How ACO REACH Sets Providers up for Financial and Quality-care Success

By: Frank Richter, Chief Financial Officer

As healthcare costs continue to increase and the population ages, the Centers for Medicare & Medicaid (CMS) looks for new ways to improve healthcare. They’re ready to shake up the current fee-for-service healthcare model to a more sustainable model that provides better results.

This transactional model requires providers to focus on getting patients through the door and encourages them to perform tests and procedures that might be unnecessary. That can create a revolving door of care, with patients coming in and out. Primary care practitioners end up referring patients to specialists instead of going after root causes of issues. On the flip side, patients put off going to the doctor until it’s unavoidable, instead of on a regular basis for proactive care.

The Accountable Care Organization Realizing Equity, Access and Community Health (ACO REACH) model is a CMS program that aims to make healthcare work better for both patients and providers. This model empowers and incentivizes providers to be good stewards of their patients’ best health.

ACO REACH is a better financial model for providers

In the fee-for-service model, providers only have one way to get paid: bill more services and tests. In ACO REACH, providers can get paid up to three ways. It’s more manageable and lucrative for providers who put their patients’ health first.

First, there’s an upfront monthly payment per beneficiary, called a capitation rate. It’s generally 150–175% of fee-for-service payment from CMS. This offers a predictable monthly cash flow to help pay for day-to-day operations or can be used to invest back into the business. It’s a more sustainable and reliable method of payment, compared to the fee-for-service model.

Second, they could earn quality bonuses, which are bonuses paid based on patient outcomes. When the patient has improved outcomes, providers get a bonus for high-quality care, regardless of the cost.  

Finally, providers might receive extra money at the end of the year through shared surplus savings. Let’s say CMS estimates it will take $12 million to treat 1,200 beneficiaries for the year. If the provider spends only $10 million, the remaining $2 million is split between the provider and the ACO REACH organization.

This payment model ups the ante for providers. If they improve their patients’ health, they earn more. With this new model, they see patients at least once per quarter vs. annually, so they can stay on top of chronic conditions. When they interact with patients more, they can help decrease the number of unnecessary hospital visits those patients have. They then get to share in the cost savings they created.

ACO REACH sets providers up for successful quality care

Providing elevated healthcare takes a village. When providers join ilumed’s village, they get support, service and tools they wouldn’t get on their own.

1. ilumed offers multiple support teams to ensure patient success, including:

– A case-management team with nurses on staff to help manage short-term and long-term needs. Our short-term team helps patients transition home after hospital, and our long-term team helps patients with chronic conditions adhere to their treatment plans.

– A social worker team to support members with social determinants of health issues. For example, if they’re struggling with food insecurity or financial issues, the team can help them find resources like food banks, meal delivery or assistance with bills. They’re also a good resource for beneficiaries who are struggling with loneliness or social isolation.

– A member-outreach team that coordinates between members and providers to set up appointments and arrange for transportation.

2. ilumed uses data analytics to help providers get insight into their patients. BrainStream, ilumed’s proprietary analytics platform, offers a 360-degree view of patients by analyzing all Medicare claims data and other health equity indexes. It consolidates that information and easily breaks it down for providers, so they can see info like when a prescription doesn’t get filled or a hospitalization occurs.

It also helps providers pinpoint at-risk patients using predictive analytics so they can address issues before they occur. This proprietary service is free for all in-network ilumed providers.

3. There’s also a provider relations team to coach providers on how to make value-based care updates to their operations. For example, they coach providers to open their schedules and allow room for last-minute appointments. This simple solution helps prevent unnecessary emergency room visits and lets patients get more proactive care earlier in the process before issues can escalate. Providers are also encouraged to see members within 72 hours of discharge from an acute setting, which improves patients’ chances of avoiding readmittance.

4. ilumed helps providers maintain quality metrics. Our clinical team visits provider offices to review charts and ensure they’re addressing patient needs. With our team’s extensive value-based care knowledge, we ensure provider success. Plus, our document and coding teams audit charts and train your staff to improve coding accuracy.

What sets ilumed apart as an ACO REACH organization

The ACO REACH model is new, but ilumed has an expert team with experience working in value-based care for over 35 years. We understand what it takes to scale quality care across different providers and organizations. This level of expertise and care has created loyal providers who have been with us since our start in Medicare Advantage.

We also provide an extensive collection of resources, tools and support to help both providers and patients. For providers, we offer extra staff, including case management, social workers and member-outreach teams. We also offer technology to improve understanding of patient needs, track those needs in real-time and allow for better coding and record keeping.

Patients receive benefit enhancements, including teams to support their needs, rides to doctor appointments, Part B copays and waived deductibles.

ilumed has a track record of success

We know how to transform healthcare for the better. We’ve worked with practices who were in the red and struggling to care for high-needs patients. Just a few years later, and with our financial model, resources and support, they’ve turned their practices and their patients’ health around.

Contact us to discover how you can benefit from the ACO REACH model.