Delivery System Reform Incentive Payment (DSRIP) Program Accountable Care Organization (ACO) Full Participation Plan Response Form Part 1: ACO Summary
Full ACO Name: Boston Medical Center Healthnet Plan Southcoast Alliance
ACO Address: 200 Mill Road, Fairhaven, MA 02719
Part 1: Executive Summary
1.1 ACO Composition and Governance Structure
The BMCHP Southcoast Alliance is an ACO Partnership Plan joining the Southcoast Health Network (SHN) ACO and Boston Medical Center Health System (BMCHS).
SHN is a clinically integrated network with employed and community physicians and providers as well as the Southcoast Hospitals - Charlton Memorial, St. Luke’s and Tobey - and the Southcoast VNA. Southcoast Health Network (SHN) ACO is comprised of the employed Southcoast Physician’s Group and independent affiliate providers.
Organizational Structure -- ACO Governance
The SHN ACO complies with all requirements established in the MassHealth ACO Partnership Plan contract, as affirmed by attestations and other deliverables. The ACO resides under SHN, and has a clinical leadership dyad where the Physician Executive (1) provides the ACO with clinical leadership and the direction to transform the Network into an integrated ACO; and (2) sets its financial and operational goals and metrics. Along with the Physician Executive, the ACO leadership is developing and implementing an integrated and shared Medicaid ACO program across the Network with providers, affiliates, health groups, VNA and Community Partners (CP). SHN has a Board of Managers with the authority to manage its business, property and affairs. Certain actions require the approval of the SHN’s member, Southcoast Health System, Inc. (“Southcoast”). The Board of Managers consists of between 15 and 17 representative in two categories who are appointed by Southcoast: Physician Managers who are primary care and specialty physicians, and Member Managers who represent Southcoast and its subsidiary entities. SHN has appointed a behavioral health/substance use provider as a Physician Manager and a consumer as a Member Manager of the ACO. The Physician Manager actively engages with the BH staff to ensure proper provisions of care for all Medicaid ACO behavioral health patients.
SHN shares a Patient Family Advisory Council (PFAC) with Southcoast. PFAC has 11 community member representatives. Consumers with disabilities are currently represented by an individual who also serves as the Chair for the New Bedford Commission for Citizens with Disabilities. SHN also has a Utilization and Performance Improvement Committee (UPIC) that works with Southcoast’s Quality Committee to ensure enterprise-wide coordination of efforts.
Organizational Structure -- MCO Governance
BMCHP maintains a Board of Trustees (BOT or Board) as its governing board. Under the corporate bylaws, the Board consists of the president of the corporate member (BMC Health System), the president of the Corporation (BMCHP), a chairperson and no more than twelve (12) additional trustees. The trustees currently include the following individuals:
- David Ament, Chair
- Pierre Cremieux
- Mark Taber
- James Blue
- Christopher Gordon
- Kate Walsh (President and CEO of BMC)
- Ryan Carroll
- Frank Ingari
- Tarsha Weaver
- Susan Coakley
- Keith Lewis, M.D. (provider)
- Stacy Cowan
- Robert Sweet
Additionally, BMCHP has a Member Advisory Board that reports to the BOT.
The BMCHP Board of Trustees is empowered to act on the following corporate matters:
- Approval of the annual capital and operating budgets or any material amendment to, or variation from, those budgets;
- Authorization of any merger or consolidation with, or any acquisition of, another corporation by the Corporation;
- Authorization of the sale, lease, mortgage, pledge or other disposition of any assets of the Corporation, or authorization of any indebtedness of the Corporation, in excess of amounts set by the corporate member or the Board from time to time
- Determination of the threshold amount of indebtedness of the corporation, over which amount authorization is required pursuant to the bylaws; and
- Approval of the filing of any voluntary bankruptcy.
Senior Management is responsible for decisions that may impact different affiliated or network providers (including decisions about investment strategy or the distribution of shared savings payments or surplus). If these provider-related decisions impacted the annual capital or operating budgets, the distribution of material assets, or the incurrence of debt, the Board would be informed and approve such actions. The Board is regularly informed of material transactions relating to providers.
Organizational Structure -- Joint Governance
BMCHP and SHN have entered into a contractual joint venture to develop and manage the SHN Partnership Plan, and formed a Joint Operating Committee (JOC) that has authority to oversee the managed care program administered by BMCHP pursuant to the contract between Southcoast BMCHP Alliance and EOHHS. The JOC is the structure that supports DSRIP-related decision making and also is responsible for the following:
BMCHP and ACO Responsibilities, collaborating through the Joint Operating Committee
- Developing and approving the business plan, and revising it based upon changes to the program or the joint venture
- Approving a joint marketing, outreach & communications plan to promote the ACO Partnership Plan to potential members
- Overseeing the performance of the ACO Partnership program, including the review of data and reports relating to financial performance and quality, and assessing performance relative to the business plan and to performance standards agreed upon by BMCHP and the ACO Partner
- Overseeing the service performance of the ACO Partnership program, including through the development of a services scorecard and monitoring performance
- Making recommendations on issues relating to the ACO Partnership program
- Advising on any delegation of health plan functions by BMCHP
- Establishing criteria for the use of Delivery System Reform Incentive Payment (DSRIP) funds paid under the program to the ACO
- Reviewing and approving proposals by the ACO Partnership for the use of DSRIP funds to the ACO
- Establishing criteria for and reviewing and approving any care coordination programs and other clinical programs that the ACO Partner and its providers will design and implement
- Approving cost targets, quality metrics and methodology used to determine and distribute performance bonuses and shared risk payments
- Making determinations about the joint contribution of funds for certain costs and related assessments
- Assessing and making recommendations to the ACO on the addition of provider participants and community partners
1.2 ACO Population Served
According to the Delivery System Reform Incentive Payment (DSRIP) Performance Year 1 Funding Notification Letter, the Southcoast Health Network in partnership with Boston Medical Center Health Plan has a Member Count (as of March 31, 20171) of 16,592. The ACO will be covering members in the MassHealth service areas of Fall River, New Bedford, Wareham, Attleboro, Falmouth, Plymouth, and Taunton.
The ACO region, which has over 342,000 residents, has significant regional and demographic issues that impact residents’ health, particularly in the two major urban communities of Fall River and New Bedford and the large town of Wareham. Residents in these communities have lower incomes, a lower educational level and a historically higher unemployment rate than both the state and the region averages. The health status of the ACO region residents is influenced by lack of access to amenities that facilitate healthy eating and active living. And, there are many sources of environmental contamination. The ACO region’s population is also faced with a high disease burden including behavioral health and substance use disorders. The information provided below is with respect to the entire ACO region population, not just MassHealth patients.
Poverty and Income. There continues to be a gap between the state per capita income and that of the ACO region. The ACO region has a higher share of people living in poverty compared to the state overall, and the ACO’s region’s cities are home to disproportionate shares of people in poverty. Nearly onequarter of all people in Fall River (23.3%) and New Bedford (24.0%) live in households with annual incomes below the poverty level.
Education. When compared to the adult population statewide, Fall River and New Bedford have more than twice the percentage of adults who have not completed high school – 29.7% in Fall River and 28.9% in New Bedford, compared to 10.5% across the Commonwealth.
Disease Burden. Complex medical conditions are prevalent within the ACO’s membership. Top conditions faced by the population include Bipolar & Depression, Trauma, Personality Disorders, Multiple Joint Fractures, Back Disorders, Infectious Diseases, Hypertension, Obesity, and Drug Dependence.
1 The member count used to calculate PY1 funding amounts and the PY0 reconciliation amount is based on a snapshot date of March 31, 2017, reflecting any subsequent technical changes to PID/SL lists, as determined by EOHHS.
1.3 Overview of DSRIP Investment Approach
The ACO’s programmatic strategy is grounded on the guiding principles of population health management. Overarching goals of the program include:
Cost and Utilization Management
- Goal #1: Provide wrap-around medical and behavioral support for Medicaid ACO patients to drive down avoidable admissions and the percentage of 30-day readmissions to 12.8% (all cause, unplanned) over 5 years compared to baseline. This connects with the TCOC management opportunity related to Complex Care Management and the Emergency Department’s Clinical Social Workers and Community Health Workers for outreach and support of patients. This will allow the ACO to develop a holistic, targeted and high-touch care management model for the highest-risk and high-risk members; reduce avoidable admissions and readmissions to lower inpatient costs; reduce avoidable ED visits to reduce emergency room costs; develop integrated medical and behavioral health programs and protocols to address siloed health care. Hospital admissions was identified as an area where our ACO was running above market.
Integration of Physical Health, BH, LTSS, and Health-Related Social Services
- Goal #2: Reduce Behavioral Health costs to the ACO system while improving patient satisfaction and communication among various entities involved in the patient’s care and to see a reduction in avoidable admissions, the 30-day inpatient readmissions, ED visits and a decrease in TCoC in the Medicaid ACO population. Hospital admissions and emergency room utilization which were both identified as areas where our ACO was running above market.
- Goal #3: Ensure that all Medicaid ACO patients leaving an acute or sub-acute facility will have a 5-day post-discharge follow-up (transition of care) appointment with their provider. The goal of this is to engage with the patients, reduce readmissions, ensure the provider is the central hub of the patient’s care, conduct medication reconciliation, and provide further reinforcement that the provider is the option-of-choice when a Medicaid ACO patient needs medical, behavioral health or social support. Hospital admissions was identified as an area where our ACO was running above market.
- Goal #4: Practice Quality Coordinators will engage Primary Care Providers in patient quality metrics and help practice clinics optimize patient satisfaction, primary prevention through appropriate screenings as will be demonstrated through optimized quality scores. This will allow the ACO to identify actionable opportunities for performance improvement and work collaboratively toward achieving value-based care and provider accountability and provide appropriate performance feedback to providers and staff.
- Goal #5: Ensure patient medical record is properly and comprehensively documented and coded appropriately to ensure continuity of care, facilitate quality chart reviews and communicate gaps with providers.
1.4 Overview of Population Health Management Approach
The ACO’s approach to Population Health Management (PHM) is to align all of the health services throughout the system so that each Medicaid ACO patient has the right care at the right time in the right place. All components of the PHM strategy to support the Medicaid ACO are required to be implemented by all clinic sites, hospitals and provider groups.
This includes having the ACO meet the patient where they and provide services in such a way that optimizes each patient’s opportunity for success. To this end, each member site has the flexibility to implement key components of the plan in such a way that allows individual difference, when needed, but at the same time minimizes variations and promotes standardization.
Core to the ACO’s PHM approach is utilizing a care coordination model. This model relies centrally on the MCO and ACO to identify patients through 3 specific means: (1) patients admitted to an acute or subacute care facility that are identified through daily census or through other means of facility-to-facility communication; (2) referrals from providers, families, patient self-referral, or other community partners; and (3) data and analytics. To ensure equal and standard identification, the risk stratification tools are applied to all patients across the population. Registered Nurses, Social Workers, Community Health Workers and Clinical Pharmacists work closely together as a Care Team to provide wrap-around support to ACO patients. These Care Teams work closely with patients to develop patient-centered care plans,
work closely with providers to develop actionable care plans, and work with internal and external partners to provide holistic wrap-around care to the Medicaid ACO patients.
The ACO’s goals are supported by DSRIP funding to enable a 5-year DSRIP Investment Strategy. This funding capitalizes resources where and when they are most needed, allows for a robust and supportive Information Technology (IT) system and ensures that the ACO’s PHM approach, including care coordination, is implemented.
The ACO recognizes there will be challenges in implementing the PHM strategy for the Medicaid ACO patients. These include implementing complex programs across multiple systems, training and education on newly developed IT functionality, and effective outreach to hard-to-reach patients. Each of these challenges provides an excellent opportunity for improvement to keep the PHM strategy moving forward in ways that are effective and sustainable.