MassHealth’s New World of ACOs — and a Mighty Upstart

[I wrote this commentary for the spring issue of Commonwealth Magazine.  I am watching the new crop of 17 Accountable Care Organizations — ACOs — with great interest.  This is a nationally important demonstration that also holds risks for the medical care of many MassHealth enrollees.]

ON MARCH 1, the state’s Medicaid program—known as MassHealth—entered a new era with the launch of 17 accountable care organizations, or ACOs, aiming to provide better coordinated care at lower costs to its low-income enrollees. It’s an ambitious effort with lots of risk and big potential rewards. Within this is another compelling effort to redefine how community health centers fit into the changing health care landscape of Massachusetts and the nation.

Christina Severin, CEO of C3, the new accountable care organization formed by community health centers.

It began with a serendipitous encounter at a grocery store. Sometime in the fall of 2014, Christina Severin bumped into Lori Berry at the seafood counter of the Brighton Whole Foods market. Severin, a long-time leader in the MassHealth scene, had been mulling the creation of a community health center-based non-profit to join the cohort of ACOs being planned for as many as two-thirds of the 1.9 million Massachusetts residents who rely on the program. Continue reading “MassHealth’s New World of ACOs — and a Mighty Upstart”

5 Takeaways from Baker’s New Health Reform

[This commentary was published on June 24 on the Commonwealth Magazine website.]

PHASE 2 OF THE BAKER ADMINISTRATION’S ambitious health reform agenda emerged this past week.  It contains good and smart proposals – and worrisome ones needing attention.

Phase 1 is an ambitious effort to transform much of the state’s Medicaid program, known as MassHealth, into “accountable care organizations.” ACOs aim to focus hospitals, physicians, and other providers on improving population health, care integration, and efficiency.  That effort, blessed by the outgoing Obama administration last November, is well underway – unless congressional Republican efforts to repeal the Affordable Care Act throw everything into a tailspin.

Phase 2 came last week, when the Baker administration released a set of proposals to Senate and House leaders, a package of changes to MassHealth and other health programs aiming to save $314 million in fiscal year 2018, which starts July 1, and more beyond. All the proposals need state law changes (to be incorporated in the nearly finished FY 2018 state budget) and/or federal approval. Continue reading “5 Takeaways from Baker’s New Health Reform”

MassHealth Dives into Accountable Care

[I wrote this commentary for the Spring Issue of Commonwealth Magazine to profile Massachusetts’ new move into accountable care organizations, an experiment that deserves watching.  Dr. William Seligman co-wrote with me.]

IN A WILDLY uncertain national health care environment, something new, audacious, and risky is happening in MassHealth, the Medicaid program that provides health coverage to 1.9 million people who are poor, elderly, and persons with disabilities in Massachusetts. Gov. Charlie Baker’s administration is betting that an emerging health care delivery and payment model, called “accountable care organizations,” can restrain rising costs by keeping enrollees healthy and out of expensive settings, especially hospitals. Positive results will have big consequences for the state, for medical providers, and for hundreds of thousands of MassHealth enrollees who will become part of ACOs this year and into the future.

The ACO scheme is the major part of a massive new federal Medicaid waiver that Team Baker won from the outgoing Obama administration days before the November 8

MassHealth spending 17

election that put Donald Trump in the White House. The Obama administration liked the Baker plan because it fit with their mission to move US health care away from expensive fee-for-service payment and toward value-based financing that rewards quality and efficiency. Though no one knows for sure which way the Trump administration will move, right now it’s full speed ahead at MassHealth on the ACO agenda. Continue reading “MassHealth Dives into Accountable Care”

Explaining the New MassHealth 1115 Waiver Proposal

The article below — Baker’s Big Health Care Move — was published in the October 2016 issue of Commonwealth Magazine:

FOR THE THIRD time since 1996, the Massachusetts Medicaid program, called MassHealth, is preparing for transformation. After submitting a final proposal in July, state officials are anxiously awaiting a decision on the plan from the US Centers for Medicaid & Medicare Services. The goals are to: first, transform how medical services are delivered to many of MassHealth’s 1.86 million enrollees (including 40 percent of Massachusetts children); second, guarantee a five-year flow of nearly $8 billion in extra federal dollars into the state’s health care system; and third, better integrate substance abuse, mental health, and long-term services and supports into traditional medical care.

Chances are you have heard nothing about this plan that contains many worthy and some controversial changes. For state leaders, the stakes are high. Between 1997 and 2015, MassHealth’s share of the overall state budget doubled from 18 percent to 36 percent—with federal dollars accounting for more than half of the total share. At $16.4 billion in fiscal year 2017, MassHealth is the state’s biggest budget buster and most important lifeline for the state’s neediest populations. The new federal proposal represents Gov. Charlie Baker’s attempt to slow the growth rate while improving medical care and the health of enrollees.

For those who have been awaiting the Baker administration’s big health policy move, this may be it.

WHY IS THIS HAPPENING?

Since 1965, Medicaid has been a federal-state partnership that provides health coverage for low-income Americans. Originally just for poor mothers and kids on public assistance, today it is America’s largest health insurance program, covering more than 70 million people. The federal government provides most of the money, and sets tight rules governing how states run their programs. States can get flexibility from those rules by obtaining waivers from the federal government, the most pliable being the “Section 1115 research & demonstration waiver,” generally granted for 3-5 year terms. Even though federal rules require waivers to be “budget neutral,” states use creative medical and insurance redesigns to obtain substantial and desirable financial flexibility. Massachusetts Medicaid entered the 1115 game in 1997 with a major coverage expansion that transformed it into today’s MassHealth. Baker, then secretary of administration and finance under Gov. Bill Weld, was a key architect.

Since that time, Massachusetts’s 1115 waiver, now in its sixth iteration, has brought flexibility and extra dollars to support the state’s medical infrastructure for disadvantaged populations, chiefly through Boston Medical Center, Cambridge Health Alliance, and the state’s community health centers. It was the threatened loss of those extra federal dollars ($385 million in 2004) that jolted then-Gov. Mitt Romney and Sen. Ted Kennedy to formulate the plan leading to passage of the landmark 2006 Massachusetts Universal Health Care law, which in turn helped spark passage of the 2010 federal Affordable Care Act.

The state’s current 1115 funding ends in June 2017, and Baker administration officials, especially Secretary of Health and Human Services Marylou Sudders and MassHealth chief Daniel Tsai, are eager to lock in the next waiver—and the nearly $8 billion over five years—before Team Obama departs in January. Since arriving on Beacon Hill in January 2015, Team Baker has engaged in intensive planning with stakeholders, including consumer advocates, hospitals, physicians, insurers, and more. State leaders want federal approval by early fall. If federal officials like their plan—and Team Baker is hitting notes Team Obama wants to hear—they may get their wish.

WHAT’S THE PLAN?

The state’s application outlines five goals for the new five-year waiver that would begin in 2017:

  1. Enact payment and delivery system reforms that promote integrated, coordinated care and hold providers accountable for the quality and total cost of care.
  2. Improve integration of physical health, behavioral health, long-term services and supports, and health-related social services.
  3. Maintain near-universal coverage.
  4. Sustainably support safety net providers to ensure continued access to care for Medicaid and low-income uninsured individuals.
  5. Address the opioid addiction crisis by expanding access to a broad spectrum of recovery-focused substance abuse disorder services.

The most controversial goal is the first: inducing Mass-Health medical providers (hospitals, physician groups, home health agencies, community providers, and post-acute providers such as rehabilitation hospitals and nursing homes) to form or expand “accountable care organizations” (ACOs) to assume responsibility for the total cost of care for their MassHealth members.

ACOs were invented in the Affordable Care Act to push providers away from fee-for-service payments that tend to reward volume over quality and efficiency. Since 2010, more than 800 ACOs have formed across the nation in Medicare, private coverage, and, increasingly, Medicaid, with 17 states now using ACOs or looking to do so. In 2012, in that year’s health care cost control law signed by then-Gov. Deval Patrick, the Legislature directed MassHealth to move quickly to adopt “alternative payment models” such as ACOs. So the new waiver will enable MassHealth to meet both federal objectives as well as its legislative mandate.

Currently, about 840,000 of MassHealth’s 1.86 million enrollees obtain care through one of the state’s Medicaid managed care organizations such as Neighborhood Health Plan or Boston Medical Center’s Health Net. About 383,000 others participate in the loosely managed Primary Care Clinician (PCC) program. The rest, especially seniors and persons with disabilities, are in fee-for-service. MassHealth officials want to push as many PCC enrollees as possible into managed care organizations or ACOs by curbing benefits such as eyeglasses, hearing aids, and chiropractic or orthotic care and imposing new out-of-pocket costs on unwilling enrollees who choose to stay with the PCC program.

This aspect concerns patients, advocates, and medical groups. Though ACOs have grown rapidly since 2010, their track record in reducing costs and in improving quality has been modest, and their future is a topic of urgent debate among health policy experts. Some data suggest that PCC enrollees are no more expensive than managed care enrollees. Many PCC enrollees have serious, complex medical needs that can be poorly served by Medicaid managed care organizations with exclusive provider networks.

On the other side, encouraging states to jump into ACO-style “value-based payment”—and away from uncoordinated and unmanaged fee-for-service care—is among the highest priorities of federal officials such as US Health and Human Services Secretary Sylvia Burwell. If Massachusetts wants any hope of keeping the $8 billion in extra federal dollars flowing, they need to excite federal officials with ambitious designs of this variety.

The second goal—integrating physical health, behavioral health (the combined term for mental health and substance abuse treatment), long-term services and supports (the new term of art for long-term care), and health-related social services—is a major health system improvement goal advocated nationally and in Massachusetts by many, especially Sudders, a former clinical social worker and state mental health commissioner who has long fought to demolish medical care siloes.

Under the new waiver, new MassHealth ACOs will be required to build partnerships with certified “community partner” organizations that provide behavioral health plus long-term services and supports while managing the total cost of care of their enrollees. Providers will operate with per-person capitated payments that require improving the health and well-being of enrollee populations rather than just treating sick patients, a paradigm-shift for providers trained to care—and bill—for one patient at a time.

In response to health care providers worried about adapting to this new system, state officials emphasize the five-year transition to an ACO-centered MassHealth set to launch October 1, 2017. They also note that the $8 billion in federal waiver money will include $1.8 billion in additional federal payments (called Delivery System Reform Incentive Payments) specifically to help providers undertake the transition.

LET THE GAMES BEGIN – OR NOT

Opaque is a word often applied to 1115 waivers, one the Obama administration has attempted to replace with “transparent.” States must now conduct open public hearings on new waiver applications and make public all sorts of information relating to 1115 applications. MassHealth’s information, including the application, is here.

Noteworthy are 94 stakeholder letters submitted in July, 400 pages of praise and criticism from organizations large (Massachusetts Hospital Association, Massachusetts Medical Society) and small (Home Care Aide Council, Autism Housing Pathways). One letter from Leann DiDomenico, the mother of a 12-year-old adopted foster child, caught my eye:

“My son…spent the first three years of his life in an abusive birth home followed by 18 months in three different foster homes leaving him with a number of behavioral health issues, including PTSD and reactive attachment disorder (RAD). Over the past seven years my husband and I have worked hard alongside [his] primary care provider and various therapists to help [him] to heal and develop the tools he needs to live a full, productive life in spite of his mental health issues. If/when [he] is transitioned to an ACO, I have no confidence that we will be able to keep the professionals we currently have in place that are working well for [him].”

Leann’s letter gives voice to the concerns advocates have raised about the waiver plan. In 2013, MassHealth launched another ambitious demonstration to move their disabled enrollees into a new managed care program called One Care. Though One Care has made substantial improvements in quality, only about 13,000 of 115,000 MassHealth eligible enrollees have signed up after a rocky implementation (see “No time to go wobbly on One Care,” CW, Fall 2015). The new 1115 waiver is even more ambitious and dicey. Many PCC enrollees and their families have painstakingly built personal provider networks to address their serious and unique needs. ACO implementation risks serious disruption for them. MassHealth should offer these individuals and families a no-penalty “opt-out” until this experiment proves itself.

Baker’s 1115 waiver plan includes major steps forward for Massachusetts health care that may pay important dividends well into the future. Until they have demonstrated the capacity to implement this without harming any of their enrollees, they should proceed with more caution.

No Time to Go Wobbly on “One Care”

I am reprinting an article I wrote for the new issue of Commonwealth Magazine concerning One Care, Massachusetts’ bold and risky experiment to coordinate care for the so-called “dual eligibles” who are under age 65 and disabled.  It has been a tough ride in the program’s first two years.  In this piece, I give the background and context for One Care and propose that we stay the course as the smart and right thing to do:

one-care-banner-headerBACK IN 2008, when I was working in the US Senate on national health reform, a delegation of 20 business leaders from the New England Council visited Capitol Hill to offer advice. The group’s leader was Charlie Baker, then Harvard Pilgrim Health Care’s CEO. I recall his one recommendation: “You have to do something about dual eligibles because they are one of the most important and expensive pieces of the puzzle.”

As Massachusetts now struggles to sustain One Care, its nationally significant dual-eligibles demonstration project that launched in October 2013, Gov. Baker’s hope is happening. Given the project’s rocky and difficult first 18 months, he could be forgiven for wondering if he could rewrite that wish. Continue reading “No Time to Go Wobbly on “One Care””

A Most Important Demo You’ve Never Heard of… “One Care”

A new report from the Kaiser Family Foundation puts a welcome spotlight on a most important U.S. health reform demonstration — called One Care — going on first and right now in Massachusetts.   How wonky is this?  The report title says it all: Early Insights from One Care: Massachusetts’ Demonstration to Integrate Care and Align Financing for Dual Eligible BeneficiariesWhat’s it all about?

1-care-banner-headerA population of Americans known as the “dual eligibles” is among the nation’s most needy and expensive groups.  They are 9.6 million elderly and disabled low-income Americans who are dually enrolled in both Medicare and Medicaid.  For most of the 50 year history of the two programs, the “duals” fell between the cracks, getting poorly coordinated or no care.  Twelve years ago, with federal support, Massachusetts’ Medicaid program, called MassHealth, started a “Senior Care Options” (SCO) program for coordinated/managed care for duals over age 65. Continue reading “A Most Important Demo You’ve Never Heard of… “One Care””