HCFA Comments to MassHealth on ACO Design 12-16-15

Wednesday, December 16, 2015

Summary: Health Care For All Comments on MassHealth Payment and Delivery System Transformation

In December, 2015, Health Care For All submitted comprehensive recommendations to MassHealth, our Medicaid program, regarding the development of Accountable Care Organizations (ACOs). ACOs represent a new way to pay for and organize health care delivery, by bringing together doctors, hospitals and other health care providers, who work to give coordinated, high quality care to their patients. 

MassHealth is engaged in a process of consultation with health care stakeholders and the public to establish the contours of their ACO transition. You can learn more about MassHealth's thinking on ACOs in this presentation.

We believe MassHealth has an opportunity to promote approaches to payment reform that fundamentally transform the way care is delivered. ACOs should deliver high quality, high value care that treats the individual as a whole person and ensures coordination of care, improved communication, member support and empowerment, and ready access to health care providers, services and community-based resources and supports. The goal is not just better health care, but better health for the entire state.

There’s a lot of detail in our full recommendations (download the document here (warning: 29-page pdf)), along with examples from other states. Below is a much-abridged summary of our recommendations:

Member Protections

  • Monitor and track underutilization: ACOs should establish internal monitoring mechanisms for under-service to safeguard against potential incentives to deny or limit care, especially for members with high risk factors or multiple health conditions. MassHealth should monitor under-service by assessing claims data and health outcomes over time to identify patterns of variation.
  • Protect member choice of providers
    • Network adequacy: Members should have access to care across the continuum, which includes reasonable access to a sufficient number of primary and specialty care physicians, facilities, and other providers, as well as benefits delivered in a timely fashion within a reasonable distance. ACOs should have continuity of care provisions for contracting with providers outside of the ACO.
    • Attribution methodologies: Attribution methods should involve member choice to the maximum extent feasible. MassHealth should not establish a lock-in period forcing members to remain in their ACO for a particular period of time.
  • Ensure robust appeals and grievances procedures: ACO grievance and appeals processes should be easily accessible. MassHealth should establish a single source of information and accountability for under-service through an ombuds program model.

Member Engagement at Multiple Levels

  • Ensure consumer representation and input in ACO governance bodies and advisory councils: Members should be formally integrated in the design and governance of ACO policies and procedures. This includes representation on the ACO’s Governance Board and the formation of ACO Member Advisory Councils to address issues like the ACO’s quality and member experience from the member perspective.
  • Promote member engagement and activation in care: ACOs should engage members directly in their care through approaches such as using shared decision making and trained health coaches, and helping members manage their own health and health care.
  • Promote patient-centered quality measures: ACOs should use quality measures that include patient-reported outcomes measures and measures that capture members’ views regarding the care they received.

Comprehensive data collection and public reporting

  • Stratified data collection: ACOs should collect standardized data on key demographic and socioeconomic measures. Outcomes and other quality indicators should be stratified by social determinants of health indicators in order to appropriately target population health interventions, address and reduce health disparities, and improve how ACOs deliver care.
  • Promote transparency and accountability through public reporting: ACOs should publicly report quality and cost information at the provider level, as well as at the ACO level.
  • Consumer friendly education and outreach: All individuals receiving care through an ACO must be fully informed about what this means and how to protect themselves if necessary. Information should be accessible and understandable to all members, including those with limited English proficiency and who are deaf, blind or hard of hearing.  
  • Data sharing: Individuals should have electronic access to their medical records and other health information and related clinical knowledge needed to make informed choices about their care.

Access to Services and Care Delivery

  • Incorporate oral health services: Oral health should be included within the scope of ACO services in order to improve overall health and quality of life and help achieve cost savings. Integration should encompass including oral health as a component of routine primary care, creating a two-way referral network, and incentives for co-location.
  • Promote care coordination: ACOs should educate members on care coordination and care planning, including group visits and chronic disease self-management programs.
  • Promote the integration of behavioral health services: ACOs should integrate mental health and substance use disorder services with primary care, which can include co-located models, formal partnerships with community-based behavioral health providers, or the federal Health Homes opportunity. ACOs should also emphasize prevention and early interventions with children and their families.
  • Ensure access to member-centered long-term services and supports (LTSS): LTSS should be phased in as ACOs and community-based LTSS provider organizations are ready. Members in need of LTSS should have access to an independent LTSS coordinator to assess the member’s needs and develop a consumer-centered care plan.
  • Ensure adequate access to and appropriate standards for pediatric services: ACOs should establish access and quality standards specific to pediatric primary care, behavioral health, oral health, and specialty providers. MassHealth should develop pediatric-specific approaches including payment frameworks, quality standards, and delivery systems in the ACO design.

Population Health and Prevention

  • Promote linkages with community-based organizations and active coordination with community resources: ACOs should provide education and assistance with accessing the community resources in their area and coordinate with those resources to exchange member information.
  • Utilization of community health workers: ACOs should promote public and community health by using community health workers to connect people to care resources and promote overall health.
  • Support and invest in community-level changes in conditions which drive health outcomes: Population health should include measuring and analyzing health indicators to support community-level care and community-level changes in conditions. ACOs should assess community assets and challenges to target interventions and collaborate with external partners to address community-based drivers of poor health.
  • Incentives to reduce racial, ethnic and linguistic health disparities, including incentives to provide culturally and linguistically appropriate care: ACOs should be required to train their providers on cultural competence and make efforts to reduce implicit bias among caregivers.
  • Flexibility in spending: Payers should be encouraged and incentivized to pay for coordination, wellness and prevention services that are not traditionally reimbursed.

Financial Incentives and Payment Methodologies

  • Incentive payments: MassHealth should develop quality and cost-based payment incentives for ACOs that prioritize patient quality outcomes as the leading component of payment incentives, so that cost savings are not the sole motivation of provider payment reforms.
  • Risk adjustment should take into account socioeconomic status: Payer contracts with ACOs should use risk adjustment measures that include adjustments for social, cultural, and economic factors that impact the cost of high-quality care and good outcomes.