Formation and Implementation of an Accountable Care Entity

Illinois's healthcare system has endured a litany of burdens in the past 5 years, ranking 30th out of 50 states in terms of health outcomes and challenged by the need to provide high-quality, low-cost, coordinated care to a large Medicaid population. In 2011, Illinois enacted legislation mandating that 50% of Medicaid individuals be enrolled in "care coordination" by January 1, 2015. The Illinois Department of Healthcare and Family Services issued a solicitation for provider organizations to submit applications to become an Accountable Care Entity (ACE). Modeled after the federal government's CMS Accountable Care Organization initiative, the program's objective would be to provide better health, more care options, and greater coordination for Medicaid recipients while reducing the cost for care.

Responding to this solicitation, nine health systems, their employed and affiliated providers, and an experienced payer joined together to form the Illinois Partnership for Health, Inc. (IPH) ACE, a collaboration intended to provide an innovative approach to better managing the health and outcomes of Medicaid recipients across the state.

ECG has worked closely with the IPH since its inception in fall 2013. When the IPH began building the infrastructure and implementing the requirements of the ACE program in anticipation of bringing it live in late summer 2014, ECG supported the IPH within four specific work streams:

• Network Development–Assisted in the organization and implementation of a network of approximately 4,000 PCPs, obstetricians, specialists, and facilities; modeled the capacity for managing up to 126,000 members; and assisted with the planning required to convert the ACE into a managed care organization, with the associated benefit management responsibilities.
• Finance – Established and maintained the IPH budget. Developed funds flow models representative of both the ACE and managed care organization programs to centralize the costs and revenue of the program and the processes to distribute revenue and shared savings to individual providers.
• Care Model – Facilitated the development and implementation of a standardized model of care, including a robust care management and care coordination infrastructure, as well as a quality improvement program across the nine health systems.
• Information Technology – Assisted in the design and implementation of an integrated IT infrastructure to connect the nine different health systems and their disparate EMRs and HIE solutions in order to facilitate the exchange of data as well as the required analytics across the program. We are currently facilitating the implementation of a centralized population health management system to meet the program's long-term requirements.

Today, after only 6 months of being live, the IPH is the largest ACE in the state, often referred to as the "Super ACE." It spans 64 of Illinois's 102 counties and currently covers more than 45,000 lives. The IPH's provider network is inclusive of all primary, pediatric, and specialty care needed to manage the IPH member healthcare needs. To further identify and manage these needs, IPH members are stratified by risk level and managed through the use of care coordinators. The IPH also relies on a robust information technology infrastructure that includes the development of a centralized population health management system to better manage members and improve outcomes.

The IPH is moving toward full risk for the Medicaid population, at which point it will have the opportunity to share in cost savings. In the immediate term, the IPH receives care management fees – $9 per member per month (PMPM) for Family Health Plan members and $20 PMPM for newly eligible ACA members. The nine health systems of the IPH share in the infrastructure costs for population health management systems, quality analytics, and other tools that the entities would otherwise need to invest in individually.

In addition to these early successes, the IPH is poised for growth. Enrollment is anticipated to expand as the program evolves, and additional opportunities for partnerships with other health systems in Illinois have been identified. The IPH represents a true partnership and collaboration between nine health systems and their payer partner, and that relationship continues to strengthen and position the IPH for a successful future.