BOSTON – Effective December 1st, MassHealth is launching its innovative five-year Medicaid 1115 waiver with a pilot one-year Accountable Care Organization (ACO) program. ACOs, groups of doctors and other health care providers, will work together to care for their patients and will help transition MassHealth from the current fragmented, fee-for-service system towards coordinated and integrated care to improve members’ health and contain costs. The move is part of the most comprehensive restructuring of the Medicaid program in more than 20 years.
“ACOs will work closely with community-based health organizations to better integrate care for behavioral health, long-term services and supports and health-related social needs,” said Marylou Sudders, Secretary of the Executive Office of Health and Human Services. “We look forward to learning from this one year pilot as we restructure the Medicaid program.”
Beginning December 1, 2016, the following six ACO Pilot organizations will be responsible for the care of more than 160,000 MassHealth members across the state:
“Our Pilot ACOs will coordinate care and be accountable for the total cost of care for their attributed members within MassHealth’s Primary Care Clinician (PCC) Plan, “ said Dan Tsai, Assistant Secretary of Health and Human Services who leads the MassHealth program. “The ACOs will be compensated under an alternative payment methodology that includes shared savings as well as risk for shared losses and will be rewarded from improving our members care while keeping costs under a target. ”
What does the ACO Pilot mean for MassHealth members?
MassHealth members’ care will improve through better integration and coordination of care:
- Providers will be measured on the quality of their care, including prevention and wellness, managing chronic disease and avoidable utilization, and behavioral health and substance abuse treatment;
- Specialty and other care from certain providers will be more easily available through “referral circles,” for many members;
- Members’ benefits, ID cards, doctors, and other health care providers will remain the same.
- MassHealth will administer a member experience survey to determine satisfaction in the ACO Pilots.
- Members have been notified of their ACO attribution, and they may choose to not participate in the voluntary program at any time.
What do ACOs mean for health care providers?
The six Pilot ACOs include approximately 2,500 primary care doctors in the state, at 330 different practice sites and their referral circles include over 5,000 Massachusetts providers. Providers that participate in Pilot ACOs will continue to bill MassHealth and be paid fee-for-service. At the end of the ACO Pilot, MassHealth will compare the total costs of care for each Pilot ACO’s members against an expected target to determine whether the ACO has produced savings or losses for MassHealth. The Pilot ACOs will share in these savings or losses with MassHealth. MassHealth will supply the Pilot ACOs with data supports that include monthly member rosters, claims information and total cost of care and quality performance dashboards.
Assistant Secretary Tsai noted that the experience of the Pilot ACOs will enable MassHealth to:
- Evaluate and monitor how effectively ACOs coordinate and integrate the care of their attributed members and impact their health and well-being;
- Determine how MassHealth providers are affected;
- Study the impact on total cost of attributed member’s care; and
- Analyze how ACOs impact MassHealth’s operations, such as billing and claims operations and customer service.
“With this information, we will be better prepared for the full ACO implementation anticipated in December 2017,” he said.
Additional information on MassHealth’s planned restructuring and payment reforms for its 1.9 million members may be found on the MassHealth Innovations website at www.mass.gov/hhs/masshealth-innovations.
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