Michael Nickey, vice president of state programs, Fallon Health
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Worcester Business Journal
By Susan Shalhoub
Though the true numbers won’t be reported until this fall, the early word from Central Massachusetts accountable care organization (ACO) partners is they are happy with the way the MassHealth restructured system of care delivery has been established, implemented and integrated.
ACOs were championed by Gov. Charlie Baker and others throughout the healthcare world as a way to curb rising costs while improving the quality of care. Essentially, an insurer compensates a provider for keeping an entire population of people healthy, rather than simply treating individuals when they get sick.
The early returns are positive in Central Massachusetts, in part, because the region had strong foundations and took an easier road in incorporating the new structure compared to other parts of the state.
Michael Nickey, vice president of state programs, Fallon Health
Worcester insurer Fallon Health had a built-in advantage working with provider Reliant Medical Group in Worcester, said Michael Nickey, vice president of state programs for Fallon.
“These two have a very intertwined history … It was much more efficient setting up with these folks, who had patients we already knew,” Nickey said. “With Reliant, we are all rowing in the same direction.”
A bonus for the Reliant Medical Group/Fallon Health ACO – Fallon 365 Care – was both had similar values to MassHealth. Reliant has a strong IT infrastructure as well.
And so far, the ACO is on track.
“We’ve been monitoring our own financial performance, which is one piece of the puzzle,” said Jonathan Chines, Reliant’s vice president of payer contracting and network strategy. “The information we have is more qualitative at this point, but in general we expect generated cost savings for Reliant and state Medicaid.
It’s too early to say what the magnitude of that savings will look like, Chines said, but the new system has allowed the medical group to prevent a lot of emergency-room visits, which he calls a win-win.
“It’s a cost to MassHealth and the taxpayers that you’d like to avoid,” he said. “It’s also – for a lot of patients – not the appropriate place to get treatment,” like if those patients need to start on a medication-assisted treatment for opioid abuse, for example.
Reliant has about 260 physicians over 20 locations in 11 communities.
The news is good statewide, too, said MassHealth Assistant Secretary Dan Tsai.
MassHealth Assistant Secretary Dan Tsai
“As the program completes its first year of implementation, MassHealth and its 17 ACO organizations, have made progress in improving member care, strengthening the important connection between members and primary-care providers, and integrating behavioral health with physical health,” Tsai said.
ACOs are in the first of a five-year plan for MassHealth – the state’s Medicaid program – to invest more than $400 million in wraparound services for patients with more complex situations. It’s an understanding that health determinants happen outside of a medical exam room, with a goal to coordinate more preventative care, with better results and lower costs.
Under the new model, MassHealth contracts with ACOs for health care, mental health care, treatment for substance abuse, and with long-term services and support (LTSS) organizations for certain MassHealth members. Primary care providers handle the main responsibility for coordinating this care, which can sometimes include services not medical but contributing to a member’s overall health, such as housing assistance or nutritional support, said Chines.
For example, Open Sky Community Services of Worcester, formerly The Bridge of Central Massachusetts and Alternatives Unlimited Inc., is a human services provider coordinating with Reliant as a trusted partner, said Chines, and has for a long time. The organization is a local leader in serving those with issues such as opioid addiction. President and CEO Ken Bates is on the Fallon 365 Joint Governance Board, with a voice at the table of the ACO.
“We work on the evidence that coordination of non-medical drivers can significantly impact health care utilization,” said Bates. “The partnership provides care coordination and interventions to support enrollees so that they become clinically stable, acquire sustainable skills that improve their ability to navigate and engage with the health care delivery system, and are able to live in the community as fully and independently as possible.”
PHOTO | BRAD KANE
Ken Bates from Open Sky Community Services in Worcester has worked to integrate human services into accountable care organization benefits.
Partnerships with these service providers form an important network of robust communication, Chines said. This helps when it comes time to track down a patient with a behavioral health issue who is disengaging, perhaps not showing up to medical appointments. Or when a patient has certain issues going on and needs to be transferred from one facility to the next.
All systems go
Fallon’s Nickey is in a unique vantage point to provide perspective on the Central Mass. ACO with Reliant, as he can compare it to others.
His organization also is in ACOs with the Health Collaborative of the Berkshires and Wellforce, which includes partnerships with various facilities in Lowell and Tufts Medical Center in Boston. Those reporting systems are not aligned with Fallon as the Reliant system is, meaning the ACO formation process has been less smooth in comparison, he said.
Fallon actually uses the database of social service agencies developed by Reliant and UMass Medical when it needs to reach out to social service organizations. Nickey said he wishes all parts of the state had it.
“It’s a portal and helps you search by need in Central Mass.,” he said. “They know who is out there.”
In addition to the relationship between Fallon and Reliant’s superior IT infrastructure, the ACO was more streamlined as Fallon adopted a 90-day policy for patients when the ACO went into effect. Knowing the new system might be confusing, it simply honored all claims for 90 days.
“In one day, 850,000 people found out that their insurance changed,” Nickey said. “It’s an anxious period of time if you have a surgery scheduled, or sometimes it’s three months out to get a specialist visit.”
He said the 90-day policy minimized a lot of complications for the providers and members.
“Our perspective was that someone approved what you had, so we are respecting their clinical judgment,” Nickey said.
Jonathan Chines, vice president of payer contracting and network strategy, Reliant Medical Group
Chines and Nickey credit MassHealth with being easy to work with on ACO implementation. Nickey said Fallon was prepared for more disruption with the launch, and despite a few hiccups, the transition was more seamless than expected.
Chines sees opportunity in ACOs and figuring out their best structure and operations methods. He said if there as any work that needs to be done, it’s in the area of building bridges with human service providers to strengthen that network.
“We can rethink ways we provide care” with ACOs, he said. “You have to look at the whole person. If we buy into the idea of social versus medical, we are missing the opportunity.”