CMS Primary Care Flex Model: Is It For You?

Healthcare organizations that want to participate in the new ACO Primary Care Flex Model (ACO PC Flex) have until August 23, 2024, to submit their applications. The opportunity to participate in the newest Medicare program prompts some important questions. First, should your organization participate? What makes this program different from others? Are there features that could impact and improve outcomes—clinical and financial? We believe there are.

Like many CMMI and CMS programs, ACO PC Flex also has a set of focused industry goals: expand access, focus on primary care, address social determinants of health, shift the cost-to-quality ratio, and improve the patient experience.

What’s promising about this program is the “how” which is based on an idea we call “localized scale.” The program recognizes the community-oriented nature of primary care for seniors while also funding the infrastructure that includes the expertise, effectiveness, and efficiencies of scale. To use a sports analogy, think of it as being able to punch above your weight.

Four attributes relate to localized scale:

• Proactive Care: The program rewards finding, guiding, and keeping beneficiaries engaged in advance of potentially more serious health issues. It takes an engaged local primary care team—enabled with the right predictive data, prescriptive interventions, and outreach tools—to do this at a higher level of frequency and personalization that only supportive automation can provide, accurately and affordably.
• Social Needs: Like care delivery, the factors impacting social needs are typically highly localized. But the ability to identify those needs, make countless connections a day to community-based organizations, know if those referrals have been acted upon, and measure the impact—that takes a tool that can scale care team members beyond their current capacity.
• Hyperlocal vs. Regional: A history of inappropriately low spending in underserved areas and populations is well documented. Two Medicare beneficiaries living in the same area but in different neighborhoods can have vastly different care and even greater outcome disparities. This program aims to tackle long-standing equity patterns by providing a payment rate scaled to the county average.
• De-Risked Prospective Payments: Programs often underinvest in capabilities such as patient navigation and behavioral health integration when future payments are not reliable. In this model, primary care payment enhancements will not be put at risk— meaning they will not be recouped by CMS. Participants are far more likely to invest in durable, scalable resources versus short-term, make-do tactics with this kind of long-term predictability and stability.

ACO PC Flex is designed for low-revenue ACOs, meaning ACOs with total revenue less than 35% of what Medicare is spending on their assigned beneficiaries. Low-revenue ACOs generally are smaller, local, new, and/or provider-led entities.

This is where “the how” comes in. ACOs can use the program’s structure to manage their programs with tools and resources that previously were only available to more mature or larger-scale ACOs. Upfront, the one-time Advanced Shared Savings Payment can offset administrative costs associated with deploying the model and help cover costs associated with forming a new ACO. Ongoing, the payment model attributes (e.g., county-based rates and payment enhancements not tied to performance-based risk) offer more reliable funding for local team-based care and scaled provider infrastructure.

Funding to Invest in Technology

Why do operational investments play such a pivotal role in this program? CMS is not just recognizing, but also funding key resources deemed essential for these ACOs to succeed with some of the most challenging Medicare populations. Technology infrastructure factors into the power of localized scale:

• Technology enables organizations to know their patients as more than attributed lives. A comprehensive data view provides the ACO with insights into individual patients, enabling better, more holistic care. And, at a larger scale, data provides insights into patient populations, utilization patterns, and care outcomes that inform risk strategies and support providers in making informed decisions about care delivery and resource allocation, as well as complying with requirements, and monitoring and reporting on results.
• Technology enables teams to care for patients and collaborate across a network. The most successful ACOs enable providers with ready access to data at both the individual patient level and aggregated. A key requirement is the ability to share data among providers, services, and settings, enabling care coordination. Having accessible centralized data, a unified patient record and a single source of clinical and financial truth with advanced analytics enables ACOs to manage each patient, and the combined population, more effectively.
• Technology accelerates the ability to make improvements in programs—now and in the future. Many programs, both government and commercial, depend on similar performance improvement expectations including cost, quality, utilization, compliance, reporting, care coordination, and experience. Once scalable technology is in place, it often only takes incremental investments to apply data, insights, and workflows beyond a single program.
• A technology platform enables all users to have access to innovations as well as routine requirements. When a regulatory interpretation is released, everyone can get the update. When one participating ACO determines an effective clinical intervention, the higher efficacy workflow can be made available to others. When new capabilities like AI or advanced analytics are available, all clinics and providers in a network can access them without having to update individual instances.
• Technology can act as a co-pilot, redistributing tasks for the benefit of the staff and the patient. A centralized call center can handle routine inquiries or outreach that could clog a community clinic’s lines. A care manager can be prompted in real time with AI for care gap closures so their limited capacity is spent on the highest priority needs. The local primary care provider can focus on the patient in front of them while simultaneously being fed contextualized prompts from advanced analytics generated from millions of patient encounters.
• Technology can boost patient engagement. Programs like ACO PC Flex are based on individual behavior changes at the scale of a population. Patients need to attend appointments at the most appropriate site of care or be able to contact their provider when their health changes. But not every outreach needs to be personal to feel personalized. Automation, based on proclivity models, allows the care team to engage both 1:1 and 1:many, while also improving the effectiveness because the technology learns to adjust to each patient over time.

The Power of Industry Scale Applied Locally

With ACO PC Flex, CMS recognizes that when ACOs are able to invest in operational infrastructure, they are more likely to yield results. The increasing investment and adoption of value payment models by larger organizations has paved the way for smaller, new, or underserved-focused ACOs to benefit from similar tools and resources.

Through this lens, the opportunities are potentially game-changing. ACO PC Flex, coupled with a strong data infrastructure, analytics capabilities, and AI tools, can enable ACOs to optimize their value-based care contracts. This also enhances a host of other capabilities including population health management , risk stratification, decision support at the point of care, continuous care across multiple settings/providers, and robust data analytics.

Evaluating whether to voluntarily participate in a new five-year program requires looking at the conditions for success. As released, there are relevant reasons to believe that the ACO PC Flex Program offers structural features that can more predictably create sustained financial and clinical results, as well as enable provider networks and their patients to have the type of engaged experience that truly changes lives.

How ACOs in REACH, MSSP, and Other CMS Models are Leveraging Innovaccer’s Platform to Enhance Performance and Outcomes

Innovaccer is at the forefront of helping provider organizations move beyond technology point solutions and basic interoperability to true data activation, advanced analytics, and predictive insights, with intuitive end-user applications for the care team and program management.

Innovaccer's platform has enabled several MSSP ACOs to achieve shared success. For instance, CHI Health Partners realized $5.2 million in value, Franciscan Health increased potential revenue and achieved labor savings of nearly $11.5 million and $18,000 respectively, and Atlantic Health improved quality gap closure by 6.7% while also securing over $1 million in potential annual incentive payments.

Request a call or demo today to explore how Innovaccer’s solutions can propel your ACO toward similar success.