MassHealth 3.0: Accountable Care Organizations and Value ... · - Transition from a fragmented,...
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MassHealth 3.0: Accountable Care Organizations and Value Based Payments Thomas Carroll, Ruo Chen, August Felix, Lindsay McCormack, Saharsh Mehta, David Peters, John Roubil, Joseph Shortsleeve University of Massachusetts Medical School, Population Health Clerkship Faculty Leaders: Jay Himmelstein, MD, MPH, Doug Brown JD, Michael Chin, MD, and Jean Foran MA Universal Coverage Threatened By Increasing Costs Unsustainable Costs Why does Health Care cost so much? Inadequate Investment in Social Determinants of Health Possible Solution: Accountable Care Organizations (ACOs) Who is an ACO? - A team of Healthcare Providers and Coworkers who provide highly coordinated care with the goal of keeping patients healthy. What is an ACO? - A top-down structure of distributing funds to incentivize addressing the social determinants of health rather than providing the safety net. What is the Goal of an ACO? - Transition from a fragmented, fee-for-service system system to a coordinated, value-based system. What Incentivizes an ACO? - Carrot: % Savings = $$ to the ACO - Stick: Overage = Out-of-Pocket Expense paid to the state Key Concepts - Shared savings: If an ACO stays under budget, the ACO and the state share the savings. - Shared risk: If an ACO exceeds budget, the ACO and the state share responsibility for risk. - Full risk (capitation): If an ACO exceeds budget, the ACO is fully responsible for the risk. If ACO stays under budget, ACO is entitled to all savings. ACO Payments Recognize Social Determinants of Health Ash A, et al. 2017 Service Project Summary Overview: MassHealth (Medicaid and the Children’s Health Insurance Program) currently comprises 40% of the Massachusetts state budget, while serving 1.9 million MA residents. In an effort to decrease this expenditure, Massachusetts is implementing a system of accountable care organizations (ACOs) to make providers and payers accountable for financial risk and improvement of care quality. ACOs are attempting to decrease cost and improve quality in a variety of ways, namely through changing payment models, building and engaging community health centers, and continually assessing risk and quality through robust data analysis. Goals: To facilitate physician and health professional comprehension of the complex ACO model of healthcare reform in an effort to enable them to better serve their patients. Progress: We have created a poster and pamphlet resource discussing the ACO model and the various other components of MassHealth reform to distribute to healthcare professionals who attend the poster session. Outcomes: Though our goal is subjective, based on the stark difference between our change in understanding as medical students of the healthcare system and current attempt at reform, we anticipate that our resource will similarly produce a substantial improvement in the knowledge of these matters for most health professionals who review our work. Acknowledgments Volume Based vs. Value Based Care Medicaid Coverage and Composition Reimbursement Reform Before 2016: ● Medicaid payment allocation ∝ medical complexity ● Can SDH be included in Medicaid payment formulas so as to pay more equitably for the care of socially vulnerable individuals? VS. After 2016: ● MassHealth allocates $$ to ACOs based on risk adjusted model that includes SDH → “Per Member per month” (PMPM). ● Variables embedded into ICD10 coding: Integrated Care Reform ● 15 Community Health Centers integrating to coordinate primary care in the communities. ● Board of Directors = 51% patients ● Integrated Care under one roof: How Will Quality Metrics Impact Physicians? When Politics Becomes Policy 270 quality metrics are currently being used by Centers for Medicare & Medicaid Services: Examples: BP, Hemoglobin A1C levels, cancer screenings. Pro: Moving away from expensive fee-for-service model Con: Physician interest may conflict with patient health Next Steps: Care That Matters = group of clinicians creating better quality measures so that doctors’ interests will not conflict with beneficial patient care. Acknowledgements: Dr. Ronald Adler, MD, FAAFP Acknowledgements: Dr. Ronald Adler, MD, FAAFP References •Oscar Arocha, MM and Toni McGuire, RN, MPH, Edward M. Kennedy Community Health Center •Suzanne Cashman, ScD, MS, Director of Community Health, Department of Family Medicine and Community Health •Alexis Travis, PhD, Chief of Community Health, Worcester Division of Public Health •Kenneth J. Bates, President and Chief Executive Officer, The Bridge of Central Massachusetts •Frances M. Anthes, MSW, President/CEO of Family Health Center of Worcester •Alex Jean Baptiste, MSN, RN, CDDN, Chief Nursing Officer, Family Health Center of Worcester •Nicole Gagne, President and Chief Executive Officer, Community Healthlink, Inc. •Alan Brown, MD, Vice Chairman, Adult Psychiatry Clinical Services •Doug Brown, JD, President, UMass Memorial Community Hospitals and Chief Administrative Officer, UMass Memorial Health Care -Mike Doonan, PhD, Executive Director, MassHealth Policy Forum Professor, Brandeis University •Representative Jeffrey Sanchez, Chairperson, House Ways and Means Committee •Monica Bharel MD, MPH, Commissioner of the Massachusetts Department of Public Health •David Seltz, Executive Director, Massachusetts Health Policy Commission •Arlene Ash, PhD, Professor University of Massachusetts Medical School, Department of Quantitative Health Sciences •Thomas Scornavacca, Jr, DO, Medical Director, UMass Memorial Office of Clinical Integration •John Greenwood, Senior Vice President, Office of Clinical Integration, President ACO •Ronald Adler, MD, Director, Primary Care Practice Improvement, Associate Professor, University of Massachusetts Medical School •Michael Nickey, Executive Director MassHealth Programs, Fallon Health •Tom Ebert, MD, Executive Vice President and Chief Medical Officer, Fallon Health •David Brumley, MD, Senior Medical Director, Fallon Health •Lukey Nuthmann, Behavioral Health Director, Fallon Health •Betsy Hampton, RN MBA, Vice President Population Health, Office of Population Health, Reliant Medical Group, •Jonathan Chines, Vice President, Payer Contracting and Network Strategy, Reliant Medical Group •Brian Rosman, Director of Policy and Government Relations, Healthcare For All •Alyssa Vangeli, Associate Director of Policy and Government Relations, Healthcare For All •Cristina Severin, President and CEO, Community Care Cooperative. •Dan Tsai, Assistant Secretary for MassHealth and Medicaid Director •Eric Dickson MD, MHCM, FACEP, Memorial Health Care President and Chief Executive Officer •Senator Harriett L. Chandler, Chairperson, Senate Committee on Redistricting, Chairperson, Special Senate Committee on Citizen Engagement *FPL = Federal Poverty Level Friede,n 2010 This Table Illustrates the potential benefit for Hospitals. The more Medicaid Patients kept out of the hospital, the more Commercial Patients the hospital can take on.
Transcript of MassHealth 3.0: Accountable Care Organizations and Value ... · - Transition from a fragmented,...
MassHealth 3.0: Accountable Care Organizations and Value Based Payments
Thomas Carroll, Ruo Chen, August Felix, Lindsay McCormack, Saharsh Mehta, David Peters, John Roubil, Joseph Shortsleeve
University of Massachusetts Medical School, Population Health Clerkship Faculty Leaders: Jay Himmelstein, MD, MPH, Doug Brown JD, Michael Chin, MD, and Jean Foran
MA Universal Coverage Threatened By Increasing Costs Unsustainable Costs
Why does Health Care cost so much? Inadequate Investment in Social Determinants of Health
Possible Solution: Accountable Care Organizations (ACOs)Who is an ACO?
- A team of Healthcare Providers and Coworkers who provide highly coordinated care with the goal of keeping patients healthy.
What is an ACO?- A top-down structure of distributing funds to incentivize addressing the social determinants
of health rather than providing the safety net.What is the Goal of an ACO?
- Transition from a fragmented, fee-for-service system system to a coordinated, value-based system.
What Incentivizes an ACO?- Carrot: % Savings = $$ to the ACO - Stick: Overage = Out-of-Pocket Expense paid to the state
Key Concepts- Shared savings: If an ACO stays under budget, the ACO and the state share the savings.- Shared risk: If an ACO exceeds budget, the ACO and the state share responsibility for risk.- Full risk (capitation): If an ACO exceeds budget, the ACO is fully responsible for the risk. If
ACO stays under budget, ACO is entitled to all savings.
ACO Payments Recognize Social Determinants of Health
Ash A, et al. 2017
Service Project Summary Overview:MassHealth (Medicaid and the Children’s Health Insurance Program) currently comprises 40% of the Massachusetts state budget, while serving 1.9 million MA residents. In an effort to decrease this expenditure, Massachusetts is implementing a system of accountable care organizations (ACOs) to make providers and payers accountable for financial risk and improvement of care quality. ACOs are attempting to decrease cost and improve quality in a variety of ways, namely through changing payment models, building and engaging community health centers, and continually assessing risk and quality through robust data analysis. Goals: To facilitate physician and health professional comprehension of the complex ACO model of healthcare reform in an effort to enable them to better serve their patients. Progress: We have created a poster and pamphlet resource discussing the ACO model and the various other components of MassHealth reform to distribute to healthcare professionals who attend the poster session. Outcomes: Though our goal is subjective, based on the stark difference between our change in understanding as medical students of the healthcare system and current attempt at reform, we anticipate that our resource will similarly produce a substantial improvement in the knowledge of these matters for most health professionals who review our work.
Acknowledgments
Volume Based vs. Value Based Care Medicaid Coverage and Composition Reimbursement Reform
Before 2016: ● Medicaid payment allocation ∝ medical
complexity
● Can SDH be included in Medicaid payment formulas so as to pay more equitably for the care of socially vulnerable individuals?
VS.
After 2016:
● MassHealth allocates $$ to ACOs based on risk adjusted model that includes SDH → “Per Member per month” (PMPM).
● Variables embedded into ICD10 coding:
Integrated Care Reform
● 15 Community Health Centers integrating to coordinate primary care in the communities.
● Board of Directors = 51% patients● Integrated Care under one roof:
How Will Quality Metrics Impact Physicians? When Politics Becomes Policy
270 quality metrics are currently being used by Centers for Medicare & Medicaid Services:Examples: BP, Hemoglobin A1C levels, cancer screenings.Pro:Moving away from expensive fee-for-service modelCon:Physician interest may conflict with patient healthNext Steps:Care That Matters = group of clinicians creating better quality measures so that doctors’ interests will not conflict with beneficial patient care. Acknowledgements: Dr. Ronald Adler, MD, FAAFP
Acknowledgements: Dr. Ronald Adler, MD, FAAFP
References
•Oscar Arocha, MM and Toni McGuire, RN, MPH, Edward M. Kennedy Community Health Center•Suzanne Cashman, ScD, MS, Director of Community Health, Department of Family Medicine and Community Health•Alexis Travis, PhD, Chief of Community Health, Worcester Division of Public Health•Kenneth J. Bates, President and Chief Executive Officer, The Bridge of Central Massachusetts•Frances M. Anthes, MSW, President/CEO of Family Health Center of Worcester•Alex Jean Baptiste, MSN, RN, CDDN, Chief Nursing Officer, Family Health Center of Worcester•Nicole Gagne, President and Chief Executive Officer, Community Healthlink, Inc. •Alan Brown, MD, Vice Chairman, Adult Psychiatry Clinical Services•Doug Brown, JD, President, UMass Memorial Community Hospitals and Chief Administrative Officer, UMass Memorial Health Care-Mike Doonan, PhD, Executive Director, MassHealth Policy Forum Professor, Brandeis University•Representative Jeffrey Sanchez, Chairperson, House Ways and Means Committee •Monica Bharel MD, MPH, Commissioner of the Massachusetts Department of Public Health•David Seltz, Executive Director, Massachusetts Health Policy Commission•Arlene Ash, PhD, Professor University of Massachusetts Medical School, Department of Quantitative Health Sciences •Thomas Scornavacca, Jr, DO, Medical Director, UMass Memorial Office of Clinical Integration•John Greenwood, Senior Vice President, Office of Clinical Integration, President ACO•Ronald Adler, MD, Director, Primary Care Practice Improvement, Associate Professor, University of Massachusetts Medical School•Michael Nickey, Executive Director MassHealth Programs, Fallon Health•Tom Ebert, MD, Executive Vice President and Chief Medical Officer, Fallon Health•David Brumley, MD, Senior Medical Director, Fallon Health•Lukey Nuthmann, Behavioral Health Director, Fallon Health•Betsy Hampton, RN MBA, Vice President Population Health, Office of Population Health, Reliant Medical Group,•Jonathan Chines, Vice President, Payer Contracting and Network Strategy, Reliant Medical Group•Brian Rosman, Director of Policy and Government Relations, Healthcare For All•Alyssa Vangeli, Associate Director of Policy and Government Relations, Healthcare For All•Cristina Severin, President and CEO, Community Care Cooperative.•Dan Tsai, Assistant Secretary for MassHealth and Medicaid Director•Eric Dickson MD, MHCM, FACEP, Memorial Health Care President and Chief Executive Officer•Senator Harriett L. Chandler, Chairperson, Senate Committee on Redistricting, Chairperson, Special Senate Committee on Citizen Engagement
*FPL = Federal Poverty Level
Friede,n 2010
This Table Illustrates the potential benefit for Hospitals. The more Medicaid Patients kept out of the hospital, the more Commercial Patients the hospital can take on.
