State Strategies for Advancing Accountable Care in the Safety Net

Background

Duke-Margolis completed a two-year project, supported by Arnold Ventures and the Commonwealth Fund, to improve care for medically and socially underserved populations by identifying policy opportunities and best practices to promote accountable care for safety net providers through state Medicaid programs and other state-specific health payers.

Safety net providers (such as community health centers, public and critical access hospitals, and community mental health centers) play an essential role in anchoring care for millions of Americans in underserved communities. Despite safety net institutions providing high-quality, cost effective care to high-risk populations, the safety net remains a largely fragmented collection of providers offering a disparate array of services, leading to both duplication and gaps in care. Accountable care models are a tool to improve the quality and efficiency of care. However, safety net institutions have had lower participation in these models as compared to other types of providers. In previous work we identified multiple reasons for this disparity, including misaligned funding streams and payment models that inadvertently penalize providers.

Through this project, Duke-Margolis developed a compendium of strategies to promote accountable care in the safety net, identified federal actions to support states in their efforts to promote accountable care, and compiled best practices for Medicaid managed care plans and safety net providers to coordinate around accountable care implementation.

Learning from State Experiences

In November 2024 and January 2025, Duke-Margolis partnered with local organizations in Texas and New York to host two in-person, state convenings to identify multistakeholder opportunities to use accountable care to enhance care for communities served by the safety net in their states and apply lessons learned from each state’s VBP efforts. Participants—including health plans, providers, associations, hospitals, experts, consultants, and state policy leaders—engaged with the state strategies included in our deliverable, Supporting Safety Net Through Flexible Accountable Care Arrangements, discussed state-specific challenges, and identified opportunities for collaboration to strengthen care in their state’s safety net systems.

Despite differences across health systems and policy environments, safety-net stakeholders in both Texas and New York noted similar challenges and opportunities to advance meaningful participation in accountable care.

• Learn more about advancing accountable care in the New York safety net here.
• Learn more about advancing accountable care in the Texas safety net here.

Publications and Deliverables

Value-Based State-Directed Payments in Medicaid Managed Care

• A research letter examining the use of value-based state-directed payments (SDPs) as levers for states to incentivize Medicaid Managed Care Organizations (MCOs) participation in value-based payment arrangements

Recent Medicaid Managed Care Policies and Safety Net Accountable Care

• Health Affairs Forefront piece examining the current state of policy issues relevant to advancing accountable care in the safety net, opportunities where Medicaid managed care policy can better support accountable care for safety net providers, and recent changes introduced by the Centers for Medicare and Medicaid Services (CMS) in the 2024 Medicaid Managed Care Access, Finance, and Quality Final Rule.

Supporting Safety Net Through Flexible Accountable Care Arrangements: State Strategies

• A compendium of state strategies for promoting accountable care in the safety net, including innovative uses of existing Medicaid flexibilities, strategies for promoting care coordination across providers and plans, and strategies for helping safety net institutions develop the competencies for transitioning into accountable care arrangements.

Advancing Safety Net Collaboration Across Health Plans, States, and Providers

• A toolkit to help health plans and safety net providers coordinate around accountable care implementation, including considerations for developing risk-based contracts to support smaller safety net providers in transitioning to accountable care, and synthesizing best practices and lessons learned from existing arrangements.

Executive Leadership

• Elaine Batchlor, MLK Community Healthcare
• Jana Eubank, Texas Association of Community Health Centers
• Elliott Fisher, Dartmouth
• Mark McClellan, Duke-Margolis
• Christina Severin, Community Care Cooperative
• Mark Smith, UCSF