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Reliant Medical Group in partnership with Fallon Health Plan

Executive Summary

ACO Composition and Governance Structure

Reliant Medical Group is an independent, not-for-profit multispecialty medical group comprised of over 230 employed physicians at 21 sites within Worcester County. In addition Reliant operates 5 urgent care centers that provide a wide range of non-emergency medical services to members 7 days a week including evenings. Our mission is to maximize the health of our patients and the community through expert medical care, compassion, innovative delivery models, medical research and education, and the appropriate use of health care resources.

Fallon Community Health Plan, the Bidder, is a not-for-profit, independent 501(c) (3) corporation with extensive experience serving beneficiaries in capitated government health care including MassHealth, Medicare, and dual eligible programs. Fallon began serving MassHealth Medicaid recipients in 1980 and embarked on specialized programs to serve dual eligibles in 2013. Fallon’s main organizational goal is to make our communities healthy. Fallon supports our Members in a manner that is consistent with EOHHS’s approach to Medicaid managed care. Fallon has approximately 227,000 Members, of which 38,000 are MassHealth consumers.

Reliant and Fallon have created a Joint Governance Committee to oversee and direct all operations of the ACO. The Joint Governance Committee includes representatives from both organizations, as well as a patient advocate and a representative from one of our Community Partners. Reporting to the Joint Governance Committee will be a Joint Operating Committee (JOC). The JOC and its two subcommittees, Clinical Affairs and Integrated Care, will have joint decision-making authority, equally shared by Fallon and the ACO, regarding integration of medical, behavioral and social support services including Care Coordination, Care Management and all related contractual responsibilities, most notably to include care delivery, measurement improvement of outcomes and adherence to provider protocols to deliver best practice care. Reliant will participate in all activities, as needed, required to develop, implement, and monitor Care Coordination and Care Management activities.

ACO Population Served

There are approximately 27,000 Medicaid members currently attributed to this ACO in our service area, which includes the Gardner-Fitchburg, Framingham, Southbridge, and Worcester service areas defined by MassHealth.  In Worcester County, which accounts for the majority of the population in our service area, the proportion of the population under the age of 18 in the county as a whole was slightly higher than in the rest of the state.  Worcester County also is slightly less racially and ethnically diverse with 10.5% of the population identifying as Hispanic/Latino, 4.7% Asian and 4.2% African American. English is the primary language spoken by the majority of the population followed by Spanish. Worcester County varies widely in terms of other salient characteristics such as median household incomes, educational attainment and prevalent health conditions.

Overview of DSRIP Investment Approach

Both Reliant Medical Group and Fallon Health are committed to transforming health care through accountable care. Together, our organizations have a long history of collaborating on the development of innovative payment and delivery models in health care. Reliant and Fallon worked together to develop one of the first Medicare risk products in the United States in 1977. In addition, Reliant has accepted financial risk for its Medicaid patients through Fallon since 1980.

Due to this shared history with Fallon, accountable care is an integral part of Reliant’s business model. Aside from the ACO-PP, the majority of Reliant’s revenue is attributable to commercial and Medicare Advantage payer arrangements where we take substantial financial risk. Success in accountable care is therefore essential to Reliant’s long-term viability as a provider organization.

To that end, Reliant has invested significant resources in a sophisticated population health management infrastructure to enable success in the payer arrangements where we take financial risk. This infrastructure includes robust data and analytics that allow for real-time identification of opportunities to enhance quality and/or reduce costs, and a team of nurse care managers and other professionals embedded in our primary care sites that develop and monitor customized care plans for our most complex patients and those undergoing care transitions. As a result of our investment in this infrastructure, Reliant is delegated for utilization management and care management across all of our major payers.

Fallon and Reliant recognize that the core infrastructure to effectively support a managed Medicaid population already exists at Reliant. However, enhancements are required to assure that this infrastructure is sufficient to meet the needs of the expanded MassHealth population that Fallon and Reliant will serve through the ACO-PP.

Our DSRIP participation plan is intended to allow Fallon and Reliant to achieve three strategic objectives:

1. Expand resources and capacity to allow Reliant to provide care management services to the ACO-PP population. Reliant’s population health staff currently serves a commercial and Medicare

Advantage population of about 100,000.  A substantial increase in staff will be needed to support an additional Medicaid population of approximately 27,000.

2. Expand Reliant’s existing population health model to support the unique health care and psychosocial needs of a Medicaid population.  While Reliant’s core infrastructure provides the building blocks upon a population health model for MassHealth beneficiaries can rest, the tactical interventions that Reliant employs for a commercial or Medicare Advantage population may not be appropriate for MassHealth.  To that end, DSRIP funds will be used to support the development of population health interventions appropriate for a Medicaid population.  Specifically, these interventions must support greater integration of behavioral health care and expanded connections with community supportresources.

3. Automate system connections between Fallon, Reliant, and other Community Partners.  While Fallon and Reliant have a long history of collaboration on behalf of MassHealth beneficiaries, some of the work between the two organizations is managed through manual processes and workarounds.  While this has sustainable to date, such manual workflows are less optimal as our managed Medicaid population expands.  As a result, investments are needed to automate operational processes between the two organizations so that resources can be deployed more efficiently in support of our patient population.

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