PITTSFIELD — Tens of thousands of low-income Berkshires residents face changes in the MassHealth program, part of the state's first Medicaid overhaul in two decades.
For patients, it's time to act on all those letters over the past months — and it might mean selecting a new primary care physician.
For doctors, it's a large-scale rollout of the system known as "accountable care." In that, they serve as gatekeepers to improve care and contain costs.
For Berkshire Health Systems and Community Health Programs, it's the dawn of a partnership in which they take on financial risks usually borne by insurers.
And for Fallon Health, Thursday marked the start of a new business chapter in Berkshire County.
"This is our first time," said Carrie Wattu, the Worcester company's communications manager, referring to Fallon's entry into the county. "It's a busy, exciting day for us."
The new Fallon network will care for all MassHealth participants in Berkshire County. The shift does not affect people who receive health care coverage from other traditional insurers, such as employer-based plans, private plans or Medicare.
The MassHealth revamp, required through a 2016 agreement with the federal government, is designed in part to stabilize finances of the program, which serves 1.9 million residents.
The agreement with the U.S. Department of Health and Human Services allowed MassHealth to form partnerships with providers like Fallon, which will operate the Berkshire Fallon Health Collaborative.
For years, MassHealth has paid fees to medical care providers. Under accountable care, organizations like the new Berkshire collaborative will take the lead role in promoting wellness for patients.
Rather than receive fees for services, providers are paid set amounts to keep their patients healthy. If they manage to do that for less than the money allocated, they can keep the difference.
A spokeswoman for MassHealth said the point is to improve how care is coordinated. Cutting costs is a secondary goal.
As of Thursday, the care for 1.2 million MassHealth members shifted to one of 17 different "accountable care organizations" or to two other types of groups in charge of 150,000 to 200,000 members each.
Roughly 650,000 current MassHealth members will see no change, according to the state.
In Berkshire County, about 40,000 people are enrolled with MassHealth, the program says. The new network will only be used by MassHealth members younger than 65 for whom MassHealth is their primary insurance. People eligible for Medicare will not take part.
In the Berkshires, the new collaborative run by Fallon will include Berkshire Health Systems, Community Health Programs and several local physician practices.
For Community Health Programs, which oversees 10 health centers across the Berkshires, the change affects about 10,000 of its 14,000 MassHealth members.
On Thursday, the transition was going smoothly, as Fallon ran a command center in Worcester responding to calls from patients and providers.
Separately, MassHealth has boosted staff at its call centers, including people trained to answer questions about the shift to accountable care organizations like the Berkshire collaborative.
"We're off to a really good start," said Amelia Spiliotes, chief executive officer of Community Health Programs. "Fallon has been tremendous. It's worked out quite well."
Spiliotes said she believes the new network will help assure better continuity of care for patients, since their interests will be more closely monitored by specific caregivers.
"It creates rewards for providing good quality of service," she said. "Everybody at any point in time will know where the patient is in his treatment."
In addition to Fallon, Spiliotes said she was pleased to be a partner with Berkshire Health Systems.
In the Berkshires, the new Fallon network includes participation of both BHS hospitals — Berkshire Medical Center in Pittsfield and Fairview Hospital in Great Barrington.
"We have a special situation in Berkshire County because we rely on one another," she said from her Great Barrington office.
Michael Leary, a spokesman for Berkshire Health Systems, said officials are monitoring the rollout and plan to comment later on its debut.
But in an earlier interview with The Eagle, two of the nonprofit company's leaders noted the significance of the shift, which, in some ways, does for Medicaid what managed care already did for private health insurance.
Because of the county's small population, "accountable care" hasn't gotten a tryout — until now. With the state limiting overall payments, providers run the risk of incurring costs that go unreimbursed.
"It's a privilege to be able to take care of our community and participate, but it's frightening, because so much is unknown," said David E. Phelps, president and chief executive officer of Berkshire Health Systems.
"We'll be managing patients and community members differently, with the hope that we can change the cost of what's delivered and actually do better for patients," he said. "But it's an experiment."
Under the new network, Fallon is taking on most of the financial risk — and possible rewards. Over five years, its partners in the collaborative will share the risk equally.
"We are not just providers of care; we're an insurer now," said Darlene Rodowicz, Berkshire Health System's chief financial officer.
"I think we're going to be happy if we don't have a loss," she said.
Phelps and Rodowicz say they key will be getting people covered by the collaborative to obtain medical care at the right time and place.
That means early enough to prevent more significant illnesses, and in the right settings. The system sets tight rules on use of caregivers within the network.
"It remains to be seen whether we can ever get a Medicaid patient to stop using the emergency department," Rodowicz said. "We've got to figure that out."
Like Spiliotes at Community Health Programs, Phelps believes the system offers a way to shape better care, reaching thousands of people accustomed to medical attention that comes in fits and starts.
"The hope is that this fragmented system that people work in now becomes far more coordinated," he said.
Making the change
Any MassHealth member already using a physician that has teamed up with the collaborative will be automatically enrolled, according to materials supplied by the state Executive Office of Health and Human Services. Those assignments can be changed for any reason for up to 90 days.
Others have two weeks to select a primary doctor through the program's online or telephone networks. After that, members will be assigned to doctors.
To ease the transition, MassHealth is allowing members, for 30 days, to continue to go to previously booked medical appointments with former providers, as well as pick up prescriptions.
Richard Burke, Fallon's president and CEO, said he is excited that his company is playing a part in transforming how Medicaid care is delivered.
In a statement, he promised to bring coordinated, high-quality care to patients in the Berkshires.
"This approach will serve to reduce fragmented care, improve health outcomes and contain costs," he said, in response to a question from The Eagle.
Wattu, the Fallon spokeswoman, said that any MassHealth member with questions should get in touch.
"Our priority is ensuring members continue to receive care without interruption," she said.
The new system puts doctors in the driver's seat when it comes to controlling costs. MassHealth costs the state about $8 billion after federal reimbursements, according to the Massachusetts Budget and Policy Center.
The 2016 deal between the state and the federal government provided the promise of an additional $1.8 billion in U.S. investments in the state's Medicaid overhaul.
The shift to "accountable care" is one reason Gov. Charlie Baker could claim in his proposed budget that MassHealth costs will rise 0.5 percent in the next fiscal year. In 2015, costs climbed 14.9 percent.
To control costs, the new system gives primary care providers an incentive: pocketing the difference between the state's allocation for medical care based on population, with the cost of care delivered.
As a fact sheet supplied by MassHealth puts it: "When an ACO succeeds in delivering high-quality, coordinated and efficient care to its members, MassHealth will reward the ACO."
Larry Parnass can be reached at email@example.com, at @larryparnass on Twitter and 413-496-6214.