State Strategies for Advancing Accountable Care in the Safety Net

The Duke-Margolis Institute for Health Policy has launched a two-year project that seeks to improve care in the safety net 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. Supported by Arnold Ventures and the Commonwealth Fund, this project will develop resources to help states promote accountable care, propose federal actions to support states in these efforts, and compile best practices for Medicaid managed care plans and safety net providers to coordinate around accountable care implementation.

Background

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 capabilities, including a variety of value-based payment models, have the potential 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.

Advancing safety net participation in accountable care is a high priority for achieving health equity. Recent CMMI initiatives – such as the ACO REACH program, Making Care Primary, and health equity focused reforms – along with new Medicaid managed care rules and strategies to facilitate partnerships with community-based organizations present new pathways for states and federal policymakers to drive payment and delivery reform in the safety net. Achieving this vision depends on the ability of states to establish effective policies for promoting accountable care and the capabilities of health plans and providers to collaborate around accountable care goal.

Policymakers, providers, and plans need additional support and guidance to implement accountable care reforms involving the safety net. States are often unaware of existing authorities to pursue accountable care, are unclear what activities are allowable within existing authorities, or do not have the internal capacity to pursue different reforms and have instead delegated payment transformation to health plans (or Medicaid managed care plans). Implementing value-based payment models through Medicaid managed care requires the state to have expertise in specifying and monitoring detailed value-based care provisions in plan contracts, ensure the plans are sharing data, and that plans are providing needed upfront capital to safety net providers.

Approach

This project will identify policy opportunities and best practices to promote accountable care for safety net providers through state Medicaid programs and other state-specific health payers. Over two years, we will develop resources to help states identify pathways to promote accountable care (with a particular focus on promoting coordination across providers and plans), identify and propose federal actions to support states in their efforts to promote accountable care (e.g., explore where federal agencies can provide templates and case studies for states to emulate), and compile best practices for Medicaid managed care plans and safety net providers to coordinate around accountable care implementation.

We will solicit broad public and stakeholder input throughout, drawing on the expertise and experience of an executive leadership and advisory group of payment reform experts, safety net leaders, communities served by safety net institutions, and representatives of payers and funders. Evidence will be gathered through literature review, policy analysis, and stakeholder interviews to identify real-world experiences. The project team will distill findings into practical recommendations that will be disseminated to federal and state policymakers, health plans, and providers.

Deliverables

• State Strategy Compendium– 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.
• Federal Policy Recommendations – A memo proposing federal actions to support states in their efforts to promote accountable care reforms, such as guidance to states on using existing flexibilities to drive reforms, opportunities to streamline accountable care reforms in Medicaid managed care, and recommendations to ensure Medicaid programs are structured to support safety net providers.
• Toolkit for Promoting Accountable Care in the Safety Net – A resource 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
• Patty Gabow, formerly of Denver Health
• Mark McClellan, Duke-Margolis
• Christina Severin, Community Care Cooperative
• Mark Smith, UCSF