This ACO Model is Testing the Future of Home Care and Waivers

The new ACO Reach Model is testing home-bound waivers, hospice benefits, and telehealth, and who can perform home care visits.

“CMS is testing a redesigned model because accountable care organizations make it possible for people in traditional Medicare to receive greater support managing their chronic diseases, facilitate smoother transitions from the hospital to their homes, and ensure beneficiaries receive preventive care that keeps them healthy,” said Liz Fowler, CMS Deputy Administrator and Director of the CMS Innovation Center.

The ACO Realizing Equity, Access, and Community Health (REACH) Model replaced the Global and Professional Direct Contracting Model on January 1, 2023. This model offers higher levels of risk and reward than the Medicare Shared Savings Program MSSP. The model will run through 2026.

At the start of 2023, the ACO Reach Model had 132 ACOs with 131,772 health care providers and organizations providing care to an estimated 2.1 million beneficiaries.

THREE LEVELS OF PARTICIPATION

Participants can choose from three different models.

1. Standard ACOs for organizations with substantial experience serving people with traditional Medicare.
2. New-entrant ACOs for organizations with less experience serving the traditional Medicare population.
3. High-needs population ACOs for organizations that serve small traditional Medicare populations with complex health care needs.

THE ACO REACH MODEL TESTS HOME CARE’s FUTURE

Many of the benefits offered to beneficiaries are through benefit enhancements.

Benefit enhancements are optional waivers of certain Medicare requirements that give ACOs additional flexibility in providing services.

The ACO Reach Model includes six benefit enhancements, which allow CMS to waive select Medicare payment requirements.

1. Telehealth Benefit Enhancements: Waives the rural geographic component of originating site requirements so a beneficiary’s home can be the originating site.
2. Post-Discharge Home Visits Benefit Enhancement: Allows auxiliary staff to perform home visits post-discharge under general supervision, rather than direct supervision.
3. Care Management Home Visits Benefit Enhancement: Waives the requirement for direct supervision to allow for payment for certain home visits furnished to eligible beneficiaries proactively in advance of a potential hospitalization.
4. Home Health Homebound Waiver Benefit Enhancement: Allows home visits for patients with multiple chronic conditions.
5. Concurrent Care for Beneficiaries that Elect the Medicare Hospice Benefit Enhancement: Allows beneficiaries who have opted for hospice care to still receive curative/conventional care. Palliative and hospice programs are adopted within REACH ACOs to support end-of-life care.
6. SNF Participation: Three-day skilled nursing facility (SNF) rule waiver benefit enhancement allows beneficiaries meeting CMS criteria to not need a three-day inpatient stay prior to admission to an SNF.

All benefit enhancements updates are effective July 1, 2023.

THE ROLES OF NURSE PRACTITIONERS AND PHYSICIAN ASSISTANTS ARE EXPANDED

The Nurse Practitioner (NP) Services Benefit Enhancement allows for five services to be delivered by NPs, increasing the flexibility of care delivery:

1. Hospice Care Certification
2. Certification of Need for Diabetic Shoes
3. Certification of Cardiac Rehabilitation Care Plan
4. Certification of Plan of Care for Home Infusion Therapy
5. Referrals for Medical Nutrition Therapy

Physician assistants (PAs) can:

• Allow personnel other than physicians to provide post-discharge and care management home visits.
• Permit reimbursable home health even if the beneficiary is not homebound if they meet certain clinical risk factors.
• Provide previously prohibited curative services alongside palliative care for people in hospice.
• Waive the skilled nursing facility (SNF) requirement that admission be preceded by a three-day inpatient hospital stay.

ADVANCE HEALTH EQUITY TO BRING THE BENEFITS OF ACCOUNTABLE CARE TO UNDERSERVED COMMUNITIES

The ACO Reach Model promotes health equity and focuses on bringing the benefits of accountable care to Medicare beneficiaries in underserved communities. CMS will use an innovative payment approach to better support care delivery and coordination for patients in underserved communities and will require that all model participants develop and implement a robust health equity plan to identify underserved communities and implement initiatives to measurably reduce health disparities within their beneficiary populations.

The ACO Reach Model is introducing five new policies to promote health equity starting in PY2023:

• Health Equity Plan Requirement.
• Health Equity Benchmark Adjustment.
• Health Equity Data Collection Requirement.
• Nurse Practitioner Services Benefit Enhancement.
• Health Equity Questions in Application and Scoring for Health Equity Experience.

THE ACO REACH MODEL IS TESTING VALUE-BASED POPULATION-BASED PAYMENTS

The ACO Reach Model is a pilot program testing population-based payments.

Population-based payment models are an advanced value-based payment approach that offers health care providers upfront, flexible payments, and a departure from fee-for-service payments.

This is a key model to keep watching. It could change home care’s future.