Medicaid ACO Pilot: Expanding and Improving Care for BWH’s High-Risk Patients
Late last year, Gov. Charlie Baker received approval from the Centers for Medicare & Medicaid Services (CMS) to restructure MassHealth – Massachusetts’s Medicaid program – in an effort to control spiraling health care costs.
The new structure will transition MassHealth from a fee-for-service model to a system of accountable care organizations (ACOs) that work closely with community partners to provide more integrated care for the 1.9 million MassHealth members across the state. Called the MassHealth ACO, it will be launched statewide in Dec. 2017 and supported by $1.8 billion in federal funding over the next five years.
Prior to the MassHealth ACO launch, health care systems were encouraged to apply to be part of a MassHealth ACO pilot, and Partners, along with five other health systems, was selected to participate last December. The collective name for the year-long Partners pilot is Partners Care Connect.
“This is an exciting opportunity for BWH, the BWPO and Partners to impact care for some of our most vulnerable patients,” said Rose Kakoza, MD, MPH, assistant medical director of BWH’s integrated Care Management Program (iCMP) and medical director of the pilot at BWH.
ACOs first came onto the health care scene six years ago as a way for the federal government to contain rising health care costs across the country.
Described by CMS as “groups of doctors, hospitals and other health care providers who come together voluntarily to give coordinated high-quality care to their Medicare [and now Medicaid] patients,” ACOs seek to coordinate care so that patients receive “the right care at the right time while avoiding unnecessary duplication of services and preventing medical errors.”
As part of the pilot, Partners is taking financial risk for the roughly 20,000 patients who are on the MassHealth Primary Care Clinician (PCC) plan. What this means is that Partners and its hospitals must manage medical spending on this population against a benchmark. If they are able to lower costs for these patients below the benchmark, the state will share half of the savings with Partners. Similarly, if the hospitals’ costs are higher than the agreed-upon benchmark, Partners will owe the state a portion of the difference.
Kakoza says that participating in the pilot enables BWH and others to get their “feet wet” with minimal risk and test out the state’s methodologies prior to full ACO participation.
“Any work to reduce unnecessary hospitalization and improve care transitions could both improve care and decrease costs for MassHealth patients,” said Linda Lacke, MPH, senior project manager for the BWH pilot.
Added senior project manager and data analyst for the pilot Vineeta Vaidya, MS: “Making sure we achieve quality outcomes is also a critical component of this pilot. We want to be sure that we are not only reducing costs but improving quality of care.”
The BWH pilot is focused on primary care and emergency medicine. It is being implemented at the three sites where the vast majority of BWH PCC plan patients receive their care – the Phyllis Jen Center for Primary Care, Brookside Community Health Center and Southern Jamaica Plain Health Center – and the Emergency Department. While BWH’s 7,000 PCC plan members’ insurance and benefits won’t change, these patients are now eligible for existing population health management programs, such as iCMP, that they may not have been eligible for before the pilot.
The pilot will integrate a pediatric iCMP nurse care coordinator and social worker into Brookside and Southern Jamaica Plain Health Center to improve the coordination of care for high-risk pediatric patients at the two community health centers. It will also enhance the adult iCMP by expanding iCMP’s community health worker program to all three primary care pilot sites and the ED, as well as establish social workers as iCMP lead care coordinators for a subset of patients who have significant behavioral and mental health conditions and for whom care costs and hospital utilization are high.
“The pilot is a unique opportunity to really think about how to redesign care around the unique needs of our most vulnerable patients,” said Kakoza. “New care delivery strategies will help us better meet our patients’ needs and lower costs by keeping patients out of the ED and better engaged with primary care and community organizations. We want to be sure patients are getting their needs met in the appropriate place and at the appropriate time.”
Additionally, the pilot is formalizing primary care-based care coordination teams for high-risk patients who are not part of the iCMP. The team will include a nurse, population health manager, community health worker, resource specialist, health coach, domestic violence advocate and others working together in an integrated and multidisciplinary way.
Finally, the pilot is working to develop an ED high-risk care coordination team that incorporates social workers, nurses, community health worker and physician team members to determine how to best manage high-risk ED patients and support them between hospital visits. The pilot team also convened a social determinants of health working group and behavioral health and substance use disorder working group to identify and connect with key community partners.
Kakoza says that the care teams involved have shown great energy and enthusiasm for the pilot. Partners has submitted an application to begin participating in the full-scale ACO in December.
“The pilot has been received as a welcome opportunity to provide more and do more for a population of our patients who have significant needs,” said Kakoza. “We’re really excited to see how these efforts will benefit them.”