Patient-Centered Primary Care – Revising Payment Models to Improve Care

December 7, 2017

Arlene Ash, Ph.D., is a professor at the University of Massachusetts Medical School in Worcester, in the Department of Quantitative Health.

Dr. Ash and colleagues at the University of Massachusetts Medical School (UMass) have helped MassHealth (Massachusetts’ Medicaid and Children’s Health Insurance Programs) to calculate fair  payments to health care systems for providing integrated, coordinated care to patient panels whose care they manage. The key idea is that provider groups organize themselves as Accountable Care Organizations (ACOs), and the State pays them to take responsibility for the health needs of the Medicaid enrollees who sign up with them. Dr. Ash’s group has developed formulas that pay ACOs more when they care for people with more complex medical and/or “social” risks. While payments for managed care have long been tailored to pay more for medical complexity, what is new here is also paying more for social complexity. Starting in October 2016, and based on the work at UMass, MassHealth now pays managed care organizations using a social determinants of health (SDH) model that pays more for housing instability, behavioral health issues, disability, and neighborhood-level stressors in addition to medical complexity.

Dr. Ash speaks with us about her research, and how better payment systems can encourage more efficient and effective health care, and, ultimately, better health.

Dr. Ash is a methods expert on risk adjustment in health services. She has pioneered tools for using administrative data to monitor and manage health care systems, including those now used by the US Medicare program. Many of her ~200 research publications reflect her long-standing interests in women’s health; gender, age and racial disparities; and, quality, equity and efficiency in health care financing and delivery. She has also been involved in efforts to improve the integrity of US elections.

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