State trying out new model for Medicaid

Image: Thinkstock
Image: Thinkstock

STATE HOUSE, BOSTON, NOV. 29, 2016….Starting Thursday, more than 160,000 Medicaid members in Massachusetts will participate in a novel approach to safety-net health care administered by six health organizations.

“It provides us with a great opportunity to collect information, hopefully improve patient outcomes and increase care coordination for 160,000 members’ lives,” Health and Human Services Secretary Marylou Sudders told the News Service on Tuesday.

The Baker administration, which announced the year-long pilot on Tuesday, said members’ benefits, identification cards and doctors would remain the same, and members have been notified of their ACO assignment and may opt out of the program at any time.

Partners HealthCare, the largest provider group in Massachusetts and one of the organizations selected for the pilot, said it will implement a model called Partners Care Connect, offering behavioral health integrated with primary care, and an expansion of services to address substance use, housing, food insecurity, and past trauma.

Advocates and health care officials this year discussed factors outside the traditional realm of medicine that can have a bearing on a person’s health.

“Social and environmental factors do indeed contribute to or detract from the health and healthiness of our communities,” Attorney General Maura Healey told the Health Policy Commission in October, highlighting the role housing, food, transportation and sick leave can play in a person’s health.

Billed by the administration as “part of the most comprehensive restructuring of the Medicaid program in more than 20 years,” the pilot is part of a new five-year, $52.5 billion Medicaid waiver Gov. Charlie Baker negotiated with the Obama administration.

Accountable care organizations have for years been features of the commercial insurance marketplace as well as Medicare, but not MassHealth, which is the state’s administrator of Medicaid. The year-long pilot will venture into accountable care organizations for MassHealth members.

“We very much model them on the Medicare experience,” Sudders said.

Rather than receiving payments based only on the number of exams and procedures billed to insurers, an accountable care organization (ACO) in general takes on the responsibility to care for the health needs of a population and is paid for that big task. A Health and Human Services official said that the six ACOs participating in the pilot would still be paid on a fee-for-service basis, but would subsequently be able to share in any savings.

The state plans to compare the cost of care for each ACO member versus an “expected target” to determine whether the ACO saved or lost money.

Dan Tsai, the assistant secretary of Health and Human Services who runs MassHealth, said the ACOs will share savings and the risk of losses with MassHealth, and be “rewarded” for improving members care while keeping costs down.

Rising and unaffordable health costs have been riddles that have perplexed state policymakers for years as they seek to slow growth in health care costs. Some have argued that ACOs would encourage more efficient spending than under the traditional fee-for-service model.

Partners said that its Pioneer ACO, designed for Medicare, achieved nearly $31 million in savings and received recognition for its high-quality care.

“We are excited to deepen our community partnerships and collaborate with the full range of care delivery service providers required to maximize the health of this frequently underserved population,” said Dr. Tim Ferris, senior vice president of population health management at Partners.

The one-year pilot will have ramifications for the future of MassHealth, which is the biggest spending area in the state budget. MassHealth serves a total of 1.9 million members and costs more than $15 billion.

“ACOs will work closely with community-based health organizations to better integrate care for behavioral health, long-term services and supports and health-related social needs,” Sudders said in a statement. “We look forward to learning from this one year pilot as we restructure the Medicaid program.”

The six pilot ACOs are Boston Accountable Care Organization, Children’s Hospital Integrated Care Organization, Community Care Cooperative, Partners Care Connect, Steward Medicaid Care Network Inc., and UMass Memorial Healthcare Inc. A Health and Humans Services spokeswoman said those were the only six that applied.

Those six organizations include about 2,500 primary care doctors at 330 different practice sites, according to the Baker administration.

“With this information, we will be better prepared for the full ACO implementation anticipated in December 2017,” Tsai said. A fact-sheet on the Medicaid waiver indicates that full implementation of the ACO model is set to start December 2017.

Sudders told the News Service she does not know how many Medicaid ACOs there will be next December.

Copyright 2016 State House News Service

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