How a MassHealth makeover could set a new standard for care

Courtesy Dr. Michael Older, a Nashoba Valley Medical Center physician, meets with an employee. Nashoba Valley in Ayer has teamed up with Steward Health Care Network to form one of 17 MassHealth Accountable Care Organizations to launch in March.

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By Emily Micucci

It’s an experience known to many. You show up in the emergency room with an acute medical problem, and are bombarded with questions about your health, from medications taken to surgeries received.

You may be subject to tests that you’ve recently undergone, because the provider seeing you doesn’t have access to your medical history. It’s an added step at a time when you want answers and relief, and it isn’t cheap.

There are a number of ways healthcare systems and physician groups are trying to tackle this problem, but it’s difficult to do in a healthcare delivery system that lacks cohesion.

For Medicaid patients in Massachusetts, the experience will soon begin to change.

On March 1, 2018, a large portion of people covered by MassHealth, the state Medicaid insurance program, will be transitioned into a new system of healthcare delivery that is intended to improve their care while making the program economically sustainable. Designed by the Baker Administration, the new MassHealth Accountable Care Organization program will end fee-for-service payments for providers treating MassHealth patients.

Fee-for-service care has historically dominated the U.S. healthcare system, but it doesn’t provide much incentive for providers to manage the cost of care as well as the quality. Meanwhile, Accountable Care Organizations, which have been piloted by both the federal and state governments within government-funded insurance programs, hold providers accountable for delivering cost-effective healthcare, with incentives tied to certain quality measures and cost benchmarks.

An ACA feature

The ACO concept was written into the Affordable Care Act, though other managed care networks that provide similar incentives to providers have long existed within the commercial insurance space. Half a dozen ACOs have been participating in the MassHealth ACO pilot program since December 2016, accounting for 160,000 patients. But now, 850,000 patients will become part of a MassHealth ACO, a sizeable chunk of the program’s 1.9 million members.

The new MassHealth ACO program funnels $100 million to providers, to be used for a variety of initiatives, such as improving care coordination with behavioral health providers, improving electronic health records and analytic capabilities, and reducing unnecessary emergency room utilization and inpatient hospital admissions. Essentially, the money allows the providers to build the infrastructure needed to coordinate care.

Rather than a pilot, the new program is intended to be a permanent change for MassHealth, and it’s got a lot of potential to make health care better for patients, according to Dr. Michael Sheehy, chief of population health and analytics at Worcester-based Reliant Medical Group.

“It is a complex patient population to care for, and historically they have had very fragmented care. There’s a very high behavioral health need,” Sheehy said.

Reliant has joined forces with Worcester-based Fallon Health to form one of the 17 new MassHealth ACOs to launch in March. The two groups are forming a network, called Fallon 365 Care, to provide insurance, as well care, to about 45,000 MassHealth patients. That’s up from the roughly 15,000 patients Fallon and Reliant already manage together under an existing managed care contract. Sheehy explained it’s a new offering, where the insurer and the provider act as one to ensure care is coordinated and efficient. In addition, the groups will work with community partners that specialize in addressing long-term needs, particularly in the behavioral health realm.

Sheehy said historically, medical and behavioral healthcare have been “completely siloed,” creating practical problems, such as the primary care doctor not knowing what kind of medication a patient may be taking for a mental health disorder. Often, patients seek specialty care in practices unrelated to their primary care doctors’ offices, and this, too, can lead to duplicate testing and unnecessary procedures, Sheehy said.

The Reliant and Fallon MassHealth ACO is “sort of like a joint venture without going into business together,” according to Michael Nickey, executive director of the MassHealth program at Fallon Health.

The difference to patients

While patients will be autoassigned into MassHealth ACOs, they will have the opportunity to opt out within 90 days of the March 1 start date. There will be less flexibility to change plans than in the past after that window, in order to maintain stability within the ACOs.

But the expectation, according to Nickey, is that most will not opt out. For one thing, patients will follow their primary care doctors into the ACOs they’re a part of, and Fallon has strived to include the specialists that Reliant doctors already refer to. He noted that new insurance cards will be issued, so old cards will no longer work at the pharmacy counter on March 1.

Nickey added that despite the goal of cutting unnecessary Medicaid spending, quality of care and service levels will not suffer.

“Right now when folks change plans, you have a lot of duplicative testing,” Nickey said. “The idea is by keeping all this data within a set of providers, that alone will reduce some of that.”

Losing money on pilot, UMass Memorial opts out

While Fallon’s Medicaid business will nearly double, UMass Memorial Health Care, the dominant system in Central Massachusetts, will likely lose some MassHealth volume, since UMass Memorial and its planned partner, Tufts Health Plan, opted out of the the program.

While providers have the opportunity to earn incentives, they can certainly lose money operating ACOs. Such was the case for UMass Memorial, which lost money on its MassHealth ACO pilot.

“Neither (UMass Memorial or our partner Tufts Health Plan) had the financial reserves necessary to manage the potential downside risk. Hopefully there will be additional opportunities for us to participate in a Medicaid alternative payment program in the future,” UMass Memorial spokesman Anthony Berry said in an email statement.

Berry said the system is hopeful that ACOs serving Central Massachusetts patients will include UMass Memorial specialists in their networks, but acknowledged that the networks are narrow and don’t allow patients to see providers out of network.

Sheehy said that when appropriate, Fallon 365 Care will refer to UMass Memorial specialists, but the ACO will try to provide care within network when possible, and he anticipates more volume shifting to specialists at Saint Vincent Hospital in Worcester, which already works closely with Reliant.

“It’s too bad that they didn’t agree to it,” Sheehy said.

Commercial ACOs

While fee-for-service care still reigns among commercial payors, the MassHealth ACO results will likely have implications for healthcare contracting in Massachusetts and nationally. But accountable care does exist in the commercial market already. Dr. Mark Girard, president of Steward Health Care Network, which has formed and ACO in partnership with Nashoba Valley Medical Center in Ayer, said Steward has accountable care contracts with most commercial payors as well, offering the same coordinated care that MassHealth patients will receive.

“We treat everyone the same way,” Girard said.

(Editor's note: The original version of this story was updated to reflect the fact that Tufts Health Plan did not participate in a MassHealth ACO pilot program with UMass Memorial Health Care. We regret the error.)