In February, executives from the Center for Medicare & Medicaid Innovation (CMMI) discussed the upcoming LEAD alternative payment model, which starts in 2027 and aims to increase participation among small, rural, and independent primary care practices while focusing on high-need populations and long-term cost savings. After reporting on that presentation, Healthcare Innovation followed up with a discussion about LEAD with Matt Chance, CEO, and Will Robinson, senior vice president of strategic partnerships, for HarmonyCares, which operates in-home primary care practices in 12 states and participates in the high-needs track of the ACO REACH model. 

Healthcare Innovation: The execs from CMMI spoke about LEAD as a good transition from the ACO REACH model. I thought it would be interesting to hear your perspective on that.

Chance: We're excited about what we're seeing with LEAD. We've put a lot of work into advocating in this area. It's been important for us to have a voice through the Complex Care Alliance. It's also been good to have a team at CMMI that's listening and open to feedback around how these programs can serve high-needs beneficiaries in a better way. 

Because MSSP probably doesn't fit an organization like us the way that we would like. The recognition that there's a distinct population here that has complex illnesses — that really hasn't been the focus overall. We think LEAD does a pretty good job of recognizing this population and making sure this population is taken care of in a differentiated way. CMMI and CMS see that as a huge place for opportunity for them, both on the service side and on the savings side. One thing that sticks out with LEAD is accurate benchmarking for patients.

HCI: Was benchmarking something that was a challenge in ACO REACH, but that CMMI says they are going to do better on in LEAD? 

Chance: Yes, One issue we've advocated around is that the way those benchmarks are built and how they're pulled together doesn't really account for this kind of subpopulation of patients with complex needs. So for us, having a designation around that, and making that a piece of how you build the models is really important.

HCI: Could you talk about the results that CMS saw from the high-needs ACO segment of ACO REACH, both financially and in terms of quality?

Chance: We saw differentiated outcomes and differentiated savings rates from our baseline MSSP population. We were able to serve this population for things that are perhaps outside of the normal healthcare infrastructure. 

Also, the way we think about alignment and prospective risk adjustment in this versus retrospective risk adjustment is important as well. You're pulling in these patients, and you want to be able to get them into your practice quickly, so that you can get the impact that you want to be able to make. You've got to have mechanisms to do that, and MSSP just wasn't built around that. 

Robinson: What really matters here is being able to help these vulnerable people when they are experiencing difficult times in their lives. CMS does evaluations of these models, and they've done separate evaluations of the high-needs track versus standard versus new entrant. Those evaluations have been neutral to actually pretty positive. One of the evaluations recently showed that there's a 3.5% gross savings rate. If you look at all of the things that are driving those savings — reductions in hospitalizations, reductions in ED visits, increases in primary care services, increases in home health utilization — they are things that you would expect to see when you're taking this very sick population and moving them from higher acuity facilities and care settings and stabilizing them in the home. 

We operate in both MSSP and high-needs REACH because of the way that high-needs REACH eligibility is defined at the patient level. What they've said is that if you're a high-needs REACH ACO, you can only have patients qualify for the model if they meet very specific and rigorous clinical criteria. So even if patients are expensive and look like a high-needs patient, they may not actually qualify. And that has been a hard thing for high-needs organizations, because you never know if one of your patients is truly going to make it into the model, until either the claims-based alignment process works through or you submit a voluntary alignment form. 

One of the big things that the Complex Care Alliance advocated for strongly and is a foundation of the way that LEAD is designed is that all of your patients can be in. It’s just that the folks that are high-needs-eligible will have that differentiated and more accurate risk adjustment and benchmarking approach that I think will make things a lot less complicated for ACOs and for care organizations that focus on this very complex population, because they won't have to debate whether someone will or will not qualify for the model, which will be really nice.

HCI: Because there's a lag time in those CMS evaluations, there will be more evaluation periods for ACO REACH, so could we see further trajectory of improved quality and cost savings?

Robinson: I think that is likely. These evaluations are not easy to do. We do our own smaller-scale evaluations of the medical initiatives that we are doing. When you broaden it out to a complex model, doing rigorous evaluations is not simple, particularly with this subset of a very sick population. There are all sorts of technical reasons why it's challenging, but at a high level I think you're right that the evaluations should show continued improvement as they are published.

Chance: Because we’re talking about evaluations, one of the things that matters to us in LEAD is having a 10-year model that allows us to make internal investments in programs. 

We do things above and beyond what a lot of other primary care groups might do. We have an internal pharmacy. We staff a 24/7 call line that prevents a lot of ED admissions. We just went on to athena, and now we're adding pieces around that.

We've had to look at this, realizing that high-needs ACO REACH goes away at a  point in time. We might have a year after that with some sort of bridge. But now that we have a 10-year view of these things, it gets a bit easier to say we've got some time to evaluate these investments we're making around this care model. It gives us a little bit of breathing room. We’re large in the context of in-home primary care, but we're pretty small in the context of the broader healthcare ecosystem. 

HCI: As part of LEAD, CMS is planning to identify two states interested in partnering on developing a framework for ACO-Medicaid partnership arrangements. Is that something that's of interest to you guys?

Chance: It probably depends on the states. We're in 12 states right now, and 40 different MSAs, and it probably depends on how the programs between Medicaid and the federal programs coordinate in those states.

I think we want to be at the table in the conversation and see what the opportunity might be. We've taken a stance over the last few years that we're going to try to be really focused on who our patient population is and how we serve them in the best way possible. We have some Medicaid patients through some managed care constructs, but we don't have a really large volume there. 

Robinson: I think here the Innovation Center is focused on dual-eligible patients exclusively, and they're doing it because of this issue where on one side of of CMS they are moving policies forward that encourage the alignment of benefits into the same payer — so the Medicaid MCO and the Medicare Advantage plan are the same organization. I think that they're trying to do something similar in the fee-for-service space, meaning they are trying to tie organizations that manage the Medicaid benefits, particularly for very sick patients that need LTSS or home and community-based services, with organizations that look like us on the Medicare side and that are doing the primary care services. 

I do think that there is a lot of untapped potential there for better coordination between the managed care entities and the primary care entities where the benefit packages and the scope of services have been historically separate. The patients are the same, and there is a lack of coordination that exists in the market today. There are opportunities that could play out in a way that could help people avoid nursing homes or keep people healthy and at home. When you bring the Medicaid entity and the primary care entity together, I think that's where CMS sees the potential. 

And to Matt's point, I think it is something that we would be very interested in doing, particularly in the markets where we operate today, and we do have some of those connections built already.