Mapping Accountable Care Activity in the States

By Mike Stanek
January 2013
States are at the forefront of efforts to design and implement innovative payment and delivery mechanisms that encourage accountability for costs and quality in health care delivery. Bolstered by state legislative mandates, as well as provisions in the Affordable Care Act to re-orient federal health spending to promote accountable care, states are developing a variety of initiatives to improve value—achieving better health outcomes at lower cost—and foster accountability for the value of care provided.

With the support of The Commonwealth Fund, NASHP is identifying and tracking state activity to promote accountable care on an interactive map. With expert input, we have defined “accountable care” to mean: organizations or structures assume responsibility for a defined population of patients across a continuum of care, they are held accountable through payments linked to value, and reliable performance measurements demonstrate that savings are achieved in conjunction with improvements in care.[i]
As these new initiatives have continued to spread across the country, patterns have begun to emerge in state approaches to fostering accountable care. Some states are explicitly cultivating accountable care organization (ACO) models, in line with federal efforts to use shared savings models in the Medicare program to support these models, while others are fostering the creation of new provider-led organizations not explicitly conceptualized as ACOs.

• Maine is designing an Accountable Communities initiative that is designed to mirror the federal Medicare Shared Savings Program.
• New York’s Department of Health is launching a program to certify ACOs.
• New Jersey plans to launch a 3-year Medicaid ACO Demonstration Project.
• Massachusetts will use ACOs, certified by a new Independent Health Policy Commission, as a key component of the state’s cost control strategy.
• Texas is developing a certification process for health care collaboratives, new entities composed of physicians and providers that can enter into innovative payment arrangements with public and private payers to assume responsibility for a range of health care services.
• Illinois has launched Care Coordination Entities (CCEs), collaborations of providers and community agencies, governed by a lead entity that receives care coordination payments in order to provide care coordination services.
• Minnesota’s Health Care Delivery Systems Demonstration will reward groups of providers and integrated delivery systems that can achieve savings below a total cost of care target while meeting quality performance requirements.

Other states are using accountable care principles to redesign their Medicaid programs . Oregon is launching a statewide network of Coordinated Care Organizations (CCOs) that provide integrated and coordinated health care for Oregon Health Plan enrollees under global budgets, while Colorado rolled out seven Regional Care Collaborative Organizations (RCCOs) that are responsible for providing medical management, care coordination, and support to providers. In Arkansas, the state’s Department of Health and Human Services has partnered with two private insurers to introduce payments for specific episodes of care in a Health Care Payment Improvement Initiative. Utah is negotiating new ACO contracts with Medicaid health plans in the state.
Despite the range of approaches states are implementing, these models all exhibit the features we are using to define accountable care: responsibility for a defined population, payments linked to value for care provided to that population, and reliable performance measurement to accurately gauge value.
States are developing attribution models to define patient populations for the purpose of facilitating accountability. Some states plan to rely on active enrollment by beneficiaries: Illinois will allow Medicaid enrollees to select a CCE, and enrollees in Oregon will choose the CCO into which they would like to enroll. Other states, like Maine and Minnesota, will use claims analysis to attribute beneficiaries to providers participating in the accountable care initiative.
States are implementing payment mechanisms to encourage value. State accountable care initiatives are employing payments aimed at fostering innovation and transitioning away from strict fee-for-service arrangements. Shared savings approaches are popular, layering new incentives for efficiency and quality on top of fee-for-service reimbursement. Shared savings is one payment model that will be used in Illinois’s CCEs, Minnesota’s demonstration, and the ACO-style models being fostered in Maine, Massachusetts, New York, and New Jersey.
States are developing performance measurement strategies to ensure accountability. Some states, like Maine and New York, will seek to align measurement approaches for their accountable care initiatives with the Medicare Shared Savings Program. Others will rely more heavily on homegrown measurement systems. Massachusetts will develop a Statewide Quality Measure Set to assess quality and performance, while Minnesota will use components of its existing Statewide Quality Reporting and Measurement System for Health Care Delivery Systems reporting.
Emerging state initiatives are developing rapidly, making the map a constant work in progress. It continues to grow as we add new state initiatives and update existing entries, so stay tuned to NASHP’s State Accountable Care Activity map!