MassHealth Releases “Restructuring" Plan
On April 14, 2016, the $15.4 billion MassHealth program announced a major “restructuring” campaign designed to create “a sustainable, robust” health care program for its 1.8 million members. This process is the culmination of roughly a year of “intensive design and stakeholder engagement,” according to state officials.
MassHealth accounts for almost 40% of the Commonwealth’s budget. The Administration of Governor Charles Baker has made overt moves to swap out the current fee-for-service payment model, which they says results in “fragmented, siloed care,” and replace it with a managed care delivery system experiment which places large hospital and physician networks, known as “Accountable Care Organizations (ACOs),” in control of funding.
The instrument to make this change is a large federal 1115 waiver to support MassHealth restructuring. Financing for the current waiver ends June 30, 2017 with $1 billion in federal support. State law (Chapter 224) requires MassHealth to adopt alternative payment methodologies for promotion of more coordinated and efficient care. ACOs would represent for MassHealth a more “integrated” model of care. In ACO models, the health care providers are accountable for the cost and quality of care.
At the center of the “restructuring” plan are the ACOs. To be an ACO, providers must show they can coordinate care and partner with Community Partners, including primary, specialty, behavioral, acute, and community-based care. The ACO must have relationships with other providers to coordinate/ integrate care effectively. ACOs will be able to choose to create an integrated ACO/MCO entity or enter into ACO contracts with other MCOs; some ACOs may choose to contract directly with MassHealth.