Today we have the second in a series of conversations about ACO REACH with Melissa Pollock, Director of ACO Compliance and Regulatory Affairs at CHESS Health Solutions, who continues to navigate and lead through the intricacies of the newest CMS payment model.
So, last time we talked about a lot of the history behind the reimbursement models for CMS and went over some of the history, and what CMS is trying to achieve, and how they’ve moved down this timeline and value, and we’ve landed on an ACO REACH model. What happened from “hey let’s do this,” to “we’re doing this now.” Because it seems really easy to say but I know that a lot went into it. Can you walk us through that?
Yeah. So, I think we had looked at the direct contracting model and just financially it didn’t make sense. So, you know, we talked a little bit about the Next Gen model coming before it and how it was never really certified as a as a full program because CMS didn’t think that it created as much savings as that should have. You go to direct contracting and they’ve kind of put into direct contact some very steep discounts. Discount not being a good thing. Right? Discount being they’re going to take money straight off the top to make sure that they get the savings that they’re trying to generate in the model. When they revamped direct contracting, renamed it, refocused it as ACO REACH they kind of backed off on some of those discounts, which was helpful I think to a lot of us that were in the healthcare space. So, you know, all the Next Gens are providers. We’re all providers. We’re, you know, trying to do value within the health systems. We don’t have, for most of them, a lot of you know commercial companies outside of this.
And so, as we started to look at ACO REACH and the requirement or the ability within the model to take on claims processing, that is a whole other realm that we had not been. In claims processing, I mean, obviously, there are entire companies that do nothing but claims processing. And so, we had to decide is this something we’re going to take on? Do we outsource it? What kind of you know organization do we partner with to do this? And we have to go through the entire process of an RFP, a request for proposals, to determine OK who can do this, who’s done it before in direct contracting that we can also use in this process, and how do we move forward. So, there was a lot of time spent in determining number one what is our downstream model going to look like, how are we going to reimburse these providers, and number two, can we do it, can we set it up in a relatively quick time frame and do we have the expertise in-house to do that or do we need to look outside. So, there was a lot of conversation around that.
I mean, obviously, the application process for ACO REACH was a lot. It was unlike any other application that CMMI had ever put out, the Innovation Center, had ever put out. It was very detailed. They were asking very specific questions about governance structure. They were asking a lot of questions about health equity, what are you already doing in the health equity space, which is you know what they’re looking towards. They’re looking at this focus of how are we going to really affect care in the underserved communities that has traditional Medicare beneficiaries. And so, there were, you know, we had to look at what do we have now, what are our gaps in care, where do we think our populations are, what zip codes are they in. It was kind of a new foray into looking at data from a lens that we hadn’t really looked at before. Or if we had, hadn’t done a really deep dive into. So, I think those were kind of the two big things that we had to really prepare for. From a compliance and governance standpoint, we were set. That wasn’t different. And having been in Next Gen, we were very used to those types of you know the audits and the things that come with being in an innovation model that’s very different from MSSP. But from kind of a structural, internal claims processing, being able to take that claims file and figure out what we’re going to do with it and how are we going to set this up, I think it took it took us a long time to just OK let’s walk through these steps and what is this going to look like in the future.
What do you feel like was the most difficult part of that process?
Honestly, to determine how we were going to structure the downstream contracts was difficult. I just the process of OK what is it going to look like for us to process claims, who can we partner with. I think that was really difficult because we had never done it before. I don’t have expertise in that. You know, nobody specifically at CHESS did. And so, I knew we needed to bring in people that had that understanding, software that had that that ability. So, I think, trying to work with our revenue cycle teams and making sure that you know they know that the money is not coming from CMS anymore, it’s coming from CHESS, and how to post that, and work within their systems that they already have to make this work, I think was pretty difficult. There’s just a lot of moving parts in ACO REACH. There are a lot of different things going on at once. It’s a very complex contract. And so, to make sure that we have understanding and educate on it too, I think was really difficult. We spent a lot of time on doing internal and external webinars and meetings to explain what is ACO REACH. People are hearing about it, they don’t know what it is, how is this different, why does this matter. So, for me it was just a lot of education that to be done. A lot of reading on my part getting up to speed. And then, having to, you know, field lots of different questions on how it works. So that was a lot of my time was spent doing education on it as well. Not so much difficult, just time consuming.
So, we talk about in ACO REACH there’s the health equity component and that’s new. And I think that’s a really big deal as we look into population health. Right? Because we can segment populations in so many different ways, but why was there a determined need for health equity? Who is this becoming equitable for? What types of populations are we talking about here?
Yeah, that’s a great question. So, I think, you know, the COVID-19 pandemic really revealed a lot about our American healthcare system, in that you’re seeing some populations of patients have access to testing really fast, they know where to go, they know what to do, and other populations of patients don’t. And so, I think that realization that you know you’re seeing higher levels of death in certain ethnicities, those types of things, just made it very clear that health is not equitable within the United States. So, OK we need to address this and how do we do that?
So, really the population that we’re looking at, and within the ACO REACH model they are using something called the area deprivation index or ADI to kind of score patients as to whether or not they’re in underserved communities are considered underserved patients. It’s kind of on a decile scale. You’ve got, you know, those that are in really affluent communities on one end and then you’ve got those that are in very underserved communities on the other end. And being able to take your patient population and look at them from this kind of score and determine OK I’ve got a lot of population of patients, probably you know minorities, in certain areas of on our map, right, certain zip codes, certain census blocks, and I know that there seems to be in our data that we’re getting from CMS for this model that there is a, you know, a lack of colorectal cancer screening. OK that’s a gap. So, what are we going to do about it? So, I think it’s looking at those populations of patients more directly than just, “hey it’s a population of ACO patients. Let’s try to you know do what we can to affect care and value,” but really calling out smaller underserved communities within the population and saying, “what does the data look like for those people and how can we affect care specifically for those patients?”
Well, that that ties into a lot of the things that we work on here and that the buzzwords that we’ve talked about and one of those is social determinants of health. So, we talk about health equity and then we talk about social determinants. Is there flexibility since we are doing a lot of our own claims processing to make judgment calls on how we can address some of those social determinants that are outside of the clinical space? So, I know that there might be a lack of colonoscopies and mammograms and there might be a higher rate of diabetes, we talked about food deserts, we talked about hunger, we talked about transportation. Is there a leeway where we can make our own determinations about models that we set up programs initiatives that are allowable now with this new payment model?
Definitely. So, one of the benefits of being inside of ACO REACH is that you have, kind of, at your disposal a fraud, waste, and abuse, and safe harbor waivers to affect care in ways that otherwise would have been considered kind of like a kickback or of those types of things. So, there’s different waivers, sanctioned waivers, within the ACO REACH model, the ones that we know like the telehealth waiver or the skilled nursing facility three-day waiver, there’s a gift card program, that you can do at-home care management home waiver. These types of things. But I think broader, there is the ability to take some of the money and determine OK how can we use this money to really affect a social determinant for underserved populations. Does that look like partnering with a food bank to offer food to diabetic patients that are in this zip code because they don’t, they can’t get a medically tailored meal. That’s a that’s a possibility, and the ACO technically could pay for that. In traditional Medicare, outside of the ACO structure, that would be considered illegal because you’re providing something that Medicare is not paying for. But within the ACO structure, they know that this could be a way to turn around someone’s health in a real realistic way.
And so, you have the ability to model these types of programs and to partner with community organizations that are already in this space and have the resources to be able to do this. I mean, I know I don’t have the resource to stand up a food bank but there’s one down the road that I could say, “hey I really need to you know to try to provide care or provide a meal to these patients because they’re diabetic and they can’t leave the house and they don’t have transportation.” And that’s another thing is transportation issues. We have the ability to provide rides to primary care offices. So, if a patient says I know I need to come in for my primary care visit or for X, Y visit and I can’t make it, I don’t have a car, or I can’t drive, we have the ability to pay for that ride and to offer them a ride to get to their provider. Instead of the alternative being calling an ambulance and the ambulance showing up at their house and taking them to the ED, which obviously is way more expensive than if they just needed a ride to their doctor’s office. So, there are a lot of a lot of creative things you can do. I think a lot of it is, man there’s so much, how do we even start? Where do we start? And I think that really is where you rely on the data that you get, the claims data you get from CMS, the clinical data that you have from the you know the health systems, your value partners, and really putting that together and find that form a holistic picture of your population specifically in the underserved communities and determining OK where do we think we can really affect care with these patients.
I really like that because that is what it’s all about. You hear so much about the financial components, and I realize that people need to be compensated for the work that they do. Not everyone has the means with which to be philanthropic with their time, which is the greatest gift you can give. Right? Everybody’s got to eat. Even those that help other people eat. And it’s nice to hear about the Feds saying hey we realized that it’s not necessarily a straight clinical solution to optimal health and I think that’s a huge leap. So, we began at CHESS, we began ACO REACH on January 1, 2023. How’s it going so far? Do we have any data? I mean we’re a couple of months into it, how’s it? I’m sure that the road is bumpy and there’s warts and all of those things. But, you know, as one of the first group of ACOs to be tackling this, how’s it going? Is it working?
Yeah. I mean I think it has been bumpy, I’m not going to lie. It hasn’t been smooth sailing just because we, you know, a lot of this is new and anytime there’s new, you’re doing something new and different, there’s things that have to be ironed out. I think so far we’re doing well. I think we, on purpose, are starting kind of slowly into the model and haven’t availed ourselves of all the waivers that are out there just because I personally I wanted us to get our feet on the ground and just let’s just get a really solid foundation for how we’re going to do some of this stuff instead of trying to boil the ocean. Right? So, I think we’re doing good. And I think we are affecting care. Some of the data’s been delayed coming from CMS, which usually happens. I mean, I get it, it’s new. Some of this is new for them too, right. So, there’s going to be things that have to be ironed out. But, so far, I’m really optimistic about what we’re doing and how we’re affecting care.
I think we have a really great opportunity within the health equity space and that’s what we’re really working on right now. So, for ACO REACH, we have to create a health equity plan and we have to submit that to CMS the end of March. And so, right now, really trying to determine OK based on the data that we’ve received from CMS so far, where are the gaps in care, what can we do to really affect underserved communities. And then, using the next three years, 24, 25, 26 to really roll that plan out and see care effective in communities. So, we’re in the staging processes of health equity within ACO REACH. I’m sure there’s others that are farther down the road than us, but I think I think we’re doing OK for where we should be.
So, we decided we were going to participate in ACO REACH and we went through all of the hurdles, all the rigmarole, all of the vetting. Is this something that is available every year? So that next year, some ACOs out there who were just didn’t have the bandwidth because oftentimes ACOs are pretty lean run operations right and unfortunately those operations might be in communities that are best served by this type of program which is why the ACOs exist in the first place, would they have the opportunity to apply to begin next year? And if so, what advice which you give to them?
So that’s a great question. Actually, there are no more applications for ACO REACH. So, this this was the last, this was the cohort. So, a lot of the direct contracting entities that started in 2022, some started part of the way through 2021, they were kind of grandfathered in, and then you had this kind of cohort of applications for the 2023 start, and they’ve shut down applications for the future. So, for organizations that think hey this might be something that we would want to be a part of, they would have to look at joining someone that already has a contract with CMS for ACO REACH and then you know approach those different organizations to talk through what it would look like to join in 2024 through 2026.
Well seeing as how other ACOs would need to become a partner with ACOs who are involved in REACH, how difficult would that be? How does that work?
Yeah, I think it would have to go through some type of vetting process, from my standpoint. So, you know, yes, there would be obviously contracts would have to be drawn up, but we would want to look at the people that are interested in joining a current ACO. Like if it were ours, our CHESS ACO REACH, and saying is this a good fit for this advanced of a model, you know, do they have history in value based care, are they already doing things that are affecting health equity, how do they feel about taking on downside risk, are they an organization or group of organizations that feels like they want to do that, or you know how can we model something different specifically tailored for this group that wants to join. Would it look different?
And that’s the other thing within ACO REACH, you know, I talked about previously in our other podcast about it’s kind of like putting a contract within a contract, but you can alter those contracts. So, one participant within the model, like one health system, their contract of how they’re paid could look different from another contract of how another value partner or health system is paid. And so, you’d really have to do that that vetting process of determining is this something that looks like it would be a good fit based on you know their history and are they ready to take that leap, really. I mean, I think a lot of value-based care is more of a cultural change than anything else. It’s really trying to address the mentality of providers, and educate them on what this means, and how it’s going to be beneficial for the patients. And sometimes that it doesn’t go over well. I’ll be honest, you know, you have some that don’t really latch on to it. And so, there would have to be that willingness at the executive leadership position, this is something we’re really going for and we’re going to drive the culture in our organization in order to make sure that we’re successful in this model.
Have providers noticed those who are now with it have a patient population that is part of ACO REACH? Have they noticed a difference? Are they doing anything differently with how they provide care for their patients or is it just continuing along the standard successful value-based care workflows?
I think from a provider lens, especially with the with the organizations, health systems, that we currently have in ACO REACH, they’ve been doing value-based care for such a long time that they don’t see a lot of the difference. And I would say a provider, on purpose, does not want to know oh this is a this insurance patient, and this is the this one, and this is this. That idea of treating each patient before you equally no matter what their insurance plan looks like, I think is very important to a provider. And that’s where we, as CHESS, kind of wrap services around the provider to help drive value-based care. Yes, there is some education that has to happen, and there might be workflow changes within an EMR, or things that have to change, education that would help drive value. But I think two, a lot of this work are things that we do as CHESS to try to help them. So, you know, care coordination services and pharmacy services. A lot of those things happen a little bit on the back end, a little bit out of the spotlight of that care that is you know the 30-minute visit of a patient in front of a provider.
Our mission, and one of the basic tenets of the quadruple aim, is to help providers just take care of their patients, right? And provide the best care that they can because that’s really why they got in the business. I mean because they’re caregivers. Do you feel like this new model is going to help the provider give better care to their patients?
Yes, I think it will. I think it will provide services for their patients that they probably wouldn’t have had otherwise. Now, it may take some time to get there. You know, I think a lot of these things take time to get off the ground and make sure that we’re really affecting care, but I think, I mean, that’s what we’re here for, right? We want to see these patients be healthy and successful in their day-to-day lives. And so, I think it really will help to drive kind of that mentality of, “hey let’s put the patient first. This isn’t always about, you know, what it’s going to cost us on the back end,” but I do believe that, I think this will help to drive patient care probably in a way that isn’t being done with traditional Medicare patients right now. I mean it’s got some semblances of a Medicare Advantage plan where you have the transportation ride and you have like these different options that come in Medicare Advantage that were never available to a traditional Medicare patient, with the protections and the ability to go between providers that a traditional Medicare patient had. And so, I think a lot of those patients really value that flexibility and now there’s going to be extra things at their disposal that maybe they hadn’t had before.
Outstanding. Well, my hope is, of course, that this is going to change the way healthcare is delivered. But I am interested to keep talking as this progresses because I think it’s fascinating to be at the beginning of a new care model that really addresses societal issues that we’ve now come to realize the impact someone’s health. So, I hope you will join us again soon to give us an update on where we are. Well, Melissa Pollack thank you for joining us today on the move to value podcast.