August 15, 2022

Volume XII, Number 227

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August 12, 2022

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REACHing for More

The new, value-based ACO REACH Model[1] reflects the Biden-Harris Administration’s mission in promoting health equity, with a strong focus on improving access to healthcare for individuals in underserved communities.[2] Payments to participating accountable care organizations (“ACOs”) in this model will be based, in part, on the “measurable reductions in health disparities within their participating beneficiaries.”[3] The ACO REACH Model has five policy mechanisms[4] guiding its mission of improving health equity and reducing disparities, including creating a new benefit enhancement.[5]

The ACO REACH Request for Applications (“RFA”), published by the Centers for Medicare & Medicaid Services (“CMS”) on February 24, 2022, [6] retained some of the benefit enhancements previously available to ACOs structured as Direct Contracting Entities (“DCEs”).[7] It also introduced a new benefit enhancement, which is Nurse Practitioner Services.[8] These benefit enhancements create flexibility in managing beneficiary care by waiving certain Medicare payment requirements that might otherwise prohibit these services.[9] ACO applicants do not need to implement any of the benefit enhancements to be accepted into the ACO REACH Model.[10] However, applicants intending to use any benefit enhancements must provide information in their applications regarding proposed implementations.[11]

CMS continued the previous Telehealth[12] benefit enhancement for covered dermatology and ophthalmology services.[13] Other benefit enhancements available in the DCE Model, such as the Home Health Homebound Waiver and the 3-Day Skilled Nursing Facility Rule Waiver,[14] will also be available in the ACO REACH model.[15] CMS increased the calendar year limit on Care Management Home Visits from twelve[16] to twenty visits;[17] however, those visits are still intended to supplement, rather than substitute, visits to a primary care practitioner.[18]

The addition of Nurse Practitioner Services is expected to increase flexibility in caring for more REACH beneficiaries, while reducing costs by necessitating fewer clinician visits.[19] Absent state law restrictions on the scope of their practice, nurse practitioners in an ACO REACH will be permitted to:

  1. Initially certify that a REACH beneficiary is terminally ill and in need of hospice care;

  2. Certify the need for diabetic shoes, when the nurse practitioner is practicing incident to the physician supervising the beneficiary’s diabetic condition;

  3. Establish, review, and sign a written care plan for a REACH beneficiary’s cardiac rehabilitation;

  4. Establish, review, sign, and date a REACH Beneficiary’s home infusion therapy plan of care prescribing the type, amount, and duration of infusion services to be furnished to a REACH beneficiary; and

  5. Refer REACH Beneficiaries with diabetes or renal disease to dieticians or nutrition professionals for medical nutritional therapy.[20]

The use of Nurse Practitioner Services may be especially useful in providing professional services in underserved communities.

The ACO REACH Model appears poised to capitalize on the projected growth in nurse practitioner numbers, potentially driving down health care costs by increasing the number of available providers. The American Association of Nurse Practitioners’ 2022 fact sheet indicates that there were, at that time, more than 355,000 nurse practitioners licensed in the United States, and that 81% of full-time nurse practitioners treat Medicare patients.[21] A 2021 calculation by the Association of American Medical Colleges indicated that, assuming the current growth trends in the number of new providers trained continue, the number of advanced practice registered nurses, including nurse practitioners, could grow by another 309,000 full time employees by 2034.[22] The rapidly growing number of nurse practitioners (and physician assistants) is exceeding the rate of growth in demand for health care services.[23]

Except for the 3-Day Skilled Nursing Facility Rule, Nurse Practitioner Services, and other benefit enhancements are not provided in the traditional Medicare Shared Savings Program model.[24] If value-based models retain the strong focus on health equity moving forward, an ACO REACH may call on its benefit enhancements to help it succeed.


FOOTNOTES

[1] ACO REACH stands for “Accountable Care Organization Realizing Equity, Access, and Community Health,” a new value-based model for ACOs arising out of the Global and Professional Direct Contracting (“GDPC”) ACO Model. CMS redesigned and renamed the GDPC Model in response to and to reflect changed administrative priorities. Centers for Medicare and Medicaid Services, ACO REACH, https://innovation.cms.gov/innovation-models/aco-reach (last visited May 18, 2022).

[2] Centers for Medicare and Medicaid Services, ACO REACH, https://innovation.cms.gov/innovation-models/aco-reach (last visited May 18, 2022).

[3] Helaine Fingold, Philo Hall, et al., CMS Framework for Health Equity: An Opportunity for Client Advocacy (May 23, 2022), https://www.jdsupra.com/legalnews/cms-framework-for-health-equity-an-843...

[4] The five policy mechanisms are: (1) ACOs must create and implement a Health Equity Plan; (2) ACOs apply a beneficiary level adjustment, increasing the benchmark for those ACOs serving high proportions of underserved beneficiaries; (3) ACOs must collect and report demographic data and social determinants of health data; (4) create the Nurse Practitioner Services Benefit Enhancement; and (5) ACO applications will contain both health equity questions and scoring. Id.

[5] In this article, for emphasis, the authors have capitalized the names of different benefit enhancements. Capitalized benefit enhancements have the meanings set forth in the applicable ACO model’s request for applications as discussed in notes 6 and 7 infra.

[6] Centers for Medicare and Medicaid Services, ACO Realizing Equity, Access, and Community Health (REACH) Model Request for Applications, pp. 70-77 (February 24, 2022), https://innovation.cms.gov/media/document/aco-reach-rfa.

[7] Centers for Medicare and Medicaid Services, Direct Contracting Model: Global and Professional Options Request for Applications, pp. 57-62 (November 25, 2019), https://innovation.cms.gov/files/x/dc-rfa.pdf.

[8] See ACO Realizing Equity, Access, and Community Health (REACH) Model Request for Applications, supra note 6.

[9] Id. at 70.

[10] Id.

[11] Id.

[12] Referred to as the “Asynchronous Telehealth” benefit enhancement in the DCE Model. See Direct Contracting Model: Global and Professional Options Request for Applications, supra note 7, at 58.

[13] The ACO REACH model, as with the DCE Model, recognizes two categories of Medicare providers and suppliers: preferred providers and participant providers. The ACO REACH Model would permit an ACO REACH beneficiary’s home to be an originating site for telehealth, waives the rural geographic component of the originating site requirement, and waives the originating site fee requirement when the beneficiary’s home serves as the originating site for telehealth services furnished by an approved preferred provider. Section 1899(l) of the Social Security Act permits participant providers to access these same flexibilities without the CMS waiver and to receive payment for telehealth services furnished to ACO REACH beneficiaries. See ACO Realizing Equity, Access, and Community Health (REACH) Model Request for Applications, supra note 6, at 15, 72. See also 42 U.S.C. § 1395jj.

[14] See Direct Contracting Model: Global and Professional Options Request for Applications, supra note 7, at 58-60.

[15] See ACO Realizing Equity, Access, and Community Health (REACH) Model Request for Applications, supra note 6, at 71-74.

[16] See Direct Contracting Model: Global and Professional Options Request for Applications, supra note 7, at 59.

[17] See ACO Realizing Equity, Access, and Community Health (REACH) Model Request for Applications, supra note 6, at 73.

[18] Id.

[19] Id. at 75-77.

[20] Id. at 76-77.

[21] American Association of Nurse Practitioners, 2022 NP Facts (April 2022), https://storage.aanp.org/www/documents/NPFacts__40722.pdf.

[22] Association of American Medical Colleges, The Complexities of Physician Supply and Demand: Projections From 2019 to 2034, p. 47 (June 2021), https://www.aamc.org/media/54681/download.

[23] Id.

[24] See Physician’s Advocacy Institute, Comparison of QPP Accountable Care Organization (ACO) Alternative Payment Models (2022), http://www.physiciansadvocacyinstitute.org/Portals/0/assets/docs/Advanced-APM-Pathway/Comparison%20of%20ACO%20Advanced%20APMs.pdf?ver=M_42XZ-1LI6RythWim4lEg%3D%3D.

Copyright ©2022 Nelson Mullins Riley & Scarborough LLPNational Law Review, Volume XII, Number 159
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About this Author

Mike Segal Health Law Attorney Nelson Mullins Miami
Partner

Mike is the Chair of Nelson Mullins' Value Based Care Group. Throughout his legal career, Mike has practiced in a business management environment. For more than 25 years, he has been heavily involved in the creation and representation of large single specialty and multi–specialty physician groups.

He also has considerable experience in structuring all varieties of healthcare joint venture transactions, while keeping in mind the various regulatory issues. Additionally, he acts as general and special counsel to hospitals, large medical groups, and...

305-373-9430
Kyla Wonder Associate Raleigh North Carolina Healthcare Compliance Health HIPAA Nelson Mullins Riley & Scarborough LLP
Associate

Kyla focuses her practice on assisting healthcare providers with healthcare regulatory compliance in the rapidly evolving healthcare industry and a variety of transactional matters, including mergers and acquisitions, licensure, and operational matters. She has experience with HIPAA, the Stark law, and diverse Medicaid and Medicare issues, including overpayment audits, fraud and abuse, and provider reimbursement with an interest in managed care models. She has represented healthcare entities in employment, recruitment, and services arrangements.

...
919-329-3871
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