States Share Innovative Approaches to Improve Population Health through Accountable Health Models
More than 200 state health officials crowded into a National Academy for State Health Policy’s (NASHP) annual conference session recently to learn about strategies to improve population health and reduce costs while simultaneously transforming their state’s health care finance and delivery models.
An Accountable Community for Health (ACH) is:
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They came to hear representatives from California, Michigan, Oregon, and Washington State discuss their approaches to building population health priorities into their health system transformations through “accountable health” organizations. These entities invest in population health improvement through Accountable Communities for Health (ACHs) and care delivery structures that are accountable for population health, such as Accountable Care Organizations and Coordinated Care Organizations (CCO).
During the standing-room-only session, the four state presenters described their unique models, including financing and measurement strategies and relationships to broader health system transformation. Officials shared examples of how these new delivery models invest in social determinants of health to increase health and well-being and control costs. Examples include:
- Several of California’s Accountable Communities for Health have chosen to focus on reducing violence and trauma as a priority. One conference participant observed, “It doesn’t matter how many times people who are victims of domestic violence see a doctor, it won’t improve their health until the violence stops.”
- Michigan’s Community Health Innovation Regions identified the intersection of housing, homelessness, and health as a priority area. Its goal is to strengthen collaboration between health and housing agencies and develop solutions for Medicaid beneficiaries whose housing needs put their health at risk.
- Oregon CCOs’ global budgets give them flexibility to provide non-medical services that result in better health and lower costs, such as supporting home improvements and rental assistance, embedding mental health professionals in school systems, and promoting gym memberships.
- Washington state’s Accountable Communities of Health are addressing the opioid use public health crisis.
During the conference, NASHP also facilitated a half-day convening of state policymakers from 10 states, across departments and agencies, to advance state accountable health models. During the session, state officials discussed models, shared strategies, and identified multi-sectoral funding to support their focus on population health, health disparities, and social determinants of health. This cross-sector convening included officials from Medicaid and public health agencies and state health transformation offices, along with some key partners.
NASHP will continue to convene meetings, analyze, and report on the evolution of these state models, and build on previous analysis of State Levers to Advance Accountable Communities for Health, to help states advance these transformational efforts. Stay tuned for an upcoming cross-state comparison chart and accompanying issue brief that share lessons and themes related to accountable health models gathered during the NASHP annual conference.
For more information about NASHP’s work on state accountable health models, e-mail NASHP Senior Program Director Jill Rosenthal at jrosenthal@oldsite.nashp.org.
NASHP Identifies State Strategies to Address Mental Health and Education Inequities
State policymakers increasingly recognize the need to address the social determinants of health — housing, employment, education, and income — to reduce health care costs and improve population health. Educational attainment, for example, provides dividends for overall health. People with higher levels of education generally live longer and experience healthier lives.
The quality of education a student receives impacts educational attainment and overall health. Evidence shows the overrepresentation of certain groups of students in separate classrooms or other settings of poorer quality overwhelmingly affects students of color. Teachers have identified students of color as having disabilities at higher rates than white students, with research documenting racial bias as influencing their decisions to remove students from the classroom. Students removed from mainstream education settings are less likely to make progress, build skills, and/or return to general educational settings. Black and Latino students are more likely to be affected by disproportionality.[1]
| Disproportionality occurs when any racial or ethnic group’s numbers in special education classes or programs are statistically higher than other students. |
States are uniquely positioned to promote the mental health and educational achievement of all children by addressing the mechanisms that underlie racial and ethnic differences in mental disorder onset and persistence, and the causes and consequences of disproportionality in out-of-regular classroom settings, such as resource rooms, separate schools, or separate facilities. Using the resources of a variety of agencies, including public health, Medicaid, mental health, and education, can address disproportionality. Drawing from interviews with state officials conducted in conjunction with Massachusetts General Hospital’s Disparities Research Unit, the National Academy for State Health Policy (NASHP) identified state policy levers and programs, including mental health consultation, data sharing, convening authority, systemic interventions and supports, that states can use to eliminate mental health disparities.
State Levers to Address Disproportionality in Educational Settings
- Mental health consultation programs: Minnesota, Delaware, Colorado, Ohio and Connecticut utilize mental health consultation programs that can support efforts to address disproportionality. Mental health consultation varies across states, but commonly mental health providers support child care professionals and teachers, including Head Start, Part C Early Intervention Program, and child care workers, to improve their ability to identify and ameliorate mental health issues in children. States are also investing in training resources to improve the skills of early childhood mental health clinicians. Mental health consultants are typically funded by Medicaid agencies, education agencies, state general revenue or federal funds, or grants, and may receive cultural awareness training designed to improve their skills while reducing implicit cultural and racial bias. With leadership from the Substance Abuse and Mental Health Services Administration and other federal health and education agencies, states increasingly expect mental health consultants to carry out their consultative and clinical services in ways that help teachers provide supportive learning environments for all children.
- Data usage: State departments of education are required to monitor, report, and address disproportionality based on race and ethnicity as required by the US Department of Education’s Equity in Individual with Disabilities Education Act final regulation effective July, 1, 2018. Some state officials mentioned having a longitudinal data system to track disproportionality would be helpful, and would provide an opportunity for state health and education agencies to collaborate.
- Advisory groups: Colorado, Minnesota, and Delaware benefit from advisory groups that facilitate interagency collaboration that can address disproportionality. In Minnesota, an interagency task force including the Medicaid agency (Department of Human Services), Department of Health, and Department of Education promotes coordinated efforts to achieve equitable, universal early childhood screening and referrals. Minnesota’s task force laid the foundation to include mental health consultation services within its school-linked grants under its early childhood mental health infrastructure grants. Delaware, Connecticut, and Colorado were able to generate statewide attention to disproportionality by addressing school suspensions and expulsions. Connecticut became the first state to prohibit expulsions in publically-funded preschools and has recently instituted policies to ensure accountability.
- Ohio’s Cultural and Linguistic Competency Plan: Ohio’s Department of Mental Health and Addiction Services instituted a statewide Cultural and Linguistic Competency Plan to promote health equity and eliminate disparities. Ohio provides cultural competence and linguistic trainings to state employees that reference the Culturally and Linguistically Appropriate Services Standards. Additionally, the plan highlights incentives for providing culturally-competent services. Culturally-competent services can result in lowered health care costs stemming from a reduced number of medical errors, unnecessary or avoidable treatments, and lower numbers of missed medical visits. They also can support new business and revenue-generating opportunities, improved performance on quality measures, and alignment with Medicare and Medicaid, which have placed priorities on cultural and linguistic competency. The state also developed a business case for achieving health equity cited in its Cultural and Linguistic Competency Plan.
Mental health inequities can result from disproportionality and are systemic. Addressing this issue involves:
- Unraveling policies and practices that negatively impact students of color of all ages; and
- Implementing systemic interventions and supports to identifying and assisting individual children with specific needs.
As demonstrated by numerous states, state health officials can use several mental health policy levers and strategies to improve students’ overall health and success in school.
Notes
This blog was supported by the Massachusetts General Hospital Disparities Research Unit.
1. Green, J.G., McLaughlin, K.A., Alegria, M., Bettini, E., Gruber, M.J., Kwong, L., Sampson, N., Zaslavsky, A.M., Xuan, Z., & Kessler, R.C. (unpublished manuscript). Ethnic/racial inequities in educational placement for youth with psychiatric disorders.
Community Health Worker Resources for States
As states transform their health systems, many are turning to community health workers (CHWs) to improve health outcomes and access to care, address social determinants of health, and help control costs of care. While state definitions vary, CHWs are typically frontline workers who are trusted members of and/or have a unique and intimate understanding of the communities they serve. NASHP has produced a number of resources, below, to support state efforts to incorporate CHWs into their health and health equity improvement work. If you would like to suggest a resource or share your state’s efforts, please contact Elinor Higgins.
Resources
- Innovative Community Health Worker Strategies: Medicaid Payment Models for Community Health Worker Home Visits, December 2017. This case study examines Medicaid payment models from Minnesota, New York, Utah, and Washington for CHWs providing in-home services that address healthy home environments.
- Innovative Community Health Worker Strategies: My Health GPS in Washington, DC, Seeks to Achieve Sustainable Funding and Whole-Person Care, November 2017. This case study explores the financing and roles of CHWs in My Health GPS, the District of Columbia’s health home program.
- Community Health Workers: Policy Opportunities for Population Health and Patient-Centered Health Care, October 2017. This NASHP conference session highlighted state strategies and experiences in CHW financing, training, and oversight. Speakers from Oregon, Texas, and Wisconsin discussed the national CHW landscape and policy opportunities that could be explored to advance the CHW workforce in states. Please click on the speakers’ names to access their conference slides.
- State Community Health Worker Models Map, last updated August 2017. This map highlights state-level activities and policies to integrate CHWs into evolving health care systems in key areas such as financing, education and training, certification, and state definitions, roles and scope of practice. The map includes enacted state CHW legislation and provides links to state CHW associations, state agencies, and other leading organizations working on CHW policy in states. An instructional video, designed with support from the National Center for Healthy Housing (NCHH) and the W.K. Kellogg Foundation, is available to facilitate use of the map.
- Community Health Workers in the Wake of Health Care Reform: Considerations for State and Federal Policymakers, December 2015. This brief captures key themes that emerged during an October 2015 meeting of state and federal leaders to identify areas in which state and federal policy can align around the use of CHWs in transforming health systems to achieve better care, lower costs, and improved population health.
These resources were produced and updated with support from the Robert Wood Johnson Foundation, The W.K. Kellogg Foundation, the National Center for Healthy Housing, and The Commonwealth Fund.
State Health Policymakers Look to Washington and Each Other to Fight the Opioid Epidemic
In the last two weeks, there has been a flurry of federal and state activity focused on the nation’s opioid epidemic that currently kills more Americans than guns or car accidents.
- In Washington, the President’s Commission on Combating Drug Addiction and the Opioid Crisis released its final report featuring 56 recommendations to stem opioid and substance abuse and improve treatment, followed by a State Medicaid Director Letter from the Centers for Medicare & Medicaid Services (CMS), outlining expanded flexibility for states seeking Section 1115 Waivers to address the problem.
- At the annual National Academy for State Health Policy (NASHP) conference, it was standing room only at a day-long session entitled State Innovations and Interventions in America’s Opioid Crisis. State health officials from across the country shared their new approaches, which ranged from treatment improvements, innovative use of data, and coalition-building between public safety, businesses, and communities to stem the epidemic that claimed more than 64,000 lives in 2016.
| For more details about how states are combatting the opioid crisis, explore NASHP’s State Innovations and Interventions in America’s Opioid Crisis Preconference resource book. |
While it’s unclear whether the Trump Administration will adopt all of the commission’s recommendations, which include additional block grant funding and federal incentives for evidence-based programs, the state Medicaid directors’ letter offered guidance for state officials interested in using Section 1115 Waivers to create innovative or experimental programs that meet the goals of Medicaid. In this case, states could use Section 1115 Waivers to expand or create new prevention and treatment initiatives in order to provide a fuller continuum of services to address opioid use disorders within their states.
Section 1115 of the Social Security Act permits CMS to waive certain federal Medicaid requirements so states have more flexibility to innovate and test new models of care, including providing services and expanding Medicaid in ways not typically permitted under current Medicaid rules. States must show that their initiatives still align with the purposes of the Medicaid program, and their waiver applications can be far-reaching or narrowly tailored, and usually require discussion and negotiation with federal partners.
The recent Medicaid letter reiterates the ability of CMS to waive the restrictive “Institutions for Mental Disease” or IMD exclusion, which would enable state Medicaid programs to receive federal financial participation (FFP) support for those facilities that treat opioid use disorders. The guidance notes that IMD costs do not include room and board unless those settings qualify as inpatient facilities.
Additionally, while states may submit an implementation plan after they apply for the waiver, IMD costs will only be paid prospectively once the plan has been approved. Moreover, interested states will need to demonstrate their ability to make improvements on a number of additional goals and milestones, and, as with other 1115 Waivers, the cost of the waiver initiative must be budget-neutral, and incur no costs beyond what the federal government would otherwise have paid.
States may access technical support and resources from the Innovation Accelerator Program to develop their 1115 Waivers. The administration recently approved its first substance use disorder-focused waiver application from West Virginia, which provides additional insight for states looking to go in this direction.
West Virginia’s 1115 Waiver enables the state to expand its substance use disorder (SUD) treatment to include methadone treatment services, peer recovery support services, withdrawal management services, and short-term residential services to all Medicaid enrollees.
“In implementing the SUD demonstration, West Virginia is delivering SUD services through comprehensive managed care plans for managed care enrollees and introducing new policy, provider and managed care requirements to improve quality of the care delivered to West Virginia Medicaid beneficiaries and to ensure that SUD treatment services are delivered consistent with national treatment guidelines established in the American Society of Addiction Medicine Criteria,” CMS officials wrote in their letter announcing the waiver.
“In addition, West Virginia is taking steps to improve the quality and access to care for West Virginia Medicaid beneficiaries with SUD, such as introducing new care coordination features and collecting and reporting quality and performance measures,” they noted. While obtaining financial support for services in IMD may help support a full continuum of services for SUDs, states are also moving forward with innovative community-based approaches, using other funding and policy levers. Examples from the NASHP preconference include:
- The Drug Free Moms and Babies Program in West Virginia, spearheaded by that state’s Office of Maternal and Child Health. The program is decreasing the presence of illicit substances at delivery through screening and comprehensive care, including long-term follow-up.
- Connecticut’s multi-pronged approach incorporates increased use of medication-assisted treatment in corrections settings, a statewide access line with transportation, and targeted supports in emergency departments to initiate treatment, including recovery coaches.
- Ohio’s Episodes of Care payment model measures share data on opioid prescribing in connection with dental extraction, a common pathway for opioid access.
Federal focus on the opioid crisis is expected to produce tangible supports for state policymakers who are on the frontlines of the opioid epidemic. In the meantime, policymakers attending the NASHP conference concurred that they will continue to serve as the leaders, innovators, and problem-solvers in their battles against this devastating epidemic.
Medicaid Financing of Early Childhood Home Visiting Programs
Thursday, Oct. 12, 2017
States have a long history of using home visiting to promote the health and well-being of women, children. and their families, and to target interventions for some of the most vulnerable populations. States typically support home visiting programs through an array of public and private funds, including Medicaid. During this webinar, NASHP staff reviewed the opportunities and challenges of using Medicaid to support home visiting, and state officials from Kentucky and Michigan explored how their respective states have approached Medicaid coverage of their home visiting services.
Speakers:
- Vanessa Brewer, Health Policy Specialist II, HANDS Program, Kentucky Department for Public Health
- Suzette Burkitt-Wesolek, Acting Program Coordinator, Maternal Infant Health Program, Michigan Department of Health and Human Services
- Marie LaPres, Manager, Practitioner Services Section, Program Policy Division, Medical Services Administration, Michigan Department of Health and Human Services
- Kay Johnson, President, Johnson Group Consulting Inc.
Additional Home Visiting Resources:
- Medicaid Financing of Home Visiting Services for Women, Children, and Their Families (2017 brief)
- Medicaid Financing of Early Childhood Home Visiting Programs: Options, Opportunities, and Challenges (2012 brief)
- Using Medicaid to Finance Home Visiting Services: A Checklist for State Decision Makers
- Joining Kentucky HANDS for a Comprehensive System of Care
- Cost Savings to Medicaid from the Maternal Infant Health Program due to Reduction in Preterm Birth Rate
States Could Gain More Flexibility to Manage Medicaid Programs — What Can They Learn from the 1990s AFDC Flexibility Experience?
The new Administration has signaled a willingness to give states more flexibility to address health and prevention in new and innovative ways under Section 1115 of the Social Security Act. This provision allows the Department of Health and Human Services to approve experimental and innovative projects that promote the goals of Medicaid. This comes at a pivotal time when many states are developing new ways to improve health care, reduce costs, and address health-related social needs such as housing.
What can states learn from the AFDC flexibility experience?
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Using waivers to grant states more flexibility to manage programs is not new; nor is it limited to Medicaid. In the 1990s, states used Section 1115 waivers to redesign their Aid to Families with Dependent Children (AFDC) programs, which provided cash assistance to low-income families and was the precursor to today’s Temporary Aid to Needy Families (TANF).
Using these waivers, some states profoundly changed their AFDC programs by imposing stricter work requirements, which were later incorporated into TANF nationwide. The pace of waiver activity slowed dramatically after TANF was created in 1996. In 2012, the Obama administration encouraged states to develop innovative Section 1115 projects to help TANF recipients become and stay employed. Recently, the new Administration rescinded states’ flexibility to modify TANF work requirements, while simultaneously promoting more state flexibility over their Medicaid programs.
The debate over work requirements is now spilling over into Medicaid at a time when many state health policymakers are using Section 1115 waivers to craft innovative programs that support people’s need for health-related necessities such as safe housing and nutritious food. A look at states’ past experiences with AFDC/TANF waivers may prove instructive as policymakers consider what Medicaid innovations and new policies might emerge from the flexibility promised by the Administration.
The History of Section 1115 Demonstration Waivers in AFDC
Section 1115 demonstration projects, designed to give states flexibility to administer programs that address health care and social welfare needs, were added to the Social Security Act (SSA) in 1962, before Medicaid was created in 1965. Section 1115 allowed the Health and Human Services (HHS) secretary to waive some provisions of public assistance programs to allow for the design of pilot projects that would promote the goals of programs such as AFDC. Created in 1935 within the Social Security Act, AFDC—then known as Aid to Dependent Children—was designed to assist children in families with an absent parent. At the time, most states had laws establishing support for families headed by a single mother, so the federal law provided welcome financial support for the state programs.
Starting in 1962, states were able to waive some federal AFDC program requirements and during the 1980s and 1990s, both Democratic and Republican administrations encouraged states to use Section 1115 to test innovations. President Clinton’s administration approved more than 40 states’ waivers, many of which contained statewide program changes.
States often used the waivers to impose and tighten work requirements for AFDC participants, which paved the way for a 1988 federal law required AFDC beneficiaries to participate in the Job Opportunities and Basic Skills (JOBS) training program unless they were ill, incapacitated, elderly, or needed to take care of a family member. Exemptions were also given to pregnant women in their second or third trimester, people already working at least 30 hours per week, parents caring for children under three years of age (or children between ages one and three, according to individual state’s rules), and children who were younger than 16 or full-time students. The waivers resulted in different states imposing different work requirements, with some states requiring parents of children as young as six months, three months, or twelve weeks of age to participate in the JOBS program.
Some states used the waiver process to limit the length of time that families could receive AFDC. A number of states limited families to two years. Some states used waivers to penalize AFDC recipients who had additional children by reducing their benefits and/or their JOBS exemption. Many states used waivers to cap families’ benefits so their benefits did not increase when a child was born. Many of these common waiver elements found their way into federal regulations governing TANF block grants to states, which replaced AFDC when it was repealed in 1996. For example, TANF generally limits families to five years of benefits, whereas the prior AFDC program placed no federal time limits on benefits. TANF also does not generally exempt single parents taking care of young children beyond the child’s infancy, unlike AFDC, which allowed exemptions for parents of children up to three years old. Note that TANF, like AFDC, does not penalize parents if there is no child care available.
How Do TANF and Medicaid Compare?
While TANF and Medicaid both fall under the Social Security Act (Titles IV and XIX, respectively), the programs have important differences. The 1996 law changed cash assistance, considered a welfare program, from a guaranteed entitlement (AFDC) to a non-guaranteed block grant (TANF). However, it did not make similar changes to the structure or financing of Medicaid; in fact, it explicitly preserved Medicaid as a guaranteed health care benefit. The law also untethered Medicaid from federal eligibility for cash assistance. Medicaid is not, under federal law, a welfare program.
Waivers After TANF
After 1996, states with AFDC waivers were allowed to delay implementation of some TANF provisions until their waivers expired. Some states chose to do so in order to continue collecting data for program evaluation, or to continue program elements not permitted by TANF. Other states chose to implement TANF immediately and discontinue their AFDC waiver programs.
While Section 1115 still applied to TANF, waiver activity related to the program essentially halted with the law’s 1996 passage. In an attempt to reinvigorate state innovation in TANF, the Obama administration published guidance to states in July 2012 indicating its willingness to relax some TANF program requirements—particularly work requirements—under Section 1115 authority. It hoped this would encourage states to test innovative strategies to encourage families to find employment. Only one state—Ohio—applied for a waiver under the 2012 guidance, and it was neither approved nor denied by the Obama administration.
On Aug. 30, 2017, the Trump administration rescinded the Obama-era guidance encouraging states to apply for TANF waivers, and stated that it would no longer consider Section 1115 waiver requests from states that sought to modify work requirements under TANF. It also formally rejected Ohio’s waiver request.
Lessons for Medicaid?
Work requirement proposals that helped redesign cash assistance programs decades ago are now surfacing in health policy debates, including debates over proposed federal legislation that would have supported state Medicaid work requirements.
- On one hand, proponents of Medicaid work requirements could argue that employment has the potential to improve health, in light of studies that have long associated unemployment with poorer physical and mental health.
- On the other hand, many state health policymakers are steadfast in their support of long-standing principles that health care should be available to vulnerable people and families regardless of work status, pre-existing health conditions, or other factors. This debate will play out in Medicaid waiver policy discussions now and in months to come.
As important as the work requirement discussion is for policymakers and beneficiaries, it should not overshadow other opportunities available under the waiver authority to address health-related needs through Medicaid and TANF innovations. In their March 2017 letter to governors, former HHS Secretary Thomas E. Price and Centers for Medicare & Medicaid Services Administrator Seema Verma signaled their commitment to empower states to innovate in their Medicaid programs by giving them more freedom to tailor programs to meet the particular needs of their residents. They also indicated their intention to streamline the Section 1115 process for states developing programs to address substance abuse. This flexibility may present an opportunity for states seeking to improve the health of vulnerable, low-income populations by focusing on health-related needs and upstream prevention.
Questions for Policymakers
Questions that may help state policymakers effectively capitalize on new flexibilities include:
- What kinds of TANF flexibilities, if available, could most benefit complex Medicaid beneficiaries who struggle with non-clinical health needs?
- What kind of flexibility in TANF or Medicaid could help states ensure that program eligibility and incentives are aligned to meet common goals?
When their goals are aligned, TANF and Medicaid can be vital elements in a coordinated plan of services managed at the state level to meet the needs of Medicaid beneficiaries. However, state policymakers have noted that misaligned incentives can penalize social safety net program participants by increasing their earnings through work. For example, a small increase in earned income results in reduced TANF, SNAP, child care subsidies, medical assistance, and other safety net benefits that can reduce a family’s income.
Misalignment between Medicaid and social safety net programs can also compromise states’ abilities to maximize the collective impact of these programs. A recent study documented the synergy between SNAP and health care programs. It found that enrollment in SNAP was associated with lower health care expenditures among low-income adults. States may consider how any new federal flexibility in program design or eligibility could help programs work together to maximize each program’s effectiveness at improving health and well-being.
Other questions policymakers should consider include:
- Will federal flexibility result in a streamlined waiver application process for states seeking to replicate other states’ already-approved demonstrations that address health-related social needs?
- As with every administration, there will be a balance between state flexibility and federal policy. How can states make the most of any new federal flexibility? What support and guidance will they need from federal agencies? What might the mixed message about TANF flexibility mean for state Medicaid programs?
In this time of federal change, looking back at past programs may help state health policymakers look ahead to future challenges and opportunities to serve their most vulnerable populations.
Support for this blog was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the foundation.
Success Spurs Growth of Medicaid Managed Care for Children with Special Health Care Needs
Two decades ago, the majority of state Medicaid programs that served children and youth with special health care needs (CYSHCN) relied on a traditional, fee-for-service model to pay for the complex mix of health care services that this group of children often need. But as states became more adept at designing new health care delivery programs, they have begun enrolling Medicaid beneficiaries with chronic and complex medical needs into Medicaid managed care (MMC) programs.
Some states are discovering that MMC can provide greater opportunities for coordinating care, controlling costs, and improving health care quality and outcomes for CYSHCN.
To implement these programs, state Medicaid agencies are contracting with managed care organizations (MCOs) to provide care and support services for a set price (per member, per month) with the goal of providing high-quality care at lower costs. These state programs are unique, with each state creatively designing plans to serve specific CYSHCN populations. Knowing what plans and policies states have adopted, outlined in a 50-state scan, provides important insights into national trends and new approaches that states can use to transform their MMC models to serve CYSHCN.
A recent NASHP nationwide analysis found 47 states and Washington, DC, now use some form of managed care to serve all or some children and adults enrolled in Medicaid today. Of the states with managed care delivery systems, all enroll at least some or all of their CYSHCN into some type of Medicaid managed care. Most enrollment is in risk-based managed care, where the MCO assumes financial risk.
NASHP’s issue brief, and 50-state map and chart provide an easy-to-use reference guide to learn what individual states are doing as they redesign health care for their CYSHCN. NASHP’s analysis found that enrollment in MMC varies by state and subpopulation of CYSHCN:
- 42 states enroll children in the Medicaid Aid to the Aged, Blind and Disabled (ABD) category of assistance in MMC;
- 42 states enroll foster care youth in MMC;
- 22 states enroll children who receive Supplemental Security Income (SSI) in MMC; and
- 14 states enroll children in 1915(c) Medicaid waiver programs in MMC.
Most states with MMC enroll CYSHCN on a mandatory basis and serve CYSHCN in standard health plans that serve all Medicaid beneficiaries. A small number of states have developed specialized managed care plans for CYSHCN.
In addition to rapidly expanding MMC, states are also evaluating if this health care delivery model is truly improving the quality of care for Medicaid beneficiaries. Two-thirds of states (33) have incorporated quality measurement requirements specifically for CYSHCN into their managed care contracts to assess how well these systems are serving children’s needs. These and other findings about enrollment of CYSHCN in MMC are summarized in a new issue brief and a 50-State Chart and Map. NASHP has also taken an in-depth look at Medicaid managed care delivery systems for CYSHCN in six states, and state use of Medicaid quality metrics for CYSHCN. These and other resources will be released in the next two
State Medicaid Payment Reform Strategies Promote Improved Birth Outcomes
Improving birth outcomes, including reducing infant mortality, is a priority for state Medicaid agencies that finance nearly half of all births each year. Three states have proven to be creative and effective laboratories in developing initiatives that use Medicaid payment and delivery reform strategies to lower costs, improve access to postpartum care, reward high-quality care, and reduce unnecessary cesarean sections (C-sections).
On average, C-sections financed by Medicaid cost nearly $5,000 more than vaginal births, and the average payment for maternal and newborn care, including neonatal intensive care unit stays, is about $6,100 higher for C-sections than vaginal births. Oklahoma, Tennessee, and Wisconsin, as highlighted in three case studies, employed payment strategies, performance incentives for providers, and quality improvement initiatives to improve birth outcomes and patient experience while reducing overall health care costs.
Earlier this year, the National Academy for State Health Policy (NASHP), in partnership with the National Institute for Children’s Health Quality (NICHQ), conducted a 50-state environmental scan of Medicaid or Children’s Health Insurance Program (CHIP) strategies designed to improve women’s access to high-quality preventive and perinatal care. The scan revealed a number of innovate state payment or delivery reform initiatives, including the three highlighted in the new case studies:
The Oklahoma Health Care Authority created the Cesarean Section (C-section) Quality Initiative to reduce elective C-sections with no medical indication. The initiative is designed to decrease the primary C-section rate performed without medical necessity to 18 percent or less by ensuring providers and hospitals followed best practices when performing C-sections. As of 2016, Oklahoma had reduced the rate of primary C-sections without medical indication to 15.6 percent, resulting in substantial cost savings to the state. Read the case study.
Tennessee’s Department of Human Services’ Division of TennCare (Medicaid) implemented a perinatal episode of care (EOC) payment strategy as part of its overarching Tennessee Health Care Innovation Initiative (THCII). The perinatal EOC focused on women with low- to medium-risk pregnancies and encompasses care provided during the span of the pregnancy, delivery, and postpartum care. This payment strategy is intended to control costs while focusing on patient-centered, high-value health care for pregnant women by rewarding providers who deliver cost-effective, quality care . As a result, Tennessee’s Medicaid program has experienced a 3.4 percent decrease in medical care costs — a total of $4,719,519 — from calendar year (CY) 2014 to CY 2015. Read the case study.
The Wisconsin Department of Health Services, which administers Wisconsin Medicaid, implemented the Obstetric Medical Home (OBMH) program, which targets high-risk pregnant women to reduce birth disparities through effective, comprehensive, coordinated, and quality maternity care. The goal of the OBMH program is to provide holistic care that addresses all health needs of the pregnant patient through care coordination and home visiting. The OBMH program results indicated an improvement in the rate of postpartum care visits from 61.4 percent in 2013 to 85.5 percent in 2015. Postpartum care has the potential to improve outcomes for women and infants, and support ongoing health and well-being. Read the case study.
Federal initiatives like the Collaborative Improvement and Innovation Network to Reduce Infant Mortality (IM CoIIN), led by NICHQ and supported by the Health Resources and Services Administration’s Maternal and Child Health Bureau help to advance state efforts to prevent and reduce infant mortality and eliminate disparities in birth outcomes. These three states are active members in the IM CoIIN. As the Oklahoma, Tennessee, and Wisconsin, case studies demonstrate, Medicaid payment and delivery reform presents an opportunity for cross-agency collaboration to support shared goals of improving maternal and infant health outcomes and reducing costs.
This blog and related publications are joint products of the National Academy for State Health Policy (NASHP) and the National Institute for Children’s Health Quality (NICHQ). This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) (under grant # UF3MC26524, Providing Support for the Collaborative Improvement and Innovation Network (CoIIN) to Reduce Infant Mortality, $2,918,909, no NGO sources).
Facing Budget Uncertainties, States Seek New Opportunities to Fund Successful Home Visiting Programs
States have a long history of using home visiting programs to deliver cost-effective interventions to vulnerable children and families, and recent federal investments have been instrumental in the expansion of evidence-based home visiting programs across the United States.
Due to budget uncertainties at the state and federal level, states are exploring opportunities to maximize investments through a variety of sources in order to maintain and expand evidence-based home visiting programs. A new National Academy of State Health Policy (NASHP) issue brief, Medicaid Financing of Home Visiting Services for Women, Children, and Their Families, examines existing and emerging Medicaid financing mechanisms that states are using to support home visiting.
Evidence-based home visiting programs provide a comprehensive array of in-home services and supports to families and young children on a voluntary basis, and have been found to promote positive child and family outcomes, such as improved child and maternal health, increased school readiness, improved family economic self-sufficiency, and reductions in child maltreatment.
While the various evidence-based home visiting models vary in intensity and scope, all of them use trained providers, such as nurses, social workers, child development professionals, and other paraprofessionals, to deliver services to young children and families. The services typically include screenings, case management services, and family support and counseling. Additionally, evidence-based home visiting programs that target high-risk families have been shown to save states up to $5.70 for every $1 invested in the long run. These savings result from reduced health services utilization — including emergency department visits — and decreased special education placements and grade repetition, which leads to higher educational attainment and economic success later in life.
States typically use public and private funds, including Medicaid, to support evidence-based home visiting programs. While home visiting is not a mandated or a fully-defined set of services under Medicaid, there are numerous Medicaid financing pathways that states are using to implement, sustain, and expand home visiting programs. The NASHP brief examines these funding pathways, which include targeted case management, Early and Periodic Screening, Diagnostic and Treatment (EPSDT), and 1115 and 1915(b) waivers.
The NASHP brief also explores emerging opportunities to support home visiting as part of state payment and delivery system reform efforts. Several states, including Minnesota and Virginia, have partnered with Medicaid managed care organizations to cover home visiting services through contract requirements or other arrangements. New York is providing funding to support evidence-based programs through its Delivery System Reform Incentive Payment (DSRIP) Waiver program, which is designed to restructure Medicaid’s care delivery system and shift to primarily value-based payments.
To support the comprehensive services, rigorous staff trainings, and development of quality controls that make evidence-based home visiting programs successful, states use an array of federal and state funding sources. This is even more critical given current funding challenges at the state and federal level. Many states are experiencing gaps in their budgets, and a range of programs are facing large funding shortfalls.
In particular, the future of the federal Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) is uncertain. MIECHV, created by the Affordable Care Act, has provided grants to 50 states, Washington, DC, and five territories to establish or expand evidence-based home visiting programs. MIECHV is currently up for reauthorization in Congress, with funding slated to end Sept. 30, 2017.
Two reauthorization bills have been introduced in the House of Representatives (Home Visiting Works Act of 2017 and Increasing Opportunity through Evidence-Based Home Visiting Act), and the Senate is expected to introduce a MIECHV reauthorization bill on September 19. However, as of mid-September, it is not known if MIECHV’s funding will be reauthorized. States’ ability to use, leverage, and coordinate multiple funding streams, including Medicaid, will be even more critical to the future of this public health intervention.
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. 
