One Care at One Year

October 16, 2014 § 2 Comments

Dr. Robert J. Master, MD, Chief Executive Officer of Commonwealth Care Alliance

It’s hard to believe, but October 1st marked the first year anniversary of the Commonwealth Care Alliance One Care program. Although this one-year-old “baby” has challenged our organization as never before, I believe this first birthday is worthy of celebration.

Emerson quote

It is important to remember that One Care is a cornerstone initiative of the Affordable Care Act, with a goal of fundamentally
transforming care for those who are the most poorly served among us in the United States. It is the first time in our nation’s history that the care of our most marginalized populations such as those who experience serious mental illness, substance abuse challenges, homelessness, and HIV/AIDs has been made a national policy priority, an unprecedented commitment.

At Commonwealth Care Alliance, we’re proud that Massachusetts was selected as the state to lead this effort and that our organization became the lead contractor in this transformative national demonstration that is just now beginning to roll out in multiple states across the country.

Still, so much of the One Care demonstration terrain is “Terra Incognita,” and in this first year we were consumed with many challenges that were not anticipated. Let me describe three:

Operational issues
By the end of calendar 2013, nearly 4,000 dually eligible beneficiaries voluntarily enrolled in Commonwealth Care Alliance. This was a choice born of hope rather than fear for so many individuals who had have every reason to distrust typical approaches to care and particularly any approach that could be associated with “managed care.” But as validating as this unanticipated enrollment was, it also created an early backlog in our assessment process, which was exacerbated by the fact that many more newly enrolled members were unreachable than we anticipated.

Add in the deluge of a 2,000-member auto assignment in January, and our technology, analytic, and operational infrastructure that supports our high-touch care model was challenged as never before. Fast forwarding to the present, we can say that that there has been continuous improvement in our assessment and care plan development capabilities.

Rating category changes
What also was entirely unexpected was that more than 20% of our One Care enrollees in the C1 rating category actually belonged in the C2 and C3 rating categories, which get higher reimbursement, because of serious mental illnesses and/or high level of long term care service needs (See table). It took us a while before we fully appreciated the magnitude of this upgrade challenge, as well as the uncovered expense that we were incurring associated with the needs of those in the higher rating categories.

One Care Tier Ratings

I am glad to report that we have improved our assessment processes so that we are now able to upgrade most of these members in a timely way.

I can also report that CMS and Mass Health leadership has now tangibly demonstrated that they are with us every step of the way on this collective learning journey.

Members with serious mental illness
Perhaps the most important year-one learning relates to challenges we found in our efforts to care for enrollees with serious mental illnesses. We knew that this population was entirely new to any form of comprehensive, integrated care, with extremely poor primary care connections and significant social and economic barriers to engagement.  What we didn’t fully appreciate was the almost total absence of community-based treatment facilities that could serve as alternatives to psychiatric hospital inpatient care.

This past summer, on any given day, between 45 and 60 Commonwealth Care Alliance enrollees were in a psychiatric inpatient hospital setting at a per diem cost to us (previously Medicare) of approximately $1,100/day. At least half of these individuals could and should have been cared for in more appropriate and less restrictive community-based community respite programs at a per diem cost of approximately $550/day.

But we found that these essential capacity and community-based respite and transitional housing alternatives are virtually nonexistent due to decades of chronically constrained Department of Mental Health (DMH) funding. As a result, there has been an expensive cost shift from the state to Medicare and now to us. More significantly on human terms, many individuals are getting expensive and often inappropriate service in impersonal, overly medicalized, disempowering and expensive care settings because lower-cost, community-based, continuity care alternatives don’t currently exist.

This by far is our most powerful year-one learning and what led us to the decision to build this essential community capacity ourselves – it’s the only way we can hope to provide better care for our members with serious mental illness. This will take time to achieve, but we have started this work and have opened our first Community Respite in Dorchester just this week – a 12-bed unit providing a much better option for our One Care members experiencing crisis.

So, on its first birthday, One Care has been every bit the challenge we anticipated and lots more. We are a lot more bruised, battered, and humbled than we were a year ago, but we are a better and stronger organization for it. Because of what we have been through and what we now know, the path to demonstrating One Care delivery transformation success is so much clearer and we are on our way.

I’ll borrow a phrase from Ralph Waldo Emerson that seems to fit our experience, “Do not go where the path may lead, go instead where there is no path, and leave a trail.”



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