TECHNICAL ASSISTANCE TOOL | February 2016

Delineating Responsibilities across Accountable Care Organizations and Managed Care Organizations tates introducing accountable care organization (ACO) programs into an existing Medicaid managed care environment will need to effectively delineate responsibilities S between ACOs and managed care organizations (MCOs). Successful delineation can provide opportunities for the two types of organizations to complement one another and improve care delivery for Medicaid enrollees. This tool, made possible by the Medicaid ACO Learning Collaborative sponsored by The Commonwealth Fund, identifies five responsibilities that both ACOs and MCOs may share and outlines which entity may be better suited to perform each function. This tool can help state Medicaid agencies, as well as ACOs and MCOs, define roles and responsibilities across these organizations. For more information on the relationship between ACOs and MCOs in Medicaid and how states can help coordinate these efforts, please see: The Balancing Act: Integrating Medicaid Accountable Care Organizations into a Managed Care Environment.

Care Coordination Data Sharing & Analytics Utilization Management •ACOs are well-suited to coordinate care for their •MCOs and ACOs both need data analytics to •MCOs are experienced in evaluating the medical ACOs are well-suited to coordinate care for MCOs and ACOs both need data analytics to MCOs are experienced in evaluating the patientstheir patients since providerssince providers are clinically are clinically trained, coordinatecoordinate care care and and manage manage their their patients’ patients’ necessitymedical necessity and efficiency and efficiency of the use of of the health use of have direct contact with patients, and can health, and should work together to share care, and are usually better suited for this task. trained, have direct contact with patients, and health, and should work together to share health care, and are usually better suited for facilitate warm handoffs among physicians and information. MCOs have access to claims data As ACOs develop expertise with data analytics can facilitate warm handoffs among information. MCOs have access to claims data this task. As ACOs develop expertise with facilities. and use them to manage utilization and risk, and risk management, they may be able to physicians and facilities. and use them to manage utilization and risk, data analytics and risk management, they whilewhile ACOs ACOs have have access access to to patient patient health health assume more responsibilities in this area. may be able to assume more responsibilities recordsrecords and and benefit benefit from from the the ability ability to to act act in this area. quicklyquickly and and effectively effectively with with these these data. data.

ACO Responsibility Spectrum MCO

Quality Improvement Evidence-Based Guidelines

•ACOs are responsible for quality improvement through •While ACOs are closer to the provision of care to ACOs are responsible for quality improvement While ACOs are closer to the provision of care to their ACO contracts, and in many cases, quality results patients, MCOs have clinical advisory boards with through their ACO contracts, and in many cases, patients, MCOs have clinical advisory boards with are tied to financial compensation. ACOs may also be knowledge of up-to-date guidelines and best practices quality results are tied to financial compensation. knowledge of up-to-date guidelines and best better positioned to improve care due to their across a broad spectrum of the health care field, and ACOs may also be better positioned to improve care practices across a broad spectrum of the health care proximity to patients. However, since ACOs are rarely thus, may have a greater ability to create such due to their proximity to patients. However, since field, and thus, may have a greater ability to create statewide, MCOs will still drive quality improvement guidelines. ACOs are rarely statewide, MCOs will still drive such guidelines. wherequality ACOs improvement are not active, where or ACOs among are populations not active, orthey doamong not serve. populations they do not serve.

Advancing innovations in health care delivery for low-income Americans | www.chcs.org TECHNICAL ASSISTANCE TOOL | January 2016

2 Technical Assistance Tool | Delineating Responsibilities across ACOs and MCOs

States can use the table below to outline potential responsibilities among ACOs and MCOs. Examples of potential activiites, some of which are drawn from Minnesota and Vermont’s programs, are shown below. Note, these examples are not necessarily recommendations for how to delineate these activities, as these roles and responsibilities may vary from state to state.

Responsibility Care Coordination Quality Improvement Data Sharing and Analytics Evidence-Based Guidelines Utilization Management

. Employ multi-disciplinary care . Provide quality performance and . Collect information directly from . Develop and disseminate reports . Assume some responsibility for teams patient data to the state patients and partner on patient utilization and utilization management organizations outcomes

ACO Responsibilities

. Provide admission notifications . Audit care plans across providers . Collect and disseminate . Disseminate existing clinical . Use expertise with medical from claims data to ensure consistency expenditure data to ACOs guidelines to ACOs necessity determinations to manage utilization

MCO Responsibilities

ABOUT THE CENTER FOR HEALTH CARE STRATEGIES

The Center for Health Care Strategies (CHCS) is a nonprofit policy center dedicated to advancing innovations in health care delivery for low-income Americans. CHCS works with state and federal agencies, health plans, providers, and consumer groups to develop innovative programs that better serve people with complex and high-cost health care needs. For more information, visit: www.chcs.org.

Advancing innovations in health care delivery for low-income Americans | www.chcs.org