Advocates: Utah's managed care plan isn't true 'accountable care'

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Accountable Care Organizations are touted as a new take on managed care that can cure out-of-control costs and improve America's health.

But Utah's plan to try ACOs for low-income Medicaid patients isn't true accountable care, say advocates who want stricter patient safeguards added to the state's managed care contracts.

"I say this with sadness, because I believe accountable care is the way to go, but we've fallen off that path," says Judi Hilman, executive director of the Utah Health Policy Project.

The state Department of Health is in contract negotiations with four managed care groups that, starting in January 2013, will oversee care for 70 percent of the 252,000 Utahns on Medicaid. The experiment is expected to save taxpayers $770 million over seven years.

But advocates, some providers and Utah's Medicaid Inspector General want assurance that those savings won't come on the backs of the state's working poor adults and children.

The Inspector General is preparing an audit detailing weaknesses in draft contracts released last month. Advocates and providers, meanwhile, are pressing to delay negotiations until adequate patient safeguards and quality benchmarks are in place.

As written, the contracts don't satisfy the letter of the law mandating the creation of these ACOs, said Hilman. "We're not asking the plans to report anything different [about health outcomes] than they've reported for 20 years."

Backed by health industry chieftains and unanimously approved by the Legislature, the Medicaid overhaul was pitched as a way to preserve Utah's low-income health safety net, which is set to explode in size under federal health reform.

It envisions steering Medicaid patients into ACOs, managed care networks that would be paid lump monthly sums per patient. If an ACO spends more than allotted for care and prescription drugs, it absorbs the loss. If it spends less, it gets a share of the leftovers — similar to old HMOs of the '90s.

The savings come from limiting inflation; funding for the ACOs can't grow faster than the state's budget.

But for ACOs to avoid the trap of HMOs, which were accused of shaving costs by denying care, they need prove the maxim that less care is better care.

For doctors and providers that means finding more efficient ways to deliver care.

The Medicaid overhaul envisions steering Medicaid patients into ACOs, managed care networks that would be paid lump monthly sums per patient. If an ACO spends more than allotted for care and prescription drugs, it absorbs the loss. If it spends less, it gets a share of the leftovers — similar to old HMOs of the '90s.

The savings come from limiting inflation; funding for the ACOs can't grow faster than the state's budget.

But for ACOs to avoid the trap of HMOs, which were accused of shaving costs by denying care, providers must find more efficient ways to deliver care.

But if the health plans – Intermountain Healthcare's SelectHealth, the University of Utah's HealthyU, Molina and IASIS – know how this will work, they're not communicating it with providers who will be delivering the care.

"We have all kinds of ideas for reducing costs and improving health outcomes, but none of the health plans have talked to us about that," said Dan Hull, executive director of the Utah Association for Home Care and Hospice.

Without clearly defined quality measures and penalties and incentives to enforce them, there's no holding health plans accountable, he said. It's business as usual, "other than we get paid less."

The ACO plan's chief architect, former Sen. Dan Liljenquist, R-Bountiful, agrees there's room to push on quality measures but warns against being too prescriptive.

"We said to the health plans we want you to be creative. We want the same or better quality and access to care, but we're not going to nickel and dime you on these things," he said.

Liljenquist dropped out of the Legislature to run a failed bid for Congress. "I'm an interested citizen at this point. But I think this is the most important legislation that's passed in this country. To extent that I can be helpful I will be," he said.