From 2013 to 2017, America’s Essential Hospitals joined The National Partnership for the Health Care Safety Net to improve vulnerable patients’ access to high-quality health care and help groups of providers navigate health reform.
Supported by Kaiser Permanente Community Benefit and The East Bay Community Foundation, this collaborative also included the National Association of Community Health Centers and the Department of Health Policy and Management at the Milken Institute School of Public Health at The George Washington University.
The National Partnership fostered cooperation among local providers who care for the underserved by helping provider groups navigate and adapt to the systemwide policy changes and accountability standards of the Affordable Care Act (ACA). To that end, the National Partnership convened local partnerships and provided technical assistance and evidence-based analysis to four communities: Atlanta, Cleveland, Denver, and Richmond, Va.
The Atlanta Safety Net Collaborative Initiative, founded in 2010, worked to better serve the community’s most-vulnerable patients. Comprising association member Grady Health System, along with Southside Medical Center, Family Health Centers of Georgia, Saint Joseph’s Mercy Care Services, Oakhurst Medical Center, and HEALing Community Center, the Initiative built on earlier efforts to create a coordinated care network.
With technical assistance and guidance from the National Partnership, the Initiative began a new phase in 2014, in the wake of larger, ACA-initiated reforms. Many low-income patients in the Atlanta metro area were unable to access needed critical-care services, and Georgia’s decision not to expand Medicaid left many of these patients uninsured. Together, Initiative members navigated federal and state legislatures to leverage ACA provisions that helped increase access and improve care delivery. The Initiative also explored options piloted by other non-expansion states that increased access to services for the low-income, uninsured population.
With the support of the National Partnership, the Partnership for Cleveland Health Care Safety Net convened to examine concerns about the future of Medicaid in Ohio. Essential hospital MetroHealth Medical Center joined five federally qualified health centers and several community organizations, including Asian Services In Action, Care Alliance, Free Clinic of Greater Cleveland, Neighborhood Family Practice, and Northeast Ohio Neighborhood Health Services.
To increase Medicaid enrollment and ensure the sustainability of Medicaid expansion in Ohio, the Cleveland partnership promoted enrollment process improvements and information sharing among key local and regional stakeholders. The partnership launched a “Why Medicaid Matters” campaign to raise awareness of the effect of Medicaid expansion and investigated state and local policies that could help increase Medicaid enrollment. The Cleveland partnership met with the state Department of Jobs and Family Services to better understand barriers to enrollment and to explore strategies for improving enrollment processes, such as using presumptive eligibility or streamlining administrative processes.
Although safety-net providers worked diligently to serve their patients, no single organization could overcome Denver’s specialty care access challenges. The Partnership for Denver’s Safety Net, including association member Denver Health, formed the Mile High Health Alliance in 2015 as part of a wider regional initiative. Based on a recommendation from Denver’s Community Health Improvement Plan, the Alliance created a collaborative entity to improve access to care in the city. The Alliance’s Specialty Care Access Group developed a detailed plan to pilot a specialty care referral hub in Denver. Based on a review of specialty care access programs across the country and consultations with local stakeholders, Denver Health and the Mile High Health Alliance determined that combining eConsults and in-person referrals into a single model would provide the best opportunity to meet specialty care needs in Denver. While eConsults met some of the need for specialty care, particularly for more cognitive specialties, in-person referrals were needed in many cases. The referral hub distributed in-person visits in an equitable way across participating specialty care providers.
In 2014, Richmond providers with a safety-net role began collaborating to help newly eligible, low-income individuals and families manage the costs of deductibles and copayments. The launch of an ACA insurance marketplace offered an exciting opportunity to enroll previously uninsured individuals and families in the greater Richmond area in marketplace plans and increase access to care. But many people were unable to afford the premiums, deductibles, and copayments that were part of these health plans, which compromised their ability to fully benefit from this opportunity for insurance coverage.
The Richmond partners — association member Virginia Commonwealth University Health System, Virginia Capital Area Health Network, Daily Planet Health Services, and the Richmond Academy of Medicine — partnered with local organizations to create the Health Exchange Financial Assistance initiative, a program that helps with cost-sharing for individuals and families who qualify for premium subsidies for marketplace plans.
As part of this community work, the National Partnership in 2015 convened the Cross-Community Summit to allow safety-net providers to exchange collaborative strategies to improve the health care delivery system for vulnerable patients. Attendees include representatives from each organization participating in the Atlanta, Cleveland, Denver, and Richmond collaboratives. The summit included three expert panels that highlighted a variety of safety-net partnerships on policy change and implementation and the legal, technological, and financial sustainability considerations for these collaborations.
Additionally, the National Partnership published three issue briefs that highlighted different health policy topics related to the initiatives in the four communities:
- Removing Barriers to Coverage and Access: Third Party Foundations Offer Premium and Cost-Sharing Assistance (February 2016);
- The New York State DSRIP: A Collaborative Approach to Reform (May 2016); and
- Increasing Access to Specialty Care Through Collaboration: eReferral and eConsult (June 2016).
The National Partnership’s work progressed with the changing health care landscape under the ACA and explored safety-net partnerships in value-based payment. To investigate value-based payment partnerships between hospitals and health centers, the National Partnership sought to conduct a series of case studies of established, collaborative payment arrangements.
Following the inclusion/exclusion criteria, the number of potential case studies was smaller than anticipated. Some cases were not mature enough to warrant informative case studies, unique local market dynamics made models difficult to replicate, and some arrangements between hospitals and health centers involved either collaborative work arrangements or shared financial investments and risks, but not both.
Thus, only two case studies of accountable care/shared savings models between hospitals and health centers were completed, highlighting the Adirondacks Accountable Care Organization (ACO) and Medical Home Network ACO. The two studies comprise data collected from 24 interviews, as well as reviews of quality reports, annual reports, and other community and quality assessments.
Established in 2014 under the Medicare Shared Savings Program (MSSP), the Adirondacks ACO serves patients across Vermont and northern New York through the hospital and community health center partners — Champlain Valley Physicians Hospital (CVPH), owned by association member University of Vermont Health Network, and Hudson Headwaters Health Network (HHHN).
The collaboration between CVPH and HHHN predates the ACO and was established through a 2010 New York state patient-centered medical home (PCMH) pilot, funded by the Center for Medicare and Medicaid Innovation’s Multi-Payer Advanced Primary Care demonstration project. The Adirondacks Medical Home Demonstration project was fundamental to the development of the ACO in terms of collaboration, leadership, and delivery system infrastructure. Specifically, ACO leadership leveraged the systems established within the PCMH project to develop the ACO, first as a Medicare shared savings demonstration and, later, as a risk-based model of care.
Participants hope that buy-in from commercial payers and Medicaid will enable the ACO to continue sharing both upside and downside risk. The ACO currently serves only Medicare patients as part of the MSSP. However, the built infrastructure of the PCMH project, as well as contracts with local and regional payers, provides care to commercial, Medicaid, and Medicare beneficiaries.
Medical Home Network (MHN) Accountable Care Organization
MHN ACO is a Medicaid ACO involving three hospitals, their affiliated medical groups, and nine community health centers on the South Side and West Side of Chicago. It is a partnership between providers and CountyCare, a Medicaid managed-care plan run by association member Cook County Health & Hospitals System (CCHHS). The ACO is operated by MHN, a health care provider collaborative founded in 2009 to improve services for Cook County’s vulnerable Medicaid population with the support of Chicago’s Comer Family Foundation.
In 2011, the MHN provider collaborative became a Medicaid pilot project, working with the Illinois Department of Healthcare and Family Services to test service delivery and payment innovations; the department designated MHN a “care coordination innovations project” in August 2013. In July 2014, the ACO formed as a provider-owned limited liability corporation, and CCHHS took on the new role as payer for the ACO, after initially participating as a provider in the MHN provider collaborative. The MHN ACO seeks to build on the successes of the MHN provider collaborative and take the next steps toward value-based payment and delivery system transformation.
Following the completion of the case studies, the National Partnership developed Collaboration Under Value-Based Payment: Lesson Learned. This report includes a high-level synopsis of the current value-based payment landscape, particularly as it pertains to the context of the case study research; lessons learned from both case study recruitment and analysis; and guidance for value-based payment specific to collaboration between safety-net providers and future policy recommendations.
Further, the National Partnership developed a compendium of value-based payment resources for hospital and community health center partnerships and held two webinars showcasing innovative partnerships between hospitals and health centers, which spotlighted Hennepin Health, in Minneapolis, and a community paramedic program in St. Paul, Minn.
While the National Partnership program officially ended in July 2017, program partners have continued to disseminate findings through conferences and academic journals and use the project findings to inform future programming.