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New Jersey’s Medicaid ACO Demonstration and the Transition to Regional Health Hubs:

Implications for COVID-19 ResponseRutgers Center for State Health Policy

Policy Forum Series January 15, 2021

Visit us at www.CSHP.Rutgers.edu or on Twitter @RutgersCSHP

Rutgers Center for State Health Policy (CSHP) is a unit of the Institute for Health, Healthcare Policy and Aging Research within Rutgers Biomedical and Health Sciences (RBHS)

Center for State Health PolicyInstitute for Health, Health Care Policy and Aging Research

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Acknowledgements• Support for this event was provided by the Robert Wood Johnson

Foundation. The views expressed here do not necessarily reflect those of the Foundation.

• Findings shared in this presentation are from a project supported by funding from the Agency for Healthcare Research and Quality (AHRQ) under grant R18HS023493. (The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.)

• We acknowledge our colleagues, Oliver Lontok, Bram Poquette, and John Palatucci for their efforts in planning & executing this virtual forum.

• We thank our panelists in advance for sharing their expertise and insights and all of you for participating in this discussion.

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Acknowledgements

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About the Center for State Health Policy

• Launched in 1999 with core support from the Robert Wood Johnson Foundation

• Translational health policy center with a mission to inform, support and stimulate sound and creative health policy in New Jersey and around the nation

• The Center’s research and project portfolio focuses on:– Health System Performance Improvement– Access to Care and Coverage– Population Health – Health and Long-Term Care Workforce– Long-Term Services and Supports

Visit us at www.cshp.Rutgers.edu or on Twitter @RutgersCSHP

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Goal of the Policy Forum Series

• Address some of the most critical health and health care policy issues impacted by the COVID-19 pandemic in New Jersey

• Draw on timely and relevant data and expert discussion of policy strategies to address short- and long-term challenges

• Upcoming Forums – COVID 19’s Impact on NJ Families (April 2021) – Strategies to Address Barriers to Workforce and Program Licensure

(Summer 2021)

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Presenters & Panelists

Derek DeLiaDirector of Health Economics & Health Systems Research

MedStar Health Research Institute

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Yannai KranzlerDirector

Office of Population HealthNJ Department of Health

Gregory PaulsonExecutive Director

Trenton Health Team

Aaron TruchillDirector for AnalyticsCamden Coalition of Healthcare Providers

Tyla HousmanVice President of External Affairs

NJ Health Care Quality Institute

Joel C. CantorDistinguished Professor & Director

Rutgers Center for State Health Policy

Margaret KollerExecutive DirectorRutgers Center for State Health Policy

Rob HoustonDirector, Payment Reform

Center for Health Care Strategies

Keri Logosso-MisurellExecutive DirectorGreater Newark

Health Care Coalition

Broad goals of the ACO Demonstration

• 3-year experiment w/accountable care & shared savings– Improved care management, quality benchmarks, financial

sustainability

• Begin w/low provider risk‒ 1-sided shared savings‒ Slowly move to greater risk bearing

• Balance flexibility & oversight

• Limit the state’s financial exposure

• Learn from experience

Demonstration timeline Date Action

August 2011 Demonstration signed into law.

May 2013 Proposed Demonstration rules issued.

May 2014 Final Demonstration rules issued.

July 2015 Beginning of Demonstration Year 1 with 3 ACOs certified to participate.

February 2016

First round of claims & encounter data provided to ACOs from the state.

June 2016 End of Demonstration Year 1.

July 2016 Beginning of Demonstration Year 2. $1 million appropriation to each ACO.

June 2017 End of Demonstration Year 2.

July 2017 Beginning of Demonstration Year 3. $1 million appropriation to each ACO.

June 2018 Original end of Demonstration.

July 2018 Demonstration extended for 1 year w/continued data access & $1 million appropriation to each ACO.

Main distinctions from other Medicaid ACO initiatives

Feature New Jersey Other StatesPatient assignment

All Medicaid enrollees w/in geography chosen by ACOs subject to Demo rules.

All Medicaid enrollees w/in assigned geography or patient assignment algorithm.

MCO participation

Voluntary. Mandatory participation or MCOs excluded.

Spending targeted for shared savings

In FFS Medicaid, TCOC including pharmacy & LTSS. Negotiated w/MCOs.

Defined categories of spending (e.g., hospital use) or spending w/carveouts (e.g., behavioral health, LTSS).

Source: DeLia & Yedidia, 2020MCO: Managed care organizationTCOC: Total cost of care FFS: Fee-for-serviceLTSS: Long-term services & supports

Key implementation features & requirements

• Multi-stakeholder board (healthcare, social services, patient/community representation)

• Shared savings arrangements– Required for fee-for-service (FFS) population– Voluntary for managed care organizations (MCOs)

• Quality metrics – FFS: ACOs choose from state-endorsed options– Managed care: Negotiate w/ MCOs

• Provider participation (based on ACO area)– All area hospitals– ≥ 4 Behavioral healthcare providers– ≥ 75% of Medicaid primary care providers

• ACOs receive monthly feeds of Medicaid claims data from the State for their geographic areas

NJ ACO communities

3 certified ACOs• Camden Coalition of Healthcare Providers (CCHP)• Trenton Health Team (THT)• Healthy Greater Newark (HGN)

ACO-like coalition• Healthcare Coalition of Passaic County (HCPC)

– Did not meet certification requirements– Functioned as an ACO with non-state resources (e.g., The

Nicholson Foundation)– Did not receive data feeds from NJ Medicaid

• Each community began w/different levels of coalition experience & activities

Number of Medicaid/CHIP beneficiaries per ACO community (in 1,000s), CY-2015*

57.151.9 52.5

43.3

0

10

20

30

40

50

60

CCHP THT HGN HCPC

Source: DeLia & Yedidia (2020)*Individuals with at least one day of Medicaid/CHIP enrollment

The demonstration community

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Broad themes from the Demonstration experience

• Collaborative infrastructure for broad community initiatives– E.g., Health surveillance, grant applications

• Data infrastructure centered on Medicaid claims data– Linking institutional partners’ clinical & social service data– Shared information & data-driven decision-making

• Catalyzing & strengthening intensive care management– Direct care management deemphasized– Serve as convening & connecting organization

• Relationships with MCOs– Difficult to align incentives under voluntary arrangements w/MCOs– Few shared savings arrangements, some service contracts

• Learning & advocacy network– Support for other community health initiatives– Groundwork for transition to RHHs

From ACOs to Regional Health Hubs (RHHs)

• Public law: NJ Stat. 30:4D, 8.16-19• Signed by Governor Murphy in January 2020

“The Regional Health Hub Program shall replace the Medicaid Accountable Care Organization Demonstration Project established pursuant to P.L.2011, c.114 (C.30:4D-8.1 et seq.), which is now subject to expiration by law.”

• 3 ACOs & 1 ACO-like organization transitioned to RHHs

Demonstration features retained under RHHs

• Similar coalition structure: community, health, & social services

• Coalition takes responsibility for clearly defined geographic area proposed by the coalition

• Emphasis on care coordination, connection to social services, & community engagement

• RHHs receive routine Medicaid claims data feeds & link with other data ==> regional data analysis

Demonstration features removed under RHHs

• No longer ACOs

• No shared savings required

• No list of performance measures created & endorsed by state agencies

• No numerical requirements for primary care and other providers

New features added under RHHs

• RHHs act as partners with Department of Human Services & other state agencies

• Negotiated goals, deliverables, performance metrics, & funding

• Department of Human Services can solicit applications to create other RHHs

National context for RHHs

• Similar to Accountable Health Communities (AHCs)– Connect health and social service providers– Address health-related social needs

• CMS AHC model includes 29 organizations nationwide– 2 from NJ (Camden Coalition of HealthCare Providers & Hackensack

UMC)

• Similar models in other states w/different names– CA, CT, MI, MN, RI, VT, WA– Many developed under State Innovation Model (SIM) awards

• Many varieties w/mixed results

Key takeaways

1. ACO Demo provided valuable lessons for creating RHHs (moved to AHC-like model from ACO model)

2. RHHs will continue data-driven community collaborations without expectations of shared savings or prespecified quality metrics

3. New issues as of January 2020: – Optimal scale & scope of RHH activities– Accounting for cross-sectoral impacts (i.e., beyond Medicaid)– Possible spread of RHH model

4. RHH are now serving as a community resource during the COVID-19 pandemic

BibliographyDerek DeLia & Michael J. Yedidia. “The Policy and Practice Legacy of the New Jersey Medicaid ACO Demonstration Project”. Journal of Ambulatory Care Management 43(1): 2-10, 2020.

Derek DeLia, Michael Yedidia, & Oliver Lontok. Update on Operations and Care Management Strategies in the New Jersey Medicaid Accountable Care Organization Demonstration Project. Rutgers Center for State Health Policy: New Brunswick, NJ, November 2018.

Derek DeLia, Rizie Kumar, Jose Nova, Kristen Lloyd, & David Goldin. Spending and Utilization Indicators in the New Jersey Medicaid Accountable Care Organization Demonstration Project. Rutgers Center for State Health Policy: New Brunswick, NJ, November 2018.

Derek DeLia, Michael Yedidia, & Oliver Lontok. Year 1 of the New Jersey Medicaid Accountable Care Organization Demonstration Project: Assessment of Operations and Care Management Strategies. Rutgers Center for State Health Policy: New Brunswick, NJ, February 2017.

Frank J. Thompson & Joel C. Cantor. The New Jersey Medicaid Accountable Care Organization Demonstration: Lessons from the Implementation Process. Rutgers Center for State Health Policy: New Brunswick, NJ, May 2016.

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