From Direct Contracting Model to ACO REACH: Navigating the Continued Evolution of Value-Based Care in Traditional Medicare

With a speedy makeover for the Global and Professional Direct Contracting Model, CMS is making sure to incorporate lessons learned from previous value-based care programs. The revamped ACO REACH initiative aims to make it easier and more rewarding to embrace value-driven principles in traditional Medicare.

Introduction

Ever since the Affordable Care Act (ACA) became the law of the land in 2010, healthcare providers and payers have faced a rapid-fire array of programs, pilots, and projects designed to help achieve the legislation’s Triple Aim: improving outcomes, reducing costs, and offering better experiences to patients and their care providers.

Starting with the EHR Incentive Programs and continuing with the Quality Payment Program (QPP), the Medicare Shared Savings Program (MSSP), a flurry of smaller bundled payment models, and a dizzying number of regional or specialty-specific innovation pilots, the Centers for Medicare and Medicaid Services (CMS) has been very busy with innovation…

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Innovation is no longer optional for established health payers and digital native startups. Without revamping inefficient processes, payers risk falling behind in the race for provider participating providers and market share.
Here are the first steps payers can take on the path toward sustainable, successful innovation.

 

The health plan marketplace is evolving quickly as changing demographics, new regulations, and cutting-edge technologies sweep away the status quo. Both commercial health plans and Medicare Advantage (MA) plans are seeing increased competition for visibility and market share, especially as consumers become more and more savvy about their preferences and needs.

But are internal health plan operations innovating at the same rate? Unfortunately for many payers, the answer is “no.”

Even as an emerging class of fresh-faced, digital-first payers and direct-to-consumer (DTC) telehealth companies rises up to challenge the notion of business as usual, a worrying number of payers are still relying on manual processes and fragmented workflows for network development and maintenance. As a result, they are missing out on key opportunities and creating frustration for internal stakeholders and their external partners.

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