Following Caravan Health’s recently completed acquisition by Signify Health, Caravan CEO Tim Gronniger spoke with Healthcare Innovation about the synergies between the two companies and what he likes about the new ACO REACH model.
Gronniger, who has worked at Caravan for four and a half years, said the company has strengths in ACO enablement, in building robust primary care networks organized around community hospitals in rural areas and their affiliated practices that are independent. “Last year, we identified as an area for growth the ability to better support post-acute care services — following patients after a discharge, helping navigate through nursing facilities, rehab facilities and back to home at appropriate points in time, as well as a number of software development activities in supporting patients in home-based care as well," he said.
“As we were out looking at our options for how to build those capabilities, we met Signify, which had already built those capabilities through their in-home evaluation business that is going to be in 2 million Medicare Advantage homes this year, as well as their episodes of care business, which is care transformation organized around specialty networks,” Gronniger continued. “The fit was perfect, because they had a whole bunch of capabilities we wanted, and they didn't have a robust primary care enablement platform. Bringing the two together was a no-brainer, once we dug into it. It has been really gratifying to go out and talk to clients with Kyler Armbrester, our CEO, and lay out the new capabilities and the new services that we can bring clients.”
I asked Gronniger, if there was a need to bring both companies onto a single technology platform.
“We do have a number of platforms across the company at this point, and obviously we want to strive for the best customer experience possible,” he responded. “I think that, for now, we're continuing to use the multiple applicable platforms where they make sense. Long-term, we obviously want to have everyone on the same platform, and not just for the Medicare Shared Savings Program or ACO patients, but have the same platform for Medicare Advantage and commercial patients as well. So long-term we've got some building to do. But right now, our disparate platforms are working together just fine.”
In part to quell criticisms of the its Global and Professional Direct Contracting (GPDC) model, the Center for Medicare and Medicaid Services (CMMI) announced the ACO REACH (Realizing Equity, Access, and Community Health) model will replace it in 2023. I asked Gronniger about this transition.
“We were enthusiastic that CMS was able to turn the page on that and to really clarify with their public messaging some of the less accurate criticisms and demonstrate that there still is patient choice, there is still robust patient involvement and governance,” Gronniger said, adding that there are other positive changes with ACO REACH. “There are a lot of opportunities for providing non-traditional services to patients to help them better stay connected to their to their providers,” he said. “We are excited about the opportunity to, for example, not just waive co-pays for chronic care management services, which can be a real barrier, but also to provide up to $75 of incentives for engaging with chronic care management services.”
In ACO REACH, he added, there are better ways to provide follow-up care to patients in the home. There's a continued ability to leverage remote care and provide remote care management services that are available in ACO programs and in fee-for-service today, but that will go away as soon as the public health emergency expires.
“The capitation structure is something that is very attractive for providers who are willing to invest in this,” he said. “That allows you to get away from that hamster wheel of having to provide that same 15-minute visit for every patient and get the same fee-for-service rate for every patient — even those who need really intensive attention from a higher-level practitioner, like a physician. Now you have the ability to parse a number of your patients into management by phone call where appropriate, or by non-physician staff follow-up and spend more of your time on the higher-need patients in the office setting. That capitation structure underlying the program is super-important and is something that a number of our clients are interested in tapping into.”
Overall, Gronniger said, “we think there's a lot to like here. There's an opportunity for experienced ACO participants and operators, and there are multiple years of runway here. This isn't really a program for beginners, from our perspective. This is something that needs population health experience to succeed at. We would take new clients through progression in the basic program, that MSSP entry-level program, build the capabilities, expand access, ramp up your preventive care and care management capabilities, and then be ready to go into a more advanced program as early as year two.”
ACO REACH has significant requirements around developing equity plans to reduce health disparities. That is relatively new for CMS and was a core part of updating the model. These requirements look a little bit like a community health needs assessment process, Gronniger noted. “We want it to be much more actionable and engaging than that, though,” he said. Community health needs assessment documents have tended to be bureaucratic and formulaic. “We want to approach this from a perspective of identifying on a patient level what social needs might be affecting their care or their health,” he said. For example, clinics can identify patients who are struggling with access to transportation to be able to see their provider or struggling with co-pays.
One of CMMI’s stated goals with ACO REACH is to attract different types of providers working with underserved populations, such as Federally Qualified Health Centers (FQHCs), to participate in value-based care arrangements.
Gronniger stressed that there are multiple ways to bring people into the program — you don't have to be the primary contract holder to be serving patients in the REACH program. “We have a number of FQHC clients that could be candidates for this program over time,” he said. “You can think of it on an individual practitioner level as well as activating social workers and bringing community health workers into the full wrap-around primary care services in a way where they don't have to become the contracting entity with CMS, but they can be enriching the patient's experience and helping them avoid bad outcomes.”
CMMI also has talked about a goal of streamlining alternative payment models. I asked Gronniger if that would be a welcome change.
“I think it's more important for CMS as a policy objective than it is for a lot of providers right now,” he said. “I think that CMS needs to get its arms around where it wants these programs to go, where they're investing their resources in growing population-based models and bundled payment models. They want to get to a point where they have a more digestible and manageable portfolio, because they they're trying to drive participation in risk-sharing programs to 100 percent of Medicare by 2030. If you do that, you don't want providers to have to choose five competing programs off the menu; you want a really robust set of options that all work together as a unified whole. And we definitely haven't gotten to that point yet. We have programs where there are different benchmarks in different roles, depending on which program you choose, and that does lead to confusion and inefficiency for both providers and CMS.”
I noted that CMS also has had challenges figuring out how to engage more specialists in value-based care programs.
“That has been a definite problem for CMS and for the value-based movement,” Gronniger agreed. “Overall, I'd say ACOs, and I would include Caravan in this historically, haven't done a great job of engaging specialists or in delivering the best care for patients who are experiencing specialty care episodes or are experiencing really sick episodes. It was one of the gaps that we were looking to address, and that I think with Signify we have the ability to support that now. If you have a patient who is recovering from a heart attack or a patient with cancer, most ACOs do very little with those patients.”
Gronniger reiterated that CMS’ goal is to get 100 percent of patients in accountable relationships by 2030. He estimated that for half of patients, if they are experiencing a significant health event, the most important relationships they are going to be in is with their specialists. “Long-term, even medium-term, CMMI does need to get their arms around that,” he said. “I think that starts with the bundled payment program, which ends after 2023. That is 18-plus months from now, but CMS hasn't indicated what's going to come after that, other than they want it to work well with the ACO programs. I'm completely supportive of that approach, but they need to avoid having big gaps in that program, and they need to connect it more clearly so that we can get more specialists involved and get more accountability baked into these programs for the whole continuum of care, not just primary care.”
