3 Ways to Use Enhanced Primary Care Services as Part of ACO FLEX

In CareJourney’s recent blog post, we highlighted CMMI’s new ACO FLEX model that offers an innovative structure for providers to deliver high quality, coordinated primary care. One of ACO FLEX’s key features is a prospective payment for enhanced services that’s expected to bolster positive outcomes, particularly among underserved populations. Medicare has leveraged similar alternatives to fee for service reimbursement in other models including ACO REACH, Primary Care First, the Medicare Shared Savings Program’s Advance Investment Payment initiative, and the upcoming States Advancing AllPayer Health Equity Approaches and Development (AHEAD) model.

We have also seen these fixed payments for enhanced services in specialty care models as well. Participants of the Oncology Care Model, for example, were able to use the Monthly Enhanced Oncology Services (MEOS) payments to drive care transformation.

Embracing Enhanced Services For Your Practice Group

Below, we summarize three specific examples of enhanced services that a participant of ACO FLEX could use their new prospective funds to support.

Example 1: Implement and expand patient navigation services

One way successful value-based care organizations (VBCs) are implementing enhanced services is through patient navigation. These patient navigation services offer invaluable support to patients and their families as they move through a complicated healthcare ecosystem.

Navigators conduct an array of services including patient education and empowerment, coordination of care across different providers and settings to drive continuity, and coordination of resources to address health related social needs. These services directly impact patients and promote better health outcomes.

Yet while patient navigation optimizes resources and enables better patient outcomes, many provider organizations lack sufficient funds to implement these resources. In CY2024, CMS introduced new Principle Illness Navigation codes that are expected to help improve the financial viability of navigation services, particularly for practices treating a high proportion of patients with qualifying high-risk conditions.

However, the ACO FLEX predictable revenue stream and broader application of enhanced payments will better allow value based care organizations to scale this service for their patients.

Example 2: Screen for and address social determinants and drivers of health

Delivering holistic, patient centered care extends beyond treating patients’ medical needs. Recognizing and addressing patients’ social determinants and drivers of health is a key piece to reducing unwarranted variation in health outcomes. Many providers, however, have not adapted mechanisms to identify and meet these needs, with resource constraints being a barrier to greater adoption.

This brings us to our second way successful VBCs are utilizing enhanced services. Social needs screening tools enable providers to identify unmet social needs, such as food insecurity, transportation barriers, housing instability, financial challenges, social isolation, and lack of access to education and employment opportunities that may be negatively impacting their patients’ health. Once social needs are identified, providers can better tailor care plans for their patients. For example, if a patient is struggling with food insecurity, their provider can offer meal vouchers and connect them with community resources such as food assistance programs. If a patient does not have transportation to medical appointments, their provider can provide vouchers for ride shares.

Coupled with hiring new patient navigators as discussed above, the enhanced payments received under ACO FLEX can be used to screen and address these exact needs that otherwise inhibit optimal health outcomes and value based care.

Example 3: Enable health information exchange participation

A Health Information Exchange (HIE), or tech-enabled infrastructure that enables electronic sharing of information among healthcare organizations, is a valuable tool to support care coordination, transitions of care, quality improvement, and population health analysis. Leveraging interoperability standards, HIEs aggregate information from disparate sources such as EHRs, pharmacies, public health registries, and other lab and imaging providers to offer more complete and timely patient information in support of patient centered care.

With cost and resource constraints often being a barrier to HIE participation, ACO FLEX participants can use their enhanced payments to invest in technology, staff training, ongoing maintenance and HIE participation fees. Through the HIE participation, VBCs gain more data on their patients and can leverage more holistic patient insights – achieving better outcomes for those patients.

Amplifying the Impact of Enhanced Services

Patient navigation, screening for and addressing social drivers of health, and participation in a HIE are crucial enhancements that allow providers to deliver higher value, patient centered care. In isolation, however, these new capabilities will fall short of being truly transformative.

Providers must integrate and ignite the power of these enhanced services through care redesign activities and timely, actionable insights. The Beneficiary Claims Data API (BCDA), available to Medicare ACOs including ACO FLEX participants, helps providers build on the momentum of enhanced capabilities to drive real results.

As mentioned in our previous blog, the BCDA program enables improved care coordination, as well as detection of early health trends. Imagine the impact of knowing a new chronic disease diagnosis weeks earlier, identifying a social needs barrier, and most importantly – being financially able to intervene to improve a patient’s care.

In tandem, BCDA and enhanced service payments allow just that – earlier utilization histories, preventative screening flags, diagnoses records, and transitions of care coupled with the ability to address social needs, help patients navigate services, and see the most complete picture of patient journeys.

In partnering with CareJourney and Arcadia, organizations combine BCDA feeds with other data sources. On top of these data assets, we apply predictive modeling and rigorous insights to drive action — identifying patterns, early signals, and patient needs to provide the highest quality of care. This enables the maximum impact for patients when organizations utilize these insights to allocate their enhanced services payments.

About CareJourney by Arcadia

CareJourney was founded in 2014 under the belief that our nation’s transition to value-based care is an important one, but without an “operating manual” that can reliably deliver on the promise of better quality at a lower cost. Our mission is to empower individuals and organizations they trust with open, clinically-relevant analytics and insights in the pursuit of the optimal healthcare journey.

In mid-2024, Arcadia acquired CareJourney, blending CareJourney’s clinically relevant cost, quality, and benchmark data into its next-generation healthcare data platform and workflow tools. Together,we put data to work at the speed, scale, and sophistication required to grow high-performing networks, accelerate digital transformation, and succeed in value-based care.