The Centers for Medicare & Medicaid Services (CMS) recently published new changes to further advance health equity and increase participation under the ACO REACH model.
National Association of ACOs President and CEO Clif Gaus said the changes will “satisfy many concerns and stabilize future participation.”
Among numerous tweaks, CMS reduced the beneficiary alignment minimum for new entrant accountable care organizations from 5,000 to 4,000. It also reduced minimums for high needs populations. A 10% buffer will be applied across all ACO types, allowing an ACO to temporarily drop below the new beneficiary minimum, but an ACO cannot remain below the threshold for more than one of the model’s remaining years, according to the newly released standards.
For high needs population ACOs, the agency is expanding criteria to incorporate more beneficiaries in a bid to identify more eligible members with complex needs. Criteria include 90 Medicare-covered days of home health service utilization or 45 Medicare-covered days in a skilled nursing facility, and the minimum has decreased from 1,200 to 1,000 for 2025.
Risk methodology is now aligned with the Medicare Advantage program, as risk scores will be “blended using 67% of the risk scores under the current 2020 risk adjustment model and 33% of the risk scores under the revised 2024 risk adjustment model,” CMS posted on its website.
Retrospective Trend Adjustment (RTA) benchmarks were addressed as part of the changes, with CMS now applying symmetric risk corridors, meaning REACH ACOs are responsible for 100% of an RTA up to 4%. Their responsibility decreases as the RTA increases beyond 4%.
CMS is also adding two variables, low-income subsidy status and state-based area deprivation index, to its composite score when identifying underserved beneficiaries. The new formula is designed to advance health equity efforts. Health Equity Benchmark Adjustments will be adjusted to better allocate funds to ACOs based on their health equity score. An extra $30 per person per month will be given to ACOs with the highest-need beneficiaries.
“Additionally, we encourage CMS to explore adding features of REACH into a permanent track within the Medicare Shared Savings Program,” Gaus said in a news release. “Using MSSP as a chassis for innovation while infusing lessons from Innovation Center models into a permanent program is another path for stabilizing and growing participation in ACOs.”
Susan Dentzer, president and CEO of America's Physician Groups (APG), also released a statement in support of the newest changes.
“APG applauds the Center for Medicare and Medicaid Innovation (CMMI) for making important changes to the ACO REACH Model," she said. "APG advocated for many of these changes based on the recommendations of our ACO REACH coalition members, and we appreciate the fact that the Innovation Center was so responsive to our members’ perspectives and input. We look forward to working with CMS on additional refinements to the ACO REACH Model that will further improve the health care of Medicare patients and the model’s financial and operational sustainability.”
Currently, there are 132 participants under ACO REACH, a value-based care model that began in January and replaced the Direct Contracting Model. The new model pushes providers to form accountable care organizations, or ACOs, for fee-for-service Medicare enrollees, and allows for providers to take on more financial risk. Participants are required to implement a health equity plan identifying disparities in care.