Health Equity – Page 20 – The National Academy for State Health Policy

State Officials Work to Harness Medicaid as a Change Agent to Increase Immunization Rates

July 17, 2018/in Policy Blogs CHIP, CHIP, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Health Coverage and Access, Health Equity, Healthy Child Development, Immunization, Integrated Care for Children, Integrated for Pregnant/Parenting Women, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Population Health, Primary Care/Patient-Centered/Health Home, Social Determinants of Health /by Megan Lent, Tina Kartika and Jill Rosenthal

Despite vaccines’ effectiveness in preventing infectious diseases and strong public funding for childhood immunizations, vaccination rates among children living in poverty remain stubbornly lower than for children living above poverty and who are privately insured.
Recently, officials from several organizations, including the National Academy for State Health Policy (NASHP), AcademyHealth, and the Colorado Children’s Immunization Coalition, convened state officials and subject matter experts to identify strategies to improve immunization rates among Medicaid-enrolled children and pregnant women.
What Vaccine Benefits Do State Medicaid Programs Offer?
Recognizing their critical role in protecting public health, Medicaid covers all recommended vaccines for children and many state Medicaid programs do not charge pregnant women copayments for vaccinations in order to remove financial barriers. As a result of this publicly-funded initiative, immunization rates for Medicaid-covered children are higher than for children without health insurance, demonstrating the value Medicaid provides in overcoming socioeconomic barriers to provide essential health benefits.

What is the Community of Practice?
With support from a CDC cooperative agreement, NASHP and AcademyHealth, with support from the Colorado Children’s Immunization Coalition, are leading a Community of Practice to identify ways to improve immunization rates among Medicaid-enrolled children and pregnant women.
These partners, participating states (CO, HI, KY, MT and NM), and experts will continue to convene the Community of Practice and share findings with other states seeking to increase immunization rates.

Vaccination rates also vary by vaccination type. For example, Medicaid-covered newborns are vaccinated with the hepatitis B birth dose at higher rates than newborns covered by private insurance, demonstrating Medicaid’s effectiveness. Considering that Medicaid covers nearly half of all children in some states, this state program can build on its successes and serve as a change agent to make sure even more children receive crucial vaccinations.
Socioeconomic Disparities in Vaccination Rates Persist
Despite Medicaid’s success in boosting immunization rates, according to Centers for Disease Control and Prevention (CDC) data, socioeconomic disparities persist in vaccination rates among young children enrolled in Medicaid and pregnant women. Children living below poverty level, as well as Medicaid-enrolled and uninsured children, have significantly lower immunization rates for many vaccines compared to children living at or above poverty level and/or with private insurance. Similarly, Tdap (diphtheria, tetanus, and whooping cough) and influenza immunization rates are lower among pregnant women living below the poverty level and/or enrolled in public insurance programs.
CDC shared these findings recently when NASHP, AcademyHealth, and the Colorado Children’s Immunization Coalition gathered state officials and experts together to identify strategies to improve immunization rates among Medicaid-enrolled children and pregnant women.
Strategies to Narrow the Immunization Gap
Attendees noted that lower vaccination rates among Medicaid enrollees could result from many factors, including poor access to care or lack of provider recommendations. Meeting participants discussed several evidence-based interventions recommended by the Community Preventive Services Task Force to increase immunization rates among Medicaid beneficiaries. These include:

Monitoring immunization status during home visits;
Providing immunizations in school-based health clinics, Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) settings, and other non-traditional venues; and
Using standing orders for age-appropriate immunizations as defined by CDC during well-child visits.

Meeting participants also suggested leveraging relationships with managed care organizations and patient-centered medical homes, where applicable, to increase immunization rates and providing non-emergency medical transportation to help families adhere to well-child and prenatal appointments, where immunizations are commonly administered.
Meeting participants also identified use of data, primarily Immunization Information Systems (IIS), as a strategy to identify disparities and target immunization outreach. An IIS records immunization doses administered by participating providers and can provide both patient immunization histories for use by providers in a clinical setting. IIS can also collect data at the population level to guide actions to improve immunization rates.
However, attendees identified barriers to using IIS effectively at both the state and provider level, including:

A lack of funding to support development and maintenance;
Legal and technical barriers to data exchange;
Data silos within and between agencies;
Data-sharing challenges between electronic health records and other health information exchanges; and
Onboarding and implementation hurdles.

Tools and websites are available to help states fully maximize their IIS and data-sharing capacities, and additional tools are under development.
States participating in the Community of Practice have employed successful strategies to reduce barriers to immunization among Medicaid participants. For example, Colorado has engaged in provider outreach and collaborated with WIC programs to share the immunization status of WIC clients. Montana developed performance-tracking measures for immunization rates and incorporated these into managed care organization contracts.
The Community Preventive Services Task Force also recommends the following evidence-based best practices to increase immunization rates:

Reduce client out-of-pocket costs for vaccinations (Medicaid pays for vaccine administration, but low-income, uninsured patients must pay for administration of the free vaccines);
Establish vaccination requirements for childcare, school, and college settings;
Create client or family incentive rewards;
Design client and provider reminder/recall systems;
Encourage provider assessments and feedback;
Generate provider reminders; and
Create combination community- and health care system-based interventions.

As Community of Practice states identify strategies and lessons learned to improve vaccination rates among Medicaid-covered children and pregnant women, they will be shared nationally to support similar efforts in other states.
Photo Courtesy of the CDC

Flurry of Bills Targeting the Opioid Epidemic’s Impact on Families Reach Congress

July 17, 2018/in Policy Blogs Behavioral/Mental Health and SUD, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Eligibility and Enrollment, Health Coverage and Access, Health Equity, Healthy Child Development, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Population Health, Primary Care/Patient-Centered/Health Home, Quality and Measurement, Safety Net Providers and Rural Health, Social Determinants of Health, Workforce Capacity /by Miara Handler and Carrie Hanlon

The country’s opioid crisis has had a devastating effect on women, children, and families, and continues to strain state health, foster care, and social service agency budgets. A flurry of bills has recently been introduced in Congress to prevent or reduce the effects of the opioid crisis and many directly impact families and children.
The bills provide key insights into Congressional efforts to help states tackle the opioid crisis. In the past month, the House passed the omnibus SUPPORT for Patients and Communities Act by a resounding vote of 396-14, and a number of other related bills have recently passed their committees. Additionally, the Senate Health, Education, Labor and Pensions (HELP) Committee advanced the Opioid Crisis Response Act of 2018. These bills support families and children affected by opioid use disorder (OUD) and are an early indication of what programs may win approval in the coming weeks. Two key approaches stand out:

Promotion of innovative, family-centered care models that serve women and infants together; and
A focus on data collection and research related to the needs and experiences of children and youth.

Innovative Care Models Promoted in the Proposed Legislation
Care delivery models that address the complex needs of families and children affected by opioid use are key to promoting recovery among parents and mitigating long-term impacts on children’s health.
The Senate’s Opioid Crisis Response Act of 2018 funds family-centered, residential treatment programs that serve women and infants together and provides grants and technical assistance to states to implement plans of safe care for substance-exposed infants.

The bill also authorizes a program to support substance use disorder (SUD) prevention and recovery services for children, adolescents, and young adults, and requires the US Department of Health and Human Services (HHS) to identify and disseminate best practices for serving this population in collaboration with the US Department of Education.
Additionally, it provides demonstration grants to better integrate mental health care into schools — an important delivery site of care for children. By integrating mental health services into schools, states can promote access to services and support for children affected by trauma, including parental opioid use.

The House SUPPORT for Patients and Communities Act would streamline services for pregnant and postpartum woman by enabling Medicaid financing of pregnancy-related services in SUD treatment facilities. It would also make it easier for Medicaid to finance community-based facilities where infants with neonatal abstinence syndrome could receive treatment along with their mothers. The bill also requires HHS to issue guidance and conduct studies to improve care for these populations.
Data collection and research into the opioid epidemic can shed light on the scope of the problem and opioid use trends, and they are critical for guiding policymaking and targeting effective interventions.

The SUPPORT for Patients and Communities Act requires the Surgeon General to submit a report to Congress on the public health effects of the rise of synthetic drug use among individuals age 12 to 18. States can use this information to guide prevention efforts and target services and supports to address synthetic drug use and its impact on adolescents’ health.
The Opioid Crisis Response Act supports data collection and research on prenatal substance misuse, including the long-term outcomes of children affected by neonatal abstinence syndrome. It also permits the Centers for Disease Control and Prevention to collect and report data on adverse childhood experiences. These data and research could inform state decisions about resource allocation for OUD prevention or treatment services for infants, children, and families.

Many of these and other bills have bipartisan support, but it remains to be seen if these or other bills will be enacted. The strategies proposed in these bills were also discussed at a recent meeting about SUD and families for state and local officials from Maine, Mississippi, and West Virginia hosted by the Association of State and Territorial Health Officials, the National Academy for State Health Policy (NASHP), the National Association of County & City Health Officials, and the National Conference of State Legislatures as part of a cooperative agreement with the Health Resources and Services Administration.
Developing services for infants, children, and families is already underway in states, and new innovations and planning will begin if these bills become law. To learn more about how states are working to meet the needs of women, children, and families affected by SUD, attend the following sessions at NASHP’s Annual State Health Policy Conference, Aug. 15-18, 2018 in Jacksonville, FL:

Turning the Tide: State Strategies to Meet the Needs of Families Affected by Substance Use Disorder, a day-long preconference on Aug. 15, 2018; and
Staying Afloat: Keeping Moms Connected to Opioid and Substance Abuse Services 3:30-5 p.m. Thursday, Aug. 16, 2018

Stay tuned for two upcoming NASHP issue briefs and national webinars exploring this issue, scheduled for late summer and early fall.

Health Services Initiative Gives States Unique Tools to Improve the Health of Low-Income Children

June 19, 2018/in Policy Arkansas, Delaware Blogs Behavioral/Mental Health and SUD, Care Coordination, Children/Youth with Special Health Care Needs, CHIP, CHIP, Chronic and Complex Populations, Chronic Disease Prevention and Management, Eligibility and Enrollment, EPSDT, Health Coverage and Access, Health Equity, Healthy Child Development, Integrated Care for Children, Maternal, Child, and Adolescent Health, Medicaid Expansion, Medicaid Managed Care, Population Health, Social Determinants of Health /by Olivia Bacon

With federal funding for the Children’s Health Insurance Program (CHIP) assured through 2027, states can consider using a portion of their CHIP dollars to improve the health of low-income children through innovative Health Services Initiative (HSI). HSIs provide states with a mechanism to use CHIP administrative dollars to fund a range of activities beyond just health insurance.
To date, states have used HSIs to provide preventive services and interventions, such as school health or youth violence prevention programs, and more direct services like lead testing and poison control programs. States are also using HSIs to address emerging health issues. Recently, New York used an HSI to train school officials to administer naloxone to reverse opioid overdoses and Michigan expanded lead abatement activities through an HSI in response to the water crisis in Flint.
While HSIs offer states a unique way to fund new programs or support existing services for children, some states may debate whether to implement a long-term versus short-term HSI because of upcoming changes in the federal CHIP match rate. The most recent federal funding package that extended CHIP includes a phasing down of the 23 percent increase to the enhanced CHIP match rate – known as the 23 percent “bump”— that was initially included in the Affordable Care Act and available through FFY 2019. Despite this future phase-down, a number of states are still pursuing HSIs, and more than 15 have already implemented them.
For an example of a creative way to use an HSI for a short-term project, read NASHP’s report, Oklahoma Uses Focus Groups to Identify Strategies to Better Serve Foster Care Youth, to learn how one state used an HSI to study antipsychotic use among foster care youth.
Arkansas and Delaware provide two additional examples of states that are using HSI funding for unique projects to improve the health of low-income children.
Arkansas: Intensive Home and Community-Based Family and Child/Youth Support
Similar to Oklahoma, Arkansas implemented an HSI in 2017 to improve the quality of care provided to foster care youth. Under the HSI, the state uses a small portion of its CHIP funds to provide intensive home- and community-based family and support services for children with serious mental health issues who are involved in the Arkansas welfare system. The goal is to provide behavior management and wrap-around services to children and foster families to allow children to move out of a psychiatric or behavioral health treatment facility and into a home/community setting.
This transition is often a period of significant adjustment and can cause stress on both the child and family. To support children and families during this process, Arkansas’ HSI provides services to prepare and help families navigate the transition, and to help families safely manage the child’s behavioral health issues after discharge. These services are provided in conjunction with a state care coordination program and are outcome-oriented, trauma-informed, and individualized based on the child’s behaviors.
In addition to providing wrap-around services, this HSI also has the long-term goal of reducing the number of children in the state’s welfare system who are living in psychiatric residential treatment facilities by helping move them into family homes.
Delaware: Vision to Learn
Beginning in January 2017, Delaware used an HSI to launch a school-based initiative to increase access to vision services and eyeglasses for under- or uninsured children. The state CHIP program partners with Vision to Learn, a nonprofit Medicaid provider that administers eye exams and provides glasses on-site at schools through a mobile eye clinic. Although Vision to Learn has been operating in Delaware since 2014, this HSI provides additional public funds through CHIP to enable the program to reach more children in need.
In order to connect these services with low-income children, the HSI specifically targets Title I schools where at least 51 percent of the student body receives free or reduced price meals. In addition to providing vision services, Delaware uses this initiative to perform outreach to children not currently enrolled in Medicaid or CHIP by supplying the mobile clinics with brochures and information about enrollment in these programs.
HSIs offer states the flexibility to use a portion of their CHIP funding to implement a wide range of activities to improve children’s health. The projects in Arkansas and Delaware offer two recent examples, however, many states have used HSIs or are considering them as a unique option to fund vital new programs or support existing services for low-income children.

The Roadmap Ahead: New York’s Value-Based Payments Reward Communities and Providers for Addressing the Social Determinants of Health

June 4, 2018/in Policy New York Blogs Accountable Health, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Health Coverage and Access, Health Equity, Health System Costs, Medicaid Expansion, Medicaid Managed Care, Population Health, Quality and Measurement, Social Determinants of Health, State Insurance Marketplaces, Value-Based Purchasing /by Amy Clary

Medicaid payment models in many states are shifting away from rewarding providers for the quantity of care they provide to models that reward high-quality, coordinated care that addresses some of the broader social factors that influence health and well-being. One example is New York’s Value-Based Payment (VBP) Roadmap, which rewards Medicaid providers and community-based organizations for addressing the social and economic impacts on health — such as access to healthy food, safe housing, and reliable transportation — that make up 80 percent of the factors affecting people’s health.
In New York’s model, Medicaid VBP contractors — such as accountable care organizations (ACOs), hospitals, or individual providers and their partnering networks — enter into value-based payment arrangements with Medicaid managed care organizations (MCOs). Those arrangements take one of three forms. In the Level One VBP arrangement, a traditional fee-for-service arrangement is augmented by a shared savings payment to the VBP contractor when quality scores are met. Level Two is similar to Level One, but the VBP contractor is responsible for losses if care costs more than expected and if quality targets are not met. In Level Three VBP, the MCO gives VBP contractors a set amount — a capitated or per patient, per month payment — to cover the total cost of care while meeting quality targets.
For example, a Medicaid MCO can pay a VBP contractor a flat rate or capitated payment for all the care and services required by a person with diabetes, including assistance meeting health-related social needs. VBP contractors can also develop innovations to support their VBP models. For example, one ACO in western New York partnered with a ride-sharing company to take people to urgent care or after-hours primary care as needed.
As part of the National Academy for State Health Policy’s (NASHP) accountable health models workgroup, Ryan P. Ashe, director of Medicaid Payment Reform at the New York State Department of Health, explained in a recent interview how his state’s Value-Based Payment Roadmap addresses social determinants of health.
What is your state’s value-based payment roadmap?
It is a plan to move New York Medicaid’s payment system toward a VBP model that emphasizes value instead of volume, in order to ensure the long-term sustainability of investments in clinical improvement, system transformation, population health, and community engagement, among other things. The roadmap, which charts a path toward making at least 80 percent of Medicaid managed care provider payments contracted in a VBP model, was approved in July, 2015 and updated in June 2016 and given final approval by the US Centers for Medicare & Medicaid Services (CMS) as part of the state’s Section 1115 demonstration project. The shift to value-based payment is intended to improve health and well-being of people and populations, increase the quality of clinical care, and reduce costs.

Ryan Ashe

Did patients, providers, community members, and other stakeholders provide input into the roadmap’s design?
Yes. The roadmap was developed through a comprehensive and significant stakeholder engagement process. A VBP workgroup served as the advisory body guiding all major policy decisions that shape the model. The VBP workgroup was composed of providers as well as individuals from advocacy groups, community-based organizations, MC0s, and representative associations (including health plan, hospital, and physician-focused associations), among other groups. Clinical advisory groups were developed to inform clinical and behavioral health-related VBP arrangements. They also provided expertise and thought leadership, especially in relation to the design of the individual VBP arrangements such as integrated primary care and the total cost of care arrangements, for example. Subcommittees were developed to tackle specific opportunities within the VBP model. For example, a social determinants of health (SDH) subcommittee tackled a number of topics, including how the state can incentivize providers and MCOs to invest in the social factors affecting health. Comprehensive stakeholder engagement has been a cornerstone of our VBP model, and enabling a channel for public comment on the roadmap was a very important element as we moved forward. In fact, it is a practice we continue today and will continue tomorrow.
How does the roadmap motivate payers and providers to address the social determinants of health?
The VBP model requires VBP contractors — such as ACOs, hospitals, or individual providers and their partnering networks — to implement at least one intervention that addresses an SDH. The model also requires investment in interventions and rewards contractors for addressing social determinants of health, depending on the level of risk adopted in the VBP arrangement.
VBP contractors contract with MCOs under one of three arrangements:

Level 1 is an upside-only shared savings arrangement
Level 2 is an upside and downside risk-sharing arrangement
Level 3 is a prospective per-member, per-month payment and/or prospective bundled payments

“… effectively addressing social determinants of health gets to the root cause of poor health. For example, establishing stable housing helps individuals manage their medication, and access to healthy food helps address complications related to obesity or diabetes.”

VBP contractors in Levels 2 or 3 must address at least one social determinant of health.
VBP is a mechanism to stimulate innovation and sustain transformation where it occurs. The idea is that by establishing a target goal based on overall spend and incentivizing quality, health care providers at all levels, including MCOs, will work together to provide the absolute best level of care, achieving the highest level of quality in a manner that avoids complications or emergency rooms visits that otherwise results in higher costs. In many instances, effectively addressing social determinants of health gets to the root cause of poor health. For example, establishing stable housing helps individuals manage their medication, and access to healthy food helps address complications related to obesity or diabetes. VBP creates a framework where investments in SDH interventions becomes much more important and a foundation for successful arrangements between provider partners and MCOs.
Community organizations have important insight into the needs of the communities they serve. How are they involved in implementing and guiding the roadmap?
Community based organizations are a key stakeholder in the our VBP model. It’s the community-based organizations that often have the direct line into the communities. VBP contractors in Levels 2 or 3 are required to contract with at least one community-based organization. The roadmap also recommends that MCOs and providers work with community-based organizations on interventions targeting SDH. There is a template that MCOs and community-based organizations must use when contracting with one another to implement an intervention targeting a social determinant of health. The template asks the MCO and community-based organization why they selected the intervention. For example, did they leverage an existing assessment of community needs? Or, was the decision informed by existing information sources such as the 211 service database, which tracks calls to the state’s health and human services information line? The template is a way for the state to operationalize the inclusion of CBOs in VBP arrangements. Moreover, it helps us to begin to collect information on best practices that explain why SDH interventions are being selected and how their success is being measured.
Does the state have any say over which social determinants of health that MCOs, providers, and community-based organizations address?
We want to give MCOs and community-based organizations the flexibility to design their interventions to meet the needs they see, and we want to emphasize and support opportunities to achieve the true value of the interventions. The VBP model accepts interventions that focus on five key social domains. To that end, the social determinants of health subcommittee developed a menu of evidence-based interventions that target these five key areas:

Economic stability;
Education;
Health and health care;
Neighborhood environment; and
Social, family, and community context.

The menu identifies the specific social determinants affecting each area, and lists evidence-based interventions providers can use to address them. For example, prescriptions for fruits and vegetables and nutritional counseling are possible VBP-funded interventions for food insecurity. Rental assistance, respite care, and legal services are interventions for people experiencing homelessness and housing instability. VBP contractors can pay for such interventions with savings from their Medicaid MCO payments.
Can you share any examples of how partners have used the menu of interventions to address the social determinants of health?
Yes. One provider partnered with a ride-sharing company to provide better access to medical appointments for low-income patients, because evidence shows that a lack of reliable transportation is often the main cause for missed appointments.
Another community-based organization subcontracts with some Medicaid plans to deliver medically-tailored meals to people with life-threatening illnesses. The organization says it has reduced health care costs by 28 percent compared to the costs incurred by people with similar diagnoses who did not receive medically-tailored meals, and evidence suggests such programs can improve health by reducing spending.
What is next for the roadmap?
The roadmap is a “living document,” that is updated annually and reviewed with CMS. Updates to the roadmap reflect the evolution of the model, which includes feedback from the stakeholder community. We continue to refine our arrangements and overall approach and those updates are included in the annual submission to CMS. The VBP model will continue to look at all areas of health care within Medicaid, including pharmacy, dental and transportation.
The state is committed to achieving the goal of transitioning at least 80 to 90 percent of total MCO expenditures into Level I or higher VBP arrangements. It is important to establish a framework where innovative models of care delivery can move forward, and once refined, can be sustained. This is a transformation about the way we deliver care, and also about the way we think about care, and that is where social determinants become very important. The roadmap establishes the way forward, but it also seeks to achieve a key goal — improving health outcomes for people — and that is important to remember.
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.

Ohio Implements Value-Based Payment Reform to Improve Population Health

May 15, 2018/in Policy Ohio Behavioral/Mental Health and SUD, Care Coordination, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Health Coverage and Access, Health Equity, Health IT/Data, Health System Costs, Medicaid Expansion, Medicaid Managed Care, Medicaid Managed Care, Physical and Behavioral Health Integration, Population Health, Quality and Measurement, Social Determinants of Health, State Insurance Marketplaces, Value-Based Purchasing /by NASHP Writers

Greg Moody, director of Ohio’s Office of Health Transformation, has quietly spearheaded one of the most effective redesigns of a state health care payment system in the country, generating cost savings and improving public health by showing providers how the cost and quality of their care compares with their peers.

This value-based cost-savings and quality improvement approach, embraced by Ohio’s employers, insurers, and Medicaid managed care plans, pays for health care value instead of volume by analyzing two factors — how much it costs a provider:

To provide high-quality comprehensive primary care, and
To treat an “episode of care,” such as treating an acute asthma episode.

Providers are given a report card that assesses their charges, quality of care, and patient outcomes. If they deliver value-based care, they are financially rewarded with a $4 per patient per month bonus. If their care is over-priced and poor quality, compared to their peers, they get bad reviews and no rewards.

Greg Moody, Director of Ohio’s Office of Health Transformation

This value-based payment approach with its financial inducements has reduced acute asthma treatment costs by 21 percent and acute COPD treatment costs by 18 percent in 1 million Medicaid enrollees over a two-year period. Not only are the state’s Medicaid and employer plans saving money, patients are healthier because doctors are doing more to keep them well, which benefits overall population health.
“We can spend time fighting about health care coverage, like the federal government has for the last few years, or we can address the underlying health care costs,” observed Moody, a member of the National Academy for State Health Policy’s executive committee. “Today, I think it’s up to states to experiment and explore how to create sustainable health care costs.”

How Ohio Launched Value-Based Payment Reform

Ohio, which has been conducting its health care payment delivery reform experiment for eight years, is finding success with a value-based approach that replaces a pay-per-visit system with one that promotes comprehensive primary care and rewards providers who deliver efficient episodes of care. The state focused on improving care coordination, integrating physical and behavioral health, rebuilding behavioral health system capacity, strengthening home- and community-based services, improving community services for the disabled, and modernizing its Medicaid administration.
To date, a handful of states have taken small steps to develop a value-based payment system, but early results have not yielded dramatic, financial successes and many state policy makers are still casting about for a system that quickly delivers cost savings and quality care. According to Moody, Ohio found it and has spent more years implementing and refining it than any other states.
Moody, who worked for then-Congressman John R. Kasich researching Medicaid funding while staffing the US House Budget Committee, was appointed by newly-elected Governor Kasich to Ohio’s new Office of Health Transformation in 2011.
“Governor Kasich did something I never saw anyone do and it is key to how we got it done,” he explained. “About 18 months before he became governor, he assembled a health care team and told us, ‘I’m not running for governor unless we have ideas to propose.’ Now normally, you start recruiting and developing policy proposals after you get elected, but on his third day in office in January 2011, we had already done our homework and released our strategic plan. Now, eight years later, we are using the same plan.”
Ohio modernized its Medicaid system by creating a stand-alone Medicaid department with a new claims payment system and it provided an online eligibility tool to residents who no longer had to travel to county offices to apply. It also consolidated mental health and addiction services as the state’s opioid epidemic exploded and expanded Medicaid.
State leaders also began engaging partners, including provider groups, health plans, and Medicaid managed care organizations, to identify public health priorities that their payment reforms – in this case applying the episodes-of-care payment system – could support. “The starting point,” Moody explains, “is to be clear about our population health priorities – or in payment terms, define what we want to buy.’”
Ohio decided it wanted to prioritize improvements in three main health care areas:

Mental health and addiction, addressing depression, suicide, drug dependency, and drug overdoses;
Three chronic diseases: heart disease, diabetes, and asthma; and
Maternal and infant health.

Shaping Physician Reimbursements to Improve Population Health

Next, Moody’s office asked high-performing primary care practices what they did to keep patients well. “The problem is none of these activities [recommended by doctors] are properly reimbursed under fee-for-service – for example, holding time for same-day appointments, providing 24/7 access to care, risk stratification of patients, and scheduling based on risk.” Moody knew that a new value-based care system had to reward providers who delivered those successful — though uncompensated — services.
To achieve these goals, Ohio created a Comprehensive Primary Care Model that enrolled 161 primary care practices to serve 1 million patients. Ohio collected and evaluated 1,800 performance reports that included patient cost and care quality measures. It also provided $3 million in “enhanced payments” to providers who delivered value-based care. To qualify for the $4 PMPM bonus, providers had to keep patients well by meeting the new quality requirements, including the same-day appointments, team-based care, patient outcomes, and reduced hospitalizations and emergency department use.
In December 2014, Ohio won a federal State Innovation Model test grant to implement an episode-based payment model statewide. The timing of the grant was perfect, Moody noted. It allowed Ohio to expand the state’s limited data analytic capacity, and create new insights about how best to improve health outcomes while holding down the total cost of care. Ohio could now pull in all insurance claims related to certain episodes of care for its value-based analysis.
For example, to assess a joint replacement episode of care cost, Ohio combined the total cost of the surgeon, implanted device, hospitalization, medication, and rehabilitation, and used the data to compare providers’ cost-effectiveness across the state. “We then take back money from the rates of the high-cost providers (in red) and share savings with the high-value providers (in green),” Moody explained.
To qualify for bonuses, providers had to meet both cost and quality targets. “This creates a powerful incentive for the principal accountable provider to pay attention to the total cost of the episode,” Moody explained, “[which is] very different from fee-for-service, which pays the surgeon the same regardless of other costs.”
In January, 2018, Ohio started paying the 161 practices that participated in Ohio’s comprehensive primary care pilot program $4 PMPM for meeting the basic efficiency and quality targets. “In addition, practices that meet quality targets while holding down the total costs of care compared to peers and based on self-improvement earn a significant annual performance bonus,” Moody explained.
Similar initiatives in other states are starting to yield substantial savings and care improvements. Minnesota achieved cost savings and an 89 percent improvement in quality measures and one regional initiative in northeast Pennsylvania achieved an 83 percent improvement in quality measures.
With this performance data, primary care providers are able to make value-based recommendations when referring patients to specialists, and insurance plans can also promote providers who receive high value-based rankings to their members.

Using Episodes of Care Costs to Tackle the Opioid Epidemic

By breaking down costs within each episode of care, Ohio has also been able to address another population health-related problem – opioid over-prescribing – by analyzing claims information to see which providers over-prescribe. The analysis, for example, revealed a provider who prescribed opioid painkillers 100 percent of the time for ankle sprains — meanwhile the state average hovered below 18 percent. More careful opioid prescribing data collections and oversight has produced a 28.4 percent decline in the number of opioid doses prescribed in Ohio between 2012 and 2017.
While the cost-savings opportunities generated by this value-based system appear tailor-made for simple procedures like joint replacement, its application to more complex care, such as perinatal episodes of care, is not currently clear. While acute COPD and asthma episodes of care costs dropped markedly 2014 and 2016, perinatal costs increased 3 percent, about what Moody would have expected in a conventional fee-for-service environment. “At this stage, these results create new questions,” he said, “for example, how do we make complex episodes more sensitive to value-based results? How do we identify the greatest sources of value in complex care and share that information with providers who can use it to improve?”
Ohio recently expanded its episodes of care data collection from three episodes to 43, which include many opioid clinical and quality measures. “Eventually, all of this needs to be transparent to the public and easily available online — it’s what we need everyone to see to make real progress on population health priorities,” he said.
Moody considers his work in Ohio as the pinnacle of his professional experience. He encourages other states to replicate Ohio’s approach. “You don’t wake up one morning and do this, it took years for us to get buy-in to make this happen,” he said. “This is something any state can do, but it takes time. We spent a lot of time defining the key health care delivery problems in Ohio, inventorying existing resources, and identifying the two to three policy changes that would leverage change, it’s a fairly rigorous process.
“There are now more than 30 states with gubernatorial elections in November, those candidates should start now to develop their policies and approaches,” said Moody, who will step down from his job in December when Gov. Kasich leaves office. “Ohio has created a blueprint to make these reforms. There are other ways to do this and be successful, but it’s critical that candidates start thinking and planning now.”
Read Ohio’s Health Transformation report, Moving Ohio’s Health Care Payment System Upstream.

States Work to Hold Hospitals Accountable for Community Benefits Spending

May 8, 2018/in Policy Blogs Community Benefit, Cost, Payment, and Delivery Reform, Health Equity, Health System Costs, Hospital/Health System Oversight, Population Health, Social Determinants of Health /by NASHP Writers

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Hospitals get billions in tax breaks and in return they’re supposed to invest in community health. How can state policymakers ensure that money is spent on the right issues to support state health goals?

Nonprofit hospitals benefited from at least $24.6 billion in tax exemptions in 2011, according to a 2015 analysis that used the most recent data available. In exchange for these exemptions, federal tax policy requires hospitals to invest in activities that benefit the health of their communities. But do these activities truly target the most pressing health needs of area residents?

Community benefits requirements for nonprofit hospitals:

The IRS requires 501(c)(3) hospitals to provide charitable community benefits in exchange for their tax exemption.
Under the Affordable Care Act, tax-exempt hospitals must conduct community health needs assessments every three years and develop a plan to implement strategies to address those needs.
IRS Form 990 Schedule H requires hospitals to report their community benefits, community building, and community health improvement
States can require hospitals to do more than simply meet the federal requirements.

Policymakers know that 80 percent of people’s health is affected by factors beyond the reach of hospital or clinician care, such as access to nutritious food, safe housing, education, income security, health equity, and other socio-economic factors. Given the importance of these social determinants in shaping people’s lives and health, how can states use their policy levers to ensure that tax-exempt hospitals invest their community benefit dollars in ways that most effectively address and support state health priorities?

The Affordable Care Act (ACA) provides a foundation that states can build on when integrating hospital spending on community health with state priorities. The ACA requires charitable hospitals governed by section 501(c)(3) of the Internal Revenue Code to conduct community health needs assessments every three years, and to adopt a plan to address those needs. It also requires hospitals to establish financial assistance policies and to refrain from charging higher prices to people receiving financial assistance than is generally billed to insured people. The IRS Form 990 Schedule H also requires tax-exempt hospitals to report whether and how they considered community input when creating their community benefits plan.

The interactive Community Benefit Insight tool, supported by the Robert Wood Johnson Foundation (RWJF) in partnership with RTI International and the Public Health Institute, draws on IRS and other data to show how hospitals spend their community benefits dollars. Research shows hospitals spend the majority of their community benefits resources on clinical care — including charity care and Medicaid shortfalls — rather than on community health improvement or community-building activities that can address the social determinants of health. The Community Benefit Insight tool allows users to compare such spending across hospitals and health systems.

States can require hospitals to do more than simply meet the federal requirements. Some states go beyond by requiring hospitals to specifically report how hospitals’ community benefits investments address the social determinants of health or meet the needs of underserved populations. Some states mandate that hospitals spend at least a minimum amount on community benefits.

States also use a range of enforcement strategies to ensure that hospitals comply with state regulations. A new National Academy for State Health Policy (NASHP) table highlights effective state hospital community benefits requirements and related state law requirements in several states. The table can inform state policymakers who want to leverage their states’ community benefits process to improve community health.

States command a range of policy levers that can maximize hospital community benefits spending to address the social determinants of health. To help states deploy these levers effectively and share best practices, NASHP has convened a Hospital Community Benefits Workgroup, composed primarily of officials from state attorneys general and insurance commissioners’ offices, as well as state Medicaid, public health, and justice departments. With support from RWJF and the New England States Consortium Systems Organizations, the workgroup is exploring how states can develop more meaningful hospital community benefits and community-building investments that align with state public health priorities and address the social determinants of health. This mission includes examining:

How states define and count community benefits;
How to ensure community health needs assessments are substantive;
How community health trusts can be used as a tool for community benefits investing; and
What measurement tools are available to evaluate the benefits of community benefit spending on public health programs.

While the table — and the workgroup — currently focus on the New England states, the list will be expanded to include other states as work progresses. State officials are invited to become involved with the NASHP community benefits workgroup or share their states’ efforts to maximize hospital community benefits investments. Please contact Amy Clary at aclary@oldsite.nashp.org for more information.

Explore the Hospital Community Benefits Comparison Table – New England States, which highlights effective state hospital community benefits requirements and related state law requirements in several states.

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.

Minnesota Accountable Community for Health Saves Medicaid $3.8 Million through Its Opioid Prevention Initiative

April 12, 2018/in Policy Minnesota Blogs Accountable Health, Behavioral/Mental Health and SUD, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Essential Health Benefits, Health Coverage and Access, Health Equity, Health System Costs, Medicaid Expansion, Population Health, Social Determinants of Health /by Amy Clary

Morrison County’s Accountable Community for Health Accomplishments:

Tapered 453 patients off narcotic, stimulants, and benzodiazepine prescriptions, which resulted in 540,000 fewer doses;
Saved Medicaid $3.8 million by reducing these drug prescriptions; and
Reduced jail time from an average 17 days to less than one in 36 surveyed patients who received medication-assisted treatment (Suboxone).

*CHI St. Gabriel’s Health Family Medical Center’s Controlled Substance Team in Morrison County

In Minnesota, an innovative approach to improve population health is reducing the opioid crisis and saving taxpayers millions.
In Morrison County, Minnesota, an innovative state approach to improving population health is also helping combat the opioid crisis and saving money. The Unity Accountable Community for Health (ACH) initiative has saved the state’s Medicaid program $3.8 million over three years by reducing claims for prescription opioid and related drugs.
The accountable communities for health initiative, which takes a whole-person approach to prevention, offers a model for state policymakers seeking to develop sustainable, community-based prevention initiatives to combat opioid misuse and promote population health.
Minnesota ACHs
Minnesota is one of several states developing accountable health models that emphasize community-based health promotion and cross-sector, cross-agency partnership to address health-related social needs, such as safe and healthy housing and access to wholesome food. Minnesota’s ACHs have the flexibility to implement projects to meet the clinical and social needs of targeted populations. ACHs in Minnesota are locally planned and governed by a leadership team comprised of local providers, community partners, and members of the population served.
Each ACH in Minnesota received $370,000 in federal start-up funding through Minnesota’s SIM grant, and the Unity ACH and five others received additional SIM funding. One of the priorities of the additional funding was to support the ability of the accountable care organizations (ACOs) that partner with the ACHs to collect, analyze, and report utilization and quality data for the populations served by both the ACH and its partnering ACO. ACOs are the only entities with whom ACHs are required by the state to partner. This partnership also enables ACHs, such as the Unity ACH, to develop sustainability models and gain access to crucial health care information such as utilization and cost data.

The Unity ACH Model: How It Works
The Unity ACH includes local health care providers, pharmacies, insurers, local public health and social services agencies, and local law enforcement. The ACH’s lead agency, Catholic Health Initiatives’ St. Gabriel’s Health, uses a controlled substance care team that works closely with providers and patients to coordinate patient care and help patients safely manage their medications. The care team also identifies the health-related social needs of patients and connects them with services for housing, transportation, insurance, and mental health.
The ACH launched medication-assisted treatment (MAT) in May of 2016 to treat heroin and opioid addiction, and expanded MAT into the Morrison County Jail. This initiative — the first of its kind in Minnesota — shows promising results in its first years of operation. Before using MAT (Suboxone [buprenorphine plus naloxone]), 36 people surveyed reported serving an average 17 days in jail. After participating in MAT, participants reported spending less than one day in jail on average. This drop in incarceration for this high-risk population suggests the potential for significant cost savings to county jail systems.
Results

The Unity ACH reports saving Medicaid $3.8 million as of March 2018, due in part to providers prescribing 540,000 fewer doses of opioids, benzodiazepines, and stimulants, and safely reducing or stopping drug use in more than 450 patients. The ACH gauges savings by measuring reductions in the number of opioid prescriptions filled and tracking emergency department diagnoses for therapeutic drug monitoring. The percent of Medicaid beneficiaries with eight or more opioid claims declined in the area served by the program from 14.8 percent to 12.8 percent in one year’s time.
Unity ACH has been able to calculate cost savings by leveraging data sharing with its ACO partner, which is contracted to serve Medicaid patients in Morrison County, and therefore has access to cost and utilization data for these patients.
This cost savings gained the attention of Minnesota’s Congressional delegation. On Sept. 28, 2017, the ACH briefed Senate and Congressional staff about its rural solution to the opioid epidemic. The ACH team had earlier briefed Congressional staff in 2016.
The Unity ACH model has also led to local policy changes. Providers are now standardizing their screening processes and increasingly accessing the Minnesota Prescription Monitoring Program database, an information-sharing system that helps providers track patients’ prescriptions to inform their own prescribing practices.
The ACH team won the American Hospital Association’s 2017 NOVA award for its commitment to community collaboration in an innovative solution addressing the opioid crisis. They also won the Rural Health Team Award at the 2016 Minnesota Rural Health Conference.

Looking Ahead
In 2017, the Minnesota General Assembly appropriated $1 million for accountable community opioid abuse prevention projects, which will allow eight other communities to replicate the Unity ACH model. The ACH’s reach will also grow through the Project ECHO (Extension for Community Healthcare Outcomes) Hub program, supported by the US Substance Abuse and Mental Health Services Administration’s State Targeted Response to the Opioid Crisis. The grants will support weekly eLearning sessions for providers about opioid care and case management.
More broadly, the Unity ACH, in partnership with the state, is considering how savings might be reinvested to support health-related social needs such as transitional housing and healthy food. By incorporating a focus on the opioid crisis and community health within its health care delivery reform, Minnesota provides a model for other states seeking to build community capacity to improve health and lower costs.
Support for this work was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect those of the foundation. Thank you to the Minnesota state officials and ACH leaders who informed this update, and thanks to Felicia Heider for collaborating on an earlier version. All errors or omissions are the author’s.

NASHP State Leaders Meet to Reflect and Plan in a Changing Health Care Environment

March 27, 2018/in Policy Blogs CHIP, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Essential Health Benefits, Health Coverage and Access, Health Equity, Health System Costs, Healthy Child Development, Integrated for Pregnant/Parenting Women, Maternal, Child, and Adolescent Health, Medicaid Expansion, Population Health, Social Determinants of Health, State Insurance Marketplaces /by NASHP Writers

Last week, 24 National Academy for State Health Policy (NASHP) leaders, including state lawmakers and representatives from governors’, budget, and insurance offices, Medicaid and public health agencies, and insurance exchanges, CHIP and health policy commissions met in Washington, DC, to assess the issues and opportunities confronting state health policymakers. The robust discussion helps NASHP set its priorities for action and informs the annual NASHP conference agenda.
While NASHP members approached the discussion from markedly different states and perspectives, several clear themes emerged.
Costs, costs, costs: A recent Journal of the American Medical Association article that highlighted the high price of health care in the United States – double what is spent in other, developed countries due to high-priced services, drugs, devices, and administrative costs – helped frame the critical issue of cost and affordability. Members were eager to talk in-depth about:

The role of value-based purchasing, and how policymakers can measure value and at what price.
How investments in the social determinants of health (e.g., housing, nutrition, and education) can truly bend the health care cost trajectory.
Is there more do to with reference pricing and giving consumers more power to shop?
Are there better ways to manage long-term services and supports and provide effective chronic care and end-of-life support?

Members encouraged NASHP to continue its work to address rapidly-rising pharmaceutical costs and to expand that effort to address other drivers of escalating health care costs.
The changing health care marketplace: Consolidation of health providers, emergence of new players in the field such as the Berkshire-Hathaway proposal, and new mergers and acquisitions throughout health care raised questions about whether states’ current regulatory structures are keeping pace with these changes.

What is the role of state insurance regulators as providers develop new models of care and take on financial risk, a role that has historically been the purview of insurance companies?
Does the certificate of need program need to be re-examined and reformed to adapt to the changing market?
Do states have adequate data infrastructure to track and predict these changes?

Coverage and federal uncertainty: Officials reflected on a year of uncertainty and recounted their efforts to sustain programs while awaiting federal action or responding to federal changes. Children’s Health Insurance Programs (CHIP) were in limbo, but states managed to maintain coverage until Congress made a much-delayed decision to continue federal financing for 10 years.
Insurance regulators and state insurance exchanges reacted quickly to keep coverage in the individual market affordable when the Administration stopped funding cost-sharing reductions in the eleventh hour last fall. Now, they must contemplate how to sustain markets in light of proposed federal plans to extend short-term duration plans and launch association health plans that are exempt from Affordable Care Act rules. which could pull enrollees out of state marketplaces with their low-cost, low-benefit plans.
As the Centers for Medicare & Medicaid Services allows more flexibility in Medicaid programs, what does that mean in practice? How will work requirements play out? What other approaches might states take?
Health care workforce: A changing health care environment creates the need for new approaches to deliver care, such as telehealth, but NASHP members shared an overriding sense of urgency to address the growing demand for a health care workforce in both rural and urban areas. They reported challenges in their home states in every area of health care, including physicians, nursing, therapists, community health workers, dental providers, behavioral health practitioners, and long-term services and supports staff. Without an appropriate workforce, state efforts to improve care integration and delivery and payment reforms will be hindered. What can states do through licensure, education, salary, and benefits to expand this vital workforce? And, how does federal immigration policy affect the availability of these critical workers?
Improving health: As state leaders face day-to-day challenges, the over-arching focus of their work is to improve population health and directly address the social determinants that impact health so profoundly. The opioid crisis continues to demand leaders’ time and action, but comprehensive work is also underway to build sustainable systems to improve health. Leaders discussed new ideas to:

Create or strengthen linkages with school health programs;
Improve transitions for youth with disabilities who age out of supportive services;
Assist those leaving corrections systems;
Help children and youth with special health care needs; and
Employ new, evidence-based approaches that strengthen early child development.

Throughout the conversation, leaders stressed the need for state officials to break out of funding and administrative silos so they can work collaboratively and creatively to develop and implement efficient and effective policies during this period of uncertain federal priorities and funding.
Armed with these insights and concerns, NASHP will continue to work in these key areas and address them at its annual health care policy conference from Aug. 15 to 17, 2018, in Jacksonville, FL.

State and Federal Officials Explore Ways to Promote Healthy Child Development in a New Era

March 27, 2018/in Policy Reports Behavioral/Mental Health and SUD, Care Coordination, Children/Youth with Special Health Care Needs, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Eligibility and Enrollment, Health Equity, Health System Costs, Healthy Child Development, Integrated Care for Children, Integrated for Pregnant/Parenting Women, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Population Health, Primary Care/Patient-Centered/Health Home, Quality and Measurement, Social Determinants of Health /by Carrie Hanlon and Jill Rosenthal

The first years of life significantly impact long-term health and well-being and policymakers have worked hard to create initiatives that help children during this important period. Recently, the National Academy for State Health Policy (NASHP) convened state and federal leaders from agencies serving young children to discuss innovative approaches to advance healthy child development in a time of increased scrutiny and potential funding cuts. Read about their recommendations to promote healthy child development through delivery system, data, and payment strategies here.

How Governors Addressed Health Care in Their 2018 State of the State Addresses

February 26, 2018/in Policy Georgia, Hawaii, Idaho, Iowa, Massachusetts, New Hampshire, New Jersey, New Mexico, Rhode Island, South Dakota, Utah, Washington, Wisconsin, Wyoming Charts Behavioral/Mental Health and SUD, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Health Coverage and Access, Health Equity, Health System Costs, Healthy Child Development, Housing and Health, Integrated Care for Children, Integrated for Pregnant/Parenting Women, Maternal, Child, and Adolescent Health, Medicaid Expansion, Medicaid Managed Care, Physical and Behavioral Health Integration, Population Health, Quality and Measurement, Social Determinants of Health, Value-Based Purchasing, Workforce Capacity /by NASHP Staff

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