Some physician groups have decided to join the accountable care organization (ACO) REACH programs to better serve high needs groups given that the nursing home sector is gravitating toward value-based care – the trend being especially true if patients are already aligned with an ACO through their primary care provider.
Theoria Medical, for one, made the decision to get involved in the REACH program next year via Empassion Health, and the group feels diving into the program will help them address the higher acuity population while offering a managed care option complementary to the institutional special needs plan (I-SNP). The REACH acronym stands for Realizing Equity, Access and Community Health.
“That’s where the ship is heading. I think that absolutely, there’s going to be more groups that get involved in these programs … this is going to continue to expand, and more and more groups as they get more sophisticated and learn the [SNF] landscape are going to want to get involved. I really see this as a larger trend,” said Kevin Pezeshkian, chief strategy officer with Theoria.
The decision coincides with previously reported proposed changes to the program, including broadened criteria and an attractive high needs population track.
Dr. Scott Rifkin, founder and chairman of the board for Provider Partners Health Plan Inc., which offers both I-SNPs and ACO REACH options to the SNF community, says the REACH program thrives on more primary care and reduced hospitalizations. Rifkin also serves the same role at Real Time Medical Systems, a data mining and care decision platform that helps such value-based care programs succeed.
Being part of the ACO REACH means easier transitions, Rifkin said.
“You don’t give up Medicare billing, you don’t have patients give up Medicare, you don’t set up a network, you don’t have big financial reserves – it’s so much easier,” said Rifkin. “I think you’re going to see operators and medical groups partner up in ways that improve the care and bring REACH to lots of buildings. I was just at an [American Health Care Association] AHCA CEO meeting and that was the talk of the conference, it was REACH.”
Moreover, the ACO REACH program allows doctors and the care team to share in savings generated by better care, Rifkin said, but the Centers for Medicare & Medicaid Services (CMS) is still the payer. For I-SNPs, CMS pays a premium to the I-SNP and then that insurance arm turns around and pays the bill.
Pezeshkian sees “huge potential” in Theoria’s REACH involvement from a safety standpoint, and also the physician group’s ability to offer savings to SNF partners.
“I think that’s a unique part of it. A lot of the time ACOs don’t like to share savings with the facilities and they don’t really have a good relationship, especially with hospital ACOs,” added Pezeshkian.
While other hospital ACOs may cut SNFs out of the equation as a way to save money, Theoria’s model sees SNF involvement, specifically SNF alignment with the ACO REACH program metrics, as a vital part of program savings.
He refers to “claims-based alignment,” meaning a SNF resident’s primary care provider is already Theoria. And, residents would get their Medicare Part B fees waived as part of the program.
REACH as compliment to I-SNPs
Overall, Pezeshkian sees the REACH program as complementary to I-SNPs, as the other half of the care continuum.
“We think that’s part of the value-based equation. You’re talking about different cohorts; some patients don’t want to change their health plan. I think that’s definitely a much more complex decision,” said Pezeshkian. “With the [ACO REACH] program, nothing really changes for them, except them getting extra benefits under Medicare, with the ACO.”
Rifkin says I-SNPs and ACO REACH are really the only two options nursing homes have for value-based care. And while I-SNPs can be cumbersome and expensive to set up – depending on whether the set up is an independent I-SNP or partnership – ACO REACH doesn’t have such hurdles.
“[I-SNPs are] a wonderful program for the right operators, but it is not the program likely to dominate the space,” said Rifkin. “It’s difficult to set up an I-SNP – costs about $5 million. You’ve got to get operators to give up regular Medicare, patients to give up regular Medicare, you’ve got to set up a network, you’ve got to get an insurance license … it’s a real slog through the mud.”
That leaves the REACH program, he said. But, it’s ultimately going to be SNF operators who will drive participation rather than physician groups.
Operators looking to get involved in ACO REACH will in turn seek to partner with physician groups to meet program needs.
“The real question is, are nursing home operators and doctors going to work together to create big programs in nursing homes, in groups of nursing homes? If you’re a big nursing home operator, are you going to partner up with a medical group that has a REACH license and figure out how to do that program together? I think that’s really going to happen – the economics work in favor of that,” said Rifkin.
Building up to the REACH program
As Theoria continues to focus on the long-term care population, its claims data and historical analysis point to a significant quality improvements and cost decreases mainly due to a reduction in readmissions as part of the ACO REACH program, he said.
“ER visits and readmissions tend to be the biggest cost drivers in these models,” added Pezeshkian. “That was a big driver of our decision to do this. We’re going to be very successful, based on our historical performance. This makes a lot of sense for us.”
Having a strong tech backbone, he said, is a big help when going back and forth between traditional fee for service (FFS) Medicare and value-based care, and it’s a different way of thinking, a different perspective for providers too.
“It’s challenging because you need to change the culture, you need to change the mentality, you need to educate and train on how these things work,” noted Pezeshkian.
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