The Promise of Health Reform: Better Care, Lower Costs Through ACOs

1. The Promise of Health Reform: Better Care, Lower Costs Through ACOs March 27, 2019 Regis College Presidential Lecture Series on Health Christina Severin, President & CEO

2. This Evening’s Agenda ACO Basics How the ACO model evolved out of the ACA The MassHealth ACO Program Getting to know C3: who we are, what we do, and how we do it Social Determinants of Health Challenges for Massachusetts ACOs going forward Questions/Discussion

3. ACO Basics The goals of an ACO are two-fold: Provide coordinated care to ensure patients get the right care at the right time while avoiding unnecessary services and procedures Share in the savings produced by delivering high-quality care and spending health care dollars more wisely An ACO is a group of health care organizations (PCPs and/or hospitals and/or specialists) who come together voluntarily to provide high-quality, coordinated care to a defined population The performance of an ACO is measured by some combination of performance on cost and/or quality Some ACO arrangements are shared savings; some are shared savings and shared deficit, or two-sided risk

4. Brief history of ACOs • Arguably, although the term “ACO” might be relatively new, the concept is not • The Staff Model HMOs of the 1980s-1990s were essentially ACOs, however, a major difference from Staff Model HMOs and today’s ACOs is the ability to incorporate quality measurement in program design • In Massachusetts, BCBS has been doing ACO contracting with providers since about 2009 through their Alternative Quality Contract • Through the Affordable Care Act, CMS started a Medicare ACO program in 2011 which is still in place today

5. The Origins of the MassHealth ACO Program • MassHealth (MA Medicaid program) is unsustainable • Grown to 40% of the Commonwealth’s budget (over $15 billion per year) • Serves 1.9 million MA residents • No major structural changes in the last 20 years • CMS authorized a $1.8 billion investment over 5 years • Expansive “restructuring” initiative • Funding will support the move to ACOs

6. Overview of C3 • Founded 2016, we have 17 Federally Qualified Health Centers • We are the largest FQHC-ACO in the country taking “two-sided” ACO risk • We serve about 120,000 MassHealth beneficiaries statewide • Our 2019 revenue is about $44M and our Total Cost of Care budget is about $700M • Our Board is composed of health center CEOs and CMOs • CMO must be a MD/NP/PA practicing primary care • Several of our CMOs are NPs

7. Our Statewide Footprint 16 17 16

8. Why Did Health Centers Join Together to Form C3? Our 17 member health centers share the same mission and values to support low-income population Best chance at financial success: We are stronger together! Best strategy to preserve health center autonomy Based on national published studies, the total cost of health care associated with health centers is about 20% lower that other types of primary care, without any reduction in quality of care We are already leaders in integrated care; and in understanding how stress, trauma and social determinants of health have negative health and wellness consequences for the populations we serve

9. What Makes C3 Unique? Stronger together! VS Most Massachusetts ACOs are hospitals or health systems C3 is the only health-center based ACO and one of only three non-system based ACOs in the state We have the ability to transform the health of those we serve in a way that is uniquely agile and community-based

10. Systems & Data Flows: How We Leverage Data Assets EMK Family UMass St Vincent’s Metrowest

11. How We Use Harmonized Data Assets to Creating an Operating Platform SDoH data Claims ADT & Auth alerts EHR Patient screens Performance AnalyticsCost & Quality performance information “The Main Brain” Data Warehouse with a Rules-based engine Risk of Big Events Risk of Re-admissions Care & Social Needs Complex Care Gaps in Quality & Care Population Health & Risk Adjustment Care Coordination Transitions of Care

12. Understanding the Population Served

13. SDOH: MassHealth Risk Adjustment • Among other innovative tools, MassHealth introduced an industry leading SDOH risk adjustment methodology, on top of an DxCG v4.2 concurrent Medicaid RRS, including: • Housing Issues: • People with 3 or more addresses in a single calendar year OR with a Z-code for homeless indicated on a claim or encounter record • Neighborhood Stress, measure of “economic stress” summarizing 7 census block variables: • % of families with incomes < 100% of FPL • % < 200% of FPL • % of adults who are unemployed • % of households receiving public assistance • % of households with no car • % of households with children and a single parent • % of people age 25 or older who have no high school degree • Clients with program enrollment in the Department of Mental Health or Department of Developmental Disabilities

14. Addressing SDOH: MassHealth Flexible Services Program In October 2018, CMS approved MassHealth’s protocol for a $149 million Flexible Services Program, which is part of the 1115 waiver and will allow ACOs to pay for certain health-related social supports for their members In particular, MassHealth is now able to pay for services within the domains of nutrition and housing supports MassHealth evaluates ACO performance on screening for health-related social needs through a dedicated quality measure, and requires ACOs to report whether any needs were identified in the core domains Implementation of the Flexible Services Program is anticipated to start by January 2020

15. SDOH: Measuring Social Return on Investment As part of a grant funded project with the Health Policy we have embarked on an effort to develop a method and tool to quantify the economic Social Return on Investment (SROI) The SROI tool is designed to measure non-health care cost related ROI The beta tool includes 6 measures of community health As part of our plan for financial sustainability, we hope to measurable demonstrate SROI as a means to gain public and/or private interest in social impacting investing

16. Is There a Business Case for Addressing SDOH? Working to estimate social (non-medical) investment returns Illustration: total social returns are $358,000; avoidance of foster care & emergency shelter make largest contributions

17. Challenges: Achieving Cost & Quality Targets ▪Stateaccountabilityto CMS forDSRIPfunds alsodependson reductionin avoidableutilization andquality ▪Qualitydomains includechronic disease management, BH/LTSS, andpatient experience

18. Will this New MassHealth ACO Program Work:Key Considerations • Since the overwhelming majority of MassHealth members are in ACOs that are hospital systems, will these ACOs be successfully in taking material costs out of their system? • When DSRIP starts precipitously declining after year 3, as planned, will ACOs drop out of the program? • How will the current disruptive landscape impact the ACO program? • Policy changes from DC • CVS/Aetna • Haven (Amazon, Berkshire Hathaway, JP Morgan Chase) • Emerging AI and telehealth technologies • Continued hospital acquisition of primary care