Emerging Medicaid ACOs: A State Experiment, One Year In

By | March 20, 2019

We hope you can join us on March 28th for the Health Care Delivery Transformation Committee’s first annual meeting, “Transformation or Disruption: Changing the Focus and Pace of Change in Healthcare Delivery.”  In the post below, Katherine Record discusses the transformative change in the MassHealth Program, one of the many topics to be covered at the meeting. 

Last year, Massachusetts extended financial risk to Medicaid contracts held with 17 providers across the state, following other statesin applying the same principles of incenting coordination and efficiency that are applied to growing numbers of commercial and Medicare contracts. This move is a response to a ballooning MassHealth budget (accounting for nearly 40 percent of the state budget), but will serve not only to trim costs. MassHealth’s ACO initiative will also enable provider systems to expand on their efforts to close gaps in care (diabetes, hypertension, asthma control) and reduce unnecessary acute utilization (improving coordination of care throughout care transitions and ensuring timely access to appropriate ambulatory services). In other words, applying financial risk to Medicaid contracts enables Massachusetts health systems to take one step closer toward applying the same efforts to improving efficiency and quality of care across all patients, regardless of payer.

While the goals, and hopefully the outcomes, are positive, this effort is not without substantial challenges, as with any new initiative in healthcare reform. Many of these are germane to the unique challenges the Medicaid population presents to payors and providers alike, such as a high prevalence of unmet social needs as well as behavioral health conditions and long-term disabilities. These factors not only make this population more acute, but also present providers with challenges historically ignored by the healthcare system. Moreover, to date, risk adjustment models have not adequately accounted for these factors.

MassHealth has taken three steps to address these significant challenges to its ACO design. First, it adopted a new risk adjustment methodologythat accounts for factors such as unstable housing, relationships with other state agencies, neighborhood stress, and serious mental illness. Second, it mandated that all ACOs contract, and share patients, with certain behavioral health and long term services and support providers, which were selected by the staterather than by ACOs. Neither of these two tactics have been tested, but their efficacy will be critical to this APM working. Third, and finally, MassHealth is providing each participating provider with substantial investment dollarsto enable systems to innovate and test new ways of addressing a historically underserved population (e.g., extend data and analytics capacity, implement telehealth to expand access to care, hire nontraditional frontline providers like peer recovery coaches and community health workers).

The success and challenges of this ACO initiative, one year into its launch, will be the topic of a panel at the HFMA’s Health Care Delivery Transformation Committee’s upcoming annual meeting, Transformation or Disruption: Changing the Focus and Pace of Change in Healthcare Delivery. Panelists will include:

  • Ipek Demirsoy, Chief of Payment and Care Delivery Innovation, MassHealth
  • Deborah Morales, Program Director, Rhode Island’s Medicaid Accountable Entities
  • Jean Yang, President, Tufts Public Plans
  • Alastair Bell, Executive Vice President, Strategy, and COO, BMC Health System
  • Nancy Turnbull, Senior Associate Dean for Professional Education, Harvard T.H. Chan School of Public Health (moderator)

Registration for the event is open now.

About the Author: Katherine Record is the Executive Director of the Lahey MassHealth ACO.