Instead of attacking Medicaid, let’s celebrate its innovations

Accountable care organization model shows early promise

IT’S TIME FOR our nation’s health care leaders to stand up against those who denigrate the nation’s invaluable Medicaid program. Such talk is wrong-headed, usually untrue, and counter-productive to the provision of quality, cost-effective care. Medicaid expansion is a key component of the Affordable Care Act, and recent congressional efforts against the Affordable Care Act would have badly undermined health care for the poor and low-income Americans. Although these efforts in Washington have failed for now, offensive attitudes toward Medicaid persist.

The rising criticism by some is ironic, as 21 states – including Massachusetts — have implemented or will soon launch an innovative new Medicaid health care delivery model: Accountable Care Organizations (ACOs). ACOs are collaboratives of health care providers and insurers who are entirely focused on improving the overall health and well-being of Medicaid patients and, as a result, by extension, reducing costs of providing their care. This mandate was written into the Affordable Care Act so that we finally have a health care approach that acknowledges the realities of life below the poverty line.

ACOs shun the costly fee-for-service system and require accountability from medical care providers, case managers, and behavioral health professionals who will now work as teams to focus on all aspects of a Medicaid-enrolled patient’s well-being. ACO networks are rewarded not for saving money in providing care, but for improving patients’ health.

The ACO model acknowledges that, for people with low income, success in coping with chronic disease, or recovering from acute illness or injury, is only 10 percent dependent on the actual medical care received. Since genetics account for about 30 percent of our health, a full 60 percent of our health care is attributable to social, behavioral, and environmental factors. ACO health care providers will shine a spotlight on patients in ways they may, initially, find uncomfortable. For instance, along with taking a patient’s blood pressure, a practitioner will ask: Do you have transportation? If you live alone, are you able to cook for yourself? Do you have friends? Have you recently experienced a loss? Are you worried about paying the rent, or heating your home? Would you like to talk about mental health services? Are you and your family able to eat healthy meals at home? Not only can ACOs ask the questions, they will have the resources to help address the answers.

This year, Gov. Charlie Barker announced the formation of 17 ACO collaboratives in Massachusetts. These networks are scheduled to be up and running in January with more than 900,000 Medicaid enrollees and 4,500 primary care providers. In the Berkshires, Berkshire Health Systems, Community Health Programs, and Fallon Health have formed the Berkshire Fallon Health Collaborative. Together we will care for some 20,000 people in the Berkshire region.

Our ACO partners in Western Mass. are heartened by this collaboration and its possibilities. Soon, when Community Health Programs’ patients present needs beyond a medical issue, we will be able to offer a continuum of family support, mental health care, and resources to help with housing and food insecurity.

It’s nearly impossible to overstate the breakthrough offered by these innovations. MassHealth has drawn upon the lessons of the two-year-old Medical Home Network ACO, which serves Chicago’s poor West Side. Medical Home Network’s results demonstrate that when a comprehensive ACO offers complete and diverse care and services, health improves. Homelessness or overcrowded housing, high unemployment or low wages, poor nutrition, substance abuse, under-education, and distrust of the criminal justice system can be better addressed through this collaborative health care model.

Sound expensive? In its first year, health care costs for those served by the Chicago network declined by more than $17 million, an approximate 8 percent reduction in net risk-adjusted costs, and an additional $6 million in its second year. Medical Home Network also experienced a 13 percent reduction in emergency room visits and 35 percent reduction in hospital readmission rates.

The faith that ACO providers place in this model is reflected in their willingness to assume financial risk. ACOs receive a pre-determined annual fee for each member, and at year’s end, the ACO shares data on how that patient is doing: Are members using emergency rooms less often? Have hospitalizations been reduced or avoided? Have hospital re-admissions decreased? If the cost of a member’s care exceeds the set fee, the ACO covers the difference.

MassHealth has been operating a pilot project with six ACOs since December 2016, and the results are promising. For example, Partners HealthCare ACO, which was founded by Brigham and Women’s and Massachusetts General hospitals, reports that by connecting members with home and community based services — including providing primary care in members’ homes — preventable or unnecessary hospitalizations have declined.

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The recent national push to cut millions from Medicaid rolls, and to reduce services available for those who remain, is heartbreaking and frustrating. But for those of us working to craft a health care system that measurably improves the lives of the families and individuals — with significant cost savings — this is a time for hope.

Massachusetts has long led the nation in ensuring that all citizens have access to health care. This goal matches the mission of the community health center movement, so we are ideal ACO partners. But we all must continue to advocate and collaborate — especially now, at the cusp of positive change — to ensure that our struggling friends and neighbors benefit from a long-overdue understanding of what constitutes cost-efficient, effective, and humane health care.

Lia Spiliotes is chief executive officer of Community Health Programs in Great Barrington and serves on the board of the Massachusetts League of Community Health Centers.