agilon health Inc.
11/18/2024 | Press release | Distributed by Public on 11/18/2024 08:11
REACHing for a Full-Risk Future: Why ACO REACH and Medicare Innovation Matter
This week, Accountable Care Organizations (ACOs) participating in the ACO Realizing Equity Access and Community Health (REACH)- a pilot model run by the Center for Medicare and Medicaid Innovation (CMMI) - published their 2023 performance year results. This process occurs each year, wherein CMMI and participating ACOs complete their financial reconciliation and tally up the shared savings (and losses) to both Medicare and the ACOs.
agilon health, in partnership with physician groups across the country, operates eight REACH ACOs. Our recent press release outlines our performance in detail, but in summary, we helped CMMI save $37 million for the Medicare Trust Fund in 2023 (compared to benchmarks). Our ACOs also achieved quality scores of 95% or above, with four of our ACOs achieving 100%.
And we're not the only ones - ACOs earned shared savings payments amounting to $948.4 million.
How does the model work?
Well, in general terms, ACOs provide clinicians with data, resources and aligned incentives to enable a highly coordinated primary care experience for their patient population. ACOs typically employ sophisticated technology, coupled with clinical and care transformation strategies, that target high-risk, high-cost patients to ensure their care is optimal, helping reduce expensive health events like preventable hospital admissions. They also focus on protecting the health of lower-risk patients by ensuring they receive annual preventive care, and more targeted and intensive care if/when they experience a health event. If ACOs can reduce spending compared to the expected cost of care (aka the benchmark) for that year, they get to keep the savings. If the cost of care is higher than expected, they must pay Medicare back.
Medicare is guaranteed savings by taking a "discount" off the benchmark and keeping repayments from ACOs who exceeded their benchmark.
In our ACOs, we've placed specific emphasis on clinical programs that provide wrap-around services to patients with chronic conditions like diabetes or chronic kidney disease. We also ensure the patient's transition from a hospital stay back to home is followed closely by a member of the care team. We've also implemented a palliative care program that focuses on ensuring care delivered during a patient's final chapter aligns with their values and preferences. We published a study demonstrating the positive impact this clinical program has had on increasing days at home (vs. in hospital) and on reducing the cost of medically unnecessary care in the final six months of life.
Together, these strategies ensure patients get the care they want and need, at the right time and in the right setting. The ideal outcome is improved patient health, better quality of care, increased physician and patient satisfaction, and more efficient use of limited financial resources.
Sounds great right? We think so. And it's why we're advocating for a sustainable, long-term plan for ACO models like the one tested in the ACO REACH Model.
As of today, the ACO REACH Model is the only full-risk ACO program available in Medicare. Since it's a pilot model, it's temporary. In fact, the model is scheduled to sunset at the end of 2026 and there is currently no full-risk ACO model for participating ACOs to transition into.
You may ask, what is full-risk and why is that important? Full-risk means that an ACO is fully accountable (or at financial risk) for 100% of the health care costs for the Medicare beneficiaries receiving care from participant providers, along with the quality of care provided to them. As mentioned earlier, if ACOs save money and meet quality thresholds, they keep all of it (except for the aforementioned benchmark discount). If they spend more money than their benchmark, they are fully responsible for covering the additional costs above the benchmark, also known as "losses". Further - and this is key - they must find ways to achieve those savings without skimping on care. Luckily, primary care is the one specialty that has a significant return on investment; every dollar spent on primary care provides a return of $13.
This full-risk model incentivizes primary care providers to be highly engaged in the health care journey of their patients, making sure they have care that is coordinated across settings and specialists, that they don't experience a health crisis that could have been avoided, and that someone is paying attention to their overall experience throughout the entire health care system.
Despite these aligned incentives that are truly transforming the way health care is delivered, this care model is at risk (pun intended) of disappearing if no alternative is offered.
A coalition of like-minded health care providers are advocating strongly for a full-risk option in the permanent Medicare Shared Savings Program (MSSP) and we have endorsed a bipartisan bill in Congress titled the Value in Healthcare Act that would require the Centers for Medicare & Medicaid Services (CMS) to establish one. Additionally, we encourage CMMI to launch a new test model focusing on the impact of advanced risk primary care and additional features to address other areas of high cost in the Medicare program.
We are optimistic about the future of Medicare and remain committed to transforming health care for seniors across the country by investing in value-based care models like ACO REACH.
The statements contained in this document are solely those of the authors and do not necessarily reflect the views or policies of CMS. The authors assume responsibility for the accuracy and completeness of the information contained in this document.