The Accountable Care Organization Realizing Equity, Access and Community Health (ACO REACH) payment model will launch on Jan. 1, 2023, and hospices that collaborate with participating ACOs could realize some unique benefits.
The Center for Medicare & Medicaid Innovation announced the program in February to replace the Global and Professional Direct Contracting (GPDC) models. The agency said that ACO REACH reflects its redesigned strategy for payment system demonstrations, with advancing health equity as a key tenet.
“Accountable Care is the cornerstone of that strategy. Integration, team-based coordinated care through advanced primary care and ACOs is really the linchpin to driving better outcomes and bending the health care cost curve,” CMMI Director Elizabeth Fowler said at the National Association of ACOs (NAACOS) conference earlier this year. “As part of the strategy, we laid out five objectives. And we set a bold goal of having 100% of Medicare beneficiaries and the vast majority of Medicaid beneficiaries in accountable care relationships with providers who are responsible for cost of care and quality.”
While few hospices are likely to participate in ACO REACH directly, they can enter preferred provider relationships with Accountable Care Organizations. If effectively structured, these arrangements can bring hospices a number of advantages.
Flexible contracting options
ACOs have a great deal of flexibility when they contract with downstream providers, including hospices.
The two parties can negotiate mutually beneficial terms that are customized to the needs and characteristics of their patient population. This practice began with the direct contracting models and will continue in the new program.
Though the U.S. Centers for Medicare & Medicaid Services (CMS) does place some parameters around what organizations can do in these contracts, the agency generally considers these agreements to be between the provider and the ACO, according to Andrea Osborne, senior vice president of delegated programs for VillageMD.
The flexibility that providers have to develop customized payment contracts began in earnest with the direct contracting program, though some limited options existed in next generation ACO models.
“We follow all the Medicare rules, but the arrangement itself may look different. It could be a bundled payment,” Osborne told Hospice News. “It may be inclusive of things that aren’t always the responsibility of that provider but that really we believe provide overall better care for the patients when they’re coordinated under one payment model.”
Greater care coordination
These kinds of partnerships can foster improved care coordination across the continuum, Melody Danko-Holsomback, vice president of education at NAACOS, explained.
Hospices, for example, would have access to some data that those operators don’t have in most circumstances, such as details about the characteristics of a region’s patient population or their most prevalent health conditions, according to Danko-Holsomback.
These relationships can also promote more effective communication with patients’ primary care providers and offer a clearer picture of those individuals’ previous care experiences.
Additionally, hospices could gain the ability to network and collaborate with other affiliated providers.
“Another advantage is care coordination and having services they normally wouldn’t be able to afford or have access to, such as care management services and some pharmacy services. A lot of the ACOs now have pharmacists that are part of their care teams,” Danko-Holsomback told Hospice News. “You could have extra providers on call, potentially, to make some collaborations and make them aware of their services.”
Shared savings arrangements
These contracts can involve shared-savings arrangements in which providers can receive a portion of the dollar amount of any health care cost reductions.
Within these contracts, the ACO takes on the role of the payer for the downstream provider, and they have options in how they approach reimbursement. Payments could be based on a full-capitation model with a per-patient, per-month rate, or they can be fee-for-service.
Other possibilities include hybrid models in which the hospice or other post-acute provider will receive a portion of their reimbursement on a fee-for-service basis, as well as additional payments later on determined by performance on quality metrics.
“The billing still goes through Medicare, so it still has to qualify for Medicare to approve the bill,” Osborne said. “But once it gets to us, we can choose to have a different arrangement.”
Among the key quality metrics are reductions in hospitalizations, readmissions. and emergency department visits. Participants in the ACO REACH program will have access to three years worth of claims data to help guide those decisions.
Hospices generally have a strong track record on reducing utilization of higher-acuity care, which can make then attractive partners for ACOs.
Case in point, VillageMD found that its patients who were admitted to hospice returned to the hospital only 1% of the time, according to Osborne.
“To me, it was a really great statistic that tells me that patients are getting what they requested, which is to be at home,” Osborne told Hospice News. “So hospice was a place where we wanted to look at partnership.”
Enhanced care delivery
With the stakeholders’ ability to customize their payment contracts, they can offer services that typically would not be covered through the Medicare Hospice Benefit.
For example, a hospice’s contract with an ACO could allow for more frequent nurse visits or other services. VillageMD’s ACO, for example, allows for some types of additional concurrent care for patients who are enrolled in hospice.
“It allows you to bring you to potentially find new ways to deliver care that are restricted right now,” Osborne said. “So maybe you can’t provide an RN as often as you want. Yet, what would help the outcome? It allows you to offer alternatives to improve care and get reimbursed for it.”
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