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Medicaid and CHIP Levers to Promote Lead Screening and Treatment: Indiana’s Experience
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Addressing lead hazards today generates future economic benefits and improved health outcomes for children. In partnership with the Health Resources and Services Administration, NASHP is publishing a series of case studies highlighting state initiatives to promote lead screening and treatment. This study explores Indiana’s efforts to address this issue within its Medicaid and Children’s Health Insurance Program.
- View or download: State Levers to Promote Lead Screening and Treatment: Maryland’s Strategies
- View or download: Medicaid and Children’s Health Insurance Program Levers to Promote Lead Screening and Treatment: Indiana’s Experience
- To learn about other state initiatives, read NASHP’s 50-State Scan of State Health Care Delivery Policies Promoting Lead Screening and Treatment.
State Strategies to Advance Medical Homes for Children and Youth with Special Health Care Needs
Medical homes are critical components of comprehensive care systems for children and youth with special health needs (CYSHCN). They can reduce costs and improve outcomes and care experiences for CYSHCN and their families. This new report, State Strategies to Advance Medical Homes for Children and Youth with Special Health Care Needs, examines effective strategies used by 16 states to advance a medical home model of care for CYSHCN and their families, as part of the Maternal and Child Health Bureau, Health Resources and Services Administration’s State Implementation Grants to Enhance Systems of Services for CYSHCN through Systems Integration. Read the report.
Additional children and youth with special health care needs resources:
Mental Health and Opioid Crisis Programs Win Funding Hikes, Efforts to Stabilize Insurance Markets Fail
The new $1.3 trillion budget bill that finances the federal government through September increased funding for a number of health programs that directly impact states, including rural programs to combat the opioid crisis. There were no appropriations made to stabilize Affordable Care Act (ACA) insurance markets.
Under the budget, the Department of Health and Human Services (HHS) receives $78 billion, a $10 billion increase, and the Centers for Medicare & Medicaid Services (CMS) receives $4 billion for administrative expenses, the same as in 2017. Below is a summary of key health related spending in the federal budget.
Opioid crisis: Funding to combat the opioid crisis received a $2.55 billion hike to reach $3.6 billion. The Substance Abuse and Mental Health Services Administration (SAMHSA) received a $1.3 billion increase, bringing it to $5 billion. The legislation maintains the ban on using federal funds for the purchase of syringes and needles, but allows communities with marked increases in HIV and viral hepatitis infection rates to use federal funds for services such as substance-use counseling and treatment referrals.
The SAMHSA budget includes $1.9 billion for the Substance Abuse Block Grant, similar to last year’s appropriation, an $11 million increase in criminal justice funding (bringing it to $89 million, which includes $70 million for drug courts), and $1.7 billion to address opioid and heroin abuse (an increase of $1.5 billion), including $500 million for the state opioid response grants authorized in the 21st Century Cures Act, along with funding for programs authorized in the Comprehensive Addiction and Recovery Act.
One of the new initiatives was $105 million to expand the National Health Service Corps (NHS) to offer opioid and substance use disorder treatment in rural and underserved areas. NHS substance use disorder counselors will be eligible for loan repayment. About $30 million will be devoted to the new Rural Communities Opioid Response initiative within the Office of Rural Health.
Mental health programs: Funding for mental health programs increased about 17 percent to $3.2 billion, which includes $100 million for Certified Community Behavioral Health Clinics. That program, midway through a two-year demonstration program at 67 centers, has been used to combat the opioid crisis.
The bill also increases funding for Mental Health First Aid to $19 million and gives first responders training to help connect people having mental health or addiction crises to community help.
According to the National Council for Behavioral Health, funding was maintained for the Primary and Behavioral Healthcare Integration program, which has provided screening and treatment for conditions like diabetes and heart disease for more than 98,000 individuals living with serious mental illness or addiction at more than 213 sites.
Among the mental health programs funded by the 21st Century Cures Act, including the Mental Health Block Grant, are the National Traumatic Stress Network, the National Child Traumatic Stress Initiative, Mental and Behavioral Health Training Grants, Assisted Outpatient Treatment, and the National Suicide Prevention Lifeline. Of the new funding, 15 percent will go to states with the highest mortality rates related to opioid-use disorders.
The Health Resources and Services Administration receives $7 billion, including $315 million for the Children’s Hospital Graduate Medical Education program, $110 million for the Healthy Start program, and $652 million for the Maternal and Child Health Block Grant.
The legislation increased funding for the National Institutes of Health (NIH) by $3 billion, bringing it to $37 billion, and the Centers for Disease Control and Prevention (CDC)’s budget increased $1.1 billion, bringing it to $8.3 billion.
Impact on ACA’s public health provisions: Much of CDC’s increase results from reallocating $801 million from the ACA’s Prevention and Public Health Fund and $240 million from its Nonrecurring Expenses Fund. The CDC’s Public Health Preparedness and Response programs will get a $45 million boost, bringing it to $1.45 billion.
New ACA oversight imposed: Congress did not fund efforts to reduce premiums through cost-sharing reduction payments, nor did it fund any reinsurance programs that would allow states to spread the financial risk for high-risk individuals across insurance markets. Congress did impose more reporting requirements on ACA programs.
- CMS must now notify Congressional committees two business days before any ACA-related data or grant opportunities are released to the public.
- New “transparency” language requires the Administration to publish ACA-related spending by category since its inception.
- The Administration must publish information on the number of employees, contractors, and activities involved in implementing, administering, or enforcing ACA provisions.
State Medicaid Agencies Venture into Value-Based Purchasing with Federally Qualified Health Centers
State Medicaid agencies have generally found it challenging to include federally qualified health centers (FQHCs) in value-based purchasing initiatives because of a federal law passed in 2000 that regulates how state Medicaid programs pay FQHCs for the care they provide. State Medicaid agencies are required to reimburse FQHCs through the Prospective Payment System (PPS), a volume-based, per-visit payment rate, or through an alternative payment methodology (APM). Increasingly, states are demonstrating that value-based purchasing through APMs is not only possible, it can be beneficial for both state Medicaid agencies and FQHCs.
| How States Work with FQHCs to Promote High Quality, Efficient Care The nation’s 1,400 community health centers, including FQHCs, provide primary care to 24.3 million low-income residents.Federal law, now incorporated into section 1902(bb) of the Social Security Act, requires state Medicaid programs to reimburse FQHCs through the Prospective Payment System (PPS), which sets minimum per visit payment rates for individual clinics. PPS rates can vary by clinic location.State Medicaid agencies may reimburse FQHCs through an alternative payment model (APM) that provides financial incentives for quality and efficient care if a FQHC agrees to participate and its total payments equal what it would have received under PPS.NASHP is creating a toolkit to help state Medicaid agencies develop value-based APMs for FQHCs. For more information visit www.oldsite.nashp.org and subscribe to NASHP’s weekly e-newsletter for additional resources. |
Since May 2016, the National Academy of State Health Policy’s (NASHP) Value-Based Payment Reform Academy has been working with six states—Colorado, Washington, DC, Hawaii, Michigan, Nevada, and Oklahoma—to support their development of APMs for FQHCs that reward value over volume. Supported by the Health Resources and Services Administration (HRSA), the academy provided each state’s team, made up of Medicaid, primary care association (PCA), and FQHC leaders, with 15 months of technical assistance from NASHP staff, federal and state leaders, and national experts to help plan and develop value-based APMs.
The lessons learned from these states about value-based APM development provide important information for other states considering these models. This is an opportune time for states to begin working with their PCAs and FQHCs to develop value-based APMs for a number of reasons.
First, FQHCs are critical health care providers for Medicaid beneficiaries in many states. Second, HRSA has a long history of helping FQHCs build capacity, providing many with funding and support to make investments in electronic health record systems and registries and to help them implement practice transformation to become recognized patient-centered medical homes.
FQHCs that have made these investments in care delivery transformation are well on their way to having the necessary capacity and infrastructure to participate in value-based APMs. Medicare and state Medicaid programs are increasingly implementing value-based APMs to broadly incentivize their providers to improve health outcomes and patient experiences while reducing costs.
States are finding they can pursue value-based APMs with their FQHCs within federal Medicaid PPS regulations as long as:
- Individual FQHCs agree to the APM; and
- Each clinic’s total payments are equivalent to, or higher than, the total payments they would receive through PPS.
As long as states meet the above requirements for APMs, they have the ability to implement value-based reimbursement models to encourage and incentivize efficient, high-quality care over volume-based care.
Academy-assisted states’ efforts and progress demonstrate a growing commitment to partnering with FQHCs to develop value-based APMs that better align with comprehensive, high quality, patient-centered primary care. State policy makers interested in developing value-based APMs for FQHCs should consider the following lessons learned from the academy’s state teams:
- Identify a vision and shared goals that define how health care should be delivered to patients, then determine how payment needs to change to support providers to achieve that vision.
- Engage critical stakeholders from Medicaid, state departments of health, PCA, and FQHCs to develop collaborative processes. Strategies, such as regular meetings, help foster trust and transparency among the state agencies and organizations involved in the development efforts.
- Consider the state Medicaid agency’s bandwidth, and look for opportunities to align FQHC value-based APMs with broader Medicaid initiatives and goals. As with other payment reform efforts, the implementation of new models may involve staff from various sections, such as managed care, quality, rate setting, and information technology.
- Work with PCAs to assess FQHCs’ readiness to take on value-based APMs. Remember that FQHCs must opt-in to participate in an APM. It is not necessary for all FQHCs in a state to simultaneously adopt this new model. States may find it beneficial to pilot the APM in a few advanced FQHCs and refine the model as necessary.
To learn more about the academy and how the states’ APM initiatives are progressing across the country, explore the following NASHP resources:
- Webinar: Value-Based Alternative Payment Methodologies for Federally Qualified Health Centers: Lessons from Colorado and Minnesota [August 2017]
- Value-Based Payment Reform Academy Project Information [February 2016]
- Blog: Oregon’s Bridge to Value-Based Payments for Community Health Centers: A Win for Medicaid, Providers, and Patients [September 2015]
In October 2017, NASHP will release a toolkit that provides states with a roadmap, key steps, promising strategies, and unique considerations to develop value-based APMs for FQHCs. Visit www.oldsite.nashp.org often and subscribe to NASHP’s weekly e-newsletter for additional resources.
How States Work with FQHCs to Promote High Quality, Efficient CareThe nation’s 1,400 community health centers, including FQHCs, provide primary care to 24.3 million low-income residents.Federal law, now incorporated into section 1902(bb) of the Social Security Act, requires state Medicaid programs to reimburse FQHCs through the Prospective Payment System (PPS), which sets minimum per visit payment rates for individual clinics. PPS rates can vary by clinic location.State Medicaid agencies may reimburse FQHCs through an alternative payment model (APM) that provides financial incentives for quality and efficient care if a FQHC agrees to participate and its total payments equal what it would have received under PPS. NASHP is creating a toolkit to help state Medicaid agencies develop value-based APMs for FQHCs. For more information visit www.oldsite.nashp.org and subscribe to NASHP’s weekly e-newsletter for additional resources.
For individuals living with complex, often chronic conditions, and their families, palliative care can provide relief from symptoms, improve satisfaction and outcomes, and help address critical mental and spiritual needs during difficult times. Now more than ever, there is growing recognition of the importance of palliative care services for individuals with serious illness, such as advance care planning, pain and symptom management, care coordination, and team-based, multi-disciplinary support. These services can help patients and families cope with the symptoms and stressors of disease, better anticipate and avoid crises, and reduce unnecessary and/or unwanted care. While this model is grounded in evidence that demonstrates improved quality of life, better outcomes, and reduced cost for patients, only a fraction of individuals who could benefit from palliative care receive it. 
