ACO REACH Model: The Innovation Center's First Step Towards Equitable Healthcare

In October 2021, the Centers for Medicare & Medicaid Services published the Innovation Center's vision for the next ten years. This vision contains five strategic objectives, one of which is advancing health equity. The aim is to embed health equity in every aspect of the Innovation Center models and increase focus on underserved populations.

Since publishing the white paper, the Innovation Center announced the redesign and renaming of the Global and Professional Direct Contracting Model (GPDC) to the Accountable Care Organization Realizing Equity, Access, and Community Health, or ACO REACH Model. While there are several differences between GPDC and ACO REACH, the most significant shift is incorporating health equity. As a result, we now have a first look into how the Innovation Center will be approaching implementing a health equity lens into these models and moving the needle towards more equitable care for all.

It's essential to understand precisely how CMS defines "equity" and "underserved communities" before diving into the health equity policies included in ACO REACH.

• Equity is the "the consistent and systematic fair, just, and impartial treatment of all individuals, including individuals who belong to underserved communities that have been denied such treatment, such as Black, Latino, and Indigenous and Native American individuals, Asian Americans and Pacific Islanders and other individuals of color; members of religious minorities; lesbian, gay, bisexual, transgender, and queer (LGBTQ+) individuals; individuals with disabilities; individuals who live in rural areas; and individuals otherwise adversely affected by persistent poverty or inequality." (As defined in the Executive Order on Advancing Racial Equity and Support for Underserved Communities Through the Federal Government (Executive Order 13985)).
• Underserved communities refer to populations sharing a particular characteristic and geography; communities that have been systematically denied a full opportunity to participate in aspects of economic, social, and civic life, as exemplified by the list in the definition of "equity."

What distinguishes GPDC from ACO REACH? 

The ACO REACH Model introduces five new policies to promote health equity starting in performance year 2023. The changes are summarized below, but if you're interested in learning the ins and outs of these policies, refer to the ACO REACH Request for Applications (RFA).

Participating ACOs will develop a health equity plan

All ACOs participating in ACO REACH will be required to develop a health equity plan based on the CMS Disparities Impact Statement. The CMS will provide its version for ACOs to complete before each performance year. This plan will identify the underserved communities within the ACOs aligned beneficiary population and describe the initiatives they will implement to measure and reduce health disparities throughout the performance period.

CMS will adjust the benchmark to incorporate health equity

The benchmark will now have a health equity adjustment that will increase the benchmark for ACOs serving higher proportions of underserved beneficiaries. CMS cites that the research indicates that underserved communities have lower health care spending overall relative to their health care needs. Since past benchmarks have been based on historical expenditures, it furthered incentivized underspending in these communities. Increasing the benchmark removes the disincentive for ACOs to serve historically underserved communities by allowing them to provide the necessary services to provide quality coordinated care.

Participating ACOs will collect beneficiary-reported demographic and social determinants of health data

ACOs in ACO REACH will be required to collect and report certain beneficiary-reported demographic data and social determinants of health data on their aligned beneficiaries (such as race, ethnicity, language, gender identity, and sexual orientation). This data collection will allow CMS to monitor the model, ensure that harm does not come to REACH beneficiaries, and improve the quality of care. 

For performance year 2023, there will be a bonus to ACOs that can meet this requirement but no downward adjustment for those that do not. In performance year 2024 and subsequent performance periods, CMS may impose a downward adjustment for ACOs that cannot meet this requirement. However, since this data will be beneficiary-reported and beneficiaries may opt-out of information sharing, this will not result in a penalty for the ACO and will receive credit for reporting the data. 

CMS will implement services benefit enhancement for nurse practitioners

Another big change to ACO REACH is the new Benefit Enhancement to ACOs to reduce barriers to care access, specifically for beneficiaries in geographies with limited access to physicians. This enhancement will allow nurse practitioners to assume certain responsibilities or provide specific care without physician supervision that they would otherwise not be able to do under current Medicare law. For example, CMS intends to issue waivers that allow nurse practitioners to order and supervise cardiac rehabilitation for a REACH beneficiary or refer a REACH beneficiary to medical nutrition therapy. 

Participating ACOs will drive quality outcomes for all aligned beneficiaries 

Lastly, the application for ACO REACH is designed to encourage participation by applicants with direct patient care experience and/or experience providing high-quality care to underserved communities. This emphasis is due to research suggesting that clinicians' access to ACOs has not been equally shared across patients' different backgrounds; specifically, ACOs tend to be in non-rural communities with higher socioeconomic status. While ACO applicants will not be solely selected based on their ability to meet the above criteria, CMS hopes that it will ensure selected ACOs are well-positioned to improve quality outcomes for all aligned beneficiaries, especially those in underserved communities (while achieving savings). 

Health equity focus will persist

Health equity is not just a hot topic that will be gone by next year. Health equity is a crucial component of CMS's 10-year strategy refresh. The National Committee for Quality Assurance (NCQA) now has Health Equity Accreditation programs. Many other organizations are taking on health equity as well, which further confirms that this will become the norm.

However, it can be challenging for both health care providers and plans to know where to begin with implementing your health equity strategy. What population should be focused on? What evidence-based approach can be implemented to improve quality outcomes? What should those quality outcomes be? How can data be collected? Our experts here at RTI Health Advance can help you answer these questions, while leveraging our proprietary tool, RTI RARITY, to identify areas where highest inequities exist and develop evidence-based strategies to improve population health and equity.