There are still healthcare disparities between communities, and these disparities influence patient outcomes and the efficiency of the system. The ACO REACH Program (Realizing Equity, Access, and Community Health) is a response to these issues as it redesigns the functioning of care organizations. This CMS program targets underserved communities but still offers high standards of performance to every type of patient.
The conventional models of healthcare tend to overlook vulnerable populations. ACO REACH requires participating organizations to develop and implement a Health Equity Plan, ensuring they identify and address the needs of underserved populations among their aligned beneficiaries. The program is an integration of equity requirements and performance motivational programs, which develops a system in which inclusive access, coupled with quality care, collaborates. Organizations receive resources, funding, and support to sustainably serve diverse populations effectively.
The ACO REACH Program is a Centers for Medicare & Medicaid Services (CMS) value-based care model launched in 2023. It replaces the Global and Professional Direct Contracting models with enhanced equity requirements.
Key program features include:
The program changes to outcome-based reimbursement as opposed to fee-for-service. Capitated payments are made to organizations, and they share in the savings when they enhance the quality of care and, at the same time, reduce costs.
ACO REACH is unique because of its equity-based design. While traditional Accountable Care Organizations focus mainly on cost and quality, ACO REACH adds mandatory health equity requirements.
Core differences:
Traditional ACO models allow equity initiatives as optional. ACO REACH makes them mandatory, requiring organizations to build infrastructure specifically to support vulnerable populations rather than treating equity as optional.
The program defines underserved beneficiaries through multiple criteria. CMS uses a composite approach rather than single-factor identification.
Underserved beneficiaries include those who are:
Organizations must document beneficiary status using claims data, enrollment records, and area-level measures. This multi-dimensional approach captures multiple factors rather than relying on a single indicator.
ACO REACH operates on capitated payments rather than traditional fee-for-service. Organizations receive monthly per-beneficiary amounts covering expected care costs.
ACO REACH offers two main risk arrangements: Professional and Global. Professional covers primary and specialty care, while Global adds hospital and institutional services. Both create financial accountability for the total cost of care.
Payment calculation factors:
Organizations that meet quality benchmarks while keeping costs below projections retain the savings. Those that fall short face financial losses, reinforcing strong performance incentives.
The program evaluates organizations across multiple quality domains. These measures assess both process compliance and outcome achievement.
Primary quality categories include:
Each measure applies separately to the underserved and the general populations. Organizations must demonstrate quality across both groups, preventing scenarios where overall scores mask disparities.
This component directly measures disparity reduction. CMS compares performance between underserved beneficiaries and other populations within each organization.
Organizations receive equity scores based on gap sizes across quality measures. Smaller gaps earn higher scores. The benchmarking creates explicit accountability for closing disparities rather than accepting them as inevitable.
Equity assessment examines:
Organizations that improve their equity scores receive financial incentives. Those that fail to reduce gaps face penalties, making disparity reduction a financial priority.
The 50% underserved beneficiary requirement is a basic transformation of organizational priorities. Accountable Care Organizations ACOs software should monitor and deliver data on the measures of underserved populations at all times.
Organizations do not have an option of picking the healthier, easier-to-serve patients. The requirement compels the infrastructure development in particular, with regard to those barriers that the vulnerable groups encounter. This involves language services, transportation, and community health worker programs.
Implementation requires:
The requirement transforms equity from an optional value to an operational necessity. Organizations build capacity to serve complex populations effectively rather than viewing them as financial risks.
ACO REACH mandates formal relationships with community-based organizations. These partnerships address social determinants of health affecting care outcomes.
Participating organizations must identify community partners in their service areas. These partnerships address housing stability, food security, transportation, and other non-medical factors affecting health outcomes.
Effective partnerships typically include:
Such partnerships bring care outside the clinical environments. Organizations do not need to treat the consequences only and neglect the causes of health disparities. Digital health platforms can support these partnerships by tracking referrals and outcomes across organizations.
The program requires detailed stratified reporting. Organizations must analyze performance data by demographic and social risk factors. This data transparency reveals where disparities exist within practices. Organizations cannot hide population-level gaps behind overall averages. The visibility drives targeted improvement efforts.
Healthcare platforms combine data from a number of different sources to determine the care gap between populations. State-of-the-art analytics indicate which groups of beneficiaries have delays, poorer quality, or worse outcomes.
Organizations use these insights to redesign workflows, target interventions, and allocate resources toward the highest-need populations. Data becomes the foundation for equity-focused decision-making.
A significant quality improvement is observed in organizations involved in ACO REACH. The format of the program encourages preventive services, chronic disease, and coordinating care.
Quality improvements include:
The combined focus on equity and performance creates systems serving all populations effectively. Organizations develop standardized processes ensuring consistent care regardless of patient background.
The risk-based payment model creates strong incentives for efficient care delivery. Organizations reduce unnecessary utilization while maintaining quality standards.
Cost management strategies include:
Better care instead of service restrictions provides the organization with savings. The prevention and coordination focus brings actual efficiency instead of cost-shifting.
ACO REACH promotes the involvement of patients in the care decisions. Organizations come up with programs that make healthcare more approachable and comprehensible.
Engagement strategies include:
Greater patient involvement leads to improved adherence, outcomes, and satisfaction. Patients become active partners in managing their health rather than passive recipients of care.
Successful participation requires significant operational infrastructure. Organizations need systems that track quality, costs, and equity measures simultaneously.
Technology platforms must consolidate data from multiple sources, including claims, clinical records, and community partners. Real-time analytics are used to notify care teams of high-risk patients and unmet care gaps.
Essential infrastructure components:
Technology vendors also offer Accountable Care Organizations ACOs software that is specifically created to work with value-based care models through collaboration with organizations. These technologies manage the integration of multi-source data and regulatory reports.
Traditional care delivery models need to be restructured for ACO REACH success. Organizations expand teams beyond physicians to include coordinators, social workers, and community health workers.
Redesigned teams typically include:
This interdisciplinary approach addresses all factors influencing patient health. Teams collaborate and share information instead of working in silos.
Organizations must identify and formalize relationships with community resources. These partnerships address non-medical barriers to health.
The integration process involves:
Effective integration requires bidirectional communication. Healthcare organizations share relevant patient information (with consent) while community partners report on service delivery and outcomes.
The high-risk payment arrangements create financial exposure. Organizations accepting capitated payments bear responsibility for total care costs, including services they don’t directly provide.
Risk management strategies include:
Organizations must balance cost control with maintaining quality. Cutting back on care may save money short-term, but can lead to long-term losses from poor outcomes and penalties.
ACO REACH requires synthesizing data from disparate sources. Claims data, electronic health records, community partner systems, and social service databases use different formats and standards.
Organizations need technical capability to aggregate these data sources into unified views. Without integration, care teams lack complete information for decision-making.
Integration challenges include:
Successful organizations invest in robust data platforms that integrate multiple sources. These systems create longitudinal patient records combining clinical, claims, and social data.
In order to implement equity-based, value-based care, it takes new skills in the workforce. The staff should be trained on social determinants, cultural competency, and care coordination.
Organizations are prone to a deficit in staffing, especially in non-physician jobs. The community health workers, care coordinators, and social workers have a high demand and low supply.
Workforce solutions include:
Organizations treating workforce development as a strategic priority typically achieve better performance outcomes. Staff equipped with appropriate skills execute program requirements more effectively.
Choosing the right technology foundation proves critical for ACO REACH performance. Platforms must handle diverse data sources, sophisticated analytics, and complex reporting requirements.
Essential platform capabilities:
Organizations should evaluate platforms based on proven ACO REACH performance. Vendors with existing successful implementations understand program nuances and regulatory requirements.
Provider buy-in determines implementation success. Physicians must understand the model, believe in its value, and actively participate in care redesign.
Engagement approaches include:
Organizations that treat physicians as partners rather than employees achieve higher engagement. Shared governance models where providers help design workflows and policies typically succeed.
ACO REACH performance requires ongoing refinement. Organizations must regularly analyze results, identify improvement opportunities, and implement changes.
Quality improvement process involves:
Organizations embedding quality improvement into regular operations rather than treating it as a separate project sustain better long-term performance.
| Performance Area | Key Metric | Improvement Strategy |
| Preventive Care | Screening completion rates | Automated patient outreach with scheduling |
| Chronic Disease | HbA1c control | Pharmacist-led medication management |
| Care Coordination | Hospital readmissions | Transitional care nurse visits |
| Patient Experience | Satisfaction scores | Patient navigation services |
| Health Equity | Disparity gap measures | Targeted outreach to underserved populations |
The ACO REACH Program drives a meaningful shift toward equity-focused, performance-driven care, proving that strong support for vulnerable populations leads to better outcomes system-wide. Through equity mandates, quality measurement, and risk-based payments, ACO REACH helps organizations reduce disparities and improve overall performance.
Persivia CareSpace® strengthens this effort by combining advanced analytics, population health management, and equity tracking in one platform, giving care teams the real-time insights needed to close gaps, manage high-risk patients, and consistently meet ACO REACH benchmarks.
Yes, participating organizations must ensure that at least 50% of their aligned beneficiaries are underserved. This requirement keeps the program centered on advancing health equity and improving access for vulnerable populations.
No, organizations cannot switch models mid-contract. Any ACO interested in joining ACO REACH must wait for the next application cycle and complete the full onboarding process, including verification of underserved populations and documentation of community partnerships.
Yes, ACO REACH operates in all 50 states. CMS does not restrict participation by geography, but organizations must demonstrate they have strong provider networks and appropriate community partnerships within their proposed service areas.
Yes, standard EHRs alone are not sufficient. Successful participation requires advanced population health platforms capable of integrating multi-source data, supporting real-time analytics, tracking equity metrics, and generating CMS-compliant reports.
Typically, no. The financial risk, reporting requirements, and operational infrastructure needed for ACO REACH often exceed what small practices can manage independently. Most smaller organizations join larger ACOs or management service organizations that provide administrative support, technology, and financial protections.
