The New Jersey Medicaid ACO Demonstration Project: Seeking Opportunities for Better Care and Lower Costs among Complex Low-Income Patients

Abstract

A small but growing number of states are turning to accountable care concepts to improve their Medicaid programs. In 2011 New Jersey enacted the Medicaid Accountable Care Organization (ACO) Demonstration Project to offer local provider coalitions the opportunity to share any savings they generate. Impetus came from initiatives in Camden that aim to reduce costs through improved care coordination among hospital high users and that have received considerable media attention and substantial federal and private grant support. Though broadly similar to Medicare and commercial ACOs, the New Jersey demonstration addresses the unique concerns faced by Medicaid populations. Using hospital all-payer billing data, we estimate savings from care improvement efforts among inpatient and emergency department high users in thirteen communities that are candidates for participation in the New Jersey demonstration. We also examine their characteristics to inform Medicaid accountable care strategies. We find substantial variation in the share of high-user hospital patients across the study communities and high rates of avoidable use and costs among these patients. The potential savings among Medicaid enrollees are considerable, particularly if Medicaid ACOs can develop ways to successfully address the high burden of chronic illness and behavioral health conditions prevalent in the prospective demonstration communities.

Addressing Social Determinants of Health in a Clinic Setting: The WellRx Pilot in Albuquerque, New Mexico

“…Screening for social needs has proven valuable for certain age groups: children during well-child visits, 5 patients with chronic habits such as smoking, 6 and high-risk patients with complex chronic diseases. 7 The WellRx pilot cast a wider net, evaluating the feasibility of systematically screening for and addressing patients' social needs during every visit in busy general primary care settings.…”

From programme theory to logic models for multispecialty community providers: a realist evidence synthesis

“…Just one ACO in New Jersey (covering 2 million people) required US$2.8M start-up funding, after which it was to become self-sustaining from the savings generated. 71 Patient Care Medical Homes also required start-up funding. For example, participation in a state-funded interpractice collaboration to improve quality helped 20 medical practices to implement a PCMH approach internally.…”

“…The mechanism worked best for high users of acute care and for low-and medium-morbidity patients who could be effectively managed in the community, but high-morbidity patients still required more intensive comanagement by primary care teams and specialists. An analysis 71 of routine administrative data from 380,000 records for high users of A&E living at the poverty level found that referral network schemes for diverting patients from hospital had the greatest effect when targeted on the 1% of heavy users (five or more hospitalisations per year). Another study, 127 a 48-month interrupted time series from a baseline through PCMH implementation and post-implementation periods for 36,805 hypertension patients, also found reductions in specialist use, but only for low-and medium-morbidity patients.…”

“…the Norrtälje project 24 ) some Catalan primary care providers, USLs in Italy, LHINs in Canada and the (in that respect atypical) population-based ACO in New Jersey. 71 Planning and referral network management mechanisms developed in this context are more likely to be directly relevant to MCPs.…”

“…One US study showed no decrease in ED use but did show greater use of preventative and ambulatory care. 138 Two US studies 71,127 showed reductions in specialist use for low-and medium-morbidity patients but the opposite for high-morbidity patients. Therefore, the overall pattern suggests that MCP-like interventions can, in favourable contexts, produce the desired outcomes but with two important caveats.…”