In 2022, the Centers for Medicare & Medicaid Services (CMS) published a vision to increase access to accountable care. One of the main tenants of the vision is to help organizations new to value-based care and shared savings increase participation in accountable care organizations (ACOs), thereby expanding the reach of ACOs in underserved communities and scaling successful features of model tests into the permanent Shared Savings Program. On January 1, 2023, CMS launched ACO Realizing Equity, Access, and Community Health (REACH) to focus on these goals.
On Thursday, April 13, the Health Care Council of Chicago (HC3), in partnership with HC3 member Ziegler, hosted the discussion Advancing Health Equity Through the Expansion of ACOs. This in-person event at Ziegler, Chicago, featured experts and stakeholders exploring the value and opportunities for collaboration and patient care delivery improvement through ACO Reach.
Ken Benton, Senior Vice President, Ziegler
Henish A. Bhansali, MD, FACP, Dipl. ABOM, Senior Vice President and Medical Director, Medicare Advantage, Duly Health and Care
Melanie Tan, VP of Strategy and Growth, Medical Home Network
Fan Zhang, MD, MBA, Physician Consultant & Population Health Management Expert, Terry Group
Host's Remarks Jenny Poth, VP of Proprietary Investments, Ziegler Questions of why we don’t have enough in health care – too few providers? too few dollars? – take their toll on Chicago’s health care ecosystem. However, HC3’s co-founder David Smith has consistently encouraged HC3s members and partners to approach these questions with an “abundance " mindset instead, shifting the narrative to exploring how there are plenty of resources. However, we may need to rethink how we utilize and distribute those resources to advance opportunities for better health and health equity.
Moderator’s Remarks Ken Benton, Senior Vice President, Ziegler As many of us looked for ways to expand opportunities for value-based care, originally through just the managed Medicare population, Ziegler has had a real interest over the past several years to move away from direct contracting. Amid a deal with a group called Care Connect MD in 2021, Ziegler had a front-row seat to watching the transition of policy and practice become reality with the advancement and addition of equity in CMS’ ACO REACH program.
Ken Benton (KB): Melanie and Henish, can you please share a bit about your organizations and how they are addressing health equity in terms of this new model of care - ACO REACH? NOTE: Three areas of “health equity” outlined for this program include: having a health equity plan, data reports, and benchmarks.
Melanie Tan (MT): Medical Home Network (MHN) is a Chicago-based nonprofit that was founded in 2009 with the mission to transform care and improve the health of underserved communities. The model is anchored on what we refer to as a “practice-based care management model,” meaning we are helping expand the workforce capacity and carefully computing abilities in partnership with federally qualified health centers (FQHCs). We specifically support FQHCs’ technology, analytics, and risk stratification models and help them successfully care for their patients with value-based care principles. MHN’s portfolio is primarily focused on Medicaid, Medicare, and uninsured patients. As of today, MHN supports 52 organizations in eight states, entitlement reform, and Medicare management.
MHN’s model is based on developing the workforce capacity within primary care teams by providing the tools and processes for FQHCs to develop care management processes. Specifically, MHN supports the hiring and development of unlicensed care coordinators and Community Health Workers (CHWs) that can play a critical role in expanding the capacity and reach of the primary care team and building trust, especially with patients in underserved communities. Which such a diverse set of populations, hiring staff from within the communities ensures culturally congruent care delivery that aligns with the needs of the patients they are serving. Each of our patients take an annual health risk assessment that measures all different components of health, including medical, behavioral, and social screenings, and then systematically drives the follow-up and addresses referrals, appointments, social risk, food insecurity, transportation needs, etc. so we can provide the extended support care for the patients. MHN has found that repeating the health risk assessment year over year helps reduce the prevalence of social risk factors because any single risk can increase the patient's utilization by up to 60 percent.
From the ACO point of view, MHN provides programming and training – including cultural competency, implicit bias training, and health literacy – to ensure that this entry-level or uninitiated workforce can expand their capacity to understand the best tools to support patients. This model of care is how we can enact an extension of the primary care continuum to build a strong relationship with the primary care medical home and cultivating a coordinated system of integrated care for the patients.
Henish Bhansali: Duly Health & Care (Duly), formerly known as DuPage Medical Group, is a for-profit, private equity-backed organization. Duly has approximately 1,000 doctors and 6,000 employees in four Midwest states (Iowa, Illinois, Indiana, Missouri), serving about 2.5 million patients annually. Approximately 1 million of those patients consider Duly their medical home. As a multi-specialty group, about a quarter of our physicians are primary care physicians, and the other three-quarters are specialists, hospitalists and so on.
Unlike Medical Home Network, Duly employs all our doctors and most of the services provided for Duly patients happen within our four walls. We don't own hospitals or skilled nursing facilities (SNFs); however, we do have hospitalists, ambulatory surgical centers, and other ancillary services such as radiology.
Before Duly, I worked at Oak Street Health, a for-profit venture capital backed organization. And so, as we consider health equity and delivering it from a for-profit perspective, I think it may be helpful to compare Oak Street’s and Duly’s models.
So, why did Oak Street start in some of the lowest-income neighborhoods in the entire country? It is because that's where the highest opportunity was for impact. The great thing about taking financial risk is also having the capital to do what is necessary as a healthcare provider. There are two basic things to accomplish: 1) grow – so, have more members; 2) reduce your total cost of care, and in the case of Oak Street, going to health care deserts was the true opportunity to impact those total costs of care for some of the sickest and lowest income patients in the country. The clinic that I practiced at was in Chicago’s East Garfield Park neighborhood, not too far from here (downtown). Dr. David Ansel from Rush wrote a book called The Death Gap, where he specifically talks about the Garfield Park neighborhood, referencing health disparities within a five-mile radius. This pursuit of taking financial risk on vulnerable populations is not easy because you need to build the capabilities to impact social and behavioral factors. Compared to Duly, Oak Street has a very high Medicare-Medicaid dual-eligible population. And if we look at the biggest drivers helping reduce unnecessary costs and utilization, it really comes down to social and behavioral determinants of health. And so, many of the things Melanie mentioned as part of the strategy for MHN are the same screening tools that entities need to employ to figure out the prevalence of factors impacting the population; then create a system to address them. Some are ubiquitous, and others are not. So, for example, at Oak Street, food and housing insecurity are much more prevalent because it's a dual Medicare-Medicaid population vs. Duly, where it is mostly a non-dual population. However, other conditions, such as substance dependence and depression, are present and prevalent in both groups.
There are four different areas to consider: 1) prevalence of a disorder; 2) what your organization can impact or influence; 3) will it reduce the cost of care?; and 4) can you create a system to execute the plan. Health equity comes into play when populations are treated wholistically and sustainably in healthcare through financial risk.
KB: Fan, please share some similar background information, however, given that you work with multiple organizations, how are you considering the identification and tracking of key metrics, in particular around social determinants?
Fan Zhang (FZ): I am very passionate about this work, especially as we consider the “total cost of care.” I am a physician by background and work with the Terry Group, an actuarial firm comprising a collaborative group of individuals – actuaries, data scientists, clinicians, and operators – analyzing data and opportunities, especially regarding the total cost of care.
Defining “value” is complex regarding the total cost of care, so understanding what value means in different settings is the medical expense or the quality outcome? Additionally, contracts or programs can vary as well in what defines the overall cost of care. Terry Group works with clients to define these metrics, refine practice measurements for clinicians to understand those costs, and standardize the measurement of their work for various clinical settings and a variety of populations for a truly integrated financial and clinical integration plan. Our team helps with the assessment of various models, and what makes it more complex is the various contracted payors. It's not one-size-fits-all. Terry Group specializes in helping organizations understand how physicians' models work with their contracted plans and the difference between external and internal metrics. Another challenge that Terry Group is addressing is how to determine and assess the quality of the data an organization is collecting and how to translate that into a scorecard to be able to connect the dots around overall performance.
KB: Let’s compare ACO REACH versus some of the other CMS (Centers for Medicare and Medicaid Services) models, and what are some of the insights you can share?
MT: CMS had eighty value-based care (VBC) programs four years ago. Over the past few years, the number of programs has been dramatically reduced. The Medicare Shared Savings Program (MSSP) is a flexible program. Comparably, ACO REACH is much riskier with downside risk possibilities. Overall, there are always a lot of questions about financial performance and capital to implement VBC models properly, however, there are many operational needs like clinicians and back-room staff that are just as necessary. And ACO REACH has new health equity metrics that other CMS VBC models need to share.
KB: How does Medicare Advantage (MA) compare to ACO Reach?
HB: Duly currently has about 44,000 members in ACO REACH and 42,000 in MA. The REACH population was previously in MSSP, but we had the potential of a higher upside in REACH. As mentioned, Duly does not have SNFs or hospitals, so we are not incentivized to send individuals to inpatient facilities, which lowers our total cost of care and aligns with better patient outcomes. There are more financial incentives in ACO REACH versus MSSP – the ability to take a higher upside and timing of payments. There is a risk adjustment cap for ACO REACH but not for MA. In MA, you normally work with a payor. In ACO REACH, you work with CMS. There is no live data transfer with CMS, and you are reliant strictly on claims. However, with a payer, you can get live data on admissions and act on that to affect the total cost of care. Generally, ACO REACH is less flexible than MA, but in MA, you are often working with several payors, each with their individual contracts and nuances.
KB: How are each of you looking at ACO Reach through a Medicaid lens?
MT: The biggest difference between Medicaid-focused and Medicare-focused agencies in ACO REACH is that organizations knowledgeable in Medicaid already understand complex referral networks and how to navigate them. To impact the total cost of care, you must build a significant network of providers across specialties. I am excited about ACO REACH's new health equity metrics because these incentives are built to drive real health equity outcomes. We need to ensure that all ACO models have standards across data, metrics, etc., and all of that needs to come from CMS.
MT: Average length of care in Medicaid is about 11 months, so there needs to be a payoff, so to speak. Current redetermination challenges further exhibit why Medicaid is more difficult to work in than Medicare.
Audience Question: How do you think about risk adjustment? MT: It varies based on the state because of the various rules and factors at play with the different models of each state’s overall plans. When MHN goes into a new state market, we do a lot of research to understand the VBC rules, which is a huge indicator of how well FQHCs will perform on Medicare. States with Managed Care Organizations (MCOs) slightly lead the charge in being ready for more than the state’s fee-for-service models.
KB: Melanie, can you remind us more about what states/markets you’re operating these programs in and how robust the programs are? We work in Illinois with one MCO, supporting about 175,000 Medicaid members at full risk. We are in eight states with ACO REACH, and about half take the global risk. So broadly, we work across the country, from rural Oklahoma to New York City. Overall, the health equity methodology still needs to be revised around the edges in practice. However, in premise, the metrics are great.
Audience Question: Can anyone share more about patient outcomes in ACO Reach compared to other programs?
FZ: Terry Group has not yet advised any ACO REACH participants, but to our knowledge of these types of programs, quality metrics are very different [in ACO REACH] from MSSP and MA. They have higher standards of requirements.
HB: Regarding the MA component, CMS has done a review of a control Medicare fee-for-service vs. an MA population that shows improved outcomes, including decreased admissions (both planned and unplanned) and readmissions; decreased total spend in Part B with an increased spend in primary care; decreased need for more escalated care and better patient-centered outcomes, more people out of the hospital, and more people with better control of disease process. So, if you can and want to take risks, you need both the financial and operational components in place. It will be very worth it and, overall, better for everyone--patients, the country, and so on—to sum up, better outcomes in full-risk MA versus not.
Audience Question: What role do you see in SNFs, LTACs, and other Medicare beneficiaries with ACO REACH?
MT: Overall SNFs, home health, hospice, and post-acute care providers, are willing to be partners, in some cases better than hospitals. They are willing to make different arrangements and take accountability metrics, quality, and length of stay and are willing to work in various ways. It is worth mentioning that there are also more waiver programs in ACO REACH than in Medicaid savings programs.
Audience Question: How do you address substance use disorder attribution? Additional Audience Question: Are the shared savings making it to the ancillary providers (e.g. the SNFs)
FZ: It is complex with the upstream to CMS and downstream to ancillary providers – however, I don’t think we are currently aware of any real solutions to ensure we incentivize and coordinate with all the supportive players yet.
HB: Many factors contribute to SNF discharge compared to a home with home health, including hospital relationships and incentives. Disruptors in the industry include hospital at home, SNF at home, and aggressive home-health that will likely decrease the utilization of SNFs.
MT: ACO REACH is a great model with payment flexibilities to build chassis of care outside the traditional home. It has more payment flexibility than MSSP, which was built on a fee-for-service (FFS) chassis, and ACO REACH also has 100 percent global risk, so we must work hard to succeed.
FZ: ACO REACH is the first time CMS has prioritized and actionized health equity as part of the equation. It is exciting to see this new direction, and I would love to see private payors catch up and for us to find a unifying model.
HB: ACO REACH is more aligned with value-based care than MSSP, but MA has many more levers to deliver the type of care you think is appropriate for patients. And when the financial risk is in the hands of care providers and aligns with better outcomes, it is usually better utilized. There aren't as many levers to manage patients in REACH since they can go wherever for care and incur costs. So to summarize, ACO REACH over MSSP, MA over ACO REACH, and HMO MA products over PPO MA products.