What is ACO (Accountable Care Organization) REACH (Realizing Equity, Access, and Community Health)?

What is ACO REACH?

ACO REACH (Realizing Equity, Access, and Community Health) is a Medicare value-based payment model where groups of physicians, hospitals, and other healthcare providers coordinate care for Medicare beneficiaries, with financial incentives tied to quality improvement and cost reduction while specifically emphasizing health equity and underserved populations.

Core Structure and Purpose

ACO REACH builds upon the traditional Accountable Care Organization (ACO) framework established by the Medicare Shared Savings Program starting January 1,2012 1. The fundamental ACO model comprises groups of providers and suppliers working together to promote accountability and care coordination for Medicare fee-for-service patient populations 1.

The defining feature of ACOs is that participating providers have financial incentives to coordinate care and improve outcomes for patients 1. This means providers can share in cost savings when they successfully reduce healthcare expenditures while maintaining or improving quality metrics 1.

How ACOs Function

Patient Attribution and Population Management

• Primary care-based attribution: ACOs typically define their patient population through claims data identifying beneficiaries who received a plurality of their primary care services from ACO clinicians 1.
• Comprehensive accountability: ACOs are evaluated on total annual costs of care compared against a benchmark, unlike episode-based bundled payment models that focus only on specific procedures or conditions 1.
• 24/7 availability: ACO programs emphasize continuous access to coordinated care across the healthcare continuum 1.

Financial Model

ACOs operate under shared savings arrangements where they can receive financial rewards by maintaining or improving care quality while reducing costs 2. The model creates incentives for providers to ensure patients receive appropriate preventive care to avoid future costly healthcare events 1.

• Over the first decade, 214 Medicare ACOs lowered spending by an estimated $2.8 billion, or $316.9 million after accounting for shared savings payouts 3.
• The Centers for Medicare & Medicaid Services set a goal for all payments by 2025 to be associated with value-based care 1.

The "REACH" Component: Equity Focus

The REACH designation specifically emphasizes addressing health disparities and improving access for underserved populations 1. This builds on earlier CDC initiatives like Racial and Ethnic Approaches to Community Health (REACH) programs that addressed racial and ethnic health disparities 1.

Key equity priorities include:

• Targeting vulnerable populations: Women, minorities, populations with low socioeconomic status, and other groups historically experiencing low enrollment in healthcare programs 1.
• Social determinants of health: Recognizing SDOH as key elements in successful ACO management, including housing instability, food insecurity, transportation needs, and interpersonal safety 1.
• Dual eligibles focus: Special attention to patients eligible for both Medicare and Medicaid, who have poorer health status and higher rates of cardiovascular disease 1.

Quality Measurement Requirements

ACOs must participate in national data registries to allow benchmarking, risk adjustment, and outcomes analysis 1. Quality measures should:

• Capture different quality domains beyond just cost reduction 1.
• Include equity and patient-reported health status measures 1.
• Align across payers when possible to reduce reporting burden 1.
• Counterbalance incentives to reduce costs inappropriately 1.

Operational Requirements

Care Coordination Infrastructure

• Interprofessional collaborative practice teams: Multiple health workers from different professional backgrounds (social work, public health, pharmacy, nursing, medicine) working together 1.
• Information technology infrastructure: Significant capital investment required for data sharing and care coordination 1.
• Comprehensive care plans: Promoting care coordination between providers, especially for chronically ill patients at high risk of hospitalization 1.

Provider Participation

81% of ACOs involve new partnerships between independent healthcare organizations 4. These partnership ACOs form for resource complementarity, risk reduction, and to meet legislative requirements 4.

Common Pitfalls and Challenges

Performance Concerns

• Mixed outcomes: Some studies show ACOs failed to demonstrate reduction in 90-day morbidity and mortality for certain procedures compared to non-ACO settings 1.
• Lower capabilities in partnerships: Partnership ACOs generally report lower capabilities on care management, care coordination, and health information technology 4.
• Patient selection risk: Concern exists about ACOs potentially avoiding enrollment of high-risk patients, though evidence remains conflicting 1.

Structural Barriers

• Specialist engagement challenges: Primary care-based attribution may not explicitly include specialist care, potentially misaligning incentives 1.
• Capital requirements: Substantial infrastructure costs and potential unequal cost-sharing between providers can be prohibitive 1.
• Volume considerations: Full-service laboratories performing fewer than 200 cases annually require stringent monitoring and collaborative relationships with larger volume facilities 1.

Financial Risk

ACOs must balance taking on appropriate financial risk without engaging in care rationing or denial 5. The model requires collecting meaningful quality data that rewards quality improvement, not just volume reduction 5.

Geographic Considerations

• Approximately 24% of non-metropolitan counties are included in Medicare ACOs 2.
• 119 Medicare ACOs operate in both rural and urban counties, with seven operating exclusively in rural counties 2.
• Geographic isolation is defined as emergency transport time to another facility exceeding 30 minutes 1.

Monitoring and Accountability

Programs failing to meet established performance criteria for two consecutive quarters must undertake improvement efforts, engaging outside experts if necessary 1. Failure to improve quality metrics should be grounds for program closure regardless of location 1.