Maine

MaineCare had developed a value-based purchasing strategy centered on three components: creating “Accountable Communities”, improving transitions of care, and strengthening primary care. Under the MaineCare Accountable Communities initiative, Medicaid providers will enter into alternative contracts directly with the Maine Department of Health and Human Services. These contracts will use a shared savings model, with the amount of shared savings linked to provider attainment of quality benchmarks.
The Department of Health and Human Services released a Request for Information in November 2011 to gauge the interest of organizations and seek input on proposed design features of Accountable Communities. A subsequent Questions and Answers document provided more information about the initiative. Twenty-eight organizations—including health systems and provider groups—responded and indicated a high level of interest in the Accountable Communities Initiative. The initiative is still in development.
 
In October 2013, the Department of Health and Human Services released a Request for Applications for Accountable Communities, as well as a concept paper describing the initiative. The state intends to begin implementation of the initiative on May 1, 2014.
 
In early 2013, Maine received a State Innovation Model testing grant from the Center for Medicare & Medicaid Innovation. This grant will allow the state to implement the Maine Innovation Plan, which is intended to support “formation of multi-payer ACOs that commit to value and performance-based payment reform and public reporting of common quality benchmarks, and that build on the model of MaineCare accountable communities.” Among the state’s goals for this initiative are to:
  1. Implement payment reform across public/private payers;
  2. Spread the patient-centered medical home model of enhanced, integrated primary care, and;
  3. Achieve transparent understanding of the costs and quality outcomes of patients across all payers statewide.
To learn more about Maine’s medical home initiatives, visit the Maine page of NASHP’s medical homes map.
 
Last updated: November 2013.
 

 Project Scope

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.
 Authority
MaineCare is developing a State Plan Amendment to authorize the Accountable Communities Initiative.
 Governance
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:
  • Integration of physical and behavioral health
  • Practice and system transformation
  • Inclusion of patients and families in leadership roles and as partners in care and partners in organizational quality improvement activities
  • Developing formal and informal partnerships with community organizations, social service agencies, local government, etc.
  • Participation in Accountable Community and/or ACO learning collaborative opportunities
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: 
  • Post signs indicating participation in Accountable Communities in settings where primary care services are provided, and
  • Make available standardized written notices in plain language developed by the Department of Health and Human Services notifying members of the provider’s participation in Accountable Communities and the potential for MaineCare to share member identifiable data with the Accountable Community.
 Payment
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:
  • $50,000 for small (1,000-2,000 attributed members) Accountable Communities
  • $200,000 for medium (2,000-5,000 attributed members) Accountable Communities
  • $500,000 for large (5,000 or more attributed members) Accountable Communities
     
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: 
  • Aggregate reports on metrics, utilization and expenditure data
  • Reports of assigned members
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:
  • Data analytics
  • Public reporting of quality measures
  • Accountable Care Organization learning collaborative support through an Accountable Care Implementation Committee
  • Continuing work and learning support around the development of value based insurance design
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:
 
  1. Measure success of the Triple Aim (Better Health, Improved Patient Experience of Care, and Lower Cost)
  2. Address populations and performance areas meaningful for MaineCare’s population, providers, healthcare processes and structure
  3. Maximize alignment of metrics with currently reported metrics in the State and nationally (Medicare ACO, Health Homes, Pathways to Excellence (PTE), Improving Health Outcomes for Children (IHOC), etc.) to the extent feasible and appropriate
  4. Reflect a mix of process and outcomes measurement, and short and long term impacts
  5. Minimize reporting burden to providers, to extent feasible (i.e., keep the number of metrics to a reasonable number )
  6. Measure performance (vs. reporting only) beginning in first performance year
  7. Highlight differences between providers