CSHP Medicaid-Related Research & Evaluation Portfolio

State legislation in 2011 (P.L. 2011, Chapter 114) created a pilot project to assess the efficacy of ACOs in enhancing Medicaid’s cost-effectiveness through reducing utilization of expensive, but avoidable hospital care while enhancing the quality of community-based services. To incentivize providers to participate in the ACO demonstration, the state offered opportunities to share in savings generated by the ACOs if they achieved quality care targets. 

The law sought to promote policy learning by understanding ACOs’ effectiveness in achieving quality and savings goals. Subsequently, state Medicaid officials approved three ACOs in Camden, Newark, and Trenton, and tapped CSHP for analytic expertise, given the methodological complexity involved in assessing the ACO pilot.

In 2012, CSHP recommended an approach to calculate ACO savings, with extensive consultation with state Medicaid officials. Analyses concluded that the three ACOs did not produce appreciable cost savings over the limited period of the demonstration, yet suggested that ACOs yielded benefits in meeting the health care needs of underserved populations. 

Among other things, ACOs served as conveners and connectors among diverse health and social service providers in their communities. To preserve these benefits, New Jersey Governor Phil Murphy signed a bill in January 2020 transitioning the three ACO pilots into formal Regional Health Hub (RHH) partnerships and adding a fourth RHH in Passaic County. Learn more about the health hubs here. 

New Jersey’s decision to provide CSHP with Medicaid data as well as CSHP’s ability to produce rigorous findings established important precedents that served as the bedrock for future work. This initial analytic collaboration required navigating inherently complex legal, data security, and privacy concerns, which often impede such analytic arrangements between state Medicaid agencies and external research organizations. 

CSHP’s access to New Jersey Medicaid data fortified an analytic partnership that has deepened since this first collaboration.

Articles & Presentations

• DeLia, D., & Yedidia, M. J. (2020). The Policy and Practice Legacy of the New Jersey Medicaid ACO Demonstration Project. Journal of Ambulatory Care Management, 43(1), 2–10.
• DeLia, D. (2017). Spending Carveouts Substantially Improve the Accuracy of Performance Measurement in Shared Savings Arrangements: Findings From Simulation Analysis of Medicaid ACOs. INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 54.
• Cantor, J. "Achieving Better Care and Lower Costs in Health Care for Low-Income Populations." Public Health & Preventive Medicine Grand Rounds, Rutgers New Jersey Medical School, Newark, New Jersey, 2014.
• Chakravarty, S., Cantor, J., Tong, J. & DeLia, D. "Advancing New Jersey Safety Net ACOs: New Findings on Opportunities for Better Care and Lower Costs." State House Seminar, 2013.
• Cantor, J. "New Jersey Safety Net ACOs: New Findings on Opportunities for Better Care and Lower Costs." PICO New Jersey Conference, Promoting Good Care: Innovation and Organizing in Health Care, Newark, New Jersey, 2013.
• DeLia, D. "Statistical Risks in the Establishment of ACO Expenditure Savings." Seventh National Medicaid Congress, Arlington, Virginia, 2012.
• DeLia, D. "How Exactly Will Providers Be Held Accountable? Emerging Methods of ACO Performance Measurement." Corporate Research Group, Webinar, 2012.
• DeLia, D., Cantor, J. & Hoover, D. "Critical Issues in Performance Evaluation for Medicaid ACOs." Academy Health Annual Research Meeting, Seattle, Washington, 2011.

Reports

• DeLia, D., Kumar, R., Nova, J., Lloyd, K. & Goldin, D. (2018). "Spending and Utilization Indicators in the New Jersey Medicaid ACO Demonstration Project." Rutgers Center for State Health Policy.
• DeLia, D., Yedidia, M. & Lontok, O. (2018). "Update on ACO Operations and Care Management Strategies in the New Jersey Medicaid ACO Demonstration Project." Rutgers Center for State Health Policy.
• Cantor, J., Chakravarty, S., Tong, J., Yedidia, M., Lontok, O. & DeLia, D. (2014). "The New Jersey Medicaid ACO Demonstration Project: Seeking Opportunities for Better Care and Lower Costs among Complex Low-Income Patients." Rutgers Center for State Health Policy.
• Yedidia, M., Lonok, O. & Cantor, J. (2013). "Development of Medicaid Accountable Care Organizations (ACOs) in Three New Jersey Communities." Rutgers Center for State Health Policy.
• DeLia, D. & Cantor, J. (2012). "Recommended Approach for Calculating Savings in the NJ Medicaid ACO Demonstration Project." Rutgers Center for State Health Policy.

In the early 2000s, under then Center Co-Director and Research Professor Dr. Susan Reinhard, CSHP offered technical assistance to states that helped rebalance LTSS toward homes and communities. With the 2012-2017 §1115 demonstration, New Jersey policymakers launched a significant initiative to improve the state’s performance on this front.

In 2012, state Medicaid officials received federal approval of a demonstration waiver that, among other things, sought to transform Long Term Services and Supports (LTSS) delivery by moving it into managed care (MLTSS). LTSS involves assistance with daily living activities such as bathing and eating. The 2012 waiver demonstration aimed to advance the shift toward delivery of LTSS in home and community settings by assigning managed care organizations (MCOs) a management role.

The number and proportion of LTSS recipients receiving care in homes and communities grew dramatically over the decade of the two demonstrations. Importantly, by 2019, over half of the state’s Medicaid LTSS beneficiaries received assistance in homes and communities rather than in nursing homes or other institutions. 

In addition to increased access to HCBS, per-person costs decreased with the transition to MLTSS. By 2019, per person, inflation-adjusted spending on HCBS by MCOs declined by about 20% compared to prior costs. The evaluation did not find that waiver demonstrations reduced HCBS quality; rather, an examination of multiple indicators suggested that quality remained consistent.

In addition to MLTSS, CSHP evaluated the Delivery System Reform Incentive Program (DSRIP) embedded in the 2012-2017 waiver. DSRIP aimed to reward hospital-based networks that enhanced care access and improved quality and population health while lowering Medicaid costs. Evaluation found that DSRIP improved outcomes related to certain chronic health conditions, including hospitalization reductions and emergency department (ED) visits among those with asthma. 

Dissemination of CSHP evaluation findings about New Jersey’s DSRIP experience helped inform a national movement to implement hospital pay-for-performance initiatives to advance population health and health equity. CSHP found in surveys and interviews that while NJ DSRIP largely achieved its health improvement goals, stakeholders identified the need to cover short-term costs to maintain financial viability of DSRIP initiatives, particularly in safety net hospitals.