Customizing Palliative Care and Palliative Care Payment Contracts in ACO REACH

Customizing Palliative Care and Palliative Care Payment Contracts in ACO REACH

Hospices and accountable care organizations have the ability to customize payment contracts under the Achieving Equity, Access, and Community Health (ACO REACH) program.

Effective January 1, 2023, the US Centers for Medicare & Medicaid Services (CMS) is replacing the Global and Professional Direct Contracting (GPDC) model with ACO REACH. The agency says the new program reflects its revamped strategy for payment system demonstrations, with the promotion of health equity as a key principle.

Some features of the GPDC will continue in the new program, including flexibility in terms of payment between ACOs and downstream suppliers.

“We have full financial responsibility for our patients, including all expenses that occur within Medicare A and Medicare B. Within this, we have the ability to pay claims for people who wish to enter into a relationship with us. “, Andrea Osborne, senior vice president of delegate programs for VillageMD, told Hospice News. “When we pay claims instead of Medicare, we pay the provider who cares for one of our affiliated patients. Because we now become the payor, we can change what this payment agreement looks like. »

Understanding ACO REACH

Under the direct contracts program, providers assume 100% of the risk associated with eligible patients for the global option or 50% of the risk with the professional option.

Many participating suppliers anticipate a smooth transition from direct contracts to ACO REACH, but there are some differences between the two programs.

REACH will place greater emphasis on addressing health care disparities, as well as screening and tracking model participants to drive transparency and prevent inappropriate coding and risk score growth .

The program also institutes a health equity benchmark adjustment for payments to ACOs serving larger numbers of beneficiaries from underserved populations. CMS will identify these providers using statistical manuals such as the Zone Deprivation Index and dual Medicaid status.

Other new features include expanding the services nurse practitioners can provide and additional rules to strengthen oversight, governance and compliance.

Design payment terms

The flexibility for vendors to develop custom payment contracts began in earnest with the direct contract program, although some limited options existed in next-generation ACO models, according to Osborne.

VillageMD had partnerships with a range of other providers in the continuum through these next-generation programs, but these did not include hospice until direct contracting emerged. At the time, those relationships focused on home health agencies and skilled nursing facilities, Osborne told Hospice News.

“Our participation agreement [with CMS] says the financial arrangements are between us and that supplier, but within that we always make sure that what we do is at fair market value,” Osborne said. “We follow all Medicare rules, but the arrangement itself may look different. It can be a group payment. This may include items that are not always the responsibility of that provider, but which we believe provide better overall patient care when coordinated under a single payment model.

Flexibility can apply not only to the hospice itself, but also to the upstream services that many of these providers offer, such as palliative care, PACE, and home health, among others. Osborne said the ability to think holistically about patient needs and coordinate care are among the program’s “greatest benefits.”

However, suppliers should keep in mind that even in ACO REACH certain limitations apply, according to Melody Danko-Holsomback, vice president of education for the National Association of ACOs.

“There are regulations for certain types of contracts. For example, skilled nursing facilities must be three stars or higher in order to contract with ACOs. It is a CMS guideline that must be followed, but that is only for the use of waivers,” Danko-Holsomback told Hospice News. “It’s up to CMS to give some parameters that you have to follow. That said, this does not mean that an ACO cannot contract with providers in other ways and create business agreements to accept certain types of patients, following certain models of care or quality measures.

These contracts can be fully capitation with a fee per patient per month, or they can be fee-for-service. Other possibilities include hybrid models in which the hospice or other post-acute care provider will receive part of their reimbursement on a fee-for-service basis, along with additional payments determined later by performance on quality measures.

Among these measures are reductions in hospitalizations and readmissions. and emergency room visits. REACH ACOs will have access to three years of complaints data to help guide these decisions.

“One of the benefits of getting this data is that when we looked at hospice data, we found that once our patients entered a hospice business, only 1% of the time did they end up in the hospital,” Osborne said. “For me, that was a really good statistic that tells me that patients are getting what they asked for, which is to be home. So hospice was a place where we wanted to consider a partnership. .


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