ACOs, Start Your Engines; CMS Gives 120+ ACO REACH Applicants the Green Light
Post Written by Juliette Price, Chief Solutions Officer
After a rushed launch and hurried application timeline, CMS announces fewer than half of ACO REACH applicants have been invited to participate in the latest value-based model for Medicare beneficiaries.
Just before the long holiday weekend, CMS announced it received over 270 applications from prospective ACO REACH participants and provisionally approved 128 – resulting in an approval rate of just 47%. Given the 7-week turnaround for ACOs to submit applications and the 9-week turnaround for application review by CMS, this figure comes as a bit of a surprise. In fact, this 47% is a lower acceptance rate compared to other models put forth by the Innovation Center (CMMI).
A total of 128 ACOs are “provisionally” approved at this point - the provisional distinction necessary because ACOs may ultimately choose not to participate in the program. Final participation paperwork is due by the end of 2022, only then will the ACOs become ACO REACH program participants.
Additionally, 99 entities currently participating in the Global and Professional Direct Contracting model (known as Direct Contracting) are being given the opportunity to merge into ACO REACH by January 2023, as the Direct Contracting model is officially shutting down after this calendar year. If all 99 entities make the leap, that would bring the new model participant total to 227, quite a substantial figure for a new CMMI program.
What do we know about how the selection process played out? A lot, but not everything.
CMS maintains that they selected the provisionally approved ACOs by balancing a few factors – CMS’ own goal of having all Medicare beneficiaries in accountable care relationships as soon as possible, the need for enough beneficiaries and providers to participate in the ACO REACH model in order to evaluate its features, the volume of applications submitted, and the bandwidth/capacity of CMS to support these new model participants.
The screening and review process had four components:
1. Application completeness review
2. Assessment of application content
3. Assessment of program integrity risks posed by the applicant
4. Final determination
Application Completeness: First, CMS reviewed each of the submitted proposals for completion, meaning that no questions were left unanswered, no tables left blank, all uploads completed, and all T’s crossed and I’s dotted. CMS divulged that 271 ACO applications passed this first, most basic review.
Application Content: Next, each of the 271 applications that passed the first review process were screened by independent technical evaluation panels for quality. These independent reviewers have specific experience in ACO-based work, helping to decode applicants' answers to the many technical questions in the application. Most questions on the application had character limits of 3,000 or fewer, meaning that responses had to be kept brief, even where considerable technical explanation was necessary. Each application was then scored according to the evaluation criteria put forth in the call for applicants:
15 points for Organizational Readiness
35 points for Financial Plan and Risk-Sharing Experience
35 points for Clinical Care Model
15 points for Data and Health Information Technology Capability
From there, the technical evaluation panels had to align on a consensus recommendation for each application – to accept or not accept.
Program Integrity Assessment: Each application deemed complete was then subjected to the program integrity assessment – a process first introduced for the ACO REACH program and thus absent in the previous model, Direct Contracting (refresh yourself on this transition with my last blog post on the topic). To assess program integrity, CMS used information about the applicant, parent companies and/or interests with 5% or more ownership in the new ACO, members of the proposed Leadership Team, and members of the proposed Governing Body. Specifically, as CMS puts it, they screened for “concerns including, but not limited to, beneficiary harm, improper or fraudulent billing, improper risk adjustment or coding behavior, and financial insolvency”. This was also the specific area of review that CMS flagged as a solution in responding to criticism from the stakeholder community about private equity interest in some of the Direct Contracting entities.
Final Determination: As some may recall, CMS had a cleverly-phrased portion of the ACO REACH request for applications that gave them the right to limit the total number of ACOs accepted into the program based on the volume of applications received. This tiny but significant sentence has been talked about in many conference hallways since it was released, but CMS confirmed that after conducting steps 1-3 laid out above (completeness, content, and program integrity), they chose not to further limit the number of accepted applications.
What does this mean? Somewhere along the way (and there are only two real stops along the way) 271 applications got cut down to 128; either by failing to meet the scoring criteria related to program design or to program integrity. At which point were applications more likely to fall out? So far, CMS is tight-lipped about that, perhaps someday we’ll see the data on how the chips fell.
Who is provisionally-approved as an ACO REACH participant?
While we don’t yet know actual names/entities of the provisionally approved ACOs, CMS did release a breakdown of applicants by ACO type and model option.
Remember, ACO REACH provided three ACO types that applicants could apply under: Standard ACO, meaning the ACO/providers within the ACO had substantial experience serving Medicare beneficiaries and may have participated in prior shared savings models; New Entrant ACO, meaning the ACO/providers within the ACO did not have experience serving the Medicare population; and High Needs Population ACO, specifically organized around complex patient populations, such as duals.
By type, here’s how the approval percentages broke out:
53% of Standard ACO applicants were provisionally approved
37% of New Entrant ACO applicants were provisionally approved
38% of High Needs ACO applicants were provisionally approved
Also recall that applicants needed to select between the Professional risk-sharing option, a lower-level risk option with 50% shared savings/shared losses; or Global risk-sharing, the full-risk option with 100% shared savings/shared losses.
41% of Professional risk-sharing applicants were provisionally-approved
50% of Global risk-sharing applicants were provisionally-approved
What tea leaves can we read in all of this? CMS is delivering on some of the warnings it issued when they released the model. Specifically, they want to see more aggressive risk-sharing taken on by accountable care organizations that have experience serving these beneficiaries. And that’s exactly what the results bore out.
What’s Next?
For provisionally approved applicants, the grind continues. CMS has alerted all applicants of their status and has already begun hosting office hours and support calls for these entities. The timeline is still warp-speed, so the work has truly just begun for provisionally accepted ACOs.
Some of the tough decision making that lies ahead for these entities includes sifting through the just-released methodology papers for the REACH program, selecting providers to participate in the first year of the model (especially if the applicant ACO is already participating in other CMS models, such as MSSP), and arranging for the deployment of key care model strategies (such as social determinants of health (SDOH) interventions, equity plan implementation, and new data reporting requirements).
For applicants that did not make the cut, CMS is staying quiet about future opportunities to join the model. All CMMI is saying so far is that “CMS is not planning additional application rounds for the ACO REACH Model”. Never say never, but perhaps this program is in fact closed once and for all.
Are you an ACO REACH provisionally-approved entity searching for support in your next set of decision making? Let Helgerson Solutions Group help. We’re proud to have helped our clients successfully apply for this program and we can help you on your journey to value. Drop us a line or send us a note and we’d be happy to connect.
About the Author: Juliette Price is the Chief Solutions Officer at Helgerson Solutions Group. Follow her on Twitter and connect with her on LinkedIn.
