Many states are transforming their health care delivery systems to improve health and control costs. Reducing health disparities — and addressing their social and economic causes — is at the heart of many of these efforts.
This resource highlights the goals of 10 states’ health and equity improvement plans, certificate/determination of need processes, and COVID-19 recovery and resilience plans. Policymakers can use the information in this chart and blog to make hospitals’ community benefit investments more accountable and effective by having them reflect state health goals and then measuring their progress. These states participate in the National Academy for State Health Policy’s workgroup on community benefits.
States’ COVID-19 Recovery and Resilience Plans data comes from the National Governors Association, Summary of Public Health Criteria in Reopening Plans.
In recent years, Colorado, Minnesota, and Rhode Island began using accountable care programs to improve delivery of behavioral health services. Already, the programs have produced improvements – Colorado reports an increase in the percentage of Medicaid enrollees receiving behavioral health services and Minnesota’s accountable care organization (ACO) providers have performed better than other clinics in screening adolescents for mental health issues. This report examines these states’ policies and experiences in using accountable care programs to improve delivery of behavioral health care.
Background
Medicaid is the largest payer of behavioral health care (mental health and substance use disorder) in the United States.[1] In addition, studies show that behavioral health conditions contribute to a greater cost to treat than other medical conditions.[2] There are great disparities in health outcomes for people with behavioral health diagnoses,[3] individuals with behavioral health conditions are sicker and die younger than those without such conditions. As states grapple with unprecedented budget crises and increased demand for behavioral health services due to the COVID-19 pandemic, there are incentives for them to change how behavioral health care is delivered.
In an accountable care program, groups of providers (called ACOs) share responsibility for the quality of care, health outcomes, and costs for a defined population. These programs emphasize primary care, care coordination and integration, and value-based payment. Payment depends on the ACO’s performance on defined metrics.
There is broad recognition that integrating behavioral and physical health care, and identifying and treating behavioral health conditions early can lead to improved outcomes.[4] States also face severe behavioral health workforce shortages, especially in lower-income areas — where many of those served by the Medicaid program live.[5]
As a result, states have for many years sought to reform their delivery systems to improve identification and treatment of behavioral health conditions, better integrate behavioral and physical health, and increase Medicaid enrollees’ access to behavioral health care. Many of these previous efforts were based in managed care or on a patient-centered medical home (PCMH) model.
A decade ago, state Medicaid agencies began to implement accountable care programs. In early 2020, the National Academy for State Health Policy identified eight states that had begun to use their accountable care programs to improve their delivery of behavioral health care: Colorado, Maine, Massachusetts, Minnesota, New Jersey, Oregon, Rhode Island, and Vermont. The ACOs participating in these programs focus on coordination and integration of care and provide an infrastructure to improve behavioral health services that, due to their focus on primary care, may prove particularly useful for advancing behavioral health integration.
The pandemic is already causing some states to delay delivery system reforms. However, over the longer term, the pandemic may cause more states to turn to accountable care to help them manage behavioral health services. In recent months, state Medicaid officials have had to focus their attention on ensuring that Medicaid enrollees receive the care they need, leaving little time to develop new reforms. Large state budget shortfalls are also projected,[6] which are likely to lead states to implement cost containment strategies. States may turn to accountable care programs, which hold ACOs and their affiliated providers accountable for cost, quality, and health outcomes, as a way to provide quality services while containing cost. The pandemic is also likely to create increased need for behavioral health services.[7] According to a July 2020 Kaiser Family Foundation poll, more than half of the adults reported that “stress and worry related to the pandemic has had a negative impact on their mental health.”[8] State Medicaid agencies may, ultimately, turn to accountable care to address the combined effect of decreased state funding and increased need for behavioral health services.
This report outlines the program policies, implementation experience, and lessons learned in three states that have all used accountable care to improve behavioral health care and contain cost.
How Colorado, Minnesota, and Rhode Island Structure their Programs
The three states structured their accountable care programs in different ways.
This report uses “ACO” when describing more than one state’s accountable care organization, as each state has a unique name for its ACO.
Colorado began its accountable care program in 2011, but the state did not emphasize behavioral health care in the program until it launched the second phase in July 2018. At that point, Colorado folded its specialized managed care program for behavioral health services into its accountable care program. Since 2018, Colorado has contracted directly with seven regional accountable entities (RAEs). Colorado assigns almost all Medicaid enrollees to a RAE (representing about 97 percent of Colorado’s 1.3 million Medicaid enrollees in July 2020).[9] RAEs support a local network of primary care medical providers (PCMPs), deliver behavioral health services, coordinate members’ care across systems, and are accountable for the cost and quality of care delivered to Medicaid members.
RAEs are paid through a combination of per member per month (PMPM) administrative payments, capitation, and incentive payments. RAEs receive $15.50 PMPM as an administrative payment. The Medicaid agency withholds $4 of each $15.50 to fund the Key Performance Indicator (KPI) payments. The Medicaid agency assigns each of seven KPI metrics a specific PMPM amount, and if a RAE produces sufficient improvement on the measure, it receives a payment based on the PMPM amount assigned to the measure. KPI payments are calculated and distributed each quarter. Unearned incentive payments are used to fund a challenge pool that is distributed based on performance in pursuing specified state policy priorities (e.g., collaboration with institutes of mental diseases or achieving progress on other performance metrics. RAEs also receive capitation payments for behavioral health services and are eligible to receive incentives tied to performance on a set of behavioral health measures. These payments are referred to as behavioral health incentive payments.
Both PCMPs and behavioral health providers must contract with a RAE in order to serve Medicaid enrollees. PCMPs receive fee-for-service payments from the Medicaid agency and administrative and incentive payments from the RAEs. Behavioral health providers contract with the RAEs and receive all payments directly from their RAE.
Minnesota began its accountable care program in 2013. The state considered behavioral health when designing the initial phase of its program, but strengthened its behavioral health focus in Phase 2 of the program (IHP 2.0), which launched in January 2018. As of June 2020, Minnesota Medicaid contracts with 26 Integrated Health Partnerships (IHPs) that, together, serve 430,000 Medicaid and MinnesotaCare (Minnesota’s basic health plan) enrollees. IHPs are provider organizations. They and their associated providers receive payment for services from either the MCOs or the Medicaid fee-for-service system.
In addition, IHPs are paid through one of two payment models.
All IHPs (both tracks) receive a clinical and social risk-adjusted monthly population-based payment. In exchange, all IHPs must develop and implement specific health initiatives that address certain social risk factors that their patient populations are facing and achieve satisfactory performance on a set of quality and performance measures in order to continue to participate in the program. Both the initiative itself and the measures are negotiated between the individual IHP and the Medicaid agency. IHPs that participate under Track 2 also share in both savings and losses.
Savings and losses are calculated by comparing the actual total cost of care (TCOC) of the members attributed to the IHP with the members’ projected TCOC absent the IHP. If actual TCOC is less than projected, the difference is savings; if actual is more than projected, the difference is a loss. TCOC is defined to include the cost of providing most services. (See page 54 of Minnesota’s Integrated Health Partnerships Contract for a list of included services.)
The calculation of the amount of savings to be paid to the IHP or the amount of loss to be paid to the agency is based on multiple factors. First, the IHP is only eligible to share in any amount of savings or losses that fall within a negotiated risk corridor (e.g., 6 percent). All profit or loss outside the corridor belongs solely to the agency. The exact share of the amount within the risk corridor (e.g., the available savings) each IHP receives depends on two factors — the savings split it has negotiated with the agency and its performance in three domains (care quality, health information exchange, and alerting exchange).
But the share of losses depends only on the losses split negotiated with the agency and not its performance. The standard split is 50/50, meaning that IHPs can earn up to 50 percent of available savings and will pay 50 percent of available losses. But an IHP can secure a different split by entering into an accountable partnership with a community partner (e.g., a community mental health center [CMHC]) and negotiating a different split with the Medicaid agency — typically IHPs with an accountable partnership agree to take up to 70 percent of the available savings and pay 35 percent of available losses.
Rhode Island Medicaid began piloting its accountable care program in 2016 and launched its full program in July 2018 when it certified six comprehensive accountable entities (AEs). The Medicaid agency does not contract directly with its certified AEs. Instead, it requires Medicaid MCOs to contract with the AEs (and AEs to contract with MCOs). Each AE and MCO negotiate their own payment models within parameters set by the state. State officials shared that they have become more prescriptive on payment model as their and other stakeholders’ experience has grown and as the number of AEs (and thus the number of contracts that must be negotiated between MCOs and AEs and overseen by the state) grows. Both MCOs and AEs agreed on the need for increased standardization. Currently, all payment models must be based in TCOC calculated according to state requirements and MCOs must share up to 50 percent of any savings with AEs. AEs may accept shared losses if the Office of the Health Insurance Commissioner, which licenses commercial health plans, has determined that the AE is qualified to accept that risk. The amount of savings awarded to an AE must depend on the AE’s performance on at least three measures selected from a common measure set. State payment model parameters also govern how people are attributed to AEs.
In 2016, the Centers for Medicare & Medicaid (CMS) authorized the creation of AEs through approval of an amendment to Rhode Island’s Section 1115 Comprehensive Demonstration waiver. This amendment also authorized the state to create the Medicaid Infrastructure Incentive Program (MIIP) as a Designated State Health Program (DSHP). This designation, which CMS stopped awarding in 2017, authorized the state to receive, over the five-year period of November 2016 to December 2020, up to $129.8 million in federal funding to match state expenditures to support AE infrastructure development. In program Year 3, MCOs may earn up to $1.60 PMPM for each member attributed to a qualified AE. AEs may earn up to $8.44 PMPM by developing and completing projects that support the state’s goals, including those related to behavioral health. Actual payment is based on the achievement of performance milestones, most of which are negotiated between each AE and MCO, subject to state approval.[10]
Why States Included Behavioral Health in Accountable Care
“[In Rhode Island] managed care needed to evolve to be responsible for the needs of individuals with chronic conditions and needs. This pushed managed care to be more holistic across the board.”
Colorado, Minnesota, and Rhode Island chose to include behavioral health in their accountable care programs in order to improve chronic care, increase behavioral health integration, and produce cost savings. Officials from both Colorado and Rhode Island reported that that their new accountable care programs built on their previous efforts to strengthen primary care and better integrate behavioral health into primary care. Rhode Island officials explained that the primary care-centered approach worked well for individuals with moderate or low behavioral health needs, but the “needs of the other end of continuum also need to be considered.” Rhode Island believed that the structure of the accountable care program gave the CMHCs, which can better serve high need individuals, more opportunity to leverage their skills and strengths to be a resource for primary care. Eventually, this state would like to bring primary care to CMHCs in at least some of their AEs.
“Due to high spending for behavioral health on high utilizers, there is value in homing in on integrating physical and behavioral health from a savings perspective.” – Colorado official
Both Colorado and Rhode Island emphasize that behavioral health providers are well-positioned to engage patients with complex needs. Colorado officials also believe that RAEs’ structure, which makes them responsible for both primary and behavioral health care, would increase integration between the two types of services. Officials stated that the care coordination provided by CMHCs under its managed behavioral health program was strong. But they believed that folding the behavioral health program (and CMHCs) into their accountable care program fostered whole person care coordination for those with complex needs. They believed that increased integration and more holistic care coordination would lead to less fragmentation of care, create economies of scale, and, in turn, produce cost savings.
Colorado had also hoped that the RAEs would increase access to behavioral health services. This state has seen an increase in the proportion of Medicaid enrollees who receive one or more behavioral health services, and stakeholders are reporting that access and choice are both stronger.
All three states through their ACO contracts (Colorado and Minnesota) or certification standards (Rhode Island), consider performance on behavioral health measures in ACO payments. All three states also considered behavioral health in the performance requirements they created for their ACOs regarding network adequacy, care coordination and integration, and health information technology (HIT) supports. One or more of these states also called out behavioral health in the requirements they established in many other areas of performance.
Attribution is the process used to identify the members of the defined population for which the ACO is accountable. All attribution processes consider where the patient has obtained care in the past. All three states featured in this brief first attribute Medicaid enrollees to a primary care provider (PCP) or a subset of PCPs who have met state-established qualifications. These states then consider each ACO to be “accountable” for the enrollees attributed to the providers affiliated with the ACO. All three states attribute enrollees with behavioral health conditions to a primary care provider, but only Minnesota currently considers behavioral health in that process. The first step of Minnesota’s process is to attribute Medicaid enrollees who have received services from a behavioral health home (or health care home) to the IHP with which that provider is affiliated.
Rhode Island had implemented a similar policy at program launch but now considers only primary care in attribution. Officials reported that they made this change because they determined that including attribution to an Integrated Health Home as the first step was difficult and time consuming. This, along with member churn impacted the state’s ability to confidently collect performance data. Additionally, Rhode Island found that many of the people served by integrated health homes were engaged in primary care with a separate provider.
Payment Models
As previously described, Colorado, Minnesota, and Rhode Island have each created a unique payment model for their ACOs. All three states, however, consider behavioral health performance in ACO payments and have established policies that foster consideration of behavioral health performance in payments to individual providers.
ACO Payment
Payment is considered to be the driving force to ensure ACO accountability for performance. All three states have tied ACO payment to behavioral health performance. Colorado’s RAEs may earn two types of incentive payments for performance. A RAE may earn incentives of up to $4 PMPM in key performance indicator (KPI) payments, which are primarily tied to the performance of the PCMP network. The RAE may also earn up to 5 percent of its behavioral health capitation rate (about $30 million) in behavioral health incentive (BHI) payments, which are primarily tied to the performance of the behavioral health network.
In both Minnesota and Rhode Island, ACOs may earn a share of the savings they produce — and are sometimes required to also share in any losses. Both of these states calculate savings and losses using a TCOC methodology. Both also include behavioral health services in the TCOC calculation, and Minnesota considers behavioral health services when calculating the monthly population-based payment that each of its IHPs also receives.
Regardless of their specific ACO payment model, all three states tie ACO payment to performance on a set of metrics that includes behavioral health measures, along with measures of other types of performance. In Colorado, performance on the metrics governs the amount of the incentives the RAEs earn. In Minnesota, performance on the metrics governs whether Track 1 IHPs may continue to participate in the program and whether Track 2 IHPs earn the full portion of their contracted share of any savings they produce. In Rhode Island, performance on the metrics governs what portion of savings are paid to the AE and how much the MCO may retain (and for those AEs that have been approved to accept downside risk, what portion of the losses they are required to pay to the MCO).
“Measures [in Rhode Island] were shaped by high-level goals of the organization and we wanted to make sure that there are mechanisms for balanced, useful data.”
There is little commonality between the behavioral health measures these states chose to factor into payment (Table 1). Only one measure is used by all three states – follow-up appointments within X days after an inpatient hospital discharge for a mental health condition, although even on this measure, states have made different choices as to when to specify seven-day follow-up and when to specify 30-day follow-up. Although there was little commonality between the specific measures used, there was some commonality regarding the domains to be measured. All three states included measures of engagement and follow-up.
When asked why they chose their specific measures, state interviewees uniformly reported that the choices were based on their goals for the program and stakeholder input. They also reported that the choices were informed by previous efforts.
Table 1: Behavioral Health Measures that Factor into ACO Payments
| Colorado | Minnesota | Rhode Island | |
| Screening and Assessment | |||
| Screening for depression and follow-up plan | Some IHPs* | Optional | |
| Behavioral health screening or assessment for children in the foster care system | BHI | ||
| Developmental screening in first three years of life | Optional | ||
| Engagement and Follow-up | |||
| Initiation and engagement of alcohol and other drug abuse or dependence (AOD) treatment | Required | ||
| Engagement in outpatient substance use disorder (SUD) treatment | BHI | ||
| Behavioral health engagement: Percentage of members who received a behavioral health service delivered either in primary care settings or under the capitated behavioral health benefit within a 12-month evaluation period | KPI | ||
| Follow-up appointment within 7 or 30 days After an inpatient hospital discharge for a mental health condition | BHI; 7-day | Track 1: 7- or 30-day
Track 2: 30-day |
Required, opt for 7- or 30-day |
| Follow-up appointment within 7 days after an emergency department (ED) visit for a substance use disorder | BHI | ||
| Follow-up after a positive depression screen | BHI | Some IHPs* | |
| Medication | |||
| Antidepressant medication management: acute and continuous | Required | ||
| Adherence to antipsychotics for individuals with schizophrenia | Required | ||
Acronyms: BHI=behavioral health incentive payment; KPI=key performance indicator payment; IHP=Integrated Health Partnership.
*The measure is used if it is appropriate to the topic of the health intervention that the IHP and Minnesota Medicaid jointly select.
Colorado’s RAEs have increased the percent of Medicaid enrollees who receive behavioral health care.
To date, only Colorado has published a summary of ACO performance on the measures that factor into incentive payments. This state has seen some positive results. On the primary care side, payment is tied to behavioral health engagement. During the first year of program operation, the RAEs produced almost a two-percentage point increase in this metric. On the behavioral health side, Colorado established incentives for performance on five measures.
During the program’s first year of operation:
Although not yet complete, Rhode Island is conducting an evaluation of its program which, when complete, will shed more light on its program’s impact on behavioral health care.
Minnesota officials report that IHPs perform above average when compared to clinics and/or systems that are not IHPs, on many quality measures, including those related to diabetes, asthma, and vascular care. In terms of behavioral health metrics, IHPs perform better than non-IHPs on ensuring adolescents are screened for mental health issues. Additionally, those IHPs with health interventions with a behavioral health focus have seen some positive results, including high levels of relative improvement across years.
Payment to Individual Providers
Colorado and Rhode Island both sought to ensure that the individual providers, including behavioral health providers, affiliated with their ACOs would benefit from performance payments earned by the ACO. Colorado explicitly requires its RAEs to share any incentive payments the RAE receives with the providers who form the RAE’s health neighborhood, which consists of the providers (including behavioral health providers) and facilities that work with an individual’s PCMP to meet all of the person’s health needs. RAEs are also required to report all payment arrangements, including those with behavioral health providers to the Medicaid agency. Rhode Island does not require its AEs to share savings, but it does require the AEs to have documented relationships with behavioral health provider partners to meet their patients’ needs, and Rhode Island Medicaid envisions that some of those relationships will include shared savings. It also requires the AEs to share 10 percent of any incentive pool payments they receive with a partner organization, which may be a behavioral health provider.
Minnesota encourages its IHPs to implement accountable care partnerships by potentially rewarding the IHP with more favorable financial arrangements. For example, instead of receiving 50 percent of any savings, the IHP might receive 70 percent. An IHP can use this mechanism to also reduce the share of any losses that it must pay, and Medicaid officials report that it is this attribute that is often most attractive to the IHP. The financial arrangements are negotiated with each IHP. Minnesota offered an example of a potential partnership between an IHP and a CMHC. The CMHC agrees to provide behavioral health services to a targeted set of patients who screen positive for a behavioral health need. IHP-affiliated providers will screen patients, refer those who screen positive to the CMHC, and the CMHC will provide any needed services and ‘close the loop’ by providing information back to the referring provider. Minnesota Medicaid also negotiates the specific measures that will be used to judge the success of the partnership. In this case, that might include the number of patients that were screened for behavioral health needs divided by the total number of patients, or it could also include the total patients who received services divided by the total patients referred. Although there is no requirement that partners be paid, eligibility for a more favorable risk arrangement depends on several factors that encourage payment, including how well the partners are working together.
Finally, when it launched its accountable care program, Colorado Medicaid began directly paying PCMPs (i.e., primary care providers) for short-term behavioral health treatment (up to six visits) on a fee-for-service basis. Other behavioral health services are paid for by the RAEs. Colorado Medicaid had anticipated that this change would foster behavioral health integration and support then-existing partnerships between some federally qualified health centers (FQHCs) and CMHCs. As expected, this policy did improve access for patients with more mild behavioral health conditions. However, some FQHCs chose to withdraw from the partnerships and hire staff to provide the short-term services. Colorado Medicaid also found the policy more difficult to implement than anticipated, as the agency had to adjust the payments it made to the RAEs for behavioral health services to reflect that payment for some short-term services that would now be made by the agency.
ACO Performance Requirements
Colorado, Minnesota, and Rhode Island all complemented their payment reforms with performance requirements to help ensure that their ACOs were prepared to deliver accountable care and that savings would be produced by improving care rather than curtailing access. These three states all chose to address behavioral health in their ACO performance requirements governing provider network composition and access to services, care coordination, and health information technology.
Table 2: Performance Area Requirements
| Performance Area | Colorado | Minnesota | Rhode Island |
| Network and access to services | √ | √ | √ |
| Care coordination | √ | √ | √ |
| Health information technology | √ | √ | √ |
| Provider support | √ | √ | |
| Quality | √ | √ |
Network Composition and Access to Behavioral Health Services
All three states required their ACOs to include at least some behavioral health providers among their affiliated providers, although only two required contracts. Colorado required its RAEs to create a statewide behavioral health network and offer contracts to CMHCs and substance use disorder (SUD) clinics. Similarly, Minnesota’s IHPs must contract with CMHCs “to the extent possible,” and each AE in Rhode Island must demonstrate that they have sufficient partnerships with behavioral health providers to provide the population that the AE plans to serve with access to a range of treatment options that represent a continuum of care. Rhode Island officials reported that in the early years of their program, they required the AEs to partner with CMHCs. Now that many of the AE/CMHC partnerships are well-established, this performance standard has been broadened to count partnerships with all types of behavioral health providers, not just CMHCs. Rhode Island has broadened the requirement to include all behavioral health providers. These three states also established other performance expectations. For example, Rhode Island requires each AE to include a representative of a community-based behavioral health provider within its governance structure.
“Care coordination…with CMHCs was strong, but with the [primary care and behavioral health] combination there is more whole-person care coordination…”
Colorado officials reported that access to behavioral health services increased because those providers who had been delivering care through the specialty managed care program continued to deliver care as part of the RAEs’ networks, but the RAEs had expanded their independent provider network as well. Officials viewed this to be an overall positive outcome because both traditional providers (e.g., CMHCs) and independent providers who had not previously treated Medicaid enrollees were needed to meet the current Medicaid population’s full range of needs. However, some RAEs, especially those that hadn’t established some utilization review requirements, found that utilization of expensive services, such as inpatient services, increased. These RAEs are now working to ensure that the right utilization management is in place, and one aspect of that work is to assess whom the independent provider networks are serving and consider if that is the best place for those enrollees to receive care.
Care Coordination and Population Health Management
One of the hallmarks of accountable care is ensuring that patients’ needs are systematically identified and addressed, and that care is coordinated across systems and providers. All three states established policies for care coordination that addressed behavioral health issues.
“The important piece is that the expansion of the independent provider network [in Colorado] reshaped the landscape of services being performed while CMHCs remained in the game…”
Colorado and Rhode Island also created requirements to ensure that behavioral health was addressed at the population level by requiring their ACOs to prepare population health plans that address behavioral health issues. Rhode Island also includes requirements designed to ensure that the plan guides each AE’s population health management activities, including behavioral health integration that considers risk factors for poor behavioral (as well as physical) health outcomes.
Health Information Technology (HIT)
Data is key to systematically identifying and managing a population’s health needs, identifying gaps in care, and measuring health outcomes. Colorado, Minnesota, and Rhode Island took slightly different approaches to ensuring that providers had, and could use, data to improve delivery of behavioral health services.
Provider Support
“More [technical assistance] was needed in the beginning to help behavioral health providers understand workflow and [payment] models.”
Shifting to a new delivery and payment model can be difficult, even when providers voluntarily shift. Changing providers’ approaches to delivering care, including behavioral health care, to enable them to thrive under a new system can be particularly difficult. Colorado and Rhode Island both addressed these concerns in their accountable care programs but took very different approaches.
Colorado required its RAEs to provide the support. Each RAE was required to prepare and implement a provider support plan that addressed the RAE’s plan to help providers work toward behavioral health integration. Under these plans, RAEs offer providers access to care coordinators, practice transformation coaches, and ongoing training. They also offer in-person coaching and online support, including access to tools and resources for provider use.
Rhode Island’s MIIP, which is funded as a Designated State Health Program under the state’s 1115 waiver, paid for projects that support the providers associated with the AEs. Each AE develops projects to help build its capacity in specific areas, including some related to behavioral health, such as implementation of evidence-based behavioral health integration and consultation services.
Through this work, officials found that behavioral health providers, even more so than primary care providers, needed a better understanding of alternative payment methodologies (APMs) and how to manage their practices to thrive under these arrangements. Those that had not previously served Medicaid enrollees (e.g., independent behavioral health providers) had even greater technical assistance needs because they often also had to learn Medicaid policies and create new infrastructure. One state official noted the program would have benefited from a comprehensive assessment of providers’, including behavioral health providers, technical assistance needs well before program launch to identify and address critical gaps in provider understanding before they affected the program’s success.
Quality
One of the aims of accountable care programs is to hold providers accountable for the quality of care they deliver. Colorado and Rhode Island chose not only to hold their ACOs accountable by measuring the outcomes they produce on quality metrics, but also the process each ACO used to achieve quality. Rhode Island requires each AE to establish a quality committee to oversee the AE’s quality assurance and improvement program. This state requires that the committee membership include at least one licensed behavioral health clinician who is an AE participant.
Colorado’s requirements are based in Medicaid managed care requirements. Each RAE must conduct two performance improvement projects each year. One of these projects must address behavioral health, and RAEs may choose to dedicate both to improving integration of physical and behavioral health care. RAEs must also prepare quality plans that address behavioral health.
Lessons Learned and Conclusion
Officials from the three states advised those seeking to use ACOs to improve behavioral health services to seek and use stakeholder input, leverage infrastructure and relationships built during previous initiatives as well as the knowledge and experience of the providers currently serving Medicaid enrollees, and expect growing pains. In addition, an examination of these states’ experience finds three overarching takeaways.
States worked to strengthen the primary care system and integrate primary care and behavioral health before introducing accountability for behavioral health services. State officials in all three states used an iterative process to incorporate behavioral health services into their ACOs. Both Colorado and Minnesota waited to incorporate behavioral health until they had several years of experience operating their programs. Colorado officials stated that even when they were planning the first phase of their program, they knew that they ultimately wanted to include behavioral health. They did not do so at that time because they wanted to first focus on ensuring that the primary care aspects of their program were working well. They also knew that the shift to the new delivery system was going to require the reworking of a long-standing behavioral health services delivery structure and believed that making major simultaneous changes to both primary and behavioral health care would cause too much disruption. Rhode Island included behavioral health in its accountable care program from the beginning, but had a very strong, widespread patient centered medical home (PCMH) program in place prior to launching the accountable care program.
All three states had also previously worked to increase behavioral health integration. Rhode Island, for example, had funded an Integrated Behavioral Health Pilot (IBH) that supported primary care practices in incorporating co-located behavioral health clinicians into their operations. Minnesota had established a behavioral health home program to promote whole-person care. Colorado established learning collaboratives to help primary care and behavioral health providers develop the skills needed to support integration, such as creating a multidisciplinary team.
States adjusted program policies as their own and other stakeholders’ experience grew. Both Colorado and Rhode Island reported that they considered their programs to be iterative after launch. Rhode Island officials shared that, during the third year of the program, they began requiring MCOs to calculate shared savings in a specific way and allowed the AEs to earn up to 50 percent of the savings based on their performance. The Medicaid agency made this change due to feedback from both AE and MCOs about the difficulty of managing a growing number of contracts, each with potentially different financial arrangements. Increased standardization also eased the state’s oversight and monitoring. Rhode Island had anticipated that it would need to adjust its policies as its experience grew because the Medicaid agency was, as one official described, “Designing, building, and flying [the airplane] at the same time.”
A Colorado official similarly reported that, “Our program is iterative, and we continue to tweak and learn from it.” Recently, Colorado is encountering challenges related to COVID-19, including questions about how to integrate specialty providers and behavioral health.
States found that ACO leadership, like their associated providers, benefit from support. Officials recognized and planned for provider support, although some wished that they had offered more support. The states also knew that ACOs would need support in order to achieve success. They found that many ACO technical assistance needs were similar to those of providers. Some ACOs, like providers, needed a better understanding of the type of alternative payment models that could work for behavioral health providers. Rhode Island engaged a contractor to provide individual and group technical assistance to both MCOs and AEs — one focus of which was to support both as they entered into shared-risk contracts.
Colorado reported that some newer RAEs had moved back to fee-for-service reimbursement for behavioral health providers but were now working with CMHCs to develop more value-based payment arrangements. Also similar to providers, ACOs that had not previously served Medicaid enrollees had greater technical assistance needs. In Colorado, new RAEs were less familiar with Colorado Medicaid and its emphasis on community-based services. One official wished that the state had allowed sufficient time during implementation to support peer learning for new RAEs, perhaps through shadowing existing contractors, underscoring that education and collaboration were critical. Although Colorado found that new RAEs needed to improve their understanding of Medicaid policies, experienced RAEs needed to be “shaken up” to encourage continued engagement and innovation. Officials in this state worked to engage both newer and more experienced RAEs in peer learning. As one official stated, “When they [RAEs] first started, it was a competition. Now they meet and learn from each-other.”
Conclusion
In recent years, states have begun to use Medicaid accountable care programs to better integrate behavioral and physical health, improve identification and treatment of behavioral health conditions, and increase Medicaid enrollees’ access to behavioral health care. Examining the strategies and outcomes of three of these states offers others valuable information that they can apply to their own programs. All three states’ Medicaid agencies took different approaches to selecting and paying their ACOs, but all three based ACO payment in performance and established ACO performance standards — and considered behavioral health in both of these aspects of their programs. All interviewees reported that their programs were improving care but, to date, only Colorado has published a summary of ACO performance on the measures that factor into payment. This state has seen some positive results, including a modest increase by all RAEs in the percent of Medicaid enrollees receiving behavioral health services and follow-ups after a positive depression screening.
End Notes
[1] “Report to Congress on Medicaid and CHIP”, Medicaid and CHIP Payment and Access Commission, June, 2015.
[2] Roeber, C., McClellan, C., and Woodward, A. “Adults in Poor Physical Health Reporting Behavioral Health Conditions Have Higher Health Costs”, Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality, April 26, 2016.
https://www.samhsa.gov/data/sites/default/files/report_2107/ShortReport-2107.html
[3] Roberts, L.W., Louie, A.K., Guerrero, A.P.S. et al, “Premature Mortality Among People with Mental Illness: Advocacy in Academic Psychiatry”, Academic Psychiatry, June 5, 2017. Psychiatryhttps://link.springer.com/article/10.1007/s40596-017-0738-9
[4] Correll CU, Galling B, Pawar A, et al,“Comparison of Early Intervention Services vs Treatment as Usual for Early-Phase Psychosis: A Systematic Review, Meta-analysis, and Meta-regression, JAMA Psychiatry, June 2018. https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2679768
[5] “National Projections of Supply and Demand for Behavioral Health Practitioners: 2013-2025”, Health Resources and Services Administration, November, 2016. https://bhw.hrsa.gov/sites/default/files/bhw/health-workforce-analysis/research/projections/behavioral-health2013-2025.pdf
[6] E. McNichol and M. Leachman. States Continue to Face Large Shortfalls Due to COVID-19 Effects. Center on Budget and Policy Priorities. July 2020. https://www.cbpp.org/research/state-budget-and-tax/states-continue-to-face-large-shortfalls-due-to-covid-19-effects
[7] N. Panchel et al., The Implications of COVID-19 for Mental Health and Substance Use. Kaiser Family Foundation. April 2020. https://www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/
[8] L Hamel, et al. KFF Health Tracking Poll – July 2020. https://www.kff.org/coronavirus-covid-19/report/kff-health-tracking-poll-july-2020/
[9] Colorado Department of Health Care Policy and Fib=nuancing. ACC Operational Dashboard. September 2020.https://www.colorado.gov/pacific/sites/default/files/ACC%20Phase%20II%20Operational%20Dashboard%20September%202020.xlsx
[10] Rhode Island EOHHS. Attachment K – Infrastructure Incentive Program: Requirements for Managed Care Organizations and Certified Accountable Entities. http://www.eohhs.ri.gov/Portals/0/Uploads/Documents/PY3Attach_K_Incentive_Program_Requirements_PY3_Final%20Updated%205.28.20%20for%20Web.pdf
[11] Colorado Department of Health Care Policy and Financing. Behavioral Health Incentive Program https://www.colorado.gov/pacific/sites/default/files/Accountable%20Care%20Collaborative%20Program%20Improvement%20Advisory%20Committee%20BHIP%20Preliminary%20Data%20Handout%20March%202020.pdf
Acknowledgements: The National Academy for State Health Policy (NASHP) would like to thank the state officials from Colorado, Minnesota, and Rhode Island who contributed to this brief as well as Health Resources and Services Administration Project Officer Carolyn Robbins and her colleagues for their feedback and guidance. The author also wishes to thank Trish Riley, Kitty Purington, Jodi Manz, and Kristina Long of NASHP for their contributions to the paper. This project was supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under co-operative agreement number UD3OA22891, National Organizations of State and Local Officials. The information, content, and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the US government.
States have long faced budget limitations, a history of systemic racism, and a mandate to contain costs while maintaining access to quality care. COVID-19 has exacerbated these issues as state revenues decline and communities of color are disproportionately impacted by the pandemic. These challenges raise an important question – how does a state advance health equity while addressing health system costs?
The rising cost of health care has created an additional barrier to accessing quality care, particularly for racial/ethnic minorities. In 2018, 13 percent of White patients reported going without needed care due to its prohibitively high cost. For nearly every other racial/ethnic group, this number ranged from 17 to 21 percent.
One contributing factor is that people of color are disproportionately uninsured. Not only are the uninsured solely responsible for their medical costs, but they are charged a higher rate for their care without the advantage of an insurer’s negotiated pricing with providers. Additionally, as millions of people have lost insurance coverage due to pandemic-related job loss, there remains a clear need for strategies that lower health care system costs rather than simply through insurance coverage.
Leveraging Payment Systems to Enable Community Investments
One such strategy discussed by state leaders at the National Academy for State Health Policy’s (NASHP) recent annual conference is a global hospital budget approach. Under this system, a state works with a hospital to determine the hospital’s allowed revenues for the year. As implemented in Maryland, a hospital’s deviation from its allowed revenues – whether by surplus or deficit – by more than a narrow 0.5 percent margin resulted in penalties against the hospital’s budget the following year.
Through this approach, a state offers predictable payments to hospitals and incentivizes them to avoid excess costs. While fee-for-service hospitals across the country express concerns of closures due to unpredictable revenue from the pandemic-related pause in elective procedures, participating global budget hospitals in Maryland have been able to rely on more consistent revenue despite a decline in care utilization.
This predictability better enables hospitals to retain revenue and invest those funds within the community to address the upstream determinants of health, as required of tax-exempt hospitals under community benefit laws. While research shows the majority of nonprofit hospitals do not address health disparities in their investments, Maryland is one of the states working to pivot hospital investments to meet equity goals. Maryland requires nonprofit hospitals to submit an annual report that includes a list of its community benefit initiatives and the cost of each one.
At NASHP’s conference, Katie Wunderlich, executive director of the Maryland Health Services Cost Review Commission, described a Baltimore hospital that has reduced its inpatient footprint and increased its spending on substance use disorder counseling, a healthy food market, and job training. Investments in the socioeconomic resources needed to foster good health (such as healthy housing, nutritious food, and sufficient income) are particularly important in communities of color, which have been historically deprived of these resources.
Just as global budgets enable hospitals to invest retained revenue in their communities, a growing number of states are utilizing cost-growth benchmark programs to avoid unnecessary public spending on health care, which can instead be invested in services beyond the scope of clinical care.
Utilizing Cost-Containment Strategies to Improve Chronic Care Management
While acute care provided in clinical settings is important for improving health, chronic conditions such as cardiovascular disease and cancer encompass a growing share of patient care needs and costs, particularly for patients of color. Managing these conditions – and preventing the costly care associated with them – require the engagement of the state, public and commercial payers, hospital and non-hospital providers, and community organizations alike.
Cost-growth benchmarks, in which a state sets a limit on annual per capita health spending growth, operate statewide and engage all stakeholders in managing a state’s total cost of care. State leaders can also use these as tools to improve health outcomes by including quality benchmarks.
Multiple entities work with the state oversight agency to set and meet these cost and quality benchmarks statewide, enhancing transparency, efficiency, and shared accountability for health care spending and quality. When it created its benchmark program through an executive order, Delaware established eight quality benchmarks, including:
Similarly, Maryland’s new total cost-of-care model seeks to reduce the burden of chronic disease – particularly diabetes – through a focus on chronic care management. The goal is to help providers pay specific attention to and provide additional resources for communities disproportionately affected by chronic diseases.
While meeting these statewide benchmarks would not inherently address equity issues within these health outcomes, the inclusion of these quality benchmarks can contain costs through effective management and prevention of chronic conditions. In turn, it would reduce health care spending among Black and Latinx adults as they are the most likely to suffer from cardiovascular disease risk factors, such as hypertension and obesity. As racial/ethnic minorities disproportionately lack health insurance coverage, it is crucial to prevent the development of inequitable health outcomes before costly clinical care intervention is needed, in addition to effectively managing these conditions in clinical settings.
Moving forward, states can use global budgets and cost-growth benchmarks as strategies to advance health equity while addressing health system costs. As states search for ways to better ingrain health equity into payment systems, these strategies offer states the ability to retain much needed revenues, focus upstream spending in non-clinical settings, better enable hospital community benefit spending, and manage chronic conditions that disproportionately impact people of color.
NASHP will be following the cost and health equity implications of these, and other, state efforts. For additional tools to help address health system costs, explore NASHP’s Model Act to Ensure Financial Transparency in Hospitals and Health Care Systems, designed to help state policymakers and the public access detailed hospital financial information to better analyze a hospital’s assets as well as its expenses and liabilities. Additionally, NASHP is also following state efforts to address health inequities highlighted by COVID-19.
Recognizing that improving oral health significantly affects overall health, Medicaid agencies in Colorado, Maine, and Oregon have begun to leverage their primary care-based accountable care programs to improve the delivery of oral health care to adults and children.
Introduction
| What’s an accountable care program?In an accountable care program, groups of providers (called accountable care organizations or ACOs) share responsibility for the quality of care, health outcomes, and cost for a defined population. These programs emphasize primary care, care coordination and integration, and value-based payment. Payment to an ACO and its affiliated providers depends, at least partially, on the ACO’s performance on defined metrics. |
For almost a decade, state Medicaid agencies and the federal government have worked to reform the health care system to produce better quality health care at a lower cost by implementing accountable care programs. States recognize that Medicaid enrollees often have difficulty accessing oral health services, even in states whose Medicaid programs cover dental services for adults. There has also been a growing consensus that integration of primary care and oral health services would help improve oral health.
The Medicaid programs in Colorado, Maine, and Oregon cover dental services provided to both adults and children. Although results are not yet available in Maine, Colorado and Oregon’s accountable care programs have generated promising results.
Policymakers seeking to improve the delivery of oral health services will benefit from an understanding of these states approaches and outcomes. In addition, as states face significant COVID-19 pandemic-related revenue declines, most will need to find ways to contain costs. As an optional Medicaid benefit, adult dental services could be targeted for cost cutting. As policymakers face difficult choices, the experience of these three states can inform those deliberations.
Each of these states established policies that address oral health in the areas of ACO payment and performance. Beyond this shared, high-level approach, the states have little in common. There is a some overlap in the measures the states chose to assess ACO performance. Both Colorado and Oregon assess ACO performance by measuring the percent of enrollees receiving preventive dental visits and factor that metric into ACO payments. Also, both Maine and Oregon assess ACOs’ performance in their rate of topical fluoride applications, but only Maine chose to factor that performance into its ACO payment. The following explains the policies developed by each state.
Colorado’s Regional Accountable Entities
| Colorado: • Considers oral health in three performance areas; • Factors performance on one oral health measure into ACO payment; and • Increased the percent of Medicaid enrollees with at least one dental visit. |
In Colorado, most Medicaid services are delivered to program enrollees through seven regional accountable entities (RAEs). RAEs support a local network of primary care medical providers (PCMPs) that deliver behavioral health services, coordinate members’ care across systems, and are accountable for the cost and quality of care delivered to Medicaid members. RAEs are paid through a combination of per member per month (PMPM) payments, capitation (for behavioral health services), and incentive payments. PCMPs receive fee-for-service payments from the Medicaid agency and administrative and incentive payments from the RAEs.) The total administrative PMPM available to the RAEs is $15.50. RAEs receive $11.50 of the administrative PMPM as a monthly payment and Colorado Medicaid withholds the remaining $4 to fund Key Performance Indicator (KPI) payments. There are seven KPI metrics, including one oral health measure. The Medicaid agency assigns each KPI a specific PMPM amount and, if a RAE produces sufficient improvement in the measure, it receives a payment based on the PMPM amount assigned to the measure. KPI payments are calculated and distributed each quarter. Unearned incentive payments are used to fund a challenge pool that is also distributed to the RAEs based on performance.
Although dental health services in Colorado are delivered under a separate contract and not through the RAEs, Colorado’s RAE contract requires RAEs to consider oral health services in several areas of operation. Examples include:
During the RAEs’ first year of operation, they increased the percent of Medicaid enrollees who had at least one dental visit from 33.83 percent during the baseline period (from July 1, 2017 to June 30, 2018) to 37.63 percent for the 12-month period from July 1, 2018 to June 30, 2019.
Oregon’s Coordinated Care Organizations
| Oregon: • Considers oral health in six performance areas; • Factors performance on four oral health measures into its ACO payments; • Increased the percent of children receiving dental sealants; and • Increased the percent of children entering foster care system who received an oral health assessment. |
In Oregon, almost all Medicaid services are delivered through regional coordinated care organizations (CCOs). Oregon’s CCOs are community-governed organizations that bring together physical, behavioral, and oral health providers to deliver coordinated physical, behavioral, and oral health care for their members. CCOs are funded through a global budget. CCOs also earn retroactive quality pool payments based on their performance on selected “incentive metrics” during the contract year. In 2018, the quality pool was $188 million, which represented 4.25 percent of the total amount all CCOs were paid in 2018. The slate of quality measures, which are selected by the Metrics and Scoring Committee, changes each year. In 2019, there were 19 incentive measures and in 2020 there are 13. CCOs must pay for all Medicaid-covered services (including dental services) provided to CCO members. CCOs may also use their funding to test new models of care and to provide services in addition to those covered by Medicaid. Finally, Oregon encourages CCOs to distribute quality pool payments to network providers, including oral health providers. Oregon’s CCO contract requires CCOs to consider oral health services in several areas of operation. Examples include:
Since Oregon began incentivizing performance on these measures, CCOs have increased the percent of children receiving dental sealants on permanent molars from 18.5 in 2015 to 24.8 in 2018. The increase was greatest for younger children — that number increased from 20.7 to 27.8 percent for children ages 6 to 9. The CCOs also increased the percent of children who received an oral health assessment (along with physical and behavioral health assessments) upon entering foster care from 27.9 in 2014 to 86.7 in 2018. (The other measures of oral health performance described above had not been in place long enough to produce documented trends.) An evaluation of Oregon’s program found that CCOs were more likely to produce improvements in measures that were part of the incentive program than those that were not—emphasizing the importance of tying ACO payment to performance.
Maine’s Accountable Community Partnerships
| Maine: • Considers oral health in two performance areas, and • At ACO’s option, will factor performance on one oral health measure into ACO payments. • No performance data has been published to date. |
In Maine, primary care practices can voluntarily form networks, identify a lead entity to administer the network, and contract with the Medicaid agency to become Medicaid ACOs, called Accountable Community Partnerships (ACs). Between Aug. 1, 2018 and July 31, 2019, the four ACs that were participating in the program included 90 practices that served 59,443 patients. Primary care providers that participate in an AC receive fee-for-service payment for the services they provide and those that qualify as a health home or behavioral health home receive PMPM care management fees.
ACs are paid through one of two payment models.
Model 2 pays ACs a greater share of the savings they produce than does Model 1. Savings and losses are calculated by comparing the total cost of care (TCOC) for providing a defined package of services to the members assigned to the AC with their projected TCOC absent the AC. Each AC decides whether it will include dental services in the defined package of services. If actual TCOC is less than projected, the difference is savings – if actual TCOC is more than projected, the difference is a loss. In order to receive any portion of the savings it produces, an AC must achieve a specified level of performance on a set of quality measures (fifteen core measures, four elective measures, and one monitoring-only measure). Then, the exact portion of the savings an AC receives depends on its performance on these same measures. Maine’s AC contract requires ACs that choose to include dental services in their TCOC calculations to consider oral health services in two areas of operation:
Although no AC has yet chosen to factor the cost of dental services into its TCOC calculations, one did choose to use the oral health measure in the 2018-2019 performance year.
Conclusion
Although accountable care programs focus on primary care, Colorado, Maine, and Oregon are all leveraging these programs to improve the delivery of dental care. Although it is still too early to assess Maine’s results, Colorado’s RAEs and Oregon’s CCOs have shown improved performance on measures of oral health care performance. It is important to note that even states such as Colorado that do not deliver dental services through Medicaid ACOs can still use the ACO structure to improve oral health care. Colorado, for example, incorporated a measure of oral health access (the percent of members who received oral health services) to reinforce the contract requirement that the ACOs foster connections between primary care and oral health providers. Importantly, however, the measure was also one that the RAEs’ contracted primary care providers could impact. States that seek to improve oral health services through Medicaid ACOs should consider taking the following steps.
Acknowledgements: The author thanks state officials in Colorado, Maine, and Oregon who graciously reviewed a draft of this publication. Trish Riley, Carrie Hanlon, and Ariella Levisohn of the National Academy for State Health Policy provided helpful guidance or assistance. Finally, we thank the Health Resources and Services Administration (HRSA) officials who provided thoughtful input. This project is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services under grant number UD3OA22891, National Organizations of State and Local Officials. This information, content, or conclusions are those of the author’s and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the US government.
The COVID-19 pandemic is shining a light on well-established racial disparities in health care access and quality, and in social and economic factors affecting health status and outcomes. The racial inequities exposed by case identification and death rates data give states opportunities to improve their responses and interventions.
As state and local data becomes available, Louisiana and Illinois governors have highlighted racial disparities in COVID-19 cases and deaths. This aligns with governors’ recent public statements about equity – 22 governors mentioned the need for educational, economic, and social equity in their state of the state addresses earlier this year.
State public health agencies are working around the clock to inform the public about the pandemic by regularly monitoring and reporting data, which is one of their core functions. An analysis by the National Academy for State Health Policy (NASHP) of state public health websites found that 25 states (AL, AR, AZ, CA, CT, GA, ID, IL, IN, LA, MA, MD, MI, MN, MS, NY, NC, OH, OK, SC, TN, TX, VA, WA, and WI) and Washington, DC are reporting COVID-19 data by race and/or ethnicity.
Among the findings:
State health secretaries and legislators also are emphasizing the importance of identifying disparities to understand and respond to the pandemic and promote health equity. Recently, Massachusetts’ Health and Human Services Secretary, MaryLou Sudders said, “I want to be clear, obtaining racial and ethnic data on cases of COVID-19 is crucial for examining where and on whom the burden of illness and death is falling…It’s actually essential for the commonwealth response to the pandemic and important information for all of us to understand.”
There are additional opportunities for states to monitor and address COVID-19 disparities. Gov. Andrew Cuomo of New York has committed to collecting more comprehensive data about COVID-19 in minority communities. Publicly reporting COVID-19 testing, hospitalization, and recovery by race and ethnicity could further allow state and local policymakers, providers, and other stakeholders to monitor and ensure equity in access to resources for prevention and treatment in order to improve outcomes.
State and city leaders can harness COVID-19 data to tailor their current responses to the pandemic and continue to identify strategies to meet the health and health-related social needs of communities of color. States use race/ethnicity data in a number of ways, including targeting or soliciting funding, tailoring stakeholder outreach and engagement, informing public health initiatives, and strengthening governmental processes to address disparities strategically and comprehensively.
In response to data in her state, Gov. Gretchen Whitmer established the Michigan Coronavirus Task Force on Racial Disparities to develop recommendations for addressing disparities “right now as we work to mitigate the spread of COVID-19 in Michigan.” Task Force chair, Lt. Gov. Garlin Gilchrist II, tweeted, “COVID-19 is a constant reminder of how dangerous racial disparities and inequality are for people of color. 14% of our population is Black, but more than 40% of deaths are in Black communities. I’m working alongside @GovWhitmer to make Michigan a leader in addressing this.”
City leaders also are taking action. Chicago Mayor Lori E. Lightfoot announced a multi-pronged strategy to “address systemic health inequities within the COVID-19 crisis.” Specifically, the mayor in collaboration with nonprofit partners is:
Importantly, the city’s health department signed a public health order enhancing data-sharing requirements for certain facilities to support COVID-19 tracking.
States can incorporate lessons into their existing state initiatives to ensure access to coverage and address health equity through accountable health models, Medicaid managed care contract language for social determinants of health, unique data-sharing agreements, and workforce strategies. As the Coronavirus Aid, Relief and Economic Security Act (CARES Act) funding is made available to states and hospitals, leaders can use the funds to support communities and populations disproportionally affected by COVID-19 due to structural and social inequities. States’ efforts to address health equity will continue throughout and beyond this pandemic. NASHP will continue to track states’ public reporting of COVID-19 by race and ethnicity.
| States Publicly Reporting COVID-19 Data by Race/Ethnicity* | |||
| State | Data Reported | Categories Used to Define Race/Ethnicity | |
| AL | Cases** | Race: Asian, Black, White, Other/Unknown
Ethnicity: Hispanic/Latino, Not Hispanic/Latino, Unknown |
|
| AR | Cases and Mortality | Black, White, American Indian, Asian, Pacific Islander, Multiracial, Other, Missing | |
| AZ | Cases and Mortality | White Non-Hispanic, Hispanic or Latino, Native American, Black Non-Hispanic, Asian/Pacific Island, Other Non-Hispanic, Unknown | |
| CA | Cases and Mortality | Latinos, Whites, African Americans/Blacks, Asians, Multiracial, American Indians or Alaska Natives, Native Hawaiians or Pacific Islanders, Other | |
| CT | Cases and Mortality | Hispanic, Non-Hispanic White, Non-Hispanic Black, Non-Hispanic Asian, Non-Hispanic Other, Non-Hispanic Unknown | |
| DC | Cases and Mortality | Race: Unknown, White, Black/African American, Asian, American Indian/Alaska Native, Other/Multiracial, Refused During the Interview
Ethnicity: Unknown, Hispanic or Latinx, NOT Hispanic or Latinx, Refused During Interview |
|
| GA | Cases | Race: Black or African American, White, American Indian/Native American, Asian, Multiracial, Native Hawaiian/Pacific Islander, Other, Unknown
Ethnicity: Hispanic/Latino, Non-Hispanic/Latino, Unknown |
|
| ID | Mortality | Race: White, Black, American Indian/Alaska Native, Asian/Pacific Islander, Other Race/Multiple Race, Race Information Pending
Ethnicity: Non-Hispanic, Hispanic, Ethnicity information Pending |
|
| IL | Cases and Mortality | White, Black, Hispanic, Asian, American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, Other, Left Blank | |
| IN | Cases and Mortality | Race: White, Black or African American, Asian, Other, Unknown
Ethnicity: Not Hispanic or Latino, Hispanic or Latino, Unknown |
|
| LA | Mortality | Race: American Indian/Alaska Native, Asian, Black, Native Hawaiian/Pacific Islander, Other, Unknown, White
Ethnicity: Hispanic/Latino, Non-Hispanic/Latino |
|
| MA | Cases and Mortality | Hispanic, Non-Hispanic White, Non-Hispanic Black/African American, Non-Hispanic Asian, Non-Hispanic Other, Unknown, Missing | |
| MD | Cases and Mortality | African-American, Asian, White, Other, Data not Available | |
| MI | Cases and Mortality | Race: American Indian or Alaska Native, Asian/Pacific Islander, Black or African American, Caucasian, Multiple Races, Other, Unknown
Ethnicity: Hispanic/Latino, Non-Hispanic/Latino, Other, Unknown |
|
| MN | Cases and Mortality | Race: White, Black, Asian, Native Hawaiian/Pacific Islander, American Indian/Alaska Native, Other, Unknown/Missing
Ethnicity: Hispanic, Non-Hispanic, Unknown/Missing |
|
| MS | Cases and Mortality | Black or African American, White, Other | |
| NY | Mortality | Hispanic, Black, White, Asian | |
| NC | Cases and Mortality | Race: American Indian/Alaska Native, Asian, Black or African American, Native Hawaiian or Pacific Islander, White, Other
Ethnicity: Hispanic, Non-Hispanic |
|
| OH | Cases and Mortality | Race: White, Black, Other, Unknown
Ethnicity: Non-Hispanic or Non-Latino, Hispanic, Latino, Unknown |
|
| OK | Cases and Mortality | Race: American Indian/Alaska Native Only, Asian Only, Black Only, White Only, Other/Multiple Races
Ethnicity: Hispanic or Latino (can be any race) |
|
| SC | Cases | Race: African American, White, Asian, American Indian or Alaska Native, Unknown, Other | |
| TN | Cases | Race: White, Black or African American, Other/Multiracial, Asian, Pending
Ethnicity: Not Hispanic or Latino, Hispanic, Pending |
|
| TX | Cases | Asian, Black, Hispanic, Other, Unknown, White | |
| VA | Cases | Race: Black or African American, White, Other, Not Reported | |
| WA | Cases and Mortality | Hispanic, Non-Hispanic American Indian or Alaska Native, Non-Hispanic Asian, Non-Hispanic Black, Non-Hispanic White, Non-Hispanic Native American or Other Pacific Islander, Non-Hispanic Multiracial, Non-Hispanic Other Race, Unknown | |
| WI | Cases and Mortality | Race: American Indian, Asian or Pacific Islander, Black, White, Multiple or Other Races, Unknown
Ethnicity: Hispanic or Latino, Not Hispanic or Latino, Unknown |
|
*As of April 12, 2020. View an updated interactive map highlighting state efforts to track COVID-19 case and death rates by race and ethnicity here.
** Cases in this table refer to laboratory-confirmed positive COVID-19 cases.
Support for this work was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the foundation.
Federal funding can help states improve housing, employment, and other life conditions for their vulnerable residents. This table highlights new programs, including public-private investment opportunities from the US Treasury, integrated care models from the Center for Medicare & Medicaid Innovation, and recent federal initiatives to combat the opioid crisis. It also features key longstanding sources, such as tax-exempt hospitals’ community benefits dollars, Medicaid investments, and health promotion funds from the US Centers for Disease Control and Prevention. This table updates and complements NASHP’s chart, Meeting the Health-Related Social Needs of Low-Income Persons: Funding Sources Available to States.
Print this chart.
| Funding Sources | Agency or Entity | Awarded to: | Needs Addressed | Notes and Sources |
| Social Impact Partnerships to Pay for Results Act | Treasury | States and localities | A goal of this act is to “facilitate the creation of public-private partnerships that bundle philanthropic or other private resources with existing public spending.” Social benefits that could be funded include: – Increasing employment and earnings, increasing financial stability for a range of populations, improving birth outcomes; |
Half the funding goes to programs that benefit children Most of the fund’s $100 million is allocated for outcomes payments, awarded to projects that are considered feasible and have an implementation plan. A Notice of Funding Availability (NOFA) was published in the Feb. 21, 2019 Federal Register. Award announcements are expected by November 2019. A separate NOFA for feasibility study grants for projects in the early stages is expected later in 2019. Legislation: Title VIII of the Bipartisan Budget Act of 2018 Projects are funded for up to 10 years Urban Institute explainer |
| Opportunity Zones | Treasury/ Internal Revenue Service (IRS)
Created by the Tax Cuts and Jobs Act of Dec. 22, 2017 |
Private investors defer taxes on capital gains by investing in Opportunity Funds, which invest in businesses located in an Opportunity Zone. State departments of economic development, commerce, housing development, and others can also be involved. The “CEOs” or leaders of each state nominates census tracts to be designated as opportunity zones. |
Economic development and job creation in certain low-income communities The proposed FY 2020 White House budget prioritizes the development of affordable housing in opportunity zones. The Kresge Foundation is partnering with two impact fund managers on Opportunity Zone investments, guided by community advisory boards that prioritize affordable housing without displacement and jobs that pay living wages. |
Proposed rules on investments in qualified opportunity zones were issued in October 2018 and April 2019. The first set of opportunity zones were designated in April 2018. IRS FAQs, Jan. 2019 State legislation enacted to support opportunity zones is available here This Executive Order established the White House Opportunity and Revitalization Council to support opportunity zone investment. The National Opportunity Zones’ Ranking Report from Smart Growth America ranks designated opportunity zones on their potential to improve social equity and foster walkable communities. Center on Budget and Policy Priorities’ blog, Potential Flaws of Opportunity Zones Loom, as Do Risks of Large-Scale Tax Avoidance |
| Funding Sources | Agency or Entity | Awarded to: | Needs Addressed | Notes and Sources |
| Integrated Care for Kids (InCK) | Center for Medicare & Medicaid Innovation (CMMI) | State Medicaid agency or lead organization | Children’s health-related needs, including adverse childhood experiences | NASHP Issue Hub: Resources to Help States Improve Integrated Care for Children |
| Maternal Opioid Misuse (MOM) model | CMMI | State Medicaid agencies | The model will include referrals to community services, such as housing and supported employment. | NASHP Issue Hub: Resources to Help States Improve Integrated Care for Children (includes MOM information) |
| Funding Sources | Agency or Entity | Awarded to: | Needs Addressed | Notes and Sources |
| Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act | US Department of Health and Urban Development (HUD) | States are to distribute housing pilot funds “giving priority to entities with the greatest need and ability to deliver effective assistance in a timely manner.” | Housing: The act establishes a pilot program for states to provide temporary housing (for no more than two years) to people recovering from substance use disorder (SUD). | Section 8071 of the act, enacted in October 2018, authorizes funds for housing pilots to be appropriated FY 2019 through FY 2023. Funds will be allocated according to a needs-based funding formula established by HUD. Funds are to be treated as though they were Community Development Block grants (CDBG) funds. Read NASHP’s blog, New Funding and Flexibility for States to Address Substance Use Disorder. |
| State Opioid Response (SOR) Grants | Substance Abuse and Mental Health Services Administration (SAMHSA) | States and territories; single-state agencies delivering substance abuse services (generally departments of health, human services, or social services) | States can use it for:
– Recovery housing
|
No match required Each state gets at least $4 million Applications were due August 2018 Programs funded for up to two years See NASHP’s chart of federal opioid funding by state Pennsylvania is using SOR funds for pilot projects to help people with opioid use disorder become and remain housed. |
| Opioid State Targeted Response to the Opioid Crisis (STR) Grants | SAMHSA, created by the 21st Century Cures Act | Single-state agencies based on unmet need for opioid use disorder treatment and drug poisoning deaths. | States are using it for:
– Recovery housing
|
Example: Colorado and Pennsylvania are using it to fund co-location pilots and bi-directional referrals for women and children. Two-year program Funding was awarded for Year One and Two 2017 Funding Opportunity Announcement An FY18 supplement was available for 10 states with highest overdose rates See NASHP chart |
| Funding Sources | Agency or Entity | Awarded to: | Needs Addressed | Notes and Sources |
| Tax-Exempt Hospital Community Benefits | Tax-exempt hospitals, pursuant to Treasury/IRS requirements | Community organizations or programs. Policies overseen by state attorneys general and/or public health agencies |
A range of community health improvement services and community benefit activities, guided by the hospital’s community health needs assessment. They can include community building activities, such as housing, economic development, child care, and mentoring programs for vulnerable populations or neighborhoods. Hospitals report this information on Form 990 Schedule H. | States can create reporting and investment requirements that go beyond those established by the federal government. See NASHP’s infographic How 10 States Keep the ‘Community’ in Hospitals’ Community Health Needs Assessments, and blog States Work to Hold Hospitals Accountable for Community Benefits Spending. Sara Rosenbaum, et al., Improving Community Health through Hospital Community Benefit Spending: Charting a Path to Reform, December 2016 Robert Wood Johnson Foundation’s Community Benefit Insight tool The Hilltop Institute, Community Benefit State Law Profiles Comparison |
| Hospital Certificate of Need (CoN) requirements | Tax-exempt hospitals in states with a CoN requirement | Community organizations or programs Policies overseen by state attorneys general and/or public health agencies |
Community health needs, often identified by the hospital’s community health needs assessment | State CoN requirements are generally triggered by hospital projects and expansions, such as capital improvements. NASHP’s State Strategies to Address Rising Prices Caused by Health Care Consolidations |
| Funding Sources | Agency or Entity | Awarded to: | Needs Addressed | Notes and Sources |
| US Centers for Disease Control and Prevention (CDC) Chronic Disease Prevention and Health Promotion funding | CDC | State and local public health agencies | CDC funding supports a range of state chronic disease and violence prevention activities, as well as condition-specific funding. | CDC FY 2018 grant funding by state |
| Funding Sources | Agency or Entity | Awarded to: | Needs Addressed | Notes and Sources |
| Medicaid Section 1115 Demonstrations
|
Centers for Medicare & Medicaid Services (CMS) | State Medicaid agencies
Agencies involved could include State Innovation Model (SIM) or transformation offices. |
Housing services, transportation, education, social isolation, employment, investment in community partnerships, and other issues | NASHP’s State Delivery System and Payment Reform Map (Delivery System Reform and Incentive Payment tab) NASHP’s State Strategies to Improve Health Through Housing Services Center for Health Care Strategies (CHCS), Addressing Social Determinants of Health via Medicaid Managed Care Contracts and Section 1115 Demonstrations |
| Medicaid managed care contracting | CMS | State Medicaid agencies | States can encourage or require managed care organizations to invest in a range of non-clinical needs, including nutrition, physical activity, and housing. | NASHP’s How States Address Social Determinants of Health in their Medicaid Contracts and Contract Guidance Documents Sara Rosenbaum, et al., How Are States Addressing Primary Care Quality in Medicaid Managed Care? |
| Medicaid Section 1915(c) Home and Community Based Services waivers and 1915(i) state plan amendments | CMS | State Medicaid agencies | Housing and employment supports and others | NASHP’s Housing-Related Service Definitions in 1915(i) State Plan Amendments, 1915(c) Waivers, and Section 1115 Demonstrations NASHP’s Tenancy Supports in Three States’ Medicaid Waivers NASHP’s State Housing and Services Options in 1915(c) Waivers for People with Developmental Disabilities |
Additional resources to help states meet health-related needs, by authoring organization:
NASHP Resources
Meeting the Health-Related Social Needs of Low-Income Persons: Funding Sources Available to States, 2016. Table provides an overview of funding sources.
State Strategies to Improve Health through Housing Services, 2016. Chart contains funding mechanisms.
Financing Prevention, 2014
Blending, Braiding, and Block-Granting Funds for Public Health and Prevention: Implications for States, December 2017. Two tables: featuring block grants and state examples of Medicaid authorities to address non-clinical needs.
For New Governors: Snapshot of Major Federal Opioid Funding by State, December 2018:
Toolkit: Upstream Health Priorities for New Governors, December 2018.
*For additional information on funding health-related services, explore NASHP’s Population and Public Health resource list.
Academy Health/Nemours
Innovative Medicaid Payment Strategies for Upstream Prevention and Population Health, May 2018.
Center for Health Care Strategies
Addressing Social Determinants of Health via Medicaid Managed Care Contracts and Section 1115 Demonstrations, December 2018.
Addressing Social Determinants of Health through Medicaid Accountable Care Organizations, April 2018.
Commonwealth Fund
Enabling Sustainable Investment in Social Interventions: A Review of Medicaid Managed Care Rate-Setting Tools, January 2018.
Addressing the Social Determinants of Health through Medicaid Managed Care, November 2017.
Georgia Health Policy Center
Bridging for Health: Improving Community Health through Innovations in Financing, February 2019.
Kaiser Family Foundation
Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity, May 2018.
National Academy of Social Insurance
Strengthening Medicaid as a Critical Lever in Building a Culture of Health, January 2017.
Support for this work was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the foundation.
At least 12 states are developing accountable health models to improve health and control costs by addressing health-related community needs, such as transportation, recreation, and housing. Their goals include building healthy communities and improving health equity through cross-sector partnerships, and their organizational and governance structures are evolving to reach these goals.
In these accountable health entities, a state-level coordinating group designates and supports community-based organizations or coalitions that invest in, or are accountable for, improving population health and health equity. Generally, states provide direction to the local government agencies, community organizations, health systems, or other partners that convene accountable entities about how they should govern them. Some states encourage rather than require certain facets of governance, while other states are more prescriptive. Frequently, states ask local accountable health leaders to establish a governance structure that outlines key requirements, such as defining:
An effective governance structure can ensure the efficient operation of the accountable entity, and can also help highlight local goals and perspectives alongside state priorities.
In developing a comparison table of accountable entity governance structures, the National Academy for State Health Policy (NASHP) examined the overall goals and functions of each governing body and their required representation. The methods by which states hold entities accountable for their operations, such as mandatory reporting or open meetings requirements, were noted. For example:
NASHP also examined the language states used to ensure that the local community was meaningfully engaged in the operations of the accountable entity. For example:
Just as community representation is crucial to identifying community needs, representation from service providers, clinicians, and state and local government is key to addressing those needs. States encourage broad representation from providers, community service organizations, and others who affect the health of communities. For example:
Building meaningful community engagement into state health initiatives is a strategy that resonates far beyond accountable health entities. NASHP will be publishing an analysis of the role that community engagement has played in tax-exempt hospitals’ community health needs assessment process later this year. As states continue to prioritize community health initiatives, the question of who represents the community and how best to include their voices is becoming increasingly important for states.
The state models NASHP features in its chart are in varying stages of maturity, with key governance decisions still to come in many states. NASHP will continue to support states participating in its accountable health workgroup, and will share best practices from states working to align state and community health and prevention priorities to achieve health equity and help all residents thrive.
Support for this work was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the foundation.
More than a dozen states are developing accountable health models to improve population health and control costs by addressing community needs, such as transportation, recreation, and housing. These entities’ mission — to build healthy communities through cross-sector partnerships — is supported by innovative and evolving governance structures. This NASHP chart and a companion blog highlight how states are structuring these entities to keep them accountable and reflective of their communities.
Print this chart.
| State | Description, Goals, and Functions of Governing Body | Representation in Governing Body | Community Engagement | Governance Accountability, Incentives, or Milestones | Connection to Other State Initiatives |
| California Accountable Communities for Health Initiative (CACHI) | “An accountable communities for health (ACH) must establish a sound governance structure that ensures effective decision-making; accountability to the community; representation of stakeholders’ interests; proper fiduciary, fiscal, and social responsibilities; and control over funding and staff.” (ACH Legal & Practical Recommendations, p. 4) An ACH should have a set of rules (bylaws or agreement) to hold stakeholders accountable to their obligations, defined fiduciary duties for the Governing Body, established controls over activities and finances, and a conflict of interest policy and procedure.” (p. 4) |
The ACH collaborative must include: “-Health plans, hospitals, private providers or medical groups and community clinics serving the geographic area. -Government health and human services agency/public health department -Grassroots, community and social services organizations that include authentic and diverse representation of residents, particularly from underserved communities.” “It is desirable that every ACH include broad representation of several of the following types of entities: -County and/or city government leadership, including elected officials -Behavioral health providers – Housing agencies -Food systems -Employers and other business representatives -Labor organizations -Faith-based organizations -Schools and educational institutions -Parks and recreational organizations and agencies -Transportation and land use planning agencies -Dental providers -Local advocacy, grassroots organizations or policy-focused organizations.”(RFP, p. 7) |
CACHI’s Year 1 request for proposals awarded points for, “Meaningful resident engagement and a process for ongoing engagement throughout the funding period.” (RFP, p. 14) | Recommended key milestone: “By the end of Year 1: Develop a governance plan that includes the following: -A list of community sectors to be represented on the Governing Body of the Wellness Fund. -An outline of key components of bylaws to establish the number of directors, meetings, voting procedures, a community investment committee, and conflict of interest and anti-nepotism policies. -A document outlining how accountability to the community will be achieved and maintained (e.g., by reserving board and committee slots for community residents and providing annual reports on activities and spending).” (ACH Legal & Practical Recommendations, p. 35-36) |
| State | Description, Goals, and Functions of Governing Body | Representation in Governing Body | Community Engagement | Governance Accountability, Incentives, or Milestones | Connection to Other State Initiatives |
| Colorado Regional Accountable Entities | “The contractor shall have a governing body responsible for oversight of the Contractor’s activities in relation to this Contract.” (RFP 5.3.5) |
“The contractor shall select members of the governing body in such a way as to minimize any potential or perceived conflicts of interest.” (5.3.5.1) | “The regional accountable entities (RAE) will develop mechanisms to engage community partners within the RAE’s region for population health and nonmedical community services.” (3.3.10) The RAE will “promote physical and behavioral health ….[and] the population’s health and functioning, coordinate care across disparate providers, interface with long-term services and supports providers, and collaborate with social, educational, justice, recreational and housing agencies to foster healthy communities ….” (3.3.3) |
The contractor shall publicly list information, including, but not limited to, the names of the members of the governing body and their affiliations, on the contractor’s governing body on the contractor’s website.” (RFP, 5.3.6) | “The program will focus on greater coordination with the Colorado Departments of Human Services, Public Health and Environment, Education, and Corrections, as well as initiatives such as Comprehensive Primary Care Plus (CPC+), State Innovation Model (SIM), Hospital Transformation Program, and the Colorado Opportunity Project. The RAE will play key regional roles in these initiatives as they are well aligned with the Accountable Care Collaborative’s goals.” (3.3.11) |
| State | Description, Goals, and Functions of Governing Body | Representation in Governing Body | Community Engagement | Governance Accountability, Incentives, or Milestones | Connection to Other State Initiatives |
| Connecticut Health Enhancement Communities (HECs) | “Health Enhancement Communities (HEC) will have a defined structure, with a formal governance structure and community organizing groups. The formal governance structure will have clearly defined decision-making roles, authorities, and processes. The community organizing groups will have ownership and decision-making authority over the things that matter most to them and will lead the identification and implementation of interventions in their communities.” HEC Design Principles (See p. 52-54 of HEC model design draft proposal, Oct. 22, 2018, for chart of other governance requirements.) |
“-In addition to community organizing groups, HECs will need to identify multiple methods for gaining meaningful involvement, including in decision-making, as HECs form and operate -HECs will need to include multiple community organizations that directly address root causes of poor health in their communities.” (HEC model design draft proposal p. 52) |
“Given their unique and essential perspectives and insights about their communities, HECs’ success depends on the ongoing involvement of community members and community members making decisions about things that matter most to them. In addition to community members being involved in HEC formation and operation, the HEC structure should also support community organizers and locally owned and directed community organizing groups within communities….” (HEC model design draft proposal p. 9-10) | Minimum governance structure elements required by the state and determined by HECs: “-Partnership agreements -Bylaws -Backbone organization -Formal contracts for services.” (HEC model design draft proposal p. 52-53) |
State Innovation Model |
| State | Description, Goals, and Functions of Governing Body | Representation in Governing Body | Community Engagement | Governance Accountability, Incentives, or Milestones | Connection to Other State Initiatives |
| Delaware Healthy Neighborhoods | Neighborhood task forces: “Create and propose data driven, evidence-based initiatives, request funds…measure outcomes… engage in quality improvement. Local councils “serve as a ‘board’ of the Healthy Neighborhood (e.g. decision making about resource allocation)… [and] approve Task Forces’ requests for resources.” (HMA, Healthy Neighborhoods Model, Dec. 2017, p. 7) The role of the fiscal agent is to: -“Distribute funding to entities implementing Task Force Initiatives (once ‘readiness process’ has been completed) -Collect data/outcomes from each Task Force related to funded initiatives and utilize this practice of continuous analysis as a tool for ongoing learning -Focus on sustainability of the SIM Grant funding (e.g., establishing and managing a community trust) -Serve as a ‘Backbone Organization’ across all Local Councils.”(HMA, p. 4) |
Local neighborhood task forces contain: “-Local community stakeholders and leaders that are focused on a priority area -Two co-chairs.” Local councils are made up of: “-At least one representative from each task force -Local leaders with expertise in priority areas -Cross-sector entities and organizations recruited via the Social Network Analysis to ensure representation of all critical entities -Delivery systems as well as community-based organizations -Community advocates from neighborhoods -Community stakeholders.” (HMA, p. 7) “Voting procedures are established in the bylaws of the Local Council.” (HMA p. 18)Local councils are advised by a statewide consortium with: “-Local council co-chairs -Statewide leaders focused on user-friendly community-level data -Statewide leaders focused on sustainability of healthy neighborhoods -Statewide leaders focused on policy -Advocacy organizations from neighborhoods -The statewide fiscal agent.” (HMA p. 8) |
“Readiness assessment will assess: -Did the task force use data about community needs to develop the initiative? -Did the task force include representatives from diverse entities who weighed in on the creation of the plan? -Similarly, do you have community buy-in?” (p. HMA 15-16) |
State Innovation Model |
| State | Description, Goals, and Functions of Governing Body | Representation in Governing Body | Community Engagement | Governance Accountability, Incentives, or Milestones | Connection to Other State Initiatives |
| Massachusetts Accountable Care Organizations (ACOs) | Massachusetts Health Policy Commission (HPC)’s ACO Certification Program assessment criteria includes a “Patient-centered, accountable governance structure.” (ACO Policy Brief, April 2018, p. 3) |
“The ACO provides for meaningful participation in the composition and control of the Governing Body for its participants or their representatives.” ACOs must attest that “ACO Participants have at least 75% control of the Governing Body (Proposed 2019 ACO Certification Standards, p. 7). – [ACOs must have] “at least one patient or consumer advocate within the governance structure.” (Proposed 2019 ACO Certification Standards, p. 7-8) |
“The ACO governance structure is designed to serve the needs of its patient population, including by having … a patient and family advisory committee.” (Proposed 2019 ACO Certification Standards, p. 7-8) | The HPC requires ACOs to submit an “Organizational chart(s) of the Governance Structure(s) of the Applicant (and Component ACOs as applicable), including Governing Body, executive committees, and executive management, and indicating the location of a patient or consumer representative role within each Governance Structure.” (Proposed 2019 ACO Certification Standards, p. 5-6) ACOs are required to submit a Full Participation Plan that includes “The providers and organizations with which the ACO is partnering or plans to partner, the governance structure … [and] a population and community needs assessment.” (p. 14) |
MassHealth Medicaid Section 1115 Demonstration |
| “The ACO Governing Body regularly assesses the access to and quality of care provided by the ACO, in measure domains of access, efficiency, process, outcomes, patient safety, and patient experiences of care, for the ACO overall and for key subpopulations (i.e. medically or socially high needs individuals, vulnerable populations), including measuring any racial or ethnic disparities in care.” (Proposed 2019 ACO Certification Standards, p. 8) | ACOs are required to submit a Full Participation Plan that includes “The providers and organizations with which the ACO is partnering or plans to partner, the governance structure … [and] a population and community needs assessment.” (DSRIP protocol, p. 14) |
| State | Description, Goals, and Functions of Governing Body | Representation in Governing Body | Community Engagement | Governance Accountability, Incentives, or Milestones | Connection to Other State Initiatives |
| Michigan Community Health Innovation Regions (CHIRs) | “Each of the five regions is supported by a backbone organization that serves as a fiduciary and acts as a neutral convener for the CHIR’s governing body.” “CHIR partners are organized by a neutral backbone organization that [serves as a fiduciary and] facilitates the development and implementation of key strategies, creating the necessary capacity to sustain progress on stated objectives. CHIR steering committees provide a clear leadership structure and promote shared accountability among partners for aligning their resources to address priority community health needs.” (SIM, “About CHIRS”) |
“CHIR governance facilitates effective collaboration of providers, health plans, community based organizations and individuals to pursue community‐centered solutions to upstream factors of poor health outcomes and health disparities.” (NASHP slides, Aug. 2018) | State Innovation Model |
| State | Description, Goals, and Functions of Governing Body | Representation in Governing Body | Community Engagement | Governance Accountability, Incentives, or Milestones | Connection to Other State Initiatives |
| Minnesota Accountable Communities for Health (ACHs) | “The lead organization is responsible for convening a multi-sectoral governing body with representation from partner organizations and the community. ACH projects are exploring and testing a variety of governance approaches such as charters, formal business agreements between partners and use of technical subcommittees …. ACH leadership team structure and makeup differs across ACHs. Some ACHs created an entirely new governance structure while others use existing committees, task forces, or advisory bodies (such as Statewide Health Improvement Program – SHIP – committees) to organize their work.” (ACH: Perspectives on Grant Projects and Future Considerations, Oct. 2016, p. 12). “Besides leadership and governance, the ACH must have a ‘backbone’ or lead organization to serve as convener and integrator.” (p. 35) |
“Each ACH has a lead organization (e.g., private foundation, non-profit social service agency, local public health agency or health care system) that serves as fiscal agent and resources manager. The lead organization is responsible for convening a multi-sectoral governing body with representation from partner organizations and the community.” (ACH: Perspectives on Grant Projects and Future Considerations, p. 12) “All health plans and systems serving the population should participate in the ACH. Local public health must be an active partner, and local political leaders, government officials and other leaders should be invited to participate. Most importantly, the governing body should ensure that persons experiencing health disparities are represented in ACH partnerships, mission and vision.” (ACH: Perspectives on Grant Projects and Future Considerations, p. 35) |
“Each ACH grant project features … community-led leadership.” (Minnesota Accountable Communities for Health) | Required components of each ACH grant project are: “-Community-led leadership -Care coordination between multi-sectoral partners -Population-based prevention -Measurement and evaluation -Partnership with an Accountable Care Organization -Participation in an ACH learning community -Sustainability planning -Health equity focus.” (Minnesota Accountable Communities for Health) |
| State | Description, Goals, and Functions of Governing Body | Representation in Governing Body | Community Engagement | Governance Accountability, Incentives, or Milestones | Connection to Other State Initiatives |
| New York Performing Provider Systems (PPSs) | “The Performing Provider System will need to demonstrate that it has a governance strategy that ensures that participating providers work together as a “system” and not as a series of loosely aligned providers nominally committed to the same goal.” (DSRIP Program Funding and Mechanics Protocol, p. 14) | “Please explain how the selected members provide sufficient representation with respect to all of the providers and community organizations included within the PPS network. Please outline where coalition partners have been included in the organizational structure, and the PPS strategy to contract with community based organizations.” (DSRIP PPS Organizational Application, p. 35) |
“Describe how the PPS governing body will engage stakeholders on key and critical topics pertaining to the PPS over the life of the DSRIP program.” (DSRIP PPS Organizational Application, p. 34-36) | Medicaid Section 1115 Demonstration Delivery System Reform Incentive Payment program | |
| “Describe the decision making/voting process that will be implemented and adhered to by the governing team. Explain how conflicts and/or issues will be resolved by the governing team.” (DSRIP PPS Organizational Application, p. 35.) | State Health Innovation Plan (through the State Innovation Model) | ||||
| State Health Improvement Plan (the Prevention Agenda). |
| State | Description, Goals, and Functions of Governing Body | Representation in Governing Body | Community Engagement | Governance Accountability, Incentives, or Milestones | Connection to Other State Initiatives |
| Oregon Coordinated Care Organizations (CCOs) | “Coordinated care organizations may be local, community-based organizations or statewide organizations with community-based participation in governance or any combination of the two.” (2017 ORS 414.625) “Each coordinated care organization’s governing body establishes standards for publicizing the activities of the coordinated care organization and the organization’s community advisory councils, as necessary, to keep the community informed.” (ORS 414.625) |
“Each coordinated care organization has a governing body of which a majority of the members are persons that share in the financial risk of the organization and that includes: (a) A representative of a dental care organization selected by the coordinated care organization; (b) The major components of the health care delivery system; (c) At least two health care providers in active practice, including: (i) A physician licensed under ORS chapter 677 or a nurse practitioner certified under ORS 678.375 (Nurse practitioners), whose area of practice is primary care; and (ii) A mental health or chemical dependency treatment provider; (d) At least two members from the community at large, to ensure that the organization’s decision-making is consistent with the values of the members and the community; and (e) At least one member of the community advisory council.” (2017 ORS 414.625) |
Required to serve on the governing body are: “At least two members from the community at large, to ensure that the organization’s decision-making is consistent with the values of the members and the community; and At least one member of the community advisory council.” (2017 ORS 414.625)Community advisory councils: “A coordinated care organization must have a community advisory council to ensure that the health care needs of the consumers and the community are being addressed. The council must: (a) Include representatives of the community and of each county government served by the coordinated care organization, but consumer representatives must constitute a majority of the membership; and (b) Have its membership selected by a committee composed of equal numbers of county representatives from each county served by the coordinated care organization and members of the governing body of the coordinated care organization.” (2017 ORS 414.627) |
Medicaid Section 1115 Demonstration |
| State | Description, Goals, and Functions of Governing Body | Representation in Governing Body | Community Engagement | Governance Accountability, Incentives, or Milestones | Connection to Other State Initiatives |
| Rhode Island Accountable Entities (AEs) | “The intent of these requirements include: 1) To ensure multi-disciplinary providers are actively engaged in a shared enterprise and have a stake in both financial opportunities and decision-making of the organization; (2) to ensure that assets and resources intended to support RI Medicaid are appropriately allocated, protected, and retained in Rhode Island; (3) to ensure that the mission and goals of the new entity align with the goals of EOHHS and the needs of the Medicaid population; (4) to ensure a structured means of accountability to the population served.” (AE Certification Standards, 2017, p. 16) |
“There shall be an established means for shared governance that provides all AE Partner Providers with an appropriate, meaningful proportionate control over the AE’s decision-making process.” (AE Roadmap, April 2017, p. 42) “Board or Governing Committee Membership. The majority of voting members of the Board or the Governing Committee shall be provider representatives from participating Partner or Affiliate provider organizations, provided that at least three members shall be LTSS providers and one member shall be a behavioral health provider. Minimal representation requirements for each population certified to serve -Children: pediatric representative member of Consumer Advisory Committee, community-based organization (CBO) provider of age-appropriate supports -Adults: representative member of Consumer Advisory Committee, CBO provider of age-appropriate social supports (AE Certification Standards, 2017, p. 45) |
Draft certification standards include a requirement for AEs to have a “Community Advisory Committee consisting of at least ten persons who are attributed Medicaid beneficiaries who are representative of the populations served by the AE.” (AE Roadmap, 2.1.8) | Medicaid Section 1115 Demonstration | |
| State Innovation Model (SIM) |
| State | Description, Goals, and Functions of Governing Body | Representation in Governing Body | Community Engagement | Governance Accountability, Incentives, or Milestones | Connection to Other State Initiatives |
| Vermont Accountable Communities for Health (ACHs) | “An accountable community for health is managed through a governance structure that articulates the process for decision-making and outlines the roles and responsibilities of the integrator organization, the steering committee (or other decision-making body), and other collaborative structures or partners.” From Vermont Accountable Communities for Health Peer Learning Lab Report, March 2017 |
“The governance structure should include a diverse representation of stakeholders, including decision-makers, experts, community members, and leaders from the variety of community organizations that impact health in the region.” (Vermont ACH Peer Learning Lab Report, p. 18). | “The ACH Peer Learning Lab sought to build on this framework and test model implementation while increasing community capacity and readiness across the nine Core Elements of the ACH model.” (Vermont ACH Peer Learning Lab Report, p. 6 ) |
Governance is one of the nine core elements of the ACH model. (Vermont ACH Peer Learning Lab Report, p. 18) |
| State | Description, Goals, and Functions of Governing Body | Representation in Governing Body | Community Engagement | Governance Accountability, Incentives, or Milestones | Connection to Other State Initiatives |
| Washington Accountable Communities of Health (ACHs) | Accountable communities of health must: -Maintain a governance structure that includes balanced cross-sector collaboration and decision-making, including the necessary documented procedures and agreements, e.g. bylaws and a memorandum of understanding. -Ensure that no one sector or organization can control decision-making. -Revisit the process at least annually to determine effectiveness considering the regional landscape and specific governance structure.” (State Innovation Model Contractual Guidelines for Accountable Communities of Health, P. 5)“Minimum expectation: ACHs must develop and maintain a communications framework to keep partners informed and involved in between meetings and events.”(State Innovation Model Contractual Guidelines for Accountable Communities of Health, p. 8). |
“Washington’s tribes and urban Indian health organizations (UIHOs) are among the partners ACHs should reach out to for participation in ACH activities, including governance and decision making… Tribal governments are not stakeholders. The state maintains relations with the tribes on a government-to-government basis.” (State Innovation Model Contractual Guidelines for Accountable Communities of Health, p. 7) | “ACHs require governance structures tailored by community leaders to most effectively implement the goals of Healthier Washington at the local level.” (State Innovation Model Contractual Guidelines for Accountable Communities of Health, p. 5). “Because of the unique regional demographics, existing resources, and potential initiatives already under way, the specific community engagement strategies will not be prescribed by the state.” (State Innovation Model Contractual Guidelines for Accountable Communities of Health, p. 8). |
“Minimum expectation: ACHs must implement a cascading engagement approach tailored to the local environment that brings the voice of consumers and individual community members to ACH development and decision making, in addition to the balanced multi-sector decision making structure.” (State Innovation Model Contractual Guidelines for Accountable Communities of Health, p. 8) “ACHs are strongly encouraged, under the SIM contract, to maintain open public governing body meetings.” (State Innovation Model Contractual Guidelines for Accountable Communities of Health, p. 8) |
State Innovation Model |
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. 
