# Year 1 of Medicare’s Accountable Care Organization Realizing Equity, Access, and Community Health Model

## TL;DR

A new Medicare program aimed at reducing health inequities did not enroll a high-risk population in its first year, limiting its potential impact.

## Contribution

The study evaluates the demographic and geographic characteristics of beneficiaries enrolled in the ACO REACH initiative compared to other Medicare programs.

## Key findings

- REACH beneficiaries were less socially vulnerable compared to the overall Medicare population.
- REACH ACOs were located in less socially vulnerable areas than the broader Medicare pool.
- The initiative did not enroll a high-risk beneficiary population, which may hinder its effectiveness in reducing health inequities.

## Abstract

Did the Accountable Care Organization (ACO) Realizing Equity, Access, and Community Health (REACH) initiative enroll a beneficiary population that had high levels of social risk?

In this cross-sectional analysis including 35.8 million fee-for-service Medicare beneficiaries, along multiple dimensions of social risk, REACH beneficiaries were at significantly lower risk than the overall pool of Medicare beneficiaries, and REACH ACOs were located in less socially vulnerable areas.

The ACO REACH initiative did not enroll a high-risk beneficiary population in terms of social risk, which may limit its effectiveness in reducing health inequities in Medicare.

This cross-sectional study compares characteristics between participants in Accountable Care Organization Realizing Equity, Access, and Community Health with Medicare Shared Savings Program and the broader pool of Medicare beneficiaries, organizations, and clinicians.

The US Centers for Medicare & Medicaid Services launched the Accountable Care Organization (ACO) Realizing Equity, Access, and Community Health (REACH) payment model in January 2023. In contrast to prior ACO initiatives, such as the Medicare Shared Savings Program (MSSP), ACO REACH includes equity-focused measures and payment adjustments, including an equity plan and financial risk adjustment for ACOs with higher proportions of underserved beneficiaries. However, it is unknown whether these changes have incented participation from organizations that serve beneficiaries from marginalized communities.

To compare characteristics between participants in ACO REACH with those in MSSP and the broader pool of Medicare beneficiaries, organizations, and clinicians.

This cross-sectional study included all Medicare beneficiaries clinicians, and ACOs enrolled in fee-for-service Medicare, MSSP, and ACO REACH from January 2022 to January 2023.

Enrollment in fee-for-service Medicare, MSSP, or ACO REACH.

Beneficiary, clinician, and ACO characteristics.

In 2023, among 35 801 118 beneficiaries in the overall fee-for-service Medicare program, 18 911 213 (52.8%) were female, and 163 706 (0.5%) were American Indian or Alaska Native, 1 251 553 (3.5%) were Asian or Pacific Islander, 2 952 244 (8.2%) were Black, 2 396 771 (6.7%) were Hispanic, 27 642 765 (77.2%) were White, and 1 394 079 (3.9%) were another race (includes individuals who did not identify with a listed race, including those who self-identified as multiracial) or unknown race. A total of 1 958 881 beneficiaries were attributed to ACO REACH, and 11 340 987 were attributed to MSSP. A total of 132 ACOs participated in ACO REACH, while 456 ACOs participated in the MSSP. Compared with Medicare beneficiaries overall, REACH beneficiaries were older (85 years or older: 14.2% vs 10.3%; standardized mean difference [SMD], 0.44) and more often White (80.2% vs 77.2%) and less often Black (5.9% vs 8.2%) or Hispanic (5.8% vs 6.7%) (SMD, 0.24). REACH beneficiaries were slightly less likely to have Medicare entitlement due to disability (15.2% vs 17.6%) or be dually enrolled (15.1% vs 15.8%) (SMD, 0.07). REACH beneficiaries were less likely to be rural (3.9% vs 8.4%; SMD, 0.19) and less likely to reside in highly vulnerable geographic areas based on the Social Vulnerability Index (27.7% vs 29.4%; SMD, 0.08) compared with beneficiaries overall.

These findings suggest that, in its first year, ACO REACH did not achieve its goal of enrolling organizations that serve beneficiaries with high levels of social risk. Without broader participation, ACO REACH is unlikely to achieve its goal of reducing health inequities.