ACO program aims to integrate healthcare

Massachusetts is readying for a major restructuring of the current fee-for-service payment system for MassHealth, the state’s combined Medicaid and Children’s Health Insurance Program.

MassHealth’s Accountable Care Organization (ACO) program begins in January 2018 and 18 healthcare organizations across the state were recently selected to participate. The 18 ACOs – networks of physicians, hospitals, and other healthcare providers – will work together to provide integrated healthcare for patients with the goals of improving their health and containing costs.
The ACOs will integrate efforts with community-based health and social services organizations.

The ACO program is a component of the state’s five-year 1115 Medicaid waiver, which brings significant new federal investment to restructure the current healthcare delivery system for MassHealth’s members.

Massachusetts Psychological Association Executive Director Brian Doherty said the change will be a big shift, as the majority of MassHealth members move to an ACO model. “As far as the potential benefits, one of MassHealth’s goals of this program is to improve integration of physical and behavioral health healthcare, which is something we strongly support,” Doherty said. “Also, through the waiver the state was able to secure from Medicaid on the federal level, they were able to secure more investments in behavioral health, so there is increased funding for behavioral health.”

Doherty was one of the outside stakeholders who participated in MassHealth work groups to help formulate the program. Doherty served on the quality improvement work group. “The work group gave us the opportunity to add more behavioral health measures to the quality measures slate MassHealth will be using,” so that behavioral health has the proper emphasis within the ACO system, Doherty said. ACOs will be scored on how they perform according to the quality measures.

It’s too early to tell how some aspects of the program will work. For example, MassHealth is currently in the process of certifying “Community Partners” for behavioral health and long-term services and supports.

“The Community Partners will be a big aspect of how behavioral health is managed under the new system,” Doherty said. “We will be monitoring to what extent psychologists are being utilized under the Community Partners model,” Doherty said, and also how the Community Partners are facilitating access to quality care for MassHealth members.

Other questions, Doherty said, are to what extent the fee-for-service system will remain and how psychologists will be involved and reimbursed by the Massachusetts Behavioral Health Partnership (one of MassHealth’s primary managed behavioral health services contractors).

When fully implemented, ACOs will be the way the majority of MassHealth members receive care, but MassHealth will also maintain the traditional managed care organization program, to serve members not enrolled in ACOs.

As some MassHealth members will continue to receive services under a more traditional plan, Doherty said the MPA will continue to push for legislation or a regulatory change to allow individually licensed psychologists to be reimbursed by MassHealth for services.

“We’ve been seeking a change in that policy for a long time, to have MassHealth rescind the prohibition on individually licensed psychologists providing treatment to MassHealth clients,” Doherty said.

Vicker V. DiGravio III, President/CEO of the Association for Behavioral Healthcare, a state-wide organization representing over 80 community-based mental health and addiction treatment provider organizations that provide a wide array of services, many funded by MassHealth, said the planning process and design of the new program has been very thoughtful.

“The state deserves a lot of credit for involving stakeholders and not just listening – but absorbing and modifying the design based in part on feedback they’ve received,” DiGravio said.

“So, it was an excellent process, but like any other initiative, it’s all going to depend on how it’s implemented,” DiGravio added. “This is a really major transformation of how we provide care to MassHealth members and from our perspective, the really good news is that the state has acknowledged the importance of access to behavioral health services and the vital role that community-based organizations play in serving MassHealth members who have significant mental health needs or addiction disorders.”

DiGravio said the creation of behavioral health Community Partners is a huge step forward, but one concern he has is that among ACOs, there is a wide range of opinions and understanding of the role and value of these Community Partners and community-based services, with some embracing it more than others.

He hopes all parties come with an open mind, and work collaboratively. “There is going to need to be learning, on both sides,” DiGravio said.

DiGravio also is concerned that the established reimbursement rates for Community Partners won’t be sufficient for the intensity of services needed. “The organizations that have applied want to do a good job; they understand that this is an incredible opportunity for individual organizations and our industry as a whole to really establish our value in the larger healthcare system,” DiGravio said. “But if the rates aren’t sufficient, that really is going to potentially undercut their ability to be impactful.”