LILO H. STAINTON | JUNE 19, 2019
NJ healthcare coalitions have had success focusing on complex health and social needs of high-demand Medicaid patients. Now they have a new roadmap for an even more integrated approach
In the Camden area, healthcare and social service organizations have worked together to connect low-income women of childbearing age who have chronic illnesses to supports like housing, substance abuse treatment, and children’s services. The goal is to reduce maternal and infant mortality by improving patients’ lives outside the hospital.
In Passaic County, a similar coalition has focused on people who often end up in the emergency room struggling to properly breathe because of asthma or other lung disease, or diabetes. Early results suggest helping them to better manage these diseases at home could cut hospitalizations by 10 percent.
These are examples of how collaborations in Camden, Trenton, Newark and Paterson have made a positive difference for patients with complex health and social needs, in part by focusing on the social determinants of health — things like housing and poverty — that have an outsized impact on well-being.
But supporters said this work by Medicaid Accountable Care Organizations, or ACOs, has been hampered by their current statutory mandate which they said includes outdated financial requirements and other restrictions. A new approach, including legislation, is needed to transform the ACOs into more effective, regional organizations that can help more low-income patients, access better and more diverse data, and become truly sustainable, they maintain.
How to create the hubs
On Tuesday the New Jersey Health Care Quality Institute released a “road map for redesign” that provides a path forward for Garden State officials, ACO leaders and other stakeholders. Advocates said the strategy builds on the coalitions’ success, revises outdated elements, and creates a platform to support new “regional health hubs” in other New Jersey communities with large Medicaid populations.
“Health and wellbeing are about more than access to health care services,” said Linda Schwimmer, the Quality Institute’s president and CEO. “Good health is also about social supports, housing, safety, and access to nutritious food,” she said, adding that health hubs are a way to address these issues more holistically.
“These Regional Health Hubs are the future as we continue to find new models of care that value and support individuals beyond just the doors of the doctor’s office or hospital,” she said.
The Quality Institute and ACO advocates hope the state will continue to support the existing programs in the upcoming budget — the state has channeled $3 million to the programs in recent years, half from federal sources — and permit them some room to evolve in the short term. In the coming years, they want to work with state leaders on a multi-year plan, identify new sources of funding, and convince Trenton lawmakers to adopt new legislation to support the regional health-hub model.
Credit: Trenton Health Team
“We’ve actually been doing this work since the launch of the ACO project,” said Gregory Paulson, executive director of the Trenton Health Team, which leads the Capital City collaboration. “Regional health hubs really recognize what New Jersey has already built through the Medicaid model.”
New Jersey’s ACOs evolved from a 2011 law that aimed to better coordinate care, improve outcomes, support multi-sector partnerships, and create savings for the state’s Medicaid program by reducing the need for high-cost hospital visits; the coalitions in Camden, Trenton and Newark are officially sanctioned by the state and the Paterson partnership has done similar work without the title or funding.
Medicaid cost $17B in NJ last year
In New Jersey, Medicaid covers 1.7 million residents and cost nearly $17 billion in state and federal dollars last year, and absorbs close to one in five of the taxpayer dollars spent by the state, according to the Quality Institute. It includes involvement or oversight from both the state Department of Human Services, which runs Medicaid, and the Department of Health.
Paulson said that regional hubs can also help ensure this massive state and federal program actually meets the needs of local communities. “There is a structural gap between what the state Medicaid (program) thinks about statewide, and what a provider does in their own work,” he said. “There is this need to coordinate entities and resources.”
The ACO model was shaped in part by data that shows how improving care for certain patients can have a large-scale impact, and underscores the importance of integrating physical and behavioral health services. According to Rutgers University Center for State Health Policy, the 1 percent of state Medicaid patients with the highest healthcare costs account for 28 percent of the program’s total budget. Of these patients, more than eight in 10 experienced mental health or substance abuse issues, and one-third had been diagnosed with one or more serious mental illnesses.
Focusing on this high-needs population made sense in many ways, but ACO advocates said the potential savings never materialized because New Jersey reformed its Medicaid program by the time the 2011 law was implemented, nearly five years later. By then, the state had shifted 95 percent of Medicaid members into managed care, in which insurance companies are paid a set rate to provide a full scope of services.
Struggling to collaborate with insurance companies
Credit: Camden Coalition
While managed care is also designed to save money, it reduced insurance companies’ incentive to work with ACOs in New Jersey and the latter struggled to create meaningful partnerships with those paying for patient care. The Camden Coalition of Healthcare Providers eventually signed a deal with two insurance companies, which allowed them to access data and other resources; the Trenton Healthcare Team came to an agreement with another insurer; but the Greater Newark Healthcare Coalition has had less success. (Paterson, without a state ACO designation, faced additional problems.)Shifting from ACOs to a healthcare-hub model would eliminate the outdated requirement to create and distribute savings among participants, supporters said. It would also make it easier for these collaborations to tap new patient data — as well as records from other institutions like schools and law enforcement, information that can help hubs better understand the cause and impact of health issues. The fact that the state health department is actively working with hospitals to create a statewide system of digital health records will support this mission, the roadmap also notes.
“Hubs are ideally suited to analyze data to identify their own community’s chronic disease prevalence, high cost patient populations, and gaps in prevention services and care management,” the Quality Institute wrote. “Hubs will leverage local data by connecting community partners that address social determinants of health with the clinical partners that must now care for patient’s medical as well as medical-social challenges.”
In addition, the road map said the hub model is uniquely designed to bring together a wide range of stakeholders — including faith-based organizations, volunteer groups and others — to work collaboratively to address pressing public health needs, like maternal mortality or opioid addiction. If they succeed, patients are healthier, medical costs are avoided, and the community benefits overall, it notes.
“The unique all-inclusive approach incentivizes these competitors to collaborate, share information about patient care, and create interventions for high-cost patients that need improved access to the right care. There are very few, if any, scenarios where competitors come together around a common cause quite like providers and payers in the ACO/Hub environment,” the Quality Institute wrote.