Model participants that don’t meet requirements—like participants that restrict necessary medical care—will face corrective action and possible termination from the model.
The GPDC Model has been a hot debate in the healthcare industry recently, and physician groups are already expressing their praise, or in some cases, disappointment.
America’s Physician Groups (APG), along with APG Direct Contracting Coalition (Coalition) members shared a statement applauding the news. APG President and CEO Don Crane was quoted in the piece saying that “APG is gratified that CMMI will continue to support these valuable risk-based, Direct Contracting models by allowing Next Generation ACOs to request to join the model in the next performance year as Standard Direct Contracting Entities. These Next Generation ACOs have accumulated valuable experience and operational infrastructure that will contribute greatly to strengthening the Direct Contracting Model. Many organizations invested considerable resources to meet requirements in preparation to apply for GPDC participation in 2022 and we are glad that their investments will not be a wasted effort as GPDC receives more support from CMMI in the form of this expanded pool of applicants. The big winners are Medicare beneficiaries who will receive better quality care at lower costs.”
One group that shared their disappointment via press release is Physicians for a National Health Program (PNHP), an organization of 25,000 doctors that support Medicare for All and oppose Medicare privatization. In the release, PNHP identifies several ways that “ACO REACH perpetuates the dangerous flaws of Direct Contracting.” One example is that, like the DC model, ACO reach will “play middlemen a flat fee to ‘manage’ seniors’ health, allowing them to keep 40 percent of what they don’t spend on care as profit and overhead.”
“Next, Traditional Medicare beneficiaries will still be automatically enrolled into ACO REACH entities without their full understanding or consent, and once enrolled cannot opt out of an ACO REACH entity unless they change primary care providers,” the release adds.”
Additionally, the release says that “Like DCEs, the ACO REACH program has virtually no limits on what type of company can participate; entities can be owned by commercial insurers, private equity investors, and other profit-seeking firms, including current Direct Contracting entities.”
Moreover, “The new program increases provider governance from 25 percent to 75 percent (with loopholes built into the application process), but ACO REACH entities are ultimately accountable to investors.”
Susan Rogers, M.D., an internal medicine physician and president of PNHP, was quoted in the release saying that “You can’t slap a band-aid on a tumor and call it cured. Direct Contracting—and now ACO REACH—threatens the health of beneficiaries and the future of Traditional Medicare. As physicians committed to the health of our patients, we urge HHS to abandon this rebranding effort and focus the agency’s efforts towards strengthening and protecting Traditional Medicare.”
