1.1 ACO Composition and Governance Structure
Beth Israel Deaconess Care Organization (BIDCO) is a value-based physician and hospital network and an Accountable Care Organization (ACO). With its corporate office located in Westwood, Massachusetts, BIDCO provides physician groups and hospitals the infrastructure necessary to contract, share risk, and build care management systems together as the market moves towards alternative payment models. BIDCO works to create communities of care where physicians and hospitals can work collaboratively with the goal of providing the highest quality care in the most cost-efficient manner. For the MassHealth ACO, BIDCO will leverage the shared skills of more than 2,600 primary care physicians (PCPs) and specialists and numerous community hospitals to understand and meet the distinct needs of our MassHealth members.
Tufts Health Public Plan (THPP) has 18 years of experience serving diverse, subsidized populations, including those with specialized needs, such as pregnant women, children in substitute care, and people with disabilities, severe and persistent mental illness, and who are homeless. THPP continues to show sustained growth in its three Massachusetts health plans. Over the past two years, membership has increased from 218,000 to over 400,000 Members. As of March 1, 2018, Tufts Health Together membership is expected to be approximately 265,000 across all its ACPPs and MCO. In 2016, the Tufts Health Unify (dual eligible) membership increased by 24%, adding 499 new dual eligible Members. Likewise, Tufts Health Direct (QHP) membership continues to grow, with more than 140,000 total Members as of February 1, 2018.
Governance Structure: Tufts Health Plan together with BIDCO MassHealth ACO partnership is governed by a joint operating committee comprised of equal representation among providers and payer, with input from front-line staff and providers to drive innovation. Together, the partnership provides a fully integrated, multidisciplinary approach to care, employing medical and behavioral health providers, social care managers, and community care outreach staff.
1.2 ACO Population Served
Target Population: The target population of the THPP-BIDCO partnership is residents (birth through age 64) in the service area who are eligible for Medicaid and currently fall into Rating Category I, II, IX and X. BIDCO’s three provider partners Bowdoin Street Health Center (BSHC), Healthcare Associates (HCA) and South Cove Community Health Center (SCCHC) are currently Level 3 PCMH certified and currently provide a range of care coordination and care management services throughout this service area. In addition, BIDCO membership includes three other major provider groups that have providers practicing in communities across Easter Massachusetts. The 3 groups include Affiliated Physicians Group, Affiliated Physicians Inc., and Lower Merrimack Valley Physicians Health. Together, these providers cover 42,445 BIDCO Medicaid lives as of March 31, 2017.
The ACO serves the primary services areas:
1.3 Overview of DSRIP Investment Approach
To deliver value to our members, EOHHS and CMS, Tufts Health Plan together with BIDCO will leverage existing infrastructure and make targeted investments to improve the health and outcomes for MassHealth members and bend the total cost of care for this population across our diverse network. Specific investments priorities will include:
- Direct Care Management and Population Health Management Services to Manage Individual Risk: The Tufts Health Plan together with BIDCO will invest in clinical and non-clinical staff to provide direct care management, population health outreach and care coordination services to our members with high-risk and emerging risk needs. This investment will assure that our MassHealth members experience unified and coordinated care episodes, with robust communication across settings to reduce missed opportunities and improve outcomes. These investments will be made at both the Health Plan and provider groups to start to achieve scale quickly; transitioning to embedded, primary care-based services as capacity grows.
- Targeted Investments in Information Technology and Workforce Development to Enable Optimal Care for MassHealth Members: To build capacity for the management of MassHealth members, the Tufts Health Plan together with BIDCO MassHealth ACO will make targeted investments in a population health management platform to guide evidence-based care and facilitate efficient integration of the system for member care. The ACO will also make investments in workforce development programs across the network to close identified gaps in knowledge and skill sets to meet the needs of MassHealth members. These investments will contribute significantly to program sustainability as technology-enabled interventions are integrated into routine operations for skilled, engaged workforce across the network.
- Integration of Evidence-Based Approaches to Care that Align with Population Needs: The Tufts Health Plan together with BIDCO will invest in proven strategies to integrate care for the benefit of members and care coordination. These investments include introducing referral networks to support alignment of care. In addition, we will invest in pilot programs to enhance integration and address needs, including integration of behavioral health and primary care, tele-psychiatry to expand access, and screening and follow-up on social determinants of health in the context of primary care. These investments will transform the care delivery system to one more accountable to the needs of our MassHealth members.
- Integrated Data Reporting for Program Monitoring and Accountability: Tufts Health Plan together with BIDCO will invest in developing and integrating data reporting functionality across the payer and provider systems. This integrated model will facilitate effective reporting at all levels – from the highest level to the individual primary care provider – and will support accountability for outcomes at all levels.
Through the investments and action throughout the network, we will achieve the goal of the MassHealth ACO program including cost savings through appropriate utilization, improved integration, improved member engagement and improved quality. Specific goals are found in section 3 below.
Implementation of these programs will not be easy across a diverse healthcare delivery system with varied practice sizes and a large commercial and Medicare member population. There will be competing priorities and ongoing challenges to align between the payer and providers. Tufts Health Plan together with BIDCO will maintain open communication to address challenges and assure alignment of objectives and processes to maintain momentum through the implementation phase to assure continued progress.
On evaluation of the claims data by MassHealth and THPP/BIDCO partnership our 3 main areas of spend above the network across all rating categories include Pharmacy, Radiology and Lab.
Pharmacy: Since we already have high generic usage across the BIDCO network, we do not anticipate savings related to generic conversion. The pharmacy spend is related to unit cost in areas with little generic usage such as monoclonal antibodies for gastrointestinal and rheumatologic diseases. However with 50 % of PCC population we anticipate some savings with step up formulary design related to THPP managed care. Improved medication adherence with our programs will likely increase pharmacy usage.
Similarly we do have prior authorization for medical necessity for high tech radiology imaging to decrease unnecessary utilization as well as for high cost labs such as genetic testing. Deep dive into these areas and following trends closely will be our pathway in year one of the program.
Additional details can be found on our ACO website https://tuftshealthplan.com/bidco.