The Facilities for Medicare and Medicaid Providers (CMS) lately introduced a redesign of the International and Skilled Direct Contracting Mannequin (the GPDC Mannequin) and renamed the GPDC Mannequin the ACO REACH Mannequin. (“REACH” stands for Realizing Fairness, Entry, and Group Well being.) Functions for the brand new ACO REACH Mannequin are accepted starting March 7, 2022 and shut on April 22, 2022, for participation to start on January 1, 2023 and run for 4 (4) efficiency years. Accepted purposes have an possibility of collaborating in a 4-month implementation interval (August 1, 2022 by December 31, 2022) prematurely of the primary efficiency 12 months.
The redesign comes after rumors of the potential cancellation of the politically polarizing GDPC Mannequin. CMS concurrently introduced the everlasting cancellation of the Geographic Direct Contracting (GDC) Mannequin, which had been paused since March of 2021.
Abstract of the GPDC Mannequin
Beneath the GPDC Mannequin, collaborating suppliers are capable of acquire sure enhanced programmatic advantages below Medicare whereas taking up larger threat by partial or full capitation. Taking part suppliers obtain lowered Medicare funds and conform to obtain some compensation from the DCE that has the participation contract with CMS. There have been two participant choices:
- Skilled Choice with decrease risk-sharing – 50% of financial savings/losses, with Main Care Capitation with a risk-adjusted month-to-month per-member per-month cost protecting major care providers.
- International Choice with larger threat sharing – 100% of financial savings/losses, with both risk-adjusted Main Care Capitation (much like the Skilled possibility), or Whole Care Capitation with a risk-adjusted month-to-month cost for all coated providers (major care and specialty providers), in every case supplied to aligned beneficiaries by collaborating suppliers.
Each the Skilled and International Choices meet the factors to be Superior Various Cost Fashions (APMs) in efficiency years 2021 and 2022, and are each thought-about Benefit-based Incentive Cost Programs (MIPS) APMs.
Why are the modifications being made?
In asserting the redesign, CMS indicated that the revisions replicate the priorities of the Biden Administration and tackle legislative criticisms of elements of the GPDC Mannequin. Such priorities embrace: (i) a deal with well being fairness and bringing the advantages of value-based care to underserved communities; (ii) the promotion of supplier management, possession, and governance to assist guarantee extra supplier managed governance; and (iii) extra vetting and monitoring of knowledge, together with on possession, management, operations, and governance to assist shield beneficiaries. The GPDC Mannequin confronted rising criticism from sure members of Congress. The criticisms alleged, amongst different issues, that the GPDC Mannequin was resulting in the privatization of Medicare, which threatened entry to high quality well being care, as investor-owned entities had been reportedly taking possession and management positions in Direct Contracting Enterprises (DCEs), and that DCEs had used up-coding to recreation beneficiary threat scores.
What has modified within the redesign?
ACO REACH Mannequin makes materials modifications to the GPDC Mannequin. Notable modifications embrace:
- Advance Well being Fairness. The ACO REACH Mannequin addresses well being fairness and focuses on bringing value-based care to Medicare beneficiaries in underserved communities. The ACO REACH Mannequin:
- Requires REACH ACOs to develop a Well being Fairness Plan that identifies well being disparities and actions to provoke the recognized disparities.
- Introduces a well being fairness benchmark adjustment to raised help care supply and coordination of look after sufferers in underserved communities.
- Requires REACH ACOs to gather beneficiary reported demographics and social wants knowledge.
- Provides a profit enhancement by growing the vary of providers which may be ordered by nurse practitioners to enhance entry to care.
- Governance. Beneath the ACO REACH Mannequin collaborating suppliers might be required to have a minimum of 75% of the governing board voting rights (up from 25% below the GPDC Mannequin, and much like necessities of ACOs below the Medicare Shared Financial savings Program). As well as, the REACH ACO governing boards should have a beneficiary consultant and a shopper advocate who’s totally different from the beneficiary consultant, each of whom have voting rights (identical particular person and voting rights non-obligatory below the GDPC Mannequin).
- Extra Vetting, Monitoring and Transparency. CMS would require extra info regarding a REACH ACO applicant’s possession, management choices, and governing board. The elevated monitoring will embrace:
- An annual evaluation of whether or not beneficiaries are being shifted into or out of Medicare Benefit.
- An examination of threat scores to establish potential inappropriate coding and misuse of beneficiary knowledge.
- Monitoring of potential anti-competitive habits.
- Use of information evaluation to observe providers over time and assess beneficiary entry to care.
- Reviewing advertising and marketing supplies regularly for accuracy and to guard beneficiaries and their freedom of selection.
- Reviewing web sites commonly to make sure they’re updated and comprise required info.
- Annual auditing of downstream preparations.
- Investigation of beneficiary and supplier complaints.
There additionally might be mannequin modifications decreasing the withholds for high quality, which inspires supplier participation in comparison with different Innovation Heart fashions (e.g., Direct Contracting); decreasing the low cost price earlier than 100% threat sharing happens within the International possibility, which inspires supplier participation within the International possibility; and modifying the chance classes to mitigate inappropriate threat rating gaming. The benchmark for ACO’s serving the next proportion of underserved beneficiaries may also be elevated to assist guarantee all Medicare beneficiaries are served.
The abstract above describes notable modifications within the Mannequin redesign. A CMS abstract chart of the coverage revisions within the mannequin redesign is out there right here.
What should present individuals within the GPDC Mannequin do?
Present GPDC Mannequin individuals should preserve a powerful compliance file in 2022 and agree to satisfy the entire ACO REACH Mannequin necessities starting January 1, 2023 as a way to proceed as individuals within the ACO REACH Mannequin. Primarily based on present Innovation Heart steering and directions, GPDC Mannequin individuals will signal new participation agreements, however should not required to re-apply, to take part within the ACO Attain Mannequin.
As CMS and its Innovation Heart proceed to check and outline value-based packages, they’re addressing criticisms made in regards to the GPDC Mannequin and are centered on decreasing well being care inequities in underserved communities within the redesign and renaming of the GPDC Mannequin. The redesign offers a chance for people who anticipated to use for participation in 2021 earlier than the GDPC Mannequin was abruptly closed to new candidates, and leaves current GDPC Mannequin individuals to resolve whether or not REACH is the proper path for them and their suppliers.