Tooling Up For Multi-Payer System Transformation

By Sarah Kinsler
May 2013
Momentum is building at the state level for multi-payer payment and delivery system transformation. Across the country, states like Maine, Arkansas, and Oregon are partnering with commercial insurers and other stakeholders to pursue Triple Aim goals. NASHP’s new Multi-Payer Resource Center, supported by The Commonwealth Fund, will help them succeed.

Multi-payer programs bring together public and private sectors, aligning objectives and incentives to spur system-wide transformation. States hold unique levers as conveners and supporters: not only do states hold significant purchasing power through Medicaid and state employee benefit programs, but payers may need state supervision to avoid violating federal antitrust law. Despite the clear benefits of alignment, states grapple with a variety of challenges: consensus building is often arduous in the context of conflicting stakeholder interests, and many payers harbor concerns about losing autonomy and competitive advantage and violating antitrust law.
 
NASHP’s Multi-Payer Resource Center offers states tools they can use to overcome these barriers. It identifies five critical actions each state will need to take—and provides visitors with resources they can use to successfully complete each action. The Resource Center features the documents developed by states and others to support convening and implementing multi-payer initiatives, such as reports, memos, Requests for Proposals (RFPs), and contracts, drawing together the experience of multiple multi-payer programs.

1. Stakeholder Engagement, Pilot Convening, and Navigating Antitrust: Successful multi-payer reforms must bring stakeholders – including payers, providers, and consumers – together to reach agreement on key issues. In Washington, legislation provided critical protection from antitrust concerns. Maryland and Maine have used provider contracts and participation agreements to set core expectations for practices and conveners alike in their multi-payer PCMH initiatives.
2. Developing Infrastructure and Community Linkages: Community health teams or networks can facilitate practice transformation and support patient care regardless of insurer. In Vermont, payers are required to support community health teams, which act as a foundation for the state’s all-payer Blueprint for Health payment and delivery system reforms. Maine’s community care teams support a growing multi-payer PCMH pilot, in addition to the state’s ACA Section 2703 Health Homes program.
3. Payment: Payment reform is a vital element of health system transformation; payment models including payment to support patient-centered medical homes, pay for performance, shared savings, episode-based or bundled payments, and global payments are being broadly adopted to incentivize desired outcomes. Rhode Island incorporates a pay-for-performance component emphasizing patient experience measures into the Chronic Care Sustainability Initiative, the state’s all-payer PCMH program. In Arkansas, three major payers have partnered to implement episode-based payments, seeking to increase provider accountability for cost and quality.
4. Attribution and Enrollment: Patient attribution is an important component of many value-based payment models, but it is also an issue with which many multi-payer initiatives struggle. Enrollment and attribution define the group of patients for which providers and organizations are held accountable. Different approaches will identify groups of different sizes and patients with different characteristics. These differences, in turn, affect the total amount that payers pay and that practices receive—and may ultimately effect measurement of outcomes.
5. Evaluation: Evaluating cost and quality outcomes is a critical to demonstrate effectiveness. In response to a lack of guidance on rigorous medical home evaluation, The Commonwealth Fund convened a PCMH Evaluators’ Collaborative that has suggested core measures and other recommendations to guide analyses. The University of Minnesota School of Public Health recently released the evaluation design for Minnesota’s Health Care Homes initiative, guided by the state’s Outcomes Measurement Work Group.

 
The federal government is increasingly recognizing the potential of multi-payer reform to spur system-wide transformation and offering funds to support and test these programs at the state level. CMS has launched major initiatives focused on multi-payer activity in the past two years, including the recent State Innovation Models program, which is funding 25 states’ work to design and test multi-payer delivery system transformation and payment reform projects.
 
States across the country are capitalizing on this growing national movement. As states confront key questions and issues, NASHP’s Multi-Payer Resource Center is there to support state decision-making with the resources mentioned above and many more. The Resource Center is a work in progress; users should look for resources on health information technology and behavioral health integration, as well as a new NASHP brief on enrollment and attribution issues, in summer 2013. NASHP will continue to refine and expand this tool to meet states’ needs as they continue on the path to achieving the Triple Aim.
 
What key decisions do you see states facing as they seek to build and implement multi-payer programs? Do you have resources to share or suggestions to improve the usability of this resource center? Please help us develop a center that is responsive to your needs. Email skinsler@oldsite.nashp.org with your input.