A Call to Action:
Creating Accountable Care Organizations
Answerable to Underserved and Vulnerable Populations
The Drive to Create Access & Quality
Dennis Heaphy, Disability Policy Consortium, and Ellen Breslin, EBD Consulting A DAAHR Event, April 1, 2015
Today’s Conversation …
• What are ACOs? Opportunities and Risks? • MassHealth and ACOs
• Other States (Colorado, Minnesota, and New York) • Consumer Engagement and Agenda
The ACO Train Has Left the Station!
• Key component of the Affordable Care Act• Massachusetts law cost containment (Chapter 224)
• Division of Insurance promulgating new regulations about financial solvency • Massachusetts Health Policy Commission developing certification requirements • MassHealth under financial and political pressures for rapid change
What is an ACO?
• New type of healthcare organization
• Providers (hospitals, doctors, etc…) come together to provide care to a population • ACOs accept collective responsibility for health care costs, quality and outcomes
• May involve multiple payers, which may introduce inequities and conflicting incentives
• Goal: to create a more effective and efficient healthcare delivery, through financial alignment of incentives
Are ACOs Different from HMOs? Time will tell …
Consideration HMO ACO
Provider role Providers are gatekeepers restricting care
Providers or facilitators of care with correct incentives
Payment and
Quality Payment not tied to quality
Payment tied to outcomes and quality
Financial risk Financial risk through capitation
Financial risk, methods can vary: shared savings, upside only, upside and downside risk, global budgets
Data Poor data collection or analysis Emphasis placed on data collection, analysis and sharing
ACOs Provide Opportunity to Create Real Reform…
• Improve quality of care and coordination• Address social determinants of health
• Reduce inequities in health care access and outcomes for underserved populations and people with disabilities/chronic conditions
• Measure quality of long-term services and supports and impact on social determinants of health using appropriate quality metrics
ACOs Raise Many Questions and Risks
• What happens to consumer choice?
• Will ACOs avoid persons with high needs? • What does the financing look like?
• Are payments and incentives linked directly to the right providers and to the right outcomes? • Will large hospitals dominate the ACO market?
• Will vital community based organizations be included or excluded? • What happens to provider autonomy?
MassHealth
• MassHealth faces many financial pressures
• SFY 2016 budget $15.2 billion for 1.8 million lives
• High inpatient, high ED, does not qualify as good care
• MassHealth has great programs, but great programs do not guarantee great outcomes • Care coordination and integration (MCO, PCC Plan, SCO, PACE, One Care)
• PCPR (global payment for primary care, shared savings for non primary care) • How can MassHealth address the social needs better?
What Do MassHealth Members Need?
MassHealth members need more than health care.
They need social services, housing, nutritional assistance, transportation and employment assistance.
We know that health outcomes are driven by the social determinants.
10% medical care, 20% human biology, 20% environment, 50% lifestyle and behavior.
This is not new information, so what is the problem?
There is currently no good way to compensate providers for the social determinants. We should be paying providers more to take on the challenges related to poverty. We need to involve new partners, new providers, community based organizations.
Can Medicaid ACOs Address Social Needs?
Yes. Many states are trying to address poverty related issues through Medicaid ACOs.
Examples:
- Colorado’s Regional Care Collaborative Organizations (RCCOs) refer members to non medical supports.
- Minnesota requires its Integrated Health Partnerships (IHPs) to contract with community based organizations and social services agencies.
- New York’s Delivery System Reform Incentive Payment (DSRIP) program supports community based integration through its Performing Provider Systems (PPSs).
New York’s Delivery System Reform Incentive Program (DSRIP)
NY received a waiver from CMS to spend $6.8 billion over the next 5 years.
Key Point #1. Transformation Involves Reductions in Hospital Use.
The goal of this reform is to transform the delivery and payment system. Desired outcome is to reduce hospital use by 25% over 5 years. Winners and Losers.
Key Point #2. Significant Funds for Performing Provider Systems (PPPs).
Multiple partners, will earn funds based on their successful implementation of the projects. 95% of funds must go to safety nets. Funds for revenue loss, investment and bonus payments. This could shortchange community based organizations.
Key Point #3. Payments Linked to Successful Achievement of Numerous Measures.
Projects vary in focus: system transformation, clinical outcomes, population health. Measures are fairly typical.
Consumer Engagement – How Do We Take Advantage of this Opportunity?
•
Involvement at every stage of ACO development and implementation.
•
Receive equal status at all ACO meetings in state planning
processes, not limited to stakeholder meetings.
•
Achieve measurable results including ACO requirements.
List of Questions for Advocates to Answer
• What should ACO governance structure look like?
• How should ACOs be financed to improve consumer access to all services needed?
• What should be done to protect the rights of underserved and high-risk people in ACO assignment? • What best practices should ACOs put in place to deliver better quality coordinated care?
• How do consumers and other stakeholders hold ACOs accountable for delivering quality care? • How will quality be defined to ensure ACOs meet the community service needs of enrollees?
Major Take Aways
• Address social determinants of health housing, nutrition, mold, safety, job training.
• Ensure that non medical providers and organizations receive equal respect and value for their role; these providers are vital to addressing the social determinants of health.
• Develop the right financing approach.
• Establish consumer-driven quality metrics.
The DAAHR Experience
• Consumer choice and control must drive advocacy.
• Must have measurable community organizing and consumer engagement at the grassroots level. • Collaboration with stakeholders is key.
• Focus on the big picture. • Transparency is critical. • Protect continuity of care.
• Quality metrics that address social determinants. • Emphasize nonmedical services.
• Build capacity and competency of plans and their networks over time. • No quick fix or auto assignment.
