The Centers for Medicare and Medicaid Services (CMS) has awarded one of its ACO REACH contracts to Upward Health, a multidisciplinary at-home care provider.
ACO REACH is a risk-sharing program between companies and the government, standing for Accountable Care Organization (ACO) Realizing Equity, Access, and Community Health.
The New York-based Upward was one of 22 providers to receive a contract for the High Needs Population ACO. In total, over 100 companies have received an ACO REACH contract.
The high needs program is specifically designed to serve Medicare patients with complex health care needs, which Upward does in the home setting, as well as long-term care settings.
The company’s main service offerings include integrated physical medicine, behavioral health, addiction treatment and social determinants of health interventions. It provides care in five states and most of its business is Medicare, Medicaid or individuals who are dually-eligible.
“We’ve chosen this clientele for a mission-oriented reason, but also a business-oriented reason as well,” Upward Health CEO Glen Moller told Home Health Care News. “We hire people who are intensely mission-driven, but at the same time, it’s a good business because it’s a neglected group of people who are really running up the score in terms of health care dollars. We as a society have not figured an efficient way to take care of them, and that’s what we’re working on.”
Applying and engaging in ACO REACH was an investment in terms of time, money and resources for Upward. But Moller believes the investment will pay off in the long run.
“In effect, what Upward Health is doing is way more expensive in the short term, because it’s high-intensity services, but easily pays off by the time even a year or two is gone by,” Moller said. “This contract puts us at risk for the overall dollar and it makes us more flexible for us to spend resources how we see fit.”
Under the Trump administration, three Center for Medicare & Medicaid Innovation (CMMI) payment models were created: The Global, Professional and Geographic direct-contracting models.
The first two were paused by the Biden administration. The third was abandoned completely.
In their place, the ACO REACH model was created. It was designed to create more equity in the direct-contracting program.
According to a CMS spokesperson, 110 participants were provisionally accepted into the ACO REACH program for 2023. Another 142 organizations were not selected, marking a 47% acceptance rate. Since then, 18 applicants have withdrawn from participation.
In Moller’s mind, the ACO REACH model allows Upward Health more freedom to provide above and beyond services without worrying about the exact specifics of a Medicare fee schedule.
“Which honestly makes it impossible to care for the neediest 5%,” he said. “It’s great for the 95%, but it doesn’t really work for these high-need individuals.”
Moller also gave CMS credit for how it is implementing waivers in the new model system to allow even more flexibility.
“CMS has been very thoughtful about waivers that it’s put into the system that give both Upward Health more flexibility by working with these kinds of patients, but also some of our partners,” Moller said. “Just as an example, there’s a waiver for a nursing home to not have to send these kinds of patients to a hospital before admitting them for SNF days, and that’s really significant.”
The model is set to launch on Jan. 1, 2023. The total number of participating organizations could change from now until then, according to a CMS spokesperson.
Upward Health will initially use the ACO REACH model in Massachusetts, New York and Rhode Island.