In its “A Year in Review June 2021-May 2022,” CMS cites the introduction of the Accountable Care Organization (ACO) Realizing Equity, Access, and Community Health (REACH) model as a key accomplishment in achieving its strategic initiatives. In alignment with the first pillar of its strategic plan (advancing health equity),[1] CMS explains that the “ACO REACH model will test an innovative payment approach to better support care delivery and coordination for patients in underserved communities.”[2]
A perspective published in the New England Journal of Medicine sees the ACO[3] REACH model as a shift from the “regressive” value-based payment models. Those previous models, the report holds, have not only “failed to meaningfully reduce health care expenditures or improve quality of care,” but have also “hampered the pursuit of health equity” towards a “progressive” model that “could help advance health equity.”[4]
The authors contend that the value-based payment model, “a defining feature of the U.S. health care reform during the past decade,” unintentionally perpetuated structural racism partly because equity was not specifically prioritized in the design and implementation the program. Furthermore, “in the absence of explicit incentives to invest in equity, value-based payment models can … widen disparities.”
The ACO REACH model differs from traditional value-based payment models because it explicitly identifies equity, not just value, as a central goal. The authors highlight three main ways the model does this:
- The model includes “health equity benchmark adjustments” aimed at supporting ACOs caring for socioeconomically disadvantaged patients. CMS “acknowledges that providers may need to spend more – not less – to care for members of marginalized communities” and will increase spending benchmarks for each ACO member in the top decile of disadvantaged.
- ACO REACH will require ACOs to “develop and implement a health equity plan” that identifies disparities in their patient populations, establishes an equity strategy, and adopts actions to reduce disparities.
- CMS will require ACOs to “collect and submit data on patient-reported demographics and social determinants of health.”
While the authors acknowledge that it “remains to be seen whether the health equity plan requirement will motivate real action,” the underlying theory is promising. They conclude one key to successful implementation of this provision is proper oversight by CMS.
Over the years, the Center for Medicare Advocacy has highlighted some concerns regarding beneficiaries’ access to some of the extra benefits that ACOs can provide, such as waiver of the three-day hospital inpatient requirement for skilled nursing facility care. Further, the Center has had significant concerns about the REACH ACO predecessor program, the Direct Contracting demonstration (particularly the so-called Geographic model that has been suspended). While the effectiveness of ACO REACH remains to be seen, the Center agrees that maintaining equity should be a central policy goal to combat unintended disparities that otherwise fortify systemic racism and socioeconomic bias.
July 21, 2022 – C. St. John
[1] The other five pillars are: Expand access, engage partners, drive innovation, protect programs, and foster excellence.
[2] CMS. A Year in Review June 2021-May 2022. (Date n.a.). Available at: https://www.cms.gov/files/document/year-review-june-2021-may-2022.pdf
[3] According to CMS, Accountable Care Organizations (ACOs) are providers that voluntarily give coordinated high-quality care. The goal of coordinated care is to ensure that patients get the right care at the right time, while avoiding duplication of services. ACOs are incentivized to reduce spending below a benchmark.
[4] Gondi, S., Joynt Maddox, K., & Wadhera, R. K. “REACHING” for Equity – Moving from Regressive toward Progressive Value-Based Payment. New England Journal of Medicine. (July 9, 2022). Available at: https://www.nejm.org/doi/full/10.1056/NEJMp2204749