Considerations in moving to an Accountable Care Organization Strategy for RI Medicaid

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1 Considerations in moving to an Accountable Care Organization Strategy for RI Medicaid Executive Office of Health and Human Services Deidre Gifford, MD Medicaid Director

2 Background Medicaid program costs are driven by a small population of complex patients Over 80% of these high cost cases are complex -- with multiple needs including Mental Health and Substance Use Disorder; and social determinants. Evolving Payment Models, national and locally Consolidation of funding for BHDDH-managed services in to Medicaid Funding for BHDDH-managed services has been consolidated with funding for physical health services, providing the opportunity to integrate funding streams to an accountable entity.

3 Do we have the appropriate incentives in place in our payment and delivery system to ensure that providers are engaged in optimally managing the care of these individuals, and putting in place supports to address social determinants? How do we effectively integrate physical and behavioral health in Accountable Care models?

4 Lessons from other States Oregon: Complete, aggressive shift to ACO model Minnesota: ACO alongside MCO contract New Jersey: ACO with gain sharing opportunity Vermont: State driven structure and single MCO Pennsylvania: ACO requirements within MCO contract Connecticut: Moved to ASO contract for MCO services and direct to providers for care Colorado: Aggressive investment in data/analytic infrastructure Maine: ACO with shared savings/risk Massachusetts: PCCM program alongside MCO state MCO competes with other MCOs

5 Lessons from Other States Regional Structures Specific model matters less than the levers used in the design and execution of the project Quality standards and robust data collection are critical to assess results of standards. Quality measures must be aligned with incentives Change in payment alone is likely not sufficient to change the way in which care is delivered; efforts to support transformation are key Successful states build on what exists without adding unnecessary complexity (CO, NC, MA)

6 Basic Components of an Accountable Care Organization for RI Medicaid An ACO is a group of health care providers who accept shared accountability for the cost and quality of care delivered to a population of patients.

7 Basic Components of an Accountable Care Organization for RI Medicaid Four critical issues in accountable care development and implementation: (1) Identifying and managing high-risk patients (2) Developing high-value referral networks (3) Event notifications (4) Engaging patients *http://www.brookings.edu/research/papers/2014/11/19-accountable-care-toolkit-physician-aco#recent_rr/

8 Exhibit 2. Proposed Transition Path to Increasing Financial Risk in MSSP (http://healthaffairs.org/blog/2015/04/08/changes-needed-to-fulfill-the-potential-of-medicares-aco-program-2/)

9 Critical Issues in Model Development: Governance Quality Measures Data/Analytics Capacity Member Attribution Shared Savings Model Risk Adjustment Models

10 Potential State Policy Levers Maximize Managed Care Contracts to drive Delivery System and Payment Reform Specify Targets for Movement to Accountable Care Specify Governance Requirements, including how savings are shared, in Accountable Entities Specify Quality and Utilization Measures Define Shared Savings Methodologies Federal Authority to expand benefits to address social determinants Ensure Multi-payer alignment SIM potential to help standardize some ACO structures SIM potential to establish common quality and utilization metrics SIM potential to ensure provider transformation assistance

11 Key Questions for Discussion How will the State require movement from FFS into Accountable Care? Set MCO targets for total spend each year in Accountable Care? Set targets for membership in ACOs each year? Require ACO participation for certain populations?

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