Implement payment reform across public/private payers;
Spread the patient-centered medical home model of enhanced, integrated primary care, and;
Achieve transparent understanding of the costs and quality outcomes of patients across all payers statewide.
Last updated: November 2013.
Eligible Patient Population: All MaineCare members who receive full MaineCare benefits, including Categorically Needy, Medically Needy, SSI-related Coverage Groups, Home and Community-Based Waiver and HIV Waiver members, and others are eligible for attribution to the Accountable Communities.
Provider Population: All willing and qualified providers will be eligible to participate in the Accountable Communities initiative. Accountable communities will not be limited by geographic area.
Attribution: The Department of Health and Human Services has proposed to align Accountable Communities’ member attribution methodology with that used in the Medicare Pioneer Accountable Care Organization program.
Based on historical claims analysis, members will be prospectively assigned to an Accountable Community associated with the primary care practice or specialist where they received a plurality of visits for primary care services (as defined by HCPC codes or revenue codes for Federally Qualified Health Centers). Members who moved or received more than 50 percent of their primary care services in a non-contiguous geographic region to the Accountable Community will be excluded after the performance year. Members not assigned through a primary care or specialty practice will be assigned to the Accountable Community associated with the hospital where the member receives the majority of their emergency department care. Member freedom of choice will not be restricted.
Scope of services A Request for Applications issued by the state in October 2013 lists the defined set of 26 core services that will be factored into the total cost of care calculation for Accountable Communities. These services include primary care case management, behavioral health, inpatient and outpatient services, pharmacy, hospice and home health. Additional optional services—including dental, children’s private non-medical institution, and long term care services—can be included in the Accountable Community’s total cost of care at the Accountable Community’s discretion.
MaineCare is developing a State Plan Amendment to authorize the Accountable Communities Initiative.
The Maine Department of Health and Human Services released a Request for Applications (RFA) for its Accountable Communities initiative in October 2013. The RFA clarified that while the Accountable Community need not be an incorporated entity, each Accountable Community must establish a governance structure that is responsible for oversight and strategic direction of the Accountable Community and it must designate a Lead Entity. The Lead Entity must contract with all providers participating in the Accountable Community and the Lead Entity is responsible for receiving and distributing shared savings payments (or making shared loss payments to the Department of Health and Human Services).
|Criteria for Participation||
Accountable Communities will be required to serve a minimum number of MaineCare (Medicaid) members (the minimum number has not yet been determined). They must include MaineCare-enrolled providers. Accountable Communities must deliver primary care services and directly deliver or commit to coordinate with specialty providers, including behavioral health for non-integrated practices, and all hospitals in the proposed service area.
Accountable Communities will also be required to commit to:
The Department of Health and Human Services has proposed to align member protection requirements with the Medicare Shared Savings Program. Providers participating in an Accountable Community would be required to:
Under Maine’s proposal, two payment models would be utilized.
Accountable Communities that do not consist of integrated health systems will operate under a shared savings model. A target per member per month is identified for the Accountable Community based on risk-adjusted actuarial analysis of project costs. If the actual per member per month amounts is lower than the target amount, the savings are split between the state and the Accountable Community; the Accountable Community can share in a maximum of 50 percent of savings based on quality performance.
Accountable Communities that have capacity to assume risk will move toward a symmetric risk-sharing model over time: these Accountable Communities will be responsible for a portion of the loss associated with actual per member per month expenses that exceed the target PMPM. These Accountable Communities can share in up to 60 percent of savings (based on quality performance), but are held accountable for up to 5 percent of losses in year two and 10 percent of losses in year three.
The Department of Health and Human Services will cap the per member costs included in cost calculations for shared savings or penalties to protect Accountable Communities from being penalized for an abnormal distribution of catastrophic claims. Per enrollee costs are capped at:
Additional payment reform models will also be phased in under the Accountable Communities Program as part of a continuum of payment reform. This continuum begins with shared savings, moves to shared savings plus risk, then to partial capitation models, and finally to global capitation.
|Support for Infrastructure
The Department of Health and Human Services plans to provide participating providers with quarterly:
The state has partnered with the Maine Health Management Coalition (MHMC) as part of its State Innovation Plan. It will use the State Innovation Model testing grant funds to provide:
The MHMC’s Foundation, the lead agency for public reporting of quality information in the state, will continue to provide performance measurement and feedback to providers, employers, and insurers under this initiative.
For the innovation model, Maine’s health information exchange HealthInfoNet will provide several services, including emergency department notifications to community care teams, and capturing Health Homes clinical outcomes from electronic health records for reporting and analysis.
|Measurement and Evaluation||
According to a Request for Applications released by the state in October 2013, Maine will finalize a core set of quality measures for use in the Accountable Communities initiative by December 2013.
The state has defined seven criteria on which to base its selection of quality measures. Metrics chosen should: