1.1 ACO Composition and Governance Structure
Atrius Health is the Northeast’s largest nonprofit independent multispecialty medical group. As of July 1, 2015, three Atrius Health medical groups (Harvard Vanguard Medical Associates, Granite Medical Group and Dedham Medical Associates) merged to become one single, multi-specialty group practice. On June 1, 2017, PMG Physician Associates joined Atrius Health. Atrius Health cares for 740,000 adult and pediatric patients across 36 clinical locations providing primary and specialty care, in addition to pharmacy, lab and imaging.
Atrius Health is the sole corporate member of the VNA Care Network Foundation and also has a Participating Organization Agreement and a Management Services Agreement with VNA Care Network Foundation for home care and hospice services. Atrius Health also has strategic affiliation agreements with certain hospitals and hospital systems that are Atrius Health preferred providers. Atrius Health has participated in Medicare’s ACO models as well as other outcomes-based payer contracts that demonstrated positive financial outcomes.
Tufts Health Public Plans (THPP) (formerly known as Network Health, Inc.) was founded in 1997 as a division of Cambridge Health Alliance (CHA) to improve access to care for underserved populations through the operation of a Medicaid managed care health plan. THPP has 18 years of experience serving diverse, subsidized populations, including those with specialized needs, such as pregnant women, children in substitute care, people with disabilities, people with mental illness, and the homeless. Over the past two years, overall membership increased from 218,000 to more than 400,000 Members. As of March 1, our total Masshealth membership will be 265,000 Members.
The Joint Operating Committee (JOC), with equal representation from THPP and the Atrius Health, will be the governing committee of the ACPP and is responsible for making key decisions on the ACPP relationship and financial investment, including decisions on DSRIP. Reporting to this committee is the ACPP Governing Board, which will be accountable for provider and care delivery strategy and performance. Two committees will report directly to the ACPP Governing Board: the Patient and Family Advisory Committee (PFAC) and the Quality Committee. The former will be responsible for representing the interest of the patients and families served by the ACPP, and the latter will be accountable for monitoring the performance of joint Quality Initiatives. The Parties may establish other committees as they deem necessary and appropriate such as a Finance Committee and a Compliance Committee.
1.2 ACO Population Served
The number of patients attributed to the ACO as provided in Section I of the Funding Notification Letter equals 28,097. The patient count has been changed to 23,122 in January 2018. Atrius Health’s service area includes Attleboro, Beverly, Boston, Brockton, Falmouth, Framingham, Gardner-Fitchburg, Lawrence, Lowell, Lynn, Malden, Plymouth, Quincy, Revere, Salem, Somerville, Waltham, Wareham, and Woburn.
Both THPP and Atrius Health have long organizational histories of understanding its Member populations. Given its diverse geography, Atrius Health cares for patients across the spectrum of socioeconomic status in urban and suburban communities. Its communities are rich in ethnic and racial diversity with a multitude of primary languages represented and many unique cultural norms. Specifically, the Atrius Health Medicaid population is 58% female and 42% male. Of those that declare their race, 47% identify as Caucasian, 20% African American, 10% Hispanic, 7% Asian and 0.2% American Indian. Of those that declare their language, 89% identify speaking English, with the three other most frequently reported languages as Spanish, Portuguese, and Chinese.
Atrius Health also cares for patients across the age continuum from pregnant women to neonates through adolescence and adulthood. Atrius Health has developed models of care that address the medical, psychiatric and social needs of its patients and families with embedded clinicians, e.g. community health workers, care facilitators, and case managers, skilled in needs assessment and in providing essential care coordination. Disease burden in the adult Atrius Health Medicaid population include (with prevalence when known), asthma (14%), diabetes (7%), hypertension, obesity, chronic obstructive pulmonary disease (COPD) (2%), early coronary artery disease, substance use, depression (7%), and anxiety. Atrius Health Medicaid Pediatric patients have high incidence of asthma (19%), obesity, Autism (3%) and ADHD and other learning disabilities. Conditions with the highest PMPM spend include Asthma, Diabetes, Drug Dependence, Chronic Hepatitis, Metastatic Cancer and Sepsis.
Mental health diagnoses such as depression, anxiety and adjustment disorders are also prevalent. Enabling access to therapists and psychiatrists and prescribing Advanced Practice Clinicians is challenging, as it is throughout the State. To support the Atrius Health practice and the needs of its patients, Atrius Health maintains a large behavioral health practice with nearly 150 clinicians across nearly every one of its primary care sites. Adult patients are triaged to determine the optimal location of care. Care coordination is essential for patients with behavioral health diagnoses as health outcomes and utilization are typically areas of focus for this population.
Atrius Health partners with its subsidiary, VNA Care and with THPP to identify patients with home-based care needs. Historically, Atrius Health’s case managers, care facilitators, and community health workers connect patients with preferred community agencies and services for long term care needs. The ACPP will work to identify Members with LTSS needs, including but not limited to Members with developmental, intellectual, physical, and psychological disabilities, using information provided by the Commonwealth of Massachusetts, Member health assessment, and current use of MassHealth services that could reasonably be viewed as LTSS. Relationships with our LTSS CPs are being developed currently to support direct interfaces between the Primary Care Team, supporting Care Managers and the LTSS CPs. Other sources for individual and population health data may come from participation in the Home and Community-based Services (HCBS) waiver, affiliation with any state agency that provides HCBS waiver-like services (DDS, EOEA, Mass Commission for the Blind, Mass Commission for the Deaf and Hard of Hearing, and Mass Rehab), and THPP disease and highrisk population registries.
Atrius Health is committed to addressing the social determinants of health. Registries exist and are continually refined to support Primary Care Teams, Care Facilitators and Community Health Workers in identifying at-risk patients. Atrius Health staff members are trained in motivational interviewing, patient advocacy, and making community resource connections. The ACPP appreciates that we have a great deal to learn about the social milieus of our Members and appreciates the challenges of meeting diverse and pervasive unmet needs of this population. To that end we must invest in culturally sensitive efforts to identify those needs and develop trusting relationships that will facilitate solutions.
The ACPP will leverage its in-depth experience, comprehensive population health infrastructure, advanced data analytics and its new relationships with Community Partners to advance the care of the entire MassHealth population. Using new tools and relationships, we will also identify our most vulnerable Members and institute care plans that improve quality, reduce utilization and cost and keep the Member functioning at the highest level possible within their community.
1.3 Overview of DSRIP Investment Approach
1. ACO Programmatic Strategy
a. Overall ACO approach to PHM and provider accountability
The overall approach to population health management is to start with risk stratification. Atrius Health develops actionable registries of the Atrius Health population stratified by current utilization and cost and informed by predictive analytics to identify patients at high risk of future utilization. Next, a path for caring for these patients is developed that focuses first on prevention. Care facilitators and population health managers proactively address the preventive health needs of these patients. For those patients that cannot be engaged at the office level, Community Health Workers will work to engage them in the community. Regular case conferences about the highest risk patients allow for intensive care coordination and enhanced care. PCPs will have immediate access to their high risk cohorts in EMR based registries and will play an active role in their management. Disease and Care management programs of the ACO and MCO support the primary care team. Foundational work over the past 5 years has demonstrated that this combination of proactive care by a committed care manager and impact-focused case conferences can yield utilization reductions that support sustainability of the investment.
The Atrius Health physician compensation model has multiple incentives for productivity as well as quality. Below is the breakout of these incentives for Internal Medicine/Family Practice, Pediatrics, OBGynecology, and Behavioral Health:
|Base, citizenship, seniority||6%||0%||7%||5%|
|Quality Metrics||3 equally weighted outcome metrics measured at site level (Hypertension Control, Diabetic Hypertension Control, Diabetes A1C Control) prorated to FTE||4 equally weighted metrics (Well Child 12-21, web portal activation, site level combo10, Asthma Action Plan) prorated to panel size||2 equally weighted metrics (salpingectomy with hysterectomy, baby ASA in high risk preeclampsia patients) measured at hospital group level||Care Model implementation, individual level|
Atrius leadership does have incentives based on several domains, including quality, growth, financial results, etc. The incentives are based on the performance of the ACO across all Atrius Health patients, including the MassHealth population.
As part of the overall compensation program, THPP leadership (MCO Leadership) is eligible for an annual incentive bonus based on company’s financial, membership and quality results against objectives. In addition to these performance based targets, the Annual Incentive Plan also includes certain strategic initiatives that are set annually in alignment with the organization’s long-term goals.
b. Overall ACO approach to total cost of care management and path to sustainability
With years of experience in managing total cost of care, Atrius Health approaches this by working on prevention through PHM, by providing access to care when needed (e.g. same day appointments, telephone coverage staffed by advanced practice clinicians, urgent care offered regionally), and by managing site of care (use high value hospitals, bring care into the community, avoid use of the Emergency Department). It has been our experience that successful programs in these areas can generate savings that are self-sustaining.
2. Goals for the DSRIP that support overall ACO programmatic strategy
The ACPPs key goals for the DSRIP program to support ACO programmatic strategy are a) to continue to fund robust infrastructure around risk stratification and predictive analytics to produce actionable data and to fund to managed care quality and performance improvement infrastructure, b) to provide dedicated case management, social workers and a variety of care facilitation staff to cost effectively address the needs of the population, and c) to identify gaps in care and develop associated clinical programs.
3. DSRIP investment strategy that supports the stated goals
Atrius Health investment strategy is to fund the expansion of existing infrastructure that supports ACO programmatic strategy, and then to make new investments in the following key areas: 1. ACO Director to provide administrative leadership for the ACO, 2. invest in additional care facilitators and links to the community, and 3. develop and integrate a screening tool for social determinants supported by an effective community resource database.
4. Anticipated challenges
There are numerous challenges yet to be overcome. First is ensuring that information collected about social determinants of health is continually updated and acted upon effectively. Second, it will take some time to critically assess and prioritize programs both at the ACO and MCO level. Additionally, THPP and Atrius Health are newly developing relationships with numerous community partners and will need to determine best methods of communicating back and forth. Patients may continue to receive care at various institutions that are not Atrius Health preferred partners where effective care management is enabled through interoperability.