First Look at Open CMMI Model Data: Value-based Care Growth Drivers in 2022

Reaching Underserved Beneficiaries

One of the goals of ACO REACH is to provide quality care to underserved beneficiaries. ACO REACH uses the Area Deprivation Index combined with dual eligibility to identify underserved populations. We looked at the group of fee-for-service beneficiaries in the most deprived areas (top 10% of ADI scores) to see which groups are going into 2023 with the highest number of underserved beneficiaries. Right now, we see a total of 18,687 beneficiaries who live in an area with an ADI score greater than 90 who were aligned to a DCE in 2022. Of those, 2,848, or 15.2%, are voluntarily aligned.

The ACO REACH methodology does not simply decile the ADI scores as we have done here. The ACO REACH program calculates a monthly score by taking every beneficiary aligned to a REACH ACO that month, assigning them an ADI score, and adding 25 to it if that beneficiary was eligible for both Medicare and Medicaid in that month. They then stack rank all beneficiaries aligned to the REACH program and create decile breaks from that group. This ranking affects a REACH ACO’s monthly payment. REACH ACOs receive an extra $30 per beneficiary in the tenth (most distressed) decile each month, and they lose $6 per beneficiary in deciles 1-5. In the coming weeks we will delve further into what the distribution of beneficiary ADI+Dual scores looks like nationally and regionally.

As the 2023 performance year continues, we are committed to continuing our research into how much success ACO REACH has at bringing historically underserved populations into an accountable care relationship. As part of our research into the Retrospective Trend Adjustment in 2022, we learned that 17% of fee-for-service beneficiaries did not have any primary care spend in 2021. We also learned that minorities and beneficiaries dually eligible for Medicare and Medicaid (“Dual Eligible”) have moved to Medicare Advantage at an increased rate between 2020 and 2022. Our Principal Researcher Nate Smith published a paper showing that Medicare Advantage is now the primary payer beneficiaries who are both a racial minority and Dual Eligible.

2021-2022 Model Participant Growth

Of the 53 entities that were in Direct Contracting in 2021, 2 grew by more than 1000%, 12 grew by more than 100% and 18 grew by more than 50%.

Beneficiaries New to Value-based Care⁴

In 2022, 1,820,452 beneficiaries were aligned to a Direct Contracting Entity (“DCE”). 50% of those (911,084) beneficiaries were not part of the Medicare Shared Savings Program between 2016 and 2022, though we anticipate many had previously been aligned to an entity in the Next Generation ACO Program, or other models deemed by CMS to contribute towards the 100% goal.⁵

We intend to focus on the degree to which the DCE model expanded beneficiary access to accountable care as we incorporate all qualifying model data in the weeks ahead.

Providers New to Value-based Care

Similar to beneficiaries, of the 66,780 Participating Providers associated with a DCE, 43% of those (28,657 providers) were also not part of MSSP 2016-2021. Similar to our beneficiary analysis, once we receive all qualifying model data, we can determine which of these providers are truly new to value-based care.

Claims Based vs. Voluntary Alignment

Most beneficiaries (90%) were aligned to providers via “claims-based alignment.” Claims-based alignment looks at which primary care providers a beneficiary saw the most often and if those providers opt to participate in what is now ACO REACH, those beneficiaries are aligned with those providers and continue receiving their primary care from the providers they have historically seen the most often. 10% of the 2022 beneficiaries (179,423) were aligned via “voluntary alignment” – a process whereby beneficiaries sign a form either online or on paper that they wish to choose a particular provider as their own. Voluntary alignment is a critical strategy for bringing underserved populations to value based care because a higher percentage of these populations aren’t receiving any primary care and wouldn’t be claims aligned to a provider.

One nuance of the RIF data that we discovered is that beneficiaries are flagged as either voluntarily aligned or not. However, a beneficiary may actually be claims aligned and voluntarily aligned if they both received a majority of their primary care from a particular provider and signed a voluntary alignment attestation. In the chart below, we are unable to distinguish between beneficiaries who are only voluntarily aligned and those who are both voluntarily aligned and claims aligned. They all appear as “voluntarily aligned” in the data.

This nuance is important not just for research into how well the ACO REACH program is doing at reaching new beneficiaries, it is important for understanding the financial aspects of the ACO REACH program. Beneficiaries who are both claims and voluntary aligned will be viewed as claims aligned for risk adjustment and benchmark calculation purposes.

We at CareJourney are excited to continue exploring insights related to this data. We invite our members and industry stakeholders to share: what questions do you have about this data? Reach out to info@carejourney.com and let us know if there are areas of interest for your organization.