a. The current health care delivery and payment system often fails to provide high quality, cost-effective health care to the most vulnerable patients residing in New Jersey, many of whom have limited access to coordinated and primary care services and, therefore, tend to delay care, underutilize preventive care, seek care in hospital emergency departments or be admitted to hospitals for preventable problems;

b. The Accountable Care Organization (ACO) model has gained recognition as a mechanism that can be used to improve health care quality and health outcomes, while lowering the overall costs of medical care by providing incentives to coordinate care among providers throughout a region. Coordination is achieved through initiatives such as creation of patient-centered medical homes, sharing of patient health information among providers, and implementation of care management programs designed to facilitate best practices and improve communication among providers and social services agencies throughout the community;

c. Providers participating in the ACO are supported in their efforts to share accountability for the overall quality and cost of care rendered to patients. The ACO provides support for coordination, identification of improvements in health outcomes, quality, and cost savings, and the distribution of any overall cost savings achieved, often referred to as “gainsharing,” to the ACO participants in a manner that furthers the goals of the ACO to improve quality and accessibility while reducing or stabilizing the costs of medical care throughout a region;

d. The ACO model can facilitate improvements in health outcomes, quality, and access, and stabilize or reduce the rate of health care inflation while permitting patients to maintain their current health care relationships. The Medicaid ACO Demonstration Project to be established pursuant to this act is specifically intended to: (1) increase access to primary care, behavioral health care, pharmaceuticals, and dental care by Medicaid recipients residing in defined regions; (2) improve health outcomes and quality as measured by objective metrics and patient experience of care; and (3) reduce unnecessary and inefficient care without interfering with patients’ access to their health care providers or the providers’ access to existing Medicaid reimbursement systems. The Medicaid ACO Demonstration Project may provide a model for achievement of improved health outcomes, quality, and decreased costs that can be replicated in other settings to the benefit of patients and payers throughout New Jersey, but is not intended to inhibit, prevent, or limit development or implementation of alternative ACO models;

e. The Medicaid ACO Demonstration Project seeks to address a variety of access, health outcomes, coordination, and service utilization problems that lead to increased health costs. One major goal is to reduce the inappropriate utilization of high-cost emergency care by Medicaid recipients and others, especially where an individual’s need is more properly addressed through non-emergency primary care treatment. The Medicaid ACOs shall develop relationships with primary care, behavioral health, dental, pharmacy, and other health care providers to develop strategies to: (1) engage these individuals in treatment; (2) promote medication adherence and use of medication therapy management, and healthy lifestyles, including, but not limited to, prevention and wellness activities, smoking cessation, reducing substance use, and improving nutrition; (3) develop skills in help-seeking behavior, including self-management and illness management; (4) improve access to services for primary care and behavioral health care needs through home-based services and telephonic and web-based communication, via culturally and linguistically appropriate means; and (5) improve service coordination to ensure integrated care for primary care, behavioral health care, dental care, and other health care needs, including prescription drugs;

f. It is, therefore, in the public interest to establish a Medicaid ACO demonstration project whereby providers can continue to receive Medicaid payments from managed care organizations, and, in the case of individuals not enrolled in managed care, directly from the Medicaid program, while simultaneously participating in a certified Medicaid ACO designed to improve health outcomes, quality, and access to care through regional collaboration and shared accountability, and while reducing the costs of medical care throughout a region; and

g. The Legislature, therefore, intends to exempt activities undertaken pursuant to the Medicaid ACO Demonstration Project that might otherwise be constrained by State antitrust laws and to provide immunity for such activities from federal antitrust laws through the state action immunity doctrine; however, notwithstanding this subsection, the Legislature does not intend to allow and does not authorize any person or entity to engage in activities or to conspire to engage in activities that would constitute per se violations of State or federal antitrust laws.

L.2011, c.114, s.1.