Deciding to join, or start, a value-based care (VBC) contract is the right decision to be prepared for 2030, when CMS plans to have all Medicare and most Medicaid patients in a VBC arrangement. But which model is the right one for your organization?
Medicare Shared Savings Program ACO (MSSP ACO) and ACO Realizing Equity, Access, and Community Health (ACO REACH) Model are both excellent options with new entrant programs to assist with transitioning to the new payment models. Depending on factors such as how many attributed lives your organization has, your comfort in alternative payment models, your comfort and willingness to assume risk, and your bandwidth for submitting quality measures are some of the key areas to examine before deciding which model to join.
MSSP ACOs and ACO REACH Patients
MSSP ACOs require a larger number of patients than ACO REACH – a minimum of 5,000 attributed beneficiaries at all tiers of the program. MSSP ACO also has tiers of risk for the contract holder that helps with learning how to manage upside risk prior to entering a downside risk tier. As the ACO progresses through the tiers, the amount of shared savings able to be achieved increases along with the increases in shared loss risk. REACH ACOs have a varied minimum number of patients for each program type. For the 2025 performance year, New Entrant ACOs have a beneficiary aligned minimum of 4,000 with the requirement to grow to 5,000 by performance year 2026. High Needs ACO REACH programs have a minimum of 1,000 aligned beneficiaries in 2025 with a target of 1,250 by 2026. The Standard ACO REACH has a 5,000 minimum for aligned beneficiaries. There is also a mandatory downside risk element in all ACO REACH models. Depending on if the ACO REACH chooses a Professional ACO or a Global ACO will be a part of the determination of the amount of downside and upside risk the ACO REACH is responsible for.
Payment Options for MSSP vs. ACO REACH
Payment options are significantly different in the two models. The MSSP ACO model continues to pay providers through the Medicare fee for service (FFS) model. ACO REACH has a required fee reduction for participant providers (not for preferred providers) and the payment is sent from the ACO after the claims are processed by CMS. REACH ACOs who choose Professional REACH ACO operate under the Primary Care Capitation (PCC) model that includes a capitated payment to the ACO for specific primary care services that are shown to improve patient outcomes. ACOs who choose a Global REACH ACO model choose between PCC or Total Care Capitation (TCC) models. TCC includes capitated payments for Medicare Part A and B services to pay to the contracted providers. Choosing a Global model has more risk, but also has a higher shared savings potential as well. ACO REACH has flexibility with how they structure their payments and what reduction, or bonus payment, will be made to each provider or provider group in the ACO REACH.
Comparing Health Equity
Health Equity is a feature in both MSSP ACO and ACO REACH models. ACO REACH requires a Health Equity Plan and includes a Heath Equity Benchmark Adjustment (HEBA) to mitigate some of the increased costs associated with caring for underserved populations, currently identified by dual eligible status, Low Income Subsidy (LIS) status, and patients living in areas that show deprivation using the Area Deprivation Index (ADI). There is a requirement to collect and report Social Determinants of Health (SDOH) and patient reported advanced demographics data as well. MSSP ACO recently added Health Equity incentives to their program in 2023 with an optional advanced payment specifically for infrastructure investments needed to care for patients with higher needs such as dual eligible patients and patients who show deprivation according to the ADI. The MSSP model also has a health equity adjustment that provides bonus points on the MIPS quality performance for high performance addressing specific health equity and SDOH challenges.
Quality measurement is significantly different for these models. ACO REACH has claims based measures that reduce the administrative burden of submitting MIPS measures. MSSP ACOs have a choice between two options for reporting quality, with Web Interface (WI) mode being phased out as a reporting framework after 2025. Using WI method, the MSSP program needs to submit 10 total measures – seven on clinical quality, two claims-based measures, and CAHPS. Electronic Clinical Quality Measures (eCQM)/MIPS CQM has six total measures – three clinical quality measures, two claims-based measures, and CAHPS. The administrative burden for ACO REACH quality measures is minimal, and MSSP ACOs who have the capability to submit eCQMs directly from their certified EHR will also show a reduction in the usual work effort in submitting quality measures manually. While these are not the only factors to consider when starting or joining an ACO, these are some key areas to consider when determining which method of entry into the VBC models cold work best for your organization. Luckily, Acclivity has subject matter experts (SMEs) and built-in tools for both models to help your ACO be as successful as possible.
Visit the Acclivity ACO page for more information and helpful resources.
Carol Javens, RN, BSN, CHPN | Account Manager, Acclivity Health Solutions