Accountable Care:
A New Era of Health Care in
Ohio
Patrick Beatty, JD
Assistant Deputy Director
Ohio Office of Health Plans
Kinsey Jolliff
Policy Development
Ohio Office of Health Plans
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Quote of the Day
“There was an important job to be done and
Everybody was sure that Somebody would
do it. Anybody could have done it, but
Nobody did it…Everybody blamed
Somebody…when Nobody did what
Anybody could have done.”
(American Medical Directors Association, 2010)
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Statewide Statistics - WHY
 “Medicaid…covered 38% of Ohio children, including
nearly 38,000 children with disabilities in 2010”
(Health Policy Institute of Ohio, May 2011)
 Ohio ranked 14th worst on Child Health Scorecard
for potential to lead healthy lives (Commonwealth
Fund, 2011)
 90% of the most costly 5% within Medicaid’s child
population have manageable conditions such as
behavioral health, asthma, minor infections, or
prematurity (OHP, Medicaid Quality Strategy
Presentation, 2011)
 High Prevalence of Children Receiving Primarily
Hospital-Based Care in the Costliest Five Percent of
Medicaid Children: 40% in ABD and 50% in CFC
(OHP, Medicaid Quality Strategy Presentation, 2011)
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The Bottom Line - WHY
We have to get BETTER in order for
Ohio to have the
HEALTHIEST KIDS in the nation!
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Better Care = Better Results
Breakdown Barriers
Encourage Innovation
Teamwork
Track impacts, not numbers
Engage families
Reverse the trends
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WHAT - is a Pediatric ACO?
Providers who work together,
alongside families, to provide and
coordinate services for individuals
under 21 years of age; and collectively
take accountability for improving the
lives of these children.
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WHAT - a Pediatric ACO is NOT?
• Answer: Managed Care. BUT… an MCO can
establish an entity that seeks recognition as an
ACO.
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Ohio’s Situation - HOW
 This is not paint by numbers.
 There is NO guidance from CMS.
 We have a blank canvas and you get
to help paint.
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Authority for Ohio’s Pediatric
ACO Program – more HOW
PPACA Sec. 2706: Pediatric
Accountable Care Organization
Demonstration Project
O.R.C. 5111.161: Recognition of
Pediatric Accountable Care
Organizations
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WHEN
• The process for applying for recognition as a
Medicaid pediatric ACO will be in place in July
2012.
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SOUP TO NUTS
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OBJECTIVES
RECOGNITION PROCESS
GOVERNANCE STRUCTURE
FLEXIBILITY IN GOVERNANCE STRUCTURE
ENROLLEE AND FAMILY RIGHTS
THREE ACO MODELS
PERFORMANCE MEASURES
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Pediatric ACO Objectives
 Improve health outcomes
 Incentivize more appropriate care
 Assign high risk families and children a
primary support team that will coordinate
services across traditional boundaries
 Smoother transitions
 Create a single care plan for high risk families
and children
 Track performance measures
 Share data across providers and public
agencies
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The Recognition Process
 The law calls for a process to recognize Pediatric ACOs and new
approaches to coordinating care.
 Those seeking to be recognized in Ohio as Pediatric ACOs will have
to explain how they will be accountable for care; how they will
share data, and how they will collaborate with MCPs and
community based organizations such as schools and social services.
 They will also be required to have collaborative agreements with
agreements with Primary Care Medical Homes, Pediatric Specialists,
Community Pharmacies, Dentists, and CBHCs.
 They must explain what region of the State they will be covering.
 Finally, they must demonstrate they have performance measures in
place, and that they are tracking those measures; certain types of
pediatric ACOs will be required to agree to the State’s performance
measures.
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Governance of Pediatric ACOs
 All Pediatric ACOs in Ohio will be not-for-profit
 If the Pediatric ACO is made up of independent entities,
then they will have a 9 member governing team that will
include majority physicians
 The governing team will also include an Advanced
Practice Nurse, a Child Consumer Advocate, and a
Parent Advocate
 Executive will be chosen by the governing team and
medical director will be chosen by the Executive
 The Governing team will be responsible for partnering
with community stakeholders such as schools, children
services agencies, businesses, and other payers such as
insurance companies and hospitals
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Flexibility in Governance
If the governing team can not meet certain
requirements, the Pediatric ACO must
communicate to the State why it seeks to differ
from these requirements, and how it will involve
Pediatric ACO families and community
stakeholders in Pediatric ACO governance.
 If the Pediatric ACO is an existing organization,
then the governing body can be the same as it is
currently, as long as the governing team can
explain how it will involve Pediatric ACO families
and community stakeholders in Pediatric ACO
governance.
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Enrollee and Family Rights
 No
consumer or family will be required
to receive services from a Pediatric ACO.
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Educational materials (created by the Pediatric ACO) will
be given to Medicaid recipients and their family/legal
guardians, and will be available online.
Educational materials will include participating providers
and their contact information, pediatric specialty
locations, Website information and amount, duration,
scope and type of services offered by the Pediatric ACOs.
Ombudsmen programs and internal dispute resolution will
be responsibilities of Pediatric ACOs.
Pediatric ACOs will be required to have a staff member
manage Healthchek services ensuring that federal EPSDT
laws are being met.
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Pediatric ACO Models
 Type 1 Model: Includes a demonstrated shared savings model and
performance measures within a contractual arrangement between a
Medicaid managed care plan and a Pediatric ACO who has been
recognized by the State of Ohio.
 The practitioners involved with a Pediatric ACO under this type must
acknowledge in writing that they are accountable for the care they provide.
 Type 2 Model: Includes requirements of Type 1. The State will now
set and track the performance measures. The care coordination and
case management requirements will be delegated to the Pediatric
ACO. Other administrative functions will remain with the managed
care plan. Encounter data will be required.
 The payment methodology must include shared savings and shared risk with
the Medicaid program.
 Type 3 Model: A qualified Medicaid provider with direct payerprovider relationship with the State Medicaid agency. The full
responsibility for care will be assigned to the Pediatric ACO for a
specific region for those not in Medicaid managed care.
 The payment methodology must include shared savings and shared risk with
the Medicaid program.
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Pediatric ACO focus
• Moderate and high risk
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support
the foundation for
Create and
HEALTH
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Even with good foundations, there are still those at risk,
and others experiencing poor health
These groups need
More than routine preventive care
Support them with a
Framework
Of trust
Transparency
And Leadership
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Highest Risk:
Hub model
Moderate risk:
Case management
Uncomplicated cases:
Wellness care
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Pediatric ACO Mandatory
Elements for performance
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Education
Social
Mental Health
Physical Health
Transparency
Community Leadership
Consumer Trust
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Pediatric ACO Performance
Measures
• Type I Model: Performance measures and benchmarks
set by applicant, must be commensurate with child
measures set for Medicaid MCO’s.
• Type II Model: Performance measures must include 1
measure from each CHIPRA initial core set measures,
and one additional measure. MCO measure can fulfill
function. Measures will be set in negotiation with the
state.
• Type III Model: Performance measures must include 1
measure from each CHIPRA initial core set measures,
and two additional measures. Measures will be set in
negotiation with the state.
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Medicaid Quality Strategy
• Clinical Focus Areas for Children:
– High Risk Pregnancy/Premature Births
– Behavioral Health
– Asthma
– Upper Respiratory Infections
• Priority Areas:
– Promote Best Prevention & Treatment Practices
– Improve Care Coordination
– Support Person & Family Centered Care
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CHIPRA Initial Core Set
Measures areas
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Prevention and health Promotion.
Availability.
Management of Acute Conditions.
Management of Chronic Conditions.
Family Experiences of Care.
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Homework assignment
Recommendations for Benchmarks on
each performance measure.
Recommendations for additions to
Soup or Nuts.
Other recommendations for
alterations to proposed structure or
process.
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Next Steps
More meetings with stakeholders
Consumer/family forums
Legislature involvement
Physician champions involvement
Formal rule process
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Questions?
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