Health

HEALTH • Winter 2017 17 H Crickett Sweetwood, mammomgraphy supervisor at Nashoba Valley Medical Center, which is participating in a MassHealthACO in partnership with Steward Health Care Network. capabilities, and reducing unnecessary emergency room utilization and inpa- tient hospital admissions. Essentially, the money allows the providers to build the infrastructure needed to coordinate care. Rather than a pilot, the new pro- gram is intended to be a permanent change for MassHealth, and it's got a lot of potential to make health care better for patients, according to Dr. Michael Sheehy, chief of population health and analytics at Worcester- based Reliant Medical Group. "It is a complex patient population to care for, and historically they have had very fragmented care. There's a very high behavioral health need," Sheehy said. Reliant has joined forces with Worcester-based Fallon Health to form one of the 17 new MassHealth ACOs to launch in March. The two groups are forming a network, called Fallon 365 Care, to provide insurance, as well care, to about 45,000 MassHealth patients. That's up from the roughly 15,000 patients Fallon and Reliant already manage together under an existing managed care con- tract. Sheehy explained it's a new offering, where the insurer and the provider act as one to ensure care is coordinated and efficient. In addition, the groups will work with community partners that specialize in addressing long-term needs, particularly in the behavioral health realm. Sheehy said historically, medical and behavioral healthcare have been "com- pletely siloed," creating practical prob- lems, such as the primary care doctor not knowing what kind of medication a patient may be taking for a mental health disorder. Often, patients seek special- ty care in practices unrelat- ed to their primary care doctors' offices, and this, too, can lead to duplicate testing and unnecessary procedures, Sheehy said. The Reliant and Fallon MassHealth ACO is "sort of like a joint venture without going into busi- ness together," according to Michael Nickey, executive director of the MassHealth program at Fallon Health. The difference to patients While patients will be autoas- signed into MassHealth ACOs, they will have the opportunity to opt out within 90 days of the March 1 start date. There will be less flexibility to change plans than in the past after that window, in order to maintain stability within the ACOs. But the expectation, according to Nickey, is that most will not opt out. For one thing, patients will follow their primary care doctors into the ACOs they're a part of, and Fallon has strived to include the specialists that Reliant doctors already refer to. He noted that new insurance cards will be issued, so old cards will no longer work at the pharmacy counter on March 1. Nickey added that despite the goal of cutting unnecessary Medicaid spending, quality of care and service levels will not suffer. "Right now when folks change plans, you have a lot of duplicative testing," Nickey said. "The idea is by keeping all this data within a set of providers, that alone will reduce some of that." Losing money on pilot, UMass Memorial opts out While Fallon's Medicaid business will nearly double, UMass Memorial Health Care, the dominant system in Central Massachusetts, will likely lose some MassHealth volume, since UMass Memorial opted out of the the program. While providers have the opportu- nity to earn incentives, they can cer- tainly lose money operating ACOs. Such was the case for UMass Memorial and its partner, Tufts Health Plan, which have lost money on their MassHealth ACO pilot. "Neither (UMass Memorial or Tufts) had the financial reserves nec- essary to manage the poten- tial downside risk. Hopefully there will be addi- tional opportunities for us to participate in a Medicaid alternative payment program in the future," UMass Memorial spokesman Anthony Berry said in an email statement. Berry said the system is hopeful that ACOs serving Central Massachusetts patients will include UMass Memorial specialists in their networks, but acknowledged that the networks are narrow and don't allow patients to see providers out of network. Sheehy said that when appropriate, Fallon 365 Care will refer to UMass Memorial specialists, but the ACO will try to provide care within net- work when possible, and he antici- pates more volume shifting to special- ists at Saint Vincent Hospital in Worcester, which already works close- ly with Reliant. "It's too bad that they didn't agree to it," Sheehy said. Commercial ACOs While fee-for-service care still reigns among commercial payors, the MassHealth ACO results will likely have implications for healthcare con- tracting in Massachusetts and nation- ally. But accountable care does exist in the commercial market already. Dr. Mark Girard, president of Steward Health Care Network, which has formed and ACO in partnership with Nashoba Valley Medical Center in Ayer, said Steward has accountable care contracts with most commercial payors as well, offering the same coordinated care that MassHealth patients will receive. "We treat everyone the same way," Girard said. Michael Nickey, executive director of the MassHealth program at Fallon Health FOR LEASE • MEDICAL OFFICE SPACE 475 Pleasant Street | Worcester, MA CONTACT: Carl Burwick 508.335.9361 cburwick@glickmankovago.com David Burwick 508.847.2377 dburwick@glickmankovago.com 1 Mercantile Street | Suite 510 Worcester MA 01608 508.753.9100 www.glickmankovago.com FOR LEASE • 4,100 square feet of medical office space on Pleasant Street. • Space previously occupied by successful medical practice. • Great location just off of Park Ave. $25/sf.

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