REACH FOR IT!

March 2023 Blog

What a Difference a Year Makes

Last year when NNPEN polled NP Value Summit attendees, they didn’t see Value Based Payment [VBP] at their doors for 10 years: Not a surprise. No payers were offering VBP contracts to NPs, and NPs felt a very low sense of urgency to leave FFS, the devil they knew.  But 12 months later, as of January 1, there are >100 payers willing to contract with NPs on VBP terms—a payer or two in most states. 

Q: Who are these payers?  A: REACH ACOs

REACH ACOs are the new Medicare payers for NPs, a five year pilot of CMMI focused on delivery of primary care services that create health equity and extend the reach of primary care into underserved populations—an NP sweet spot. [ REACH stands for Realizing Equity, Access and Community Health.]

And they are the NP friendliest of the CMS ACO models thus far—for one threshold reason [aside from NP’s love affair with seniors, especially high needs homebound beneficiaries]: REACH ACOs level the playing field for all eligible PCPs, docs and NPs alike—with a claims-based assignment system called Attribution also known as Alignment].  Attribution means eligibility for any auto-assigned revenue stream associated with traditional Medicare patients for the NP and any ACO s/he is part of.  By recognizing the NP in larger numbers through claim-based auto assignment [in addition to current voluntary assignment] as both the treating and billing provider, REACH creates visibility for NP PCPs and data to quantify NP value.

We already have that with our traditional Medicare patients that we see in our nurse-led practices…right?  Not really.  NPs are still stuck in a FFS payment system that is fiscally unfair, not patient-centered and affords little opportunity to grow into a practice big enough—visible enough—to leverage payers into reimbursement contracts that value NP quality and cost outcomes.

Like other ACOs, REACH creates critical mass leverage by aggregating—but not owning—small practices, creating a powerful Double AA battery of Attribution and Aggregation.  And with CMS as overseer and financial reconciler, REACH offers transparency and training wheels to accepting both risk and reward for your panel’s health . 

How does REACH support the NP’s shift to value?

• o   You keep your non-REACH patients and bill them as usual, direct to Medicare
• o   Monthly care management payments
• o   Monthly payment advances to support cash flow [“capitation”]
• o   Value-based payer contracting and population health program management
• o   Downside risk protection
• o   Access to shared savings
• o   Opportunity to erase the 15% differential with the Medicare physician rate schedule

There are 3 types of ACO REACH but all abide by same CMS/CMMI rules.   How do I tell these REACH ACOs apart? 

• o   High needs beneficiaries only: typically HCC >4.0; minimum ACO size=500 attributed lives
• o   Standard: established Medicare expertise; 5000 attributed lives
• o   New Entrant: New as Medicare providers; 3000 attributed lives with growth timeline

REACH ACO Nurse Practitioner Services Benefit Enhancement New in 2023

Wait—one more NP friendly change!  One of NNPEN’s members points to another way REACH ACOs will impact both the NP and the beneficiary, and in a much more immediate way.  Through the Nurse Practitioner Services Benefit Enhancement 2023 the NP can certify the need for hospice, diabetic shoes,  cardiac rehabilitation and several other therapies WHICH STILL REQUIRE PHYSICIAN CERTIFICATION FOR MEDICARE BENEFICIARIES NOT ALIGNED WITH AN ACO REACH.  This is a benefit the REACH ACO can elect to offer in an effort to streamline both quality and cost for seniors.  This benefit enhancement works for the patient [diabetic shoes today!] and also supports ongoing collection of quality and cost data starting this program year, and we know that data is what we need to change policy more broadly!  See page 75 in this link for a complete list of enhancement services: https://innovation.cms.gov/media/document/aco-reach-rfa

If you’ve railed against the barriers created by the physician certification of need requirements, recognize the REACH Nurse Practitioner Services Benefit Enhancement effective  2023 as another opportunity to create  the visibility NPs need to lay the foundation for quantifying NP Value.

Best ways to learn more about REACH ACOs

• 1.      Interviews with ones in your state; are they NP -friendly? Do they understand your questions? Have they shown willingness to negotiate a cap on downside risk? Have they elected to offer the NP Services Enhancement Benefits?
• 2.      Understand their timelines and match against yours
• 3.      Follow NNPEN’s REACH reporting and strategy to build a critical mass of like-minded NP practices
• 4.      Remember One and Done: Primary care providers cannot participate in >1 REACH at a time, but can withdraw
• 5.       Join us April 1, 2023 in person or virtually for our spring conference: [In]Visible* to Value, which will focus on creating NP visibility as a precondition to NP success in VBP, and hear how peers assess the downside risk of this migration.  Here’s the link to the NNPEN 2023conference landing page: https://mailchi.mp/2ed382004d0e/je04wxx0yw 

See you April 1 [no fooling!]

SB