1. Lessons from ACO Implementation in New Jersey John V. Jacobi Dorothea Dix Professor of Health Law & Policy Seton Hall Law School john.jacobi@shu.edu

2. ACOs: new or old news? Believers  Clinical leadersip  Patient-centered care Doubters  Managed care redux  Finance will drive, not care

3. Medicaid ACO Similar technology, clinical theory Difference: patient context  Limited to areas of high Medicaid concentration NJ: socioeconomic segregation  Cities tend to have concentrations of poor  Wealthy in suburbs

4. NJ Medicaid Bottom of the barrel in provider reimbursement Two decades of “reform”  Managed care  Limited success

5. As a result… Care in cities is uncoordinated Some excellent institutions, but poor connective tissue  Hard to get primary care  Hard to get coordinated care

6. Vulnerable people within a vulnerable population The very poor People with disabilities Poorly housed Reentering prisoners

7. Jeff Brenner: Camden model Community medicine Coordination of care Use of data/electronic records High users of ED services

8. Greater Newark Healthcare Coalition Patterned on Camden model Broad membership  Hospitals, physicians, BH, city, state, community organizations, Universities

9. Project: high utilizers of ED Modeled on 6-county California study “presenting conditions”  Homelessness  BH  Chronic physical illness Intensive case mgmt for 3 years Results  Patients engaged in treatment/services  Savings IP/OP hospital costs

10. GNHC iteration Began 4 months ago Referrals from Hospital Eds Engagement by APN Case management Connect with services Handoff Preliminary results?

11. GNHC iteration, con’t Why?  Improve care  Enhance cooperation among members  Produce information for policy makers

12. Can this be generalized? Medicaid ACOs Who  100% hospitals  75% physicians  BH, community groups What?  Sits on top of Medicaid FFS/MC  Gain shared: Overall savings  Upfront funding: foundation support

13. State responsibility Regulatory structure  Antitrust Supply oversight – state action exception Enforce clinical integration  CMP/AKA Quality and patient protection measures Drawn from  OIG opinions  Medicare final regs

14. Federal ask Global Medicaid waiver CMS consideration as “pilot” Bring along their friends at FTC/DOJ?

15. So, new or old? Purpose of Medicare ACOs  We’re all Geinsinger now Virtual integration Leapfrogs decades of integrative steps  Problematic in NJ/Northeast

16. Come from the other direction? Medicaid ACOs built on cooperation in less crowded field Can produce results with, eg, chronic illness Generalizable? Maybe NJ systems can learn from both models

17. If not… At least we’ll have taken a stab at improving care for the most vulnerable patients …