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Packed Crowd at MassHealth Listening Session on ACOs

Packed Crowd at MassHealth Listening Session on ACOs

June 25, 2016

The room - actually 3 rooms combined - was packed as MassHealth held its first listening session for its federal waiver application which includes its ACO proposal and much more. The session was held in conjunction with the regular meetings of two MassHealth advisory panels. Despite it being a late Friday afternoon before the first weekend of the summer, interest in the proposal was very high. Given the number of speakers, the session, which started at 2:30 was supposed to go to 4, dragged on until almost 5. A second session will be held in Fitchburg on Monday, June 27.

MassHealth staff started with this powerpoint presentation, which summarized the waiver application.  A lot of money is at stake. MassHealth is seeking $1.8 billion over 5 years from the federal government to be used for Delivery System Reform Incentive Payments (DSRIP). These funds will support the transistion to ACOs (Accountable Care Organizations - see our blog post here for more on ACOs). Money will go to provider groups seeking to become ACOs, allowing them to pay for social services as well as medical care. Funds will also go towards integrating behavioral health and long-term care services, and other investments, In addition to the DSRIP money, the state is seeking $6.2 billion over 5 years for safety net providers and to pay for care for the uninsured.

Many speakers focused on the opportunity to expand MassHealth to provide assistance with the social determinants of health, like housing, nutrition and other social services. People representing YMCAs, the Housing and Shelter Alliance, the Pine Street Inn and other groups talked the critical role housing and other services play in promoting health. Similarly, Action for Boston Community Development suggested creating social service "hubs" to connect medical ACOs with smaller agencies which can focus on particular needs. The Boston Center for Independent Living and the Transformation Center talked about the needs of people with disabilities.

HCFA's Oral Health Integration Project spoke about the need to fully connect dental care and oral health with the primary care offered through ACOs. 

HCFA's organizational comments, copied below, focused on three areas of immediate concern. Written comments are due by July 17. In the coming weeks, we will be circulating a sign-on letter for groups to join us in expressing broad community reactions to the waiver proposal. If you are interested in this, please contact Suzanne Curry of HCFA's staff. 

Here are the comments we offered:

Health Care For All Talking Points – MassHealth Waiver Listening Session (Boston 6-24-16)

We have heard the strong emphasis from the administration on ACOs as a way to improve MassHealth’s “sustainability,” which, of course, is code for saving money.

We understand and support this goal, and we also understand the need to secure federal DSRIP funds. But we see ACOs as more than cost savings. It’s an opportunity to restructure care so that the focus is on promoting the health of MassHealth members. Health is more than just what doctors and hospitals do, though they are important. ACOs open the door to a MassHealth system that treats the member as a whole person, rather than as disconnected symptoms.

We’re pleased that the proposal is aimed at:

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

Our comments today will focus on 3 areas where we think the waiver can be strengthened, consistent with the goals of the project.

Before I get to our three categories, I want to mention that we also have critical thoughts on the integration of oral health and dental care within the ACO structure. Those issues will be addressed by representatives of the oral health integration project which we lead. We also strongly support the comments you will receive from groups concerned with community health workers, the disability community and the public health community.

Transparency and Oversight

Our first category is transparency and oversight

We’re pleased that the proposal calls for ACOs to include members in their governance, and includes PFACs – patient and family advisory councils – as a requirement for every ACO.

We have two additional suggestions. First, there should be an oversight Steering Committee, modeled after the Implementation Council for the One Care program. The steering committee should have significant authority, and include stakeholders, both clinical and non-clinical, including members, community-based organizations, social services agencies and include key state legislators and other policymakers. The Committee should serve as a public forum to provide accountability to make sure the project is meeting its goals, and to identify areas for improvement.

Second, we recommend that the Steering Committee establish a public dashboard with key data on the outcomes produced by ACOs. Just like CHIA publishes annual, public data on the performance of the state’s health care system, MassHealth and the ACO Steering Committee should continuously monitor and evaluate the program’s implementation. This will also require publicly setting system-wide, measurable goals for what we hope to accomplish by moving care to ACOs, such as reduced hospitalization, reduced institutionalization, improved health outcomes. We should also go beyond health care and look more generally at improved quality of life. The dashboard should also include data on reduction of disparities.

Carrots, not sticks

Our second category is about protecting member access and choice. Our slogan here is, “Carrots, Not Sticks.”

We appreciate the proposed elimination of copays for members below 50% FPL.

But, we’re very much opposed to the reductions in benefits, and the increases in premiums and cost-sharing intended to push people into the ACO structure. We also strongly oppose the 12-month lock-in into MCO plans. Increased cost-sharing for low-income consumers restricts access to needed care, causing many to delay, forgo, or ration care – leading to more acute, costly problems down the line and worse outcomes.

  • In order to make the ACO option appealing to members, members need an objective explanation of the positive benefits, and then members need to make their own choice for what’s best for them. We shouldn’t place artificial limitations that hurt members who make the “wrong” choice. Members should not have to choose between seeing their preferred providers and having coverage for eyeglasses, hearing aids, orthotics, and chiropractic care.

  • We learned this phrase from our friends at Atrius: “The best fence is a good pasture.” We urge MassHealth to take this message to heart and eliminate the punitive provisions.

Help Members Navigate the New System

Our final category is based on acknowledging that the waiver proposal will make the system more complicated, not simpler. Expecting members to learn the complex new vocabulary – Model A, Model B, Model C; ACO/MCO – and how to navigate the new system, is going to extraordinarily complex.

With the changes, the simple act of choosing your primary care setting will bring with it a host of important consequences. Particularly if the lock-in and open enrollment restrictions are put into place, members will need lots of help figuring out what best meets their needs.

We urge MassHealth to include a substantial investment in member education and navigation assistance. We applaud the ombudsman proposal, and want to make sure that the ombuds office will be able to address systemic issues, in addition to assisting individuals who get stuck in some way.

The need is for tailored, personalized assistance both pre- and post-enrollment.

Members should get individual navigation and assistance with choosing a plan and understanding the options available.

ACOs should also partner with community groups to set up a robust training and orientation program, to educate members on care planning, care team functions and other aspects of the model are still not fully understood by members. These will be essential when the ACO program begins. 

We truly appreciate the open process of consultation and public input leading up to the filing of the waiver, and trust that this will continue through the CMS process and, most importantly, through the implementation. Massachusetts always seems to lead the way with innovative health care policy, and we know that national groups are looking to us to be a pathfinder as we plan our systems transformation. But, the planning is one thing, and the implementation is more challenging, and much more important. Everything is in the implementation, and we pledge to continue to work with you to always make the system better and better.