Delaware considers statewide ACOs

By Anthony Brino
03:16 PM

Policy advisors for Delaware Governor Jack Markell are crafting plans to introduce accountable care models into the state’s payment and provider systems with support from the Centers for Medicare & Medicaid Services.

With a slightly older population of 917,000, Delaware spends about 25 percent more per capita on healthcare than the national average, according to the Delaware Health Care Commission, which is spearheading an application for a state innovation model grant from CMS. State leaders working on the plan, including Bettina Riveros, chair of the Delaware Health Care Commission (which also operate the state HIE), have been putting together a series of principles and general goals for introducing accountable care models into state health policy.

In a recent presentation, Riveros, a lawyer who's worked for a former governor and a legal technology company, noted a few stories from Delawareans who ran into gaps in care that could have been avoided. One was June, a 91-year-old patient with chronic heart failure, who noticed she had gained some weight, called her doctor but couldn’t get an appointment for a month, and ended up in an emergency room two days later.

“Primary care may have been able to prevent a trip to the ER,” Riveros and the group wrote. “The subsequent hospitalization caused her significant stress and was much more costly.”

Delaware has six health systems, including a children’s hospital, three community care centers and about 2,000 practicing doctors, with about half the population covered by commercial insurance, 25 percent by Medicaid and 14 percent by Medicare. About 10 percent of the state’s residents are uninsured.

Convening under the group Choose Health Delaware, the state’s health reform education program, state officials and industry representatives produced a sort of vision document to articulate goals for policies they could develop through CMS's state innovation model program, with the plan of introducing legislation in 2014 while seeking CMS funding for implementation through 2015.

So far, the group is attracted to the idea of using Medicare Shared Savings program as a model for state accountable care policies that would align commercial and public payers. The workgroup is also calling for more emphasis on team-based care, through community-based support and care coordination among care managers at providers and payers. 

The workgroup sees “an opportunity to take advantage of the small number of payers aligning to support a common model,” along with “a need for a framework accommodating private practice physicians as well as physicians employed by hospitals and health systems.”

Hospital, payer and patient representatives speaking with the workgroup identified several areas of medicine that the accountable care policies should try to improve — chronic condition management, palliative and end of life care, back-joint pain, perinatal care and cardiac-related illnesses.

As part of enabling health information exchange and care coordination — to avoid situations like June’s —  the workgroup is calling for the use of shared platforms, for risk stratification software helping identify highest-need patients, and for online learning collaboratives sharing best practices in care collaboration.

The workgroup is pointing to the Delaware Health Information Network as an asset and potential shared platform, offering a single portal for payers and providers across the state; the HIE has a 98 percent provider participation rate.

The workgroup, housed under the same organization doing insurance exchange outreach, Choose Health Delaware, has set some fairly specific goals for improvement — aiming to be the healthiest state in the nation by 2020, with health outcomes ranking among the top ten percent nationally.

The workgroup also wants to have the ACO, team-based care model improve the patient experience in Delaware, “with patients empowered and engaged in their own multidisciplinary care team,” and to have providers proactively checking on the most vulnerable patients.   

The workgroup’s presentation highlighted the experience of a Delawarean named Herb, an elderly patient with cancer, diabetes, hypertension and a previous stroke, who ended up dying from a diabetic coma after being discharged from a hospital with new medication orders that his assisted living facility missed.

As of this past spring, Delaware was the only state without an ACO; the Health Care Commission has an open request for proposals for help designing the CMS application and policy development strategy.