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MA Medicaid Embraces Accountable Care, Population Health Models

The Massachusetts Medicaid program will offer a number of accountable care organization options for providers seeking delivery structures focused on population health.

- MassHealth, the Massachusetts Medicaid program has received a CMS waiver allowing providers to significantly expand participation in accountable care organizations and innovative integrated delivery models focused on population health management.

Accountable care organizations in the Massachusetts Medicaid program

Beginning in July of 2017, MassHealth will begin to implement a statewide accountable care program which will include three ACO options for Medicaid providers.  All three tracks will focus on integrating behavioral healthcare and long-term care services with the primary care ecosystem in an effort to foster care coordination and a population health approach to the complex needs of many Medicaid patients.

“ACOs will be able to invest in certain approved community services that address health-related social needs and are not otherwise covered under Massachusetts’ Medicaid benefit,” wrote Acting CMS Administrator Andy Slavitt to Dan Tsai, the Assistant Secretary of the Massachusetts Executive Office of Health and Human Services.

“All MassHealth ACOs will be required to form linkages to state-certified Community Partners of Behavioral Health and long-term services and supports (LTSS) in order to receive infrastructure funding.  These community partners will be empowered to support ACOs with care coordination and management for members with complex behavioral health and LTSS needs.”

Substance abuse treatment and recovery will be a major focus for the behavioral healthcare portion of the project, said Slavitt.  Massachusetts providers will attempt to address rampant opioid abuse and addiction by expanding access to residential inpatient and community substance abuse treatment options.

All full-benefit MassHealth beneficiaries will have access to the entire continuum of substance abuse and dependence services, and will be eligible to receive care regardless of which delivery system they use.

The three available accountable care models give participants a variety of options for structuring their leadership, financial risk, and contracting, CMS explained.

Accountable Care Partnership Plans are managed care organizations (MCOs) that will work closely with an associated ACO to “provide vertically integrated coordinated care under a global payment.” Slavitt said. 

The second option, Primary Care ACOs, are provider-led organizations that will contract directly with the Massachusetts Medicaid agency to take financial responsibility for a defined set of enrolled beneficiaries.  Providers will be reimbursed through retrospective shared savings and risk, and may engage in more advanced payment arrangements if they see success.

The last model is the MCO-administered ACO.  These organizations “are provider-led ACOs that contract directly with Massachusetts’ Medical MCO contractors to take financial accountability for the MCO enrollees they serve through retrospective shared savings and risk,” the document states. 

“CMS is authorizing Massachusetts to contract with ACOs through these three models and to pay ACOs using upside and downside risk arrangements.”

Funding opportunities will also come in threes, Slavitt added.  The demonstration approval includes a $1.8 billion Delivery System Reform Incentive Payment (DSRIP) program that will support technical and organizations development across the state.  The funding will be spread out over five years, but will decrease over time as ACOs mature with the expectation that these programs will become financially sustainable.

One funding track will support care coordination and infrastructure costs for nascent accountable care organizations, while a second stream will help to integrate behavioral health and LTSS services into the primary care ecosystem. 

The last financial pathway will offer funding for primary care providers at community health centers, support those participating in alternative payment structures, improve access to patients with disabilities, and help to address the practice of boarding mentally ill or substance abusing patients in emergency departments.

MassHealth hopes that the new approach will help to rein in unsustainable spending, officials said in April when applying for the restructured waiver.  Medicaid costs comprise 40 percent of the state’s budget, or more than $15 billion per year, exacerbated by outdated fee-for-service payment structures that have resulted in fragmented and siloed care.

The Commonwealth is already home to several highly successful Medicare accountable care organizations, including Atrius Health, Beth Israel Deaconess Care Organization, and Partners HealthCare, all of which participate in the Pioneer ACO program.

Atrius Health, for example, earned $4.4 million in shared savings in the 2015 program year after accruing $6.8 million in savings for Medicare. 

“Atrius Health has a long history of working with what we would now call alternative payment models in which we were accountable for the whole range of services that our patients received across the healthcare continuum,” said VP of Population Health Emily Brower, MBA, to RevCycleIntelligence.com earlier this year.

“We had been working in an accountable care model in both commercial Medicaid and Medicare in the Medicare Advantage space. We had a lot of the infrastructure and support to provide that same kind of model for traditional Medicare patients aligned to us through the Pioneer ACO.”

Medicaid organizations are looking to see similar successes by developing the infrastructure, data sharing, and care coordination competencies to better serve their patients under the new federal waiver.

Massachusetts and CMS both hope that ACOs “will represent a transformative step forward for MassHealth,” Slavitt wrote, “building a system of broad and integrated provider-led care delivery organizations operating in partnership with agencies delivering health-related community services.”

“CMS looks forward to continuing work with your staff on future developments within your demonstration,” he ended the letter.


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