Health insurers often pay health plans to manage the care of their members. Good care can help prevent emergencies, such as avoidable trips to a hospital emergency department (ED). Medically complex patients, such as those with behavioral health problems or substance use disorders, tend to have a lot of ED visits. Social determinants of health (SDH) also affect outcomes for complex patients.
MassHealth, the Massachusetts Medicaid program, launched its Accountable Care Organization (ACO) program in 2018. Among its goals are to provide better coordinated care and reduce unnecessary care, including avoidable ED visits. But what does all of this mean, and how are these issues interrelated? A recent study published in Medical Care by a team at the University of Massachusetts Medical School (UMMS) examines the intersection of these hot topics.
The study looks at ED use by adult MassHealth ACO members with serious mental illness (SMI) or substance use disorders (SUD). The authors describe the development of a risk-adjusted quality measure designed to encourage reductions in ED use. The UMMS study is part of MassHealth’s e?orts to measure and reward quality in its ACO program.