THE HENRY J.

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medicaid -
uninsured

Emerging Medicaid Accountable Care Organizations:
The Role of Managed Care

May 2012
Executive Summary

An Accountable Care Organization (ACO) is a provider-run organization in which the participating
providers are collectively responsible for the care of an enrolled population, and also may share in any
savings associated with improvements in the quality and efficiency of the care they provide. Although
the concept of ACOs originated in the Medicare and commercial sectors, several states are actively
developing ACO initiatives in an effort to improve the care provided to people through the Medicaid
program. Our review of a number of state initiatives indicates that most Medicaid ACOs are currently at
an early stage of development, as states engage in relatively lengthy planning and implementation
processes, both to accommodate diverse stakeholder concerns and to address state and federal
legislative and regulatory requirements. The structure of Medicaid ACO initiatives is influenced by
individual states' history and experience with managed care, other existing care delivery arrangements
within Medicaid, and the challenges inherent in serving low-income and chronically ill populations.
While Medicaid ACOs are a strategy to more directly engage providers and provider communities in
improving care, cost-containment is also a significant motivating factor for many states. It remains to be
seen how states will balance short-term cost-containment pressures against the investments in
partnerships and delivery system redesign necessary for the success of Medicaid ACOs over the longer
term.

Introduction

Medicaid is the nation's public health insurance program for low-income Americans, covering close to
60 million children, families, seniors, and people with disabilities." Approximately two out of three
Medicaid beneficiaries are currently enrolled in a comprehensive form of managed care -- either risk-
based managed care organizations (MCOs) or primary care case management (PCCM) programs." In
recent years, states have increasingly turned to managed care in response to a growing interest in
improving care for beneficiaries with complex needs and to address ongoing budget pressures. At the
same time, states are exploring other strategies and reforms that incentivize high quality and effective
care, reward improved outcomes, and/or lower costs. In this environment of change and innovation,
states are also looking ahead to 2014, when key provisions of the Affordable Care Act (ACA) will take
effect and Medicaid enrollment will expand.

Recently, a number of states have begun to explore the possibility of implementing Accountable Care
Organizations (ACOs) in Medicaid. The ACO concept, which originated in the context of the Medicare

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Program and subsequently migrated to the private health insurance market as well, refers to a provider-
run organization in which the participating providers are collectively responsible for the care of an
enrolled population, and also may share in any savings associated with improvements in the quality and
efficiency of the care they provide.*Previous analyses have sought to define Medicaid ACOs and
discussed how states could promote their development.**However, there has been little analysis of how
the current Medicaid context, including the unique profile of the populations the program serves and
the delivery systems in place today, may influence the development of ACOs in Medicaid.

This brief examines the existing Medicaid payment and care delivery landscape in states undertaking
Medicaid ACO initiatives to gain insights into how ACOs may be structured and fit into states' Medicaid
programs, and to identify important differences between Medicaid ACOs and ACOs in Medicare and the
private insurance market. Our analysis is based on a review of the literature on these emerging ACO
programs and interviews with key informants in five states where Medicaid ACO initiatives are being
developed.©"

Background

The term "Accountable Care Organization" first appeared in 2007 as part of a discussion about targeting
Medicare's pay-for-performance incentives not to individual providers, but toward potential new
organizations comprising hospitals and their extended affiliated medical staff.2* "In this context, ACOs
refers to formal provider organizations that might vary in structure but would take responsibility for the
care of a defined group of beneficiaries, with care evaluated based on quality metrics. ACOs that
performed well would be eligible to share in any resulting cost savings. Because, in many communities,
care is delivered by autonomous, non-integrated fee-for-service (FFS) providers, the thought was that
ACOs might be a more realistic reform than encouraging providers to aggregate into multi-specialty
groups or convert immediately from FFS to full-risk arrangements. Being provider-led, with shared
stakes in their performance, there also was hope that ACOs might be effective in helping providers work
together to accept accountability for delivering coordinated care across care delivery settings and over
time."

Medicare ACOs were formally recognized in the Patient Protection and Accountable Care Act of 2010
(ACA) as entities eligible for the Medicare Shared Savings Program.'"*Subsequent regulations
authorized a specific form of Medicare ACO, in which provider-based entities with at least 5,000
Medicare patients (in general) agree to manage the care of those patients, submit quality data, and
share savings (bonus only), and possibly losses as well (considered a two-sided model)." Patients are
assigned to a specific ACO if they obtain the plurality of their primary care from a provider belonging to
that ACO. However, patients remain free to seek care from any provider, consistent with traditional
Medicare policy, and the Centers for Medicare & Medicaid Services (CMS) will update the patient
attribution periodically for purposes of calculating savings. Under the Medicare Shared Savings Program,
scheduled to be implemented in 2012, providers continue to receive Medicare FFS payment as well as
their share of any savings.

The ACA also authorized a demonstration project for the creation of pediatric ACOs within Medicaid

and/or the Children's Health Insurance Program (CHIP). The demonstration is currently unfunded, but
states have begun to plan and implement Medicaid ACO initiatives themselves.

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ACOs within the Medicare, Medicaid, or commercial sector typically include three key elements-a
provider organization as the base, accountability for patient outcomes, and the potential for shared
savings-but, otherwise, ACOs models vary. For example, Massachusetts is planning to move its
Medicaid program toward a capitated, multi-payer ACO model, while Vermont is creating a community-
based ACO model.***In the commercial market, Aetna is working with provider organizations, such as
Banner Health in Arizona, to offer risk-based ACO products.''UnitedHealthcare views a variety of
arrangements with ACOs as critical to its efforts to promote "value-driven health care."*® Medicare also
allows for alternative ACO models within the ACO Pioneer Program, which is under the authority of the
Center for Medicare & Medicaid Innovation. A review of the 32 current Pioneer ACOs reveals great
diversity in both their scope and in their care delivery features."' Medicare Pioneer ACOs range from
large, multi-market entities to relatively small, localized structures that may or may not include
hospitals. A national survey by Leavitt Partners counted as many 164 ACO entities nationwide in all
payer sectors." These ACO entities included 99 based in hospital systems, 38 based within Independent
Physician Association, and 27 based within an insurer.

Although ACOs models vary, all involve increased use of quality metrics focused on patient-centered
care, increased coordination of care, and incentives designed to reward performance (i.e., improved
outcomes). These are some of the same features of other Medicaid managed care strategies, including
risk-based contracting with MCOs, and states contemplating a Medicaid ACO initiative typically consider
their historical experience with managed care to assess whether and how ACOs fit into their Medicaid
environment.

Most Medicaid ACO Initiatives Are at an Early Stage of Development

While Medicaid ACOs have received increasing attention, very few of the initiatives that we examined in
detail are currently operational. In the table, we summarize our findings from a review of documents
and interviews with officials from five states with Medicaid ACOs initiatives, focusing on the historical
context, the apparent motivation for the strategy, the details of the ACO model, and its current status.
Among the five states, only Colorado has an operational Medicaid ACO, which is in the initial stages.
Utah and Oregon hope to be operational sometime in 2012, while Oklahoma is still developing its
approach. New Jersey's initiative has been authorized by the state legislature, but before it becomes
operational, regulations must be promulgated.

Several factors may lengthen the timeframe required to operationalize a Medicaid ACO, including
requirements in many states that the legislature authorize the program (perhaps requiring multiple
actions), the time for the state to issue necessary implementation guidance or regulations, and the
phase-in strategy. In New Jersey, for example, the legislature quickly authorized the initiative, but
progress was delayed by practical challenges associated with integrating the ACO concept into the
current Medicaid program, and with figuring out how to structure the related regulations. In contrast,
Oregon engaged in an extensive and extended planning process to gather and incorporate stakeholder
input, although implementation appears to be progressing rapidly now that authorizing legislation has
been enacted.

Some states have combined ACO initiatives with other Medicaid reform strategies that may require
federal waivers. The complexity of these reform packages can delay implementation of a state's ACO
initiative for reasons having little to do with the ACO initiative itself. Oregon plans to include
accountability for state-funded public health programs in the ACO program and to have the ability to

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cap ACO payments. New Jersey has a pending comprehensive waiver that would allow the state to
streamline what previously were a large number of diverse managed care waiver programs.""

States' Existing Medicaid Programs Shape the Features of ACO Initiatives
Current Risk-Based Arrangements Influence Development of Medicaid ACOs

Managed care has a much larger presence in Medicaid than in Medicare or the commercial sector. As of
October 2010, nearly two-thirds of Medicaid beneficiaries were enrolled in managed care for all or most
of their care, including 49.5% in comprehensive risk-based plans similar to health maintenance
organizations (HMOs).""In contrast, in 2011,just a quarter of Medicare beneficiaries were enrolled in
managed care plans and fewer than 20% of individuals with employment-based coverage were enrolled
in an HMO (the commercial MCO analogue).72*

Whether a risk-based managed care infrastructure exists or not appears to influence the approach
payers take to establishing ACOs. In Medicare and, often, in the commercial sector, where risk-based
arrangements are more limited, ACO initiatives are oriented toward providers practicing on a FFS basis
who do not bear risk. In these ACOs, Medicare or the private insurer contracts directly with provider-
based ACOs.

However, in many state Medicaid programs today, risk-based managed care is the predominant delivery
and payment system. This factor has influenced the form that Medicaid ACOs have taken and the
relationship between ACOs and MCOs. In some instances, MCOs coordinate with ACOs, and in others,
they act as the ACOs. The boundaries between traditional risk-based managed care and ACOs can be
difficult to discern in Medicaid.

e Utah, which previously converted most of its insurer- and provider-led health plans from
full-risk to partial- and no-risk arrangements, is now planning to return to risk-based
contracting, this time with the same organizations operating as ACOs charged with
managing care delivery and bearing financial risk.

e Colorado's ACO initiative, the Accountable Care Collaborative, provides an exception during
the initial stages of the initiative that allows for the continuation of existing managed care
contracts with Kaiser Permanente.

@ Oregon is implementing an ACO initiative based around Coordinated Care Organizations
that will strengthen Medicaid requirements for community and provider engagement, but
will allow existing Medicaid MCOs to apply to participate and gradually transition to meet
the new requirements.

e Minnesota is shifting away from using Medicaid MCOs that subcontract with provider
organizations. Instead, the state is adopting a strategy of contracting directly with large
provider organizations using an ACO model, and will call for providers to absorb an
increasing amount of risk over time."

Failure to anticipate questions about how ACOs will work within the context of existing managed care
programs may slow implementation of ACO initiatives. In New Jersey, regulations to implement ACOs
are progressing relatively slowly because the legislature authorized a grassroots provider-based ACO
initiative. The state wished to retain its extensive network of risk-based MCOs, which have the authority
to specify the terms of provider contracts (including any gain-sharing component). Though the state
envisioned that the MCOs would contract directly with the ACOs, the legislation did not address the

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structure of these contractual relationships in detail. The forthcoming regulations will likely make MCO
participation in the initiative voluntary, but the state expects that the intensive case management
envisioned in ACOs will be attractive to at least some MCOs.

For states in which there is minimal risk-based managed care within the Medicaid program, ACOs may
be viewed as part of the natural evolution of current delivery systems toward increased coordination of
care and realignment of provider incentives. For example, North Carolina's medical home program
already incorporates some features of ACOs, including diverse quality metrics and provider networks to
promote accountable care in Medicaid, as well as for Medicare and other payers in the state."°"

Development of Medicaid ACOs is Affected by Complex Care Delivery Arrangements in Medicaid

State Medicaid programs provide health care and social supports to beneficiaries through a complex
array of care delivery arrangements and authorities. These care delivery arrangements are, in part, a
result of states' efforts to address the complicated health care needs of a diverse beneficiary population,
including low-income pregnant women, people with physical and mental disabilities, people with
chronic diseases, and seniors."* In recent years, many states have exempted or excluded certain
subpopulations from some care delivery programs or covered specific benefits through mandatory
managed care arrangements.

These complex care arrangements bear on which subpopulations the state includes in a Medicaid ACO
initiative and the benefits for which the ACOs are at risk. In Colorado, for example, beneficiaries residing
in state psychiatric institutions or nursing facilities were initially excluded from enrollment in the
Accountable Care Collaborative. Utah specifically excludes mental health services, substance abuse
treatment services, nursing facilities, and emergency transportation from its ACO program."*These
exclusions remain in place under the ACO initiatives.

In other states, however, an ACO initiative may be viewed as an opportunity to integrate services that
had previously been carved out from managed care. For example, Oregon plans to use the ACO program
to merge previously separate medical care and behavioral health care risk arrangements, ultimately also
folding in risk for dental care. Colorado, which uses five regionally-based Behavioral Health
Organizations to operate a state-funded mental health program, determined that these geographic
areas were a good starting place for the development of the seven Regional Care Collaborative
Organizations (RCCOs) within the Medicaid ACO program. To date, all RCCOs are required to coordinate
and collaborate with the existing local Behavioral Health Organizations and with most regional
substance use disorder Managed Service Organizations."

Medicaid Beneficiaries who are Eligible for Medicare Raise Special Issues

In 2008, 15% of Medicaid beneficiaries were also enrolled in Medicare; these low-income individuals are
known as "dual eligibles."** Medicare provides coverage for most acute health care needs, while
Medicaid provides assistance with Medicare premiums and cost-sharing, and covers critical benefits not
provided by Medicare, especially long -term services and supports. On average, dual eligibles are sicker
and poorer than other Medicaid and Medicare beneficiaries, accounting for nearly 40% of total
Medicaid expenditures. Compared to other Medicaid beneficiaries, dual eligible represent a particular
challenge to Medicaid programs due to their high medical spending, complex health needs, and high
utilization of institutional and long-term care services."

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Dual-eligible beneficiaries' reliance on both Medicare and Medicaid means they pose special challenges
to states implementing Medicaid ACO initiatives. For example, while states may mandate enrollment in
such ACOs as a condition for receipt of Medicaid benefits, such a mandate is not allowed in Medicare.
Dual eligible enrollment in ACOs also raises questions of how to distribute any savings between state
Medicaid agencies and Medicare.

States with ACO initiatives have adopted various strategies regarding dual eligible beneficiaries:

e Oregon is developing separate plans for dual eligibles with a grant from CMS to improve
integration of Medicare and Medicaid services.

e New Jersey's ACO legislation generally excludes dual eligibles but state officials believe that
the ACO program may include any duals that are currently enrolled in Medicaid MCOs.

e Oklahoma has a PCCM program for most Medicaid beneficiaries that excludes dual eligibles.
At the time of our interview, the state was considering including dual eligibles in a
Medicare-based ACO initiative in the Tulsa area. The state hoped that doing so would
generate Medicaid savings by reducing utilization and, thus, Medicaid's obligations for
Medicare cost-sharing amounts.

e Colorado had an ambitious cost savings goal for its Year 1 pilot and was concerned that any
savings due to improved care for dual eligibles would accrue to the Medicare program
rather than the state. The state decided that dual eligibles would be neither explicitly
excluded nor actively enrolled in the first year of the enrollment-limited ACO program.

Stakeholder Consultation within States' Planning Process Varies

The nature and extent of stakeholder engagement in developing an ACO initiative varies across the
states. In Oregon, Medicaid reform efforts typically involve structured consultations with diverse
stakeholders in an open process. The state's strategy to establish Coordinated Care Organizations
included presentations at eight community meetings attended by 1,200 Oregonians, refinement by four
workgroups comprising 133 governor-appointed members, and opportunity for public feedback through
multiple open comment periods."? State policymakers view this public process as valuable in creating
champions, both in the legislature and on the local level. In Colorado, stakeholder engagement through
consultation is part of the normal policy development process and was cited by state officials as a
reason why one key group that initially opposed the ACO initiative came to support it.

Still, some states are developing Medicaid ACOs with less stakeholder consultation. These states may
view the ACOs as a strategy to transition from managed care to a new Medicaid delivery model, and to
make the conversion relatively invisible from the perspective of enrollees in MCOs that continue to have
market presence. However, minimizing stakeholder consultation could prove problematic to the extent
it leads to miscommunication. As an experienced state official noted, discussing the development and
implementation of a Medicaid ACO initiative, "if you have one miscommunication, it will spread like
wildfire, [taking] weeks [of work] trying to correct it."

Need to Contain Costs Influences Formation of Medicaid ACOs
Facing ongoing economic challenges, many states are under considerable budget pressure and seek

immediate savings.** Because Medicaid programs account for a large share of state spending, they are
often the focus of state cost-containment efforts. In Oregon, for example, state policymakers have

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Medicaid and the Uninsured
made clear that they would like to derive savings by getting better value for their Medicaid dollars. If
successful, the transformation to an ACO model will help Oregon reduce future health care spending,
stabilize the delivery system, and preserve available services."

Interest in Medicaid ACOs appears to be fueled partly by a belief that ACOs have potential to both
deliver higher quality care and to improve efficiency and value. Most states applying the ACO concept in
Medicaid have focused on strategies designed to increase provider engagement and accountability for
care and to realign financial incentives over time. States may seek to distinguish this strategy from prior
managed care initiatives that were seen as oriented towards insurers and cut costs by denying care or
reducing provider payments.**To differentiate these new arrangements from MCOs or HMOs, states
may embrace the newer terminology of ACOs, including state-specific variations such as Coordinated
Care Organizations as in Oregon.

Colorado had a managed care program that was repealed because the state officials perceived that
"concerns over the adequacy of managed care rates detracted from the ability of the program to focus
on broader health care issues." Using ACOs, Colorado hopes to return to a model of managed care that
delegates management authority to seven regional organizations, which are responsible for achieving
improved health outcomes, creating a network of primary care providers, and assisting the providers in
delivery care in a medical home setting. Colorado's initial phase of the program, to test the model's
ability to generate savings, included 60,000 beneficiaries, but the state doubled the enrollment target
almost immediately to address a short-term hole in the state's budget.

Utah is another example of a state that mostly abandoned capitated Medicaid managed care, in part
because MCOs objected that the state did not adjust rates to keep pace with increases in medical
expenses. Utah's current ACO plan appears to focus more on improved care delivery than on direct cost
reduction. However, the ACO initiative is embedded within a broader reform strategy that would allow
benefits to be cut based on a priority list if savings are insufficient to meet state revenue constraints and
that would allow health ACOs considerable flexibility to determine how they will share savings with
contracted provider partners.

Conclusion

The structure of early Medicaid ACO initiatives appears to be strongly influenced by states' Medicaid
managed care environments and experiences, and by whether the states with managed care currently
have risk-based contracts with MCOs or have moved away from that model. In addition, states are
exploring how Medicaid ACOs would mesh with the complex care delivery arrangements in place now,
as well as the unique challenges associated with serving dual eligibles. It will be some time before it is
clear whether Medicaid ACOs can succeed in improving quality and outcomes and restraining spending
growth.

States with nascent Medicaid ACO initiatives appear to be aware of, and responding to, the operational
issues and pitfalls associated with past managed care strategies. These states have emphasized the role
of providers, established performance metrics, and/or focused on closer alignment of financial
incentives with policy goals. At the same time, state officials have noted that the new accountable care
approach brings its own technical challenges, such as methods for attributing patients to ACOs,
allocation of shared savings and development of appropriate risk adjustment methodologies. States vary
in the resources they have available to address these challenges.

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Promoting transformation in the way services are delivered in Medicaid is not straightforward, and the
time and investment required may run counter to states' fiscal imperatives. Arguably, this tension
between rapid cost containment and delivery reform was one reason that some earlier Medicaid
managed care initiatives proved unsuccessful.*"** How states build on their experiences with managed
care and how they address the challenges associated with developing and implementing Medicaid ACOs
may determine whether this renewed emphasis on outcomes and accountability will fundamentally
affect state Medicaid programs.

 

This brief was prepared by Marsha Gold and Jessica Nysenbaum, of Mathematica Policy Research, and
Sonya Streeter of the Kaiser Family Foundation's Commission on Medicaid and the Uninsured.

 

 

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Medicaid and the Uninsured

 
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References

 

"Kaiser Commission on Medicaid and the Uninsured. "The Uninsured: A Primer." October 2011. Available at:
http://www.kff.org/uninsured/7451.cfm

2Kathleen Gifford, Vernon K. Smith, Dyke Snipes, and Julia Paradise. "A Profile of Medicaid Managed Care Programs in 2010:
Findings from a 50-State Survey." Kaiser Commission on Medicaid and the Uninsured. September 2011. Available at:
http://www.kff.org/medicaid/8220.cfm

 

3 Robert A. Berenson and Rachel AQ. Burton "Accountable Care Organizations in Medicare and the Private Sector: A Status
Update" from the Timely Analysis of Immediate Health Policy Issues. The Robert Wood Johnson Foundation and the Urban
Institute, November 2011.

"Tricia McGinnis and David Marc Small. "Accountable Care Organizations in Medicaid: Emerging Practices to Guide Program
Design." Center for Health Care Strategies, February 2012.

'kitty Purington, Anne Gauthier, Shivani Patel, and Christina Miller. "On the Road to Better Value: State Roles in Promoting
Accountable Care Organizations" The Commonwealth Fund and The National Academy for State Health Policy, February 2011.

5We interviewed state leaders about initiatives in Colorado, New Jersey, Oklahoma, Oregon, and Utah, making follow up calls in
two of these states to learn more from key partners in the initiatives. Interviews were arranged through the state Medicaid
director and typically included one or two senior staffer responsible for the ACO program and often the director as well.

7 Marsha Gold. "Accountable Care Organizations: Will They Deliver?" Mathematica Policy Research, January 2010.

8 Elliot S. Fisher, Douglas O. Staiger, Julie P.W. Bynum, and Daniel J. Gottlieb "Creating Accountable Care Organizations: The
Extended Hospital Medical Staff." Health Affairs, 26(1):w44-257, published online December 5, 2007.

*Medicare Payment Advisory Commission. "Report to Congress: Improving Incentives in the Medicare Program, June 2009.

Stephen M. Shortell and Lawrence P. Casalino. "Health Care Reform Requires Accountable Care Systems." Journal of the
American Medical Association, 300(1): 95-97, 2008.

"Eliot S. Fisher, Mark B. McClellan, John Bertko, Steven M. Lieberman, Julie J. Lee, Julie L. Lewis and Jonathan S. Skinner.
"Fostering Accountable Care: Moving Forward in Medicare." Health Affairs, 28(2): W219-231, 2009.

" Kaiser Family Foundation. "Summary of Key Changes to Medicare in the 2010 Health Reform Law." May 2010. Available at:
http://www.kff.org/healthreform/7948.cfm

13 Mark McClellan, Aaron N. McKethan, Julie L. Lewis, Joachim Roski, and Elliott S. Fishers "A National Strategy to Put
Accountable Care into Practice" Health Affairs, 29(5): 982-990, 2010.

4 «Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations; Final Rule." Federal Register
Volume 76, Number 212. November 2, 2011. Pages 67802-67990

"Chelsea Conaboy. "Massachusetts to Debut Medicare Pay Plan." Boston Globe. December 20, 2011.

*8Julie Lewis and Aaron Mckethan. "The Vermont Accountable Care Organization Pilot" A Community Health System To Control
Total Medical Costs And Improve Population Health." The Commonwealth Fund, May 2010.

17 Aetna. "Press Release: Aetna Enters Accountable Care Collaboration with Banner Health Network, Introduces Aetna Whole
Health To Employers In Phoenix Area." November 21, 2011.

*8UnitedHealthcare "Value Based Contracting and Accountable Care Organizations: UnitedHealth Network Strategies." Available
at:

http://www.uhc.com/united for reform resource center/health reform provisions/accountable care organizations/value_b
ased contracting and _acos.htm. Accessed March 26, 2012.

*center for Medicare & Medicaid Services. "Selected Participants in the Pioneer ACO Program, December 13, 2011." Available
at: http://innovations.cms.gov/Files/x/Pioneer-ACO-Model-Selectee-Descriptions-document.pdf, Accessed March 27, 2011,

°David Muhlestein, Andrew Croshaw, Tom Merrill and Christian Pena "Growth and Dispersion of Accountable Care
Organizations." Leavitt Partners, November 2011.

THE KAISER COMMISSION ON

 

Medicaid and the Uninsured
 

a Department of Human Services, State of New Jersey. "Section 1115 Demonstration Comprehensive Waiver." September 9,
2011. Available at:
http://www.state.nj.us/humanservices/dmahs/home/NJ 1115 Demonstration Comprehensive Waiver 9-9-11.pdf

22 Kathleen Gifford et al., 2011.

 

3 Kaiser Family Foundation. "Medicare at a Glance- Fact Sheet." November 2011. Available at:
http://www.kff.org/medicare/1066.cfm

*4kaiser Family Foundation and Health Research and Educational Trust."Employer Health Benefits Annual Survey, 2011."

Available at: http://ehbs.kff.org/

25 Presentation on Minnesota's initiative by Scott Leitz and Marie Zimmerman, Minnesota Department of Health, at the State
Health Policy and Research Interest Group Policy Breakfast, AcademyHealth's National Health Policy Conference, Washington
DC, February 2012. Available at: http://www.academyhealth.org/Communities/Communities.cfm?ltemNumber=8196. Accessed
March 27, 2012.

 

®Community Care of North Carolina. "Advancing Accountable Care in North Carolina." Available at
http://www.ncmedsoc.org/non_members/legislative/ac/payment_pathways/CCNC.pdf. Accessed March 27, 2012

27Community Care of North Carolina. "A History of CCNC: The Evolution of Community Care in North Carolina." Available at:
http://www.communitycarenc.com/about-us/history-ccnc-rev/. Accessed March 27, 2012.

28 «Medicaid: A Primer." The Kaiser Commission on Medicaid and the Uninsured, 2010. Available at:
http://www.kff.org/medicaid/7334.cfm

°MicGiniss and Small (2012).

advancing Colorado's Mental Health Care. "The Status of Behavioral Health Care in Colorado: 2011 Update." December 2011.
Available at: http://www.coloradomentalhealth.org/sites/all/themes/acmhc/ACMHC_StatusReport.pdf

3Kaiser Commission on Medicaid and the Uninsured. "Dual Eligibles: Medicaid's Role for Low-Income Medicare Beneficiaries."
May 2011. Available at: http://www.kff.org/medicaid/4091.cfm

32katherine Young, Rachel Garfield, MaryBeth Musumeci, Lisa Clemans-Cope, and Emily Lawton."Medicaid's Role for Dual
Eligible Beneficiaries." Kaiser Commission on Medicaid and the Uninsured, April 2012. Available at:
http://www.kff.org/medicaid/7846.cfm

33 resentation on Oregon's initiative by Jeanene Smith, Administrator for Office of Oregon Health Policy and Research, at the
State Health Policy and Research Interest Group Policy Breakfast, AcademyHealth's National Health Policy Conference,
Washington DC, February 14, 2012. http://www.academyhealth.org/Communities/Communities.cfm?ltemNumber=8196.
Accessed March 27, 2012.

National Association of State Budget Administrators. "Summary of NASBO State Expenditure Report: Economic downturn and
Recovery Act Led to Significant Shifts in State Spending from Fiscal 2009 to Fiscal Year 2011." December 13, 2012. Available at:
http://www.nasbo.org/sites/default/files/Summary%20-%20State%20Expenditure%20Report.pdf Accessed, March 27, 2012

 

3 Presentation on Oregon's initiative by Jeanene Smith, Administrator for Office of Oregon Health Policy and Research, at the
State Health Policy and Research Interest Group Policy Breakfast, AcademyHealth's National Health Policy Conference,
Washington DC, February 14, 2012. http://www.academyhealth.org/Communities/Communities.cfm?ltemNumber=8196.
Accessed March 27, 2012.

36 Special Issue titled "The Managed Care Backlash." Journal of Health Politics, Policy and Law, 24(5), October 1999.

3'Marsha Gold and Anna Aizer. "Growing an Industry: How Managed is Tennessee's Managed Care." Health Affairs, 19(1): 86-
101, January-February 2000.

8Marsha Gold and Jessica Mittler. "Second Generation Medicaid Managed Care: Will It Work? Health Care Financing Review,
22(2): 29-47, winter 2000.

THE KAISER COMMISSION ON
Medicaid and the Uninsured 11

 
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