Winnetka, News

Endeavor Health — formerly NorthShore — embarks on a new approach to primary care for Medicare patients

Scott Kent, senior vice president of Endeavor Health's Clinically Integrated Network.
Scott Kent, senior vice president of Endeavor Health’s Clinically Integrated Network.

(Editor’s Note: This story was reported by Mark Miller and originally published in the Evanston Roundtable, a neighboring independent newsroom. It was shared with The Record as part of an ongoing collaborative parntership.)

The letter from my doctor’s office set off an alarm bell. No dire health news, thankfully; instead, it was a notice about a new approach to primary care at Endeavor Health. The shift is impacting me and thousands of other Medicare patients who see primary care physicians in Endeavor Health (formerly NorthShore University Health System).

“Your primary care physician is participating in an integrated care model offered through the Centers for Medicare and Medicaid Services (CMS) called ACO REACH,” the letter began. “This model is designed to improve the quality of care through enhanced care coordination and stronger connections between health care providers and patients, including those patients who are underserved.”

If that sounds like opaque health-care speak to you, I’d agree, and it only got worse from there. But I’m in a somewhat better position than most to decode that kind of language. In my day job, I’m a journalist covering Medicare and other retirement topics for the New York Times, Reuters and Morningstar, and I’ve written previously about ACO REACH.

It turns out that this letter will be sent this year and in 2025 to thousands of Endeavor Health patients in Evanston and the broader Chicago area who are enrolled in traditional Medicare. 

So, let’s decode.

ACO REACH is part of a broader move by CMS to shift everyone who is enrolled in traditional fee-for-service Medicare into “accountable care organizations,” by 2030. The initiative does not impact Medicare enrollees who have selected Medicare Advantage, the managed care alternative to traditional Medicare offered by insurance companies. 

Critics worry that ACOs represent a form of privatization of Medicare, not too different from Advantage, which has come under fire for its provider network limits, and stinting on care through “prior authorizations” and other tortuous red tape. Reports by the Office of Inspector General in the Department of Health and Human Services have found “widespread and persistent” problems with prior authorization and payments to providers. 

Advantage has come under fire for failing to meet the promise of managed care to provide more care with less expense. The Medicare Payment Advisory Commission, which advises Congress on policy, reports that Medicare this year will pay Advantage plans an estimated 122% of the cost of similar beneficiaries in traditional Medicare. That translates into $83 billion in additional Medicare spending in 2024 and $13 billion in higher Medicare Part B premiums paid by Medicare beneficiaries in 2024.

But the backers of ACO REACH argue that they mainly offer improved data sharing and information across all of the health care providers you might see, and the promise of better care as a result of coordination. That’s an ambitious goal, since about three-quarters of Medicare enrollees report that they coordinate their own care now – no matter if they are enrolled in traditional Medicare or Advantage.

Medicare’s ACO initiatives, including REACH, do aim to reduce the cost of federal spending on health care through better coordination, and by offering financial incentives to providers. The ACO REACH program also has a health equity component; its stated aim is to improve care for underserved communities. (The word “REACH” is an acronym for “Realizing Equity, Access and Community Health.”)

Nearly all Endeavor Health primary care physicians will be enrolled into ACO REACH this year and in 2025. Some independent physician groups in the region that are also part of the medical staff at Endeavor Health hospitals are also adopting the model. It’s a big deal, involving more than 3,000 primary care physicians and specialists, who care for 35,000 patients of the system. Next year, Endeavor will expand ACO REACH to its primary care physicians historically aligned to Northwest Community Healthcare and Edward-Elmhurst Health, doubling the number of patients involved to approximately 70,000. (Endeavor was not able to provide a figure on the number of patients in Evanston who will be impacted.)

ACO REACH does not change the benefits offered in traditional Medicare, or change your relationship with your physician. Importantly, it does not restrict your choice of health care providers. But it does give the ACO the ability to gather and analyze data about your health and to make recommendations of specialists. The data side of this relies on a health data platform built by Lumeris, a technology company that entered a partnership with Endeavor late last year. 

As part of my decoding project, I interviewed Scott Kent, senior vice president of Endeavor’s Clinically Integrated Network about ACO REACH and what it will mean for Evanston residents who are enrolled in traditional Medicare. The Q&A that follows has been edited for length and clarity.

Q: What motivated Endeavor Health to make a change of this scale in the way it provides care to Medicare patients?

A: Over the past five or six years, we’ve really begun to appreciate how our own social environments have such a huge impact on health and outcomes. And the ACO REACH model really helps us to make sure we’re taking care of all patients, and really also look into those health disparities in terms of how they impact us individually.

Q: Is it patients who move into this program or physicians?

A: This is a physician participation model. It’s not something that we are moving patients into or out of; it’s really more that our physicians have agreed to participate in this model. So, if you’re a patient of one of those physicians, you are receiving these notifications that your physician is participating.

Q: How does this change things for me as a patient? Let’s say I see a specialist who is outside the Endeavor system – will this change impact me?

A: It’s largely invisible to patients. What’s really changing is the support teams behind the physician, and technology that can pull together information to help coordinate patient care.

You’ll still pick up the phone and call your specialist directly, none of that changes. But what it does do for us is this: Your primary care doctor will know you went to that specialist and will get a report about the care you received. Right now, that often doesn’t happen, so perhaps she doesn’t know about a certain drug or prescription you’re using and that can lead to problems with drug interactions. Or it might be pharmacy data or other sources of information from the community where you live. So this model gives Medicare the ability to get all this information to our physicians, so that they know about everything that’s happening with you and make the best decisions about coordinating your care. 

Q: Can you say a bit more about the health equity component of ACO Reach? 

A: There’s a great deal of information available on race, ethnicity, age and zip code that might help us understand better what might be going on in a patient’s home life. We can now pull in care managers as a support around the physician to help refer a patient to other community assets that might be helpful with problems like food or housing insecurity that can have a big impact on people. We hope to be able to ask questions of patients that help identify gaps and to refer them to community partners that will help keep them healthy.

Q: Critics worry that the financial incentives in the ACO REACH model inevitably will lead to limits on access to care. Some of that concern stems from the real world experience with Medicare Advantage. How does this model compare with Advantage?

A: The goal is not to limit access. This model shifts the financial model to reward physicians for improving outcomes and the quality of patient outcomes of their patient population and moving away from fee for service, where the doctor is paid every time you go to see them. It provides a monthly cash flow to the medical practice to help them keep the lights on while allowing providers to focus more on what’s happening with each individual patient as a whole, rather than episodes. 

All of these principles of taking care of a patient really applied to Medicare Advantage. But with Medicare Advantage, those mechanisms are coming to us from health plans like United Health or Blue Cross. Here, Medicare is trying to help take those same care models to the folks who remain in the traditional Medicare fee for service model. 

Q: But the evidence of success in Medicare Advantage is very mixed. One of the problems has been the abuse of codes used by plans to bill Medicare, inflating or exaggerating the actual care provided. Is ACO REACH just taking what’s not working in Advantage and adding it into traditional Medicare?

A: CMS is trying to help us refocus on making sure we are really focused on improving outcomes. The focus on ways that Medicare Advantage plans are using coding to impact how much they get paid is appropriate – and that’s not our goal with ACO Reach. Our goal isn’t to play these games that the insurance companies are using to build their revenue. Our goal is to really focus on each individual and making sure we’re doing the best to keep them healthy and out of our hospital and active as long as possible.

Q: Is patient involvement in ACO REACH voluntary or optional?

A: This is a program that the physician agrees to participate in. As a patient, you can opt out of having your data shared by completing a form that you send to Medicare. And then we won’t get any information about you, we won’t even know that you’re a patient of whoever that doctor is. So that would be your way to opt out. 

And none of this changes the benefits you’re entitled to under traditional Medicare. You still have the same benefits you have always had.

Q: The letter from CMS also says that ACO REACH might save me money and help save me money. How? 

A: It’s not going to save you money by changing your deductible or co-pays. But if we know more about you, we hope to minimize some of the waste that occurs – repetition of lab work that might be shared, for example. 

Q: Your announcement on ACO REACH states that the partnership with Lumeris will “allow you to collaborate to reduce healthcare disparities for underserved communities.” How will that work?

A: We are developing a health equity area within our organization. First, we need to be able to understand what’s going on with our patients, which means we need to ask questions of  patients that sometimes are uncomfortable and that we haven’t asked in the past. What’s going on in your home life? Do you have enough money to afford your medication? So the first thing we need to focus on is really making sure we’re gathering the information in a way that’s sensitive to the patient but helps us understand what’s going on. 

And then the second new skill is using that information to help patients. We’re adding some new roles that are called community health workers. These will be folks who live in the communities where the patients are and are familiar with those communities and some of the cultural differences that can occur, and to educate patients in ways that are appropriate and can really help them in their daily lives. 

Q: When CMS experiments with models like ACO Reach, they come with built-in sunset dates. This one is set to conclude at the end of 2026; although it could be renewed at that point. How is Endeavor looking at that expiration, and how it might impact its delivery of primary care at that point?

A:  We’re monitoring what might happen at the end of 2026. Medicare has a goal of moving all of their patients under what it calls value-based care arrangements like this one by 2030. If it doesn’t renew ACO REACH, we anticipate that they will create something similar. So we’re assuming that it will continue beyond 2026 in one form or another.

Note: Ascension St. Francis hospitals and medical group physicians are not participating in ACO REACH, a corporate spokesperson says; however, non-Ascension-employed physicians at Ascension St. Francis may independently elect to participate in ACO REACH. Some Ascension facilities in Illinois participate in ACO models similar to ACO REACH.

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