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June 20, 2022 Readers Write 1 Comment

How One ACO Used Analytics to Promote Health Equity: Lessons for the ACO REACH Model
By Michael Meucci

Michael Meucci is chief operating officer of Arcadia of Boston, MA.


A greater focus on promoting health equity is at the heart of changes CMS recently made to its direct contract model, now labeled as the Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) Model.

While an emphasis on health equity is long overdue, this shift creates challenges for ACOs in measuring, monitoring, and improving health equity – something that can’t happen without leveraging advanced analytics to account for those factors impacting a patient’s ability to effectively manage their health, otherwise known as social determinants of health (SDoH).

A CMS Direct Contracting Entity, Massachusetts-based Community Care Cooperative (C3) incorporated advanced analytics and tight partnership with community agencies into its health equity program under the MassHealth Medicaid ACO program, driving significant improvement in the health of its diabetes patient population, in addition to a reduction in its total cost of care, positioning C3 for eventual success under the new model.

The US Centers for Medicare and Medicaid Services (CMS) launched the ACO REACH model in February, highlighting the organization’s commitment to “promoting value-based care that improves the healthcare experience of people with Medicare, Medicaid, and Marketplace coverage.” To that end, CMS requires all model participants to develop and implement “robust” health equity plans to identify underserved communities, in addition to implementing initiatives that “measurably” reduce health disparities within their patient populations.

Next, CMS placed a high priority on ensuring that medical providers play a prominent role in ACO REACH participating organizations, requiring that at least 75% control of each ACO’s governing body must be held by participating providers or their designated representatives. That number is a significant jump from the 25% requirement held by the ACO REACH model’s predecessor, which was known as the Global and Professional Direct Contracting Model.

Additionally, the new ACO REACH model is designed to deliver better protection to patients through more ACO participant vetting, monitoring, and greater transparency. CMS will look to accomplish that by asking for more information on applicants’ ownership, leadership, and governing boards to gain better visibility into ownership interests to ensure participants’ interests align with CMS’ vision.

The new model’s first performance year begins on January 1, 2023, with the model planned to run for four performance years through 2026. Applications to participate in the first year were due near the end of April 2022.

For patients, the promise of the model is better care, but with a greater focus on addressing SDoH, such as barriers to transportation, nutrition, and healthcare. For providers, the ACO REACH model offers the potential of a more predictable revenue stream and the ability to use those funds more flexibly to meet their patients’ needs.

Community Care Cooperative is an ACO that formed when the state of Massachusetts launched the MassHealth ACO program. MassHealth, which combines the state’s Medicaid and the Children’s Health Insurance programs, has emphasized engaging with community partners to help treat the whole patient, including addressing social needs that are barriers to care. C3 was created by a network of Federally Qualified Health Centers (FQHCs) to better serve their communities by providing more opportunities for individuals to receive coordinated, holistic, and culturally appropriate care in the communities where they live and work.

Incorporated in 2016, C3 serves over 170,000 MassHealth members with a total cost-of-care budget of $1 billion at 18 statewide health centers. In early 2020, inspired by the national conversation around equity, C3 launched a health equity program aimed at addressing physical and behavioral health needs, in addition to SDoH such as nutrition and housing. Earlier this year, C3 submitted its application to CMS to become a REACH ACO.

C3 started its health equity initiative in 2020 by collecting self-reported SDoH data from members, including race, ethnicity, and language information. While self-reported data may not be perfect, it is a good starting point to begin understanding the challenges facing a population of patients.

Next, C3 formed a diversity, equity, and racial justice committee to examine its patient data to investigate areas for improvement, in addition to thinking about ways to most effectively use the data in its possession. For example, the committee investigated whether the racial and ethnic makeup of patients referred to outside social services agencies was representative of the group’s overall patient population, in addition to the racial breakdown of immunization rates for two-year-olds.

To promote greater transparency, C3 has established a scorecard of key metrics pertaining to not just the usual operational numbers such as cost and utilization, but also data pertaining to health equity, such as comparisons of hypertension control by patients’ race and ethnicity. At each leadership meeting, these scorecards are posted for each of C3’s 18 health centers, prompting discussions of how to improve the metrics.

Perhaps most importantly, the attention to detail around data has led C3 to establish several experimental “flex” programs under Medicaid that are also known as “Section 1115 Demonstrations,” in which C3 partners with various social-services organizations (SSOs) that specialize in addressing SDoH, such as helping patients obtain housing or groceries.

For example, in one demonstration, C3 partnered with an SSO that delivered nutritious meals to patients’ homes. The program yielded impressive results: 68% of members with diabetes who received home-delivered meals had lower HbA1c scores in their post-enrollment tests compared with their pre-enrollment tests. Similarly, the percentage of diabetes patients with HbA1c scores that indicate their diseases are well-controlled grew significantly as a result of the home-delivery program, from 38% prior to the program to 71% after.

Additionally, the home-meal delivery program led to a substantial drop in the cost of care. In the six months after enrollment, total healthcare costs for the 456 patients enrolled in the program dropped by an average of more than 30%, from $17,902 to $12,349, compared to the six months prior.

C3’s experience with using analytics to improve health equity offers an example that ACO REACH participants can emulate. In the future, C3 looks to leverage the cost savings its programs generate to launch expanded initiatives that promote greater health equity.

Christina Severin, president and CEO of Community Care Cooperative, contributed to this article.

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Currently there is "1 comment" on this Article:

  1. Although I LOVE this new program with emphasis on health equity through a measurable and reimbursable process… I would like to learn more about the non-pharmaceutical interventions reported in the interview. It would make clinical sense for improved attention to nutrition would have positive impacts on glucose control and possibly cost, how this is measured is really important. Since most newly diagnosed diabetics will likely stabilize and regress to the mean, the clinical and cost improvements could have happened regardless of the intervention. I think we need to have good research to show that community based organization interventions actually do improve outcomes… and even if it costs something to do that, it probably is worth it. Dr. Paul Farmer with Partners in Health famously demonstrated how prescribing food to HIV patients in Haiti remarkably improved outcomes. Is their a growing base of evidence someone can point me to? Thanks!

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