In Massachusetts, 17 Medicaid accountable care organizations (ACOs) are working to meet a June 1 deadline to submit a budget and high-level plan to the Commonwealth about how they will take advantage of new funding to support the restructuring of MassHealth’s delivery system to promote integrated, coordinated care and hold providers accountable for quality and total cost of care.
The Massachusetts Delivery System Reform Incentive Payment (DSRIP) program, which goes into effect Jan. 1, 2020, is a $1.8 billion, five-year investment authorized through MassHealth’s federal 1115 waiver.
During a March 20 webinar sponsored by ACT.md, which has developed a community information exchange platform, Lisette Roman, a consultant with Boston-based Day Health Strategies, said the Massachusetts program adds flexibility in terms of the type of service that MassHealth will reimburse providers for. It will allow them to provide food- and housing- related services.
The ACOs, Roman added, are working to create sustainability strategies and to identify how upstream their projects should focus. In other words, should they provide services to individuals or work to address community conditions such as food deserts? They also are trying to determine which services to offer themselves and which to contract for. For instance, she noted, Boston Medical Center decided to open its own food pantry.
One of the community-based organizations working with ACOs in Massachusetts is Community Servings, a not-for-profit food and nutrition program providing services throughout Massachusetts and in Rhode Island to individuals and families living with critical and chronic illnesses. This year, it will provide 650,000 meals to 2,300 critically ill individuals and their families. Speaking during the webinar, David Waters, the organization’s CEO, said that when Community Servings began working with healthcare systems, their executives wanted to see a proven return on investment. They turned to Seth Berkowitz, M.D., who was then at Massachusetts General Hospital, to lead research on the impact. In three published studies, Waters said, they found significant savings and reduced hospitalizations and emergency department visits with people using their services compared to a control group. Because of these studies, they were able to develop five contracts with payers and are now pursuing contracts with MassHealth ACO flexible service dollars.
“If any of us develop diabetes, we could probably manage our diet and glucose, but if we had end-stage kidney disease or a stroke, none of us could do that,” Waters said. “For patients in the Medicaid program, the system sort of sets you up to fail. Many people do not have stable housing and food. Providing a complex medical diet for them is often the smartest thing a health system can do for a high-utilizer patient. We manage their diet for them when they can’t do it on their own.”
Ted Quinn, CEO of ACT.md, noted that more than two-thirds of Medicaid beneficiaries are in managed care organizations. Many states are re-thinking the role of social determinants of health. Governors and state Medicaid directors are talking about how to meet citizens’ behavioral health and other social service needs. “Understanding food insecurity is a great step in the right direction but it doesn’t get to a holistic view of a person’s needs. States and regions are starting to realize they must do more to break down silos between organizations and get them talking to each other.”
ACT.md is providing services to several counties in California’s $3 billion Whole Person Care initiative, which is helping counties break down silos around homelessness.
Waters noted that it takes a big upfront investment for community-based organizations to win these contracts. They have to hire lawyers and consultants and might have to work nine months to get a contract. He said it would help if healthcare systems could help invest in capacity building, such as building the kitchens or buying the trucks and software. Asked if there is a key to building these relationships, Waters said it is important to meet not as equals but as partners. “If you meet with us as a vendor, that is more of an aggressive stance, and may not value why you want to work with a community-based organization.”
Roman added that when looking for partners, healthcare organizations might not find an ideal match in their geographic region. “How can you mitigate that risk if you don’t see 100 percent alignment?” She said that is why it is important to talk upfront about how you are going to do evaluations and measure success.