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Tennessee’s Care Coordination Tool: Marshaling Data to Help Providers Coordinate Care

September 1, 2021/in Care Coordination Tennessee Blogs, Featured News Home Care Coordination, Primary Care/Patient-Centered/Health Home /by Neva Kaye

For many years, states have worked to ensure that Medicaid participants have access to patient-centered medical homes (PCMH). In 2010, the Affordable Care Act (ACA) authorized state Medicaid programs to create health homes to improve and better coordinate the full range of services needed by Medicaid beneficiaries with chronic health needs. Capitalizing on these opportunities, Tennessee almost simultaneously implemented both a PCMH program to meet the primary care needs of all Medicaid beneficiaries and a health home program to coordinate behavioral and physical health services for beneficiaries with high behavioral health needs (Tennessee Health Link or THL). The PCMH program began in January 2017 and THL began in December 2016.

TennCare (Tennessee’s Medicaid agency) recognized both PCMH and THL providers needed comprehensive information about the service needs and services received by their Medicaid patients to be most effective. However, in the absence of a state health information exchange (Tennessee’s statewide HIE disbanded in 2012), there was no ready source of that data nor was there any existing organization seeking to turn data into the information providers could use to enhance performance. To meet this need, TennCare developed a care coordination tool (CCT) that marshalled data from diverse sources to help both PCMH and THL providers meet the primary and behavioral health care needs of their Medicaid patients. This brief is based on research and an interview with TennCare representatives.

What is the CCT?

The CCT is a cloud-based application that draws from Medicaid claims data, encounter data from TennCare’s contracted managed care organizations (MCOs), immunization data from the Tennessee Department of Health’s (TDH) statewide immunization information system (TennIIS), and information about admissions, discharges and transfers (ADTs) provided by hospitals via data exchange partners, Tennessee Hospital Association (THA), East Tennessee Health Information Network (etHIN) and Community Hospital Systems (CHS). This information, as presented by the CCT, helps providers identify and fill gaps in patient care. It also speeds notification of hospitalizations and emergency department visits enabling providers to more quickly provide transitional and follow-up care when these events occur. Specifically, the types of information in the CCT include:

Name and available demographic information for Medicaid beneficiaries who are members of a provider’s panel
Claims based clinical data drawn from both claims and encounter data, including medication and diagnosis history, as well as records of visits to providers.
ADT information from emergency departments and hospitals.
Immunization data for children under 2 years and those 9-13 years of age.
Each provider’s performance on the quality measures to which PCMH and THL value-based payments are tied.
Care alerts that identify ‘past due’ services needed by an individual patient such as, mammogram, follow-up to a hospital discharge, or an update to the patient’s comprehensive person-centered care plan.

PCMH and THL providers are eligible for bonus or outcome payments based on each organization’s performance on total cost of care, and a set of efficiency and quality measures. The method of calculating efficiency and the specific quality metrics included in the set varies between THL and PCMH providers—and among PCMH providers by the mix of children and adult Medicaid beneficiaries attributed to the practice. Although the CCT is an optional tool for providers participating in the THL and PCMH programs, it provides a platform for providers to act on near real-time data and shows the impact of their work on the quality and efficiency measures by which provider performance is measured. (More information on payment can be found in TennCare’s PCMH and Health Link operational manuals.)

Multiple data sources produce more useful data

“Reach out to providers early…find out their wishlist. What is it that would help them take care of their patients better?”

—TennCare representative

Designed for PCMH and THL providers, the CCT ultimately offers a single consolidated source of information about providers’ panel members, even when members are enrolled in different MCOs. The CCT includes information to help providers identify their members’ primary care needs, any services that have been delivered by other providers, hospital and emergency department ADTs, and more. TennCare obtains much of this information from the claims and eligibility data contained in the agency’s Medicaid Management Information System (MMIS). However, TennCare recognized there are still challenges which exist with incorporating multiple data sources for the CCT. One challenge is the sometimes significant lag between when a service was delivered and when data about that service appears in claims data. Another common barrier for providers and other users of the tool is the lack of connectivity between the CCT and their electronic health records (EHRs), which may mean users need to enter the same information in both the CCT and EHR. Both challenge providers’ ability to use the CCT to obtain the information they need to care for their patients.

TennCare’s partnerships with other organizations that maintain other data sources is a large factor in the agency’s success. The THA became the agency’s first partner when, in 2017, TennCare began contracting with the association to obtain near real-time ADT data to populate the CCT. Because TennCare needed complete ADT information it then worked with the THA to draw in those hospitals that were not already submitting data to the THA. For example, TennCare issued guidance to hospitals requiring them to submit ADT data to qualify for the directed payment of funds that were formerly distributed as unreimbursed hospital cost pool payments. 100% of hospitals in Tennessee now submit ADT data to the THA. Thus, the THA was able to create a more complete data set by partnering with TennCare.

In 2019, TennCare also began contracting with the Tennessee Department of Health (TDH) to incorporate specific immunization data from the statewide immunization information system (TennIIS) into the CCT. This data is used to supplement claims data which populates performance on specific Healthcare Effectiveness Data and Information Set (HEDIS) immunization measures and to identify patients in need of immunizations. Like the THA, the TDH benefits from the contract, as it commits TennCare to working with the TDH to improve the quantity and quality of data submitted to the registry by providers and furthers the shared work of both TennCare and the TDH of improving immunization rates for children in Tennessee.

“One of the biggest draws was that live ADT feed. It helped care coordinators keep up to date with admissions, emergency department use, and discharges so that they could follow-up in real time.”

—TennCare representative

Although these specific data sources may not be available in other states, it is likely that others are. TennCare representatives advise thorough planning is necessary to identify the information needed in the tool—both at launch and in the future. Identifying the partners and resources needed to access data outside of the Medicaid agency’s control also requires thorough planning. Further, developing mutually rewarding partnerships (and contracts) takes time. It is important to have a long-term plan in place early in development.

The CCT is a large investment, but state costs are offset by federal matching funds

The CCT is a large investment. Its development required leadership and dedication of a wide range of staff. Multiple TennCare departments were involved, including the chief medical office, behavioral health operations, information systems, legal, and others. The CCT’s development required the input and feedback of providers and MCOs that would ultimately benefit from the tool. In addition to the contracts with the CCT vendor (HealthEC), THA and TDH, TennCare information system (IS) contractors were also utilized for design and implementation. TennCare representatives estimate that a group of 15-20 were heavily involved in development, but many others were called in as needed.

Of course, the largest part of the investment is the cost to develop and maintain the CCT. TennCare conducted a procurement to select the first vendor to develop and operate the CCT—this contract was awarded in 2016. The second CCT, launched in November 2020, was procured through a current TennCare IS contractor. TennCare representatives feel the new CCT better meets their vision for the tool and the needs of THL and PCMH organizations.

Based on their experience, TennCare representatives advise states seeking to develop a tool to ensure that the selected vendor has qualifications to accurately provide and process the data as inaccuracies will quickly lead to distrust of information flowing through a tool. TennCare representatives advised that it is important for states to:

Set basic qualifications for vendors and involve knowledgeable information technology staff in determining whether potential vendors meet those qualifications.Select a vendor already working with large, multi-site locations and processing many different types of data from multiple data sources.
If state plans include generating HEDIS measures it is important the vendor have a National Committee for Quality Assurance (NCQA) Measure Certification.

“After you choose a vendor, set strategy immediately. The strategy should be as detailed and inclusive as possible, but general enough to grow to what you need in the future.”

—TennCare representative

Seek input from the providers who will be using the tool, for example by convening technical assistance groups of providers to help with design or conducting end user testing with providers.
Conduct detailed reference checks on potential vendors to find out their strengths and weaknesses.
Have a strategic training and engagement plan for the 12 months post go-live

Although the investment was large, the original CCT implementation qualified for 90/10 federal matching funds under the Health Information Technology for Economic and Clinical Health (HITECH) Act. As part of the Medicaid agency’s MMIS, TennCare receives 75/25 federal matching funds for the new HealthEC CCT. This funding greatly reduced the cost to the state. (Note: HITECH funding is only available through 2021, but other opportunities will remain to secure 90 percent funding for design and development of HIE and HIT.)

There is evidence of success

One measure of success is whether providers use the tool. As of June 2021, all PCMHs, THLs, and MCOs have registered at least one staff person to use the tool and a total of 662 MCO, PCMH, and THL users have registered. TennCare representatives report the enhanced ADT data was a big draw for these providers. TennCare offers monthly trainings to some users and individualized assistance to others. TennCare and its contractor have also developed a learning library that includes recorded trainings and quick reference guides to help providers use the CCT to accomplish tasks such as identifying frequent emergency department users.

The most important measure of success, however, is whether using the CCT produces improved cost and quality outcomes. This question is difficult to answer due to the multiple influences in reducing cost and improving quality. However, TennCare did evaluate both the PCMH and THL programs, and agency representatives believe there are indications in these evaluations that using the CCT did produce improved outcomes. Key findings from these evaluations include the following.

The state’s evaluation of the PCMH found evidence of improved quality, increased access to primary care, and increased follow-up visits following emergency department and inpatient visits.
The state’s evaluation of the THL program found indications of improved access to primary care among THL members. It also found the THL members had lower inpatient and emergency department visit rates then a comparison group of similar Medicaid program participants who were not enrolled in the program.

“There are some members THL providers cannot find. With ADT, they can locate and maybe enroll the member if they show up at the hospital.”

—TennCare representative

While these changes cannot be directly attributed to use of the CCT, TennCare representatives believe it did play a role by, as designed, helping providers identify gaps in care and providing the information needed to improve follow-up and coordination. This belief is bolstered by findings from focus groups and interviews with PCMH and THL providers. These providers frequently mentioned the importance of the tool for care coordination, especially the ADT data. Also, many of the providers wanted even more information, suggesting they see great value in the information provided by the CCT. There is anecdotal evidence the information in the CCT helped providers identify the specific primary care and behavioral health needs of their patients and facilitate access to care.

Summary

TennCare’s experience illustrates how state Medicaid agencies can develop IT tools that successfully help providers improve the care delivered to Medicaid beneficiaries, even in the absence of a statewide HIE. TennCare’s success was rooted in meeting provider needs. The agency considered end user needs and preferences during the CCT’s development, provides accurate and near real-time data to improve care coordination efforts, and focuses on giving providers the information they need to improve performance linked to payment. To accomplish this, TennCare looked to data sources outside those operated by the Medicaid agency to create a more timely and complete set of data and developed a strong partnership with the state’s IS agency. Finally, access to enhanced federal matching funds offset the cost of the investment.

Acknowledgements: The National Academy for State Health Policy (NASHP) would like to thank the state officials from Tennessee who contributed to the brief as well as Health Resources and Services Administration Project Officer Diba Rab and her colleagues for their feedback and guidance. We also thank the state officials from Montana and the staff of the Montana Healthcare Foundation whose interest in improving the care delivered to Montana Medicaid participants led to the creation of this brief. Finally, the author wishes to thank Hemi Tewarson, Kitty Purington, Jodi Manz, and Luke Pluta-Ehlers of NASHP for their contributions to the paper. This project was supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under co-operative agreement number UD3OA22891, National Organizations of State and Local Officials. The information, content, and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the US government.

Texas Improves Access to Routine Oral Health Services for Very Young Children

January 15, 2021/in Policy Texas Child Oral Health, Chronic Disease Prevention and Management, Consumer Affordability, Cost, Payment, and Delivery Reform, Health Coverage and Access, Health Equity, Health System Costs, Integrated Care for Children, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Oral Health, Population Health, Primary Care/Patient-Centered/Health Home, Quality and Measurement, Quality and Measurement, Social Determinants of Health /by Veronnica Thompson

Though largely preventable, tooth decay (caries) is the most common chronic disease in US children, affecting approximately 23 percent of children ages 2 to 5.[1],[2] Texas’s First Dental Home and its enhanced bundled payment has increased access to preventive dental service and improved the oral health of Medicaid-enrolled children ages 6 to 35 months.

Providing children with access to routine oral health services has the potential to prevent dental caries, reduce emergency dental visits, and promote overall health, resulting in significant cost savings for states. States are required to provide dental services to Medicaid-enrolled children under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. While it is recommended that all children receive an initial dental visit in their first year of life, less than 10 percent of Medicaid-enrolled children under age 3 receive preventive dental services.[3] This case study explores how Texas is improving oral health access for these very young children.

Importance of Oral Health in Very Young Children

Early childhood caries (ECC) is characterized by the presence of at least one decayed, missing, or filled primary tooth surface in a child younger than age 6.[4] Among children in this age group, nearly one-quarter have ECC,[5] with 10 percent untreated.[6]

In addition to causing pain and discomfort, dental caries, including ECC, can affect young children’s quality of life and overall development, including reduced intake of food, lower weight, and increased school absences.[7] High incidences of untreated dental caries are also associated with increased risk of hospitalizations and emergency dental visits, resulting in significant costs to state Medicaid programs.[8],[9] One report examining Medicaid-enrolled children under age 6 in Iowa found that children treated for ECC in a hospital or ambulatory setting accounted for 25 to 45 percent of total dental costs.[10]

Children who have their first preventive dental visit by age 1 are more likely to have subsequent preventive visits and lower dental-related costs.[11] Given the importance of early access to routine, preventive oral health services among young children, several leading national pediatric medical and dental organizations recommend that all children receive an initial dental visit during the first year of life.[12],[13],[14] Yet, only 9 percent of Medicaid-enrolled children under age 3 received a preventive dental service over a one-year period, compared to 84 percent of children in the same age group who received a well-child visit.[15],[16]

As states explore opportunities to improve access to oral health services, there is growing interest in strengthening routine access to oral health services among young children.

Texas First Dental Home

Implemented in 2008 by the Texas Health and Human Services Commission (HHSC) – the state’s Medicaid program – to increase children’s access to preventive services under the EPSDT benefit, the First Dental Home (FDH) is a legislatively supported, Medicaid dental initiative designed to improve the oral health of Medicaid-enrolled children, ages 6-35 month, through the following actions:

Initiate early preventive dental services (including for those children without erupted teeth);
Provide communication and education to parents and caregivers promoting the importance of children’s oral health; and
Establish dental homes for children beginning at 6 months of age or as early as possible upon enrollment in Medicaid. [17]

Children participating in FDHs are eligible for a maximum of 10 visits between 6 to 35 months of age, with at least 60 days between visits. This requirement allows for a child to begin FDH visits at six months of age with a recall schedule of every three months (for those children at moderate-to-high risk for developing severe ECC) until their third birthday.[18] In addition to completing an oral health questionnaire, a dental risk assessment questionnaire, and a comprehensive oral evaluation during the initial visit, FDH visits include:

Texas Health Steps Caries Risk Assessment Tool;
Dental prophylaxis;
Oral hygiene instructions for the child’s primary caregiver;
Application of topical fluoride varnish;
Dental anticipatory guidance, including nutritional counseling and oral developmental milestones; and
Establishment of a dental recall schedule.[19]

Due to the importance of caregiver participation and understanding of their children’s oral health, HHSC requires at least one parent or caregiver to be present with the child during the entire FDH visit.[20] An evaluation of FDH found that participation in the program increased caregivers’ oral health knowledge and some of their oral health practices to improve their children’s oral health.[21]

First Dental Home Bundled Reimbursement and Provider Enrollment

The Current Dental Terminology (CDT) code D0145 is used at an enhanced reimbursement rate of $142.07 for all FDH visits. For the purposes of FDH billing, D0145 is considered an all-inclusive (or bundled) code required for all diagnostic and preventive services rendered under FDH, including those not traditionally reimbursed for routine preventive services, such as oral hygiene instruction and nutritional counseling.[22],[23] Dentists cannot bill for any other exam, prophy, or fluoride codes for a FDH visit.[24]

Eligible providers (e.g., pediatric and general dentists) must become FDH providers to claim reimbursement using the enhanced bundled CDT code. In addition to being trained and certified by the Texas Health Steps Program, the state’s EPSDT program, dentists must have a National Provider Indicator number (NPI) and an individual Texas Provider Indicator (TPI) number of each practice location.[25] Within the first 12 months of the program’s implementation, 815 dentists became FDH providers, 674 of whom billed for services.[26]

Texas is a state with dental benefits carved-out of its medical managed care program to three dental maintenance organizations (DMOs). Collectively, these DMOs help to manage the dental care needs of the state’s Medicaid members, including participation in FDH. Under this arrangement, HHSC outlines FDH-specific contract requirements, which stipulate that each DMO must:

Implement a process to detect under-utilization of FDH services;
Verify a providers’ qualifications to submit claims for FDH services; and
Publish provider directories and note which providers are FDH providers.

In addition to these contract requirements, HHSC has a dental Pay-for-Quality (P4Q) program to further strengthen oral health utilization. Under Texas’s dental P4Q program, 1.5 percent of each DMO’s capitation is at risk of recoupment for specific performance measures (e.g., the percentage of enrolled children who receive a comprehensive or periodic oral evaluation in a reporting year) if a DMO’s performance declines beyond a defined threshold. Conversely, if a DMO’s performance improves beyond the threshold, the DMO can earn incentive payments.[27] To help bolster its performance, at least one DMO implemented value-added services for members participating in FDH, including a free dental care kit and gift card upon completion of a FDH visit.[28] As a result of limited data due to COVID-19 from which to assess quality measures, HHSC has temporarily suspended its dental P4Q program, including performance measures under FDH.[29]

Texas’s multipronged efforts to increase access to preventive oral health services for Medicaid enrolled children 6 to 35 months of age under the EPSDT benefit have resulted in increased utilization, even exceeding the rate of dental care use among commercially insured children in some years.[30],[31] Based on available dental performance measures collected by HHSC, participation in FDH has steadily increased with approximately 71 percent of children 6 to 35 months of age receiving at least one FDH visit in FY 19.[32] Based on claims data collected from 2005-2011, there was an estimated cost savings of $12.9 million (or $269.01 per member per year) among children 3 to 6 years of age receiving routine preventive dental services. The savings per member is driven, in part, by reductions in oral health utilization and treatment expenditures.[33] The goal of FDH services is to aid in the additional reduction of treatment expenditures.[34]

Due to the impact of COVID-19 on access to preventive services,[35] utilization of FDH was down 90 percent at the start of the public health emergency. By summer 2020, use of FDH services was at 80 percent compared to the previous year, with access rates slowly returning to normal.

Conclusion

To improve the oral health of Medicaid-enrolled children ages 6 to 35 months, Texas’s First Dental Home successfully implemented an enhanced bundled payment, caregiver engagement strategies, and provider-specific requirements to increase access to preventive oral health services for very young children under the EPSDT benefit. Texas’s approach is one that other state Medicaid programs can adapt as they explore strategies to improve the oral health of very young children and promote access to an initial dental visit during the first year of life.

Acknowledgements: This case study is a publication of the National Academy for State Health Policy (NASHP). This project is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under the Supporting Maternal and Child Health Innovation in States Grant No. U1XMC31658; $398,953. The information, content, and conclusions are those of the authors’ and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the US government.

Notes

[1] “Hygiene-related Diseases, Dental Caries,” U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, September 2016. https://www.cdc.gov/healthywater/hygiene/disease/dental_caries.html

[2] “Dental Caries in Primary Teeth,” U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, September 2019. https://www.cdc.gov/oralhealth/publications/OHSR-2019-dental-caries-primary-teeth.html – :~:text=The prevalence of untreated tooth,-poor, and poor children.

[3] “Utilization of Dental Services Among Medicaid Enrolled Children,” U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, October 2012. https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/MedicaidDataSourcesGenInfo/Downloads/MAX_IB9_DentalCare.pdf

[4] “Statement on Early Childhood Caries,” American Dental Association, 2000. https://www.ada.org/en/about-the-ada/ada-positions-policies-and-statements/statement-on-early-childhood-caries

[5] U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, “Dental Caries in Primary Teeth,”

[6] “Dental Caries and Sealant Prevalence in Adolescents in the United States, 2011-2011, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, March 2015. https://www.cdc.gov/nchs/products/databriefs/db191.htm#:~:text=Dental%20caries%20among%20children%20aged,31%25)%20aged%202%E2%80%938

[7]Sheiham, A., “Dental caries affects body weight, growth, and quality of life in pre-school children,” British Dental Journal, November 2006. https://www.nature.com/articles/4814259 – :~:text=First, untreated caries and associated,foods because eating is painful.&text=Second, severe caries can affect,irritability and disturbed sleeping habits

[8] “The Importance of the Age One Dental Visit,” Pediatric Oral Health Research & Policy Center, 2019. https://www.aapd.org/globalassets/media/policy-center/year1visit.pdf

[9] “Allareddy, V., et al., “Hospital-based emergency department visits involving dental conditions: profile and predictors of poor outcomes and resource utilization,” Journal of the American Dental Association, April 2014. https://pubmed.ncbi.nlm.nih.gov/24686965/

[10] “Kanellis, M., et al., “ Medicaid Costs Associated with the Hospitalization of Young Children for Restorative Dental Treatment under General Anesthesia,” Journal of Public Health Dentistry, May 2007. https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1752-7325.2000.tb03288.x?sid=nlm%3Apubmed

[11] Savage, M., et al., “Early Preventive Dental Visits: Effects of Subsequent Utilization and Costs,” Journal of the American Academy of Pediatrics, October 2004. https://pediatrics.aappublications.org/content/114/4/e418.long

[12] “Recommendations for preventive pediatric health care,” Journal of the American Academy of Pediatrics, March 2000. https://pediatrics.aappublications.org/content/105/3/645

[13] American Dental Association, “Statement on Early Childhood Caries.”

[14] “First Oral Health Assessment Policy,” American Association of Public Health Dentistry, May 4, 2004. https://www.aaphd.org/oral-health-assessment-policy

[15] Centers for Medicare and Medicaid Services, “Utilization of Dental Services Among Medicaid Enrolled Children.”

[16] “Utilization of Well-Child Care Among Medicaid Enrolled Children,” U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, October 2012. https://www.cms.gov/research-statistics-data-and-systems/computer-data-and-systems/medicaiddatasourcesgeninfo/downloads/max_ib10_wellchild.pdf

[17] “First Dental Home: Section 1: Overview of the First Dental Home Initiative,” Texas Health and Human Services, Texas Health Steps. https://www.txhealthsteps.com/static/warehouse/1076-2010-Jun-8-7c06br1a1rkyar7csn96/section_1.html

[18] “First Dental Home: Section 3: Scheduling, Treatment Planning, Documentation, and Billing,” Texas Health and Human Services, Texas Health Steps. https://www.txhealthsteps.com/static/warehouse/1076-2010-Jun-8-7c06br1a1rkyar7csn96/section_3.html

[19] “First Dental Home,” Texas Health and Human Services. https://hhs.texas.gov/doing-business-hhs/provider-portals/health-services-providers/texas-health-steps/dental-providers/first-dental-home

[20] Texas Health and Human Services, Texas Health Steps, “First Dental Home: Section 1: Overview of the First Dental Home Initiative.”

[21] Mccann, Ann., & Schneiderman, E., “Does the Texas First Dental Home Program Improve Parental Oral Care Knowledge and Practices,” Journal of Pediatric Dentistry, March 2017. https://www.researchgate.net/profile/Ann_Mccann/publication/319040790_Does_the_Texas_First_Dental_Home_Program_Improve_Parental_Oral_Care_Knowledge_and_Practices/links/5e496c8f299bf1cdb930f08e/Does-the-Texas-First-Dental-Home-Program-Improve-Parental-Oral-Care-Knowledge-and-Practices.pdf

[22] Texas Health and Human Services, Texas Health Steps, “First Dental Home: Section 3: Scheduling, Treatment Planning, Documentation, and Billing.”

[23] Use of CDT code D0145 in other state Medicaid programs is typically limited to an oral evaluation and counseling with the primary caregiver.

[24] Texas Health and Human Services, “First Dental Home.”

[25] Ibid.

[26] “State of Texas Medicaid Dental Review,” U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, October 2010. https://www.mchoralhealth.org/PDFs/CMSReview_TX.pdf

[27] “Pay-for-Quality Program,” Texas Health and Human Services. https://hhs.texas.gov/about-hhs/process-improvement/improving-services-texans/medicaid-chip-quality-efficiency-improvement/pay-quality-p4q-program – :~:text=Medical Pay-for-Quality Program,performance on certain quality measures.&text=The redesigned medic.

[28] “DentaQuest Provider Office Reference Manual: TX HHSC Dental Services,” DentaQuest, October 2020. https://dentaquest.com/getattachment/State-Plans/Regions/texas/Dentists-Page/Provider-Resources/TX_ORM.pdf/

[29] National Academy for State Health Policy, Early and Periodic Screening, Diagnostic and Treatment Network Call, “How States Can Promote Children’s Oral Health.”

[30] Nasseh, K., et al., “ Dental Care Use among Children Varies Widely across States and between Medicaid and Commercial Plans with States,” Health Policy Institute Research Brief, 2014. https://www.semanticscholar.org/paper/Dental-Care-Use-among-Children-Varies-Widely-across-Nasseh-Aravamudhan/763bbe86700c42c0f4b8a5cec50772dc20cda1a7#references

[31] Gupta, N., et al., “Medicaid Fee-for-Service Reimbursement Rates for Child and Adult Dental Care Services for all States, 2016,” American Dental Association, Health Policy Institute, 2017. https://www.ada.org/~/media/ADA/Science and Research/HPI/Files/HPIBrief_0417_1.pdf

[32] “How States Can Promote Children’s Oral Health,” National Academy for State Health Policy, Early and Periodic Screening, Diagnostic and Treatment Network Call, October 2020.

[33] Lee, I., et al., “Estimating the cost savings of preventive dental services delivered to Medicaid-enrolled children in six southeastern states,” Health Services Research, November 2017. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6153169/pdf/HESR-53-3592.pdf

[34] The research study focuses on children outside the age range of those receiving services under the First Dental Home. The study also includes claims data that precede implementation of the First Dental Home.

[35] “CMS Issues Urgent Call to Action Following Drastic Decline in Care for Children in Medicaid and Children’s Health Insurance Program Due to COVID-19 Pandemic,” U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, September 2020. https://www.cms.gov/newsroom/press-releases/cms-issues-urgent-call-action-following-drastic-decline-care-children-medicaid-and-childrens-health

Michigan Medicaid Addresses Social Determinants of Oral Health through Dental and Medical Contracts

January 15, 2021/in Medicaid Managed Care Michigan Blogs, Featured News Home Child Oral Health, CHIP, Consumer Affordability, Cost, Payment, and Delivery Reform, EPSDT, Health Coverage and Access, Health Equity, Health System Costs, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Oral Health, Population Health, Primary Care/Patient-Centered/Health Home, Quality and Measurement, Social Determinants of Health, Special Populations and Services, Workforce Capacity /by Ariella Levisohn

Inequities in dental care are prevalent across the United States, with significant disparities based on age, race, ethnicity, and socioeconomic status. Economic factors, such as ability to pay for dental insurance, and social factors such as food insecurity and access to nutritious food options also play a large role in oral health outcomes.

In Michigan, state Medicaid medical and dental managed care contracts now include requirements to address social determinants of health (SDOH) among enrollees. Examples of these requirements include:

Incorporating oral health into community health workers’ training curriculum;
Collaborating with community-based organizations (CBOs);
Collecting data on enrollees’ SDOH and using it to target outreach and educational activities; and
Implementing quality assurance and improvement projects that promote equitable access to oral health care.

Michigan’s Medicaid medical and dental managed care contracts demonstrate a proactive approach to identifying and addressing SDOH among Medicaid enrollees. While budget shortages resulting from the COVID-19 pandemic may make it more difficult for states to take on additional initiatives, addressing SDOH in Medicaid contracts can decrease costs and improve oral health outcomes. States that want to encourage dental plans to take on a larger role in promoting equitable access to care and addressing SDOH could adopt initiatives similar to Michigan’s.

These types of Medicaid contractual requirements are important first steps in improving SDOH among enrollees, while strengthening monitoring and enforcement requirements are also critical tools when adequate funding and personnel are available.

Why Focus on Oral Health and SDOH?

SDOH are the conditions in the places where individuals live, learn, and work that may affect their health risks and outcomes. They include factors such as food access, housing stability, educational attainment, poverty, health literacy, and transportation, among others. Social determinants dictate an individual’s access to health care and quality of care, which directly affect physical and oral health and exacerbate health disparities. For example:

Low-income children are twice as likely to have dental caries (tooth decay) than children from higher-income homes; and
Individuals who are poor or have less than a high school education have edentulism (toothlessness) at a rate three-times higher than those with higher incomes or more education.

Increasingly, Medicaid medical and dental managed care organizations are implementing initiatives designed to address SDOH among their members in order to improve oral health and promote health equity.

While all states cover dental care for Medicaid-enrolled children under age 21 as part of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit, adult dental coverage is optional for state Medicaid programs. Currently, 35 states provide limited dental benefits for adults and 19 states offer extensive adult dental benefits. However, optional adult benefits, such as dental care, may be affected by state efforts to meet continued budget challenges arising from the COVID-19 pandemic. Dental disease, though, not only adversely affects oral health but is also associated with diabetes, heart disease, stroke, and low birth weight and preterm births. Preventive dental care has the potential to improve overall health and well-being and reduce costs.

How Michigan Addresses Oral Health and SDOH

In NASHP’s recent 50-state scan of Medicaid managed care medical and dental contracts, Michigan was one of only three states (out of 19 reviewed) to consistently and directly reference SDOH in their Medicaid dental plan contracts.* Additionally, Michigan’s Medicaid medical managed care organization (MCO) contract includes detailed requirements for addressing SDOH, many of which align with the dental plan’s language and promotes coordination between physical and oral health care. While written contractual requirements do not guarantee that medical and dental plans are actively engaged in implementing SDOH-related initiatives – especially in the absence of funding to monitor these programs – Michigan’s contracts offer valuable examples of potential ways to address SDOH that other states could adopt as a first step.

Michigan Delivery System Overview

Michigan Medicaid uses a managed care system to deliver medical and dental care, and the Medicaid dental benefit is carved out and administered by various dental plans contracted by the state. Michigan Medicaid covers limited dental services for adults, including dental check-ups, teeth cleaning, X-rays, fillings, tooth extractions, and dentures. Additionally, the state offers an enhanced dental benefit for Medicaid-eligible pregnant women that includes emergency dental treatment and some oral surgeries. Michigan also administers the Healthy Kids Dental program, which covers comprehensive oral health care for children under age 21 enrolled in Medicaid.

Dental Contract Language

Michigan stands out because of the state’s frequent and direct mentions of SDOH throughout its Healthy Kids Dental (HKD) model contract. The HKD contract reflects a broad range of required initiatives related to SDOH, including:

Collaboration with community organizations;
Data use to target interventions and assess population-wide social needs, and
Implementation of quality assurance and improvement projects that reduce barriers to oral health care.

Collaboration with Community Organizations

One way dental plans can help address SDOH-related needs is by working with community-based organizations (CBOs). CBOs play an important role in connecting individuals to social services and helping people access health-related social needs, such as healthy food, transportation services, and educational materials that promote health literacy.

Michigan requires dental plans administering the HKD program to “collaborate with community-based organizations to facilitate the provision of enrollee oral health education services to ensure the entire spectrum of social determinants of oral health are addressed, e.g., housing, healthy diet and physical activity.” Michigan also encourages contractors to “build relationships with community partners that will engage in integrated care and promote good oral health practices.”

Through dynamic and active partnerships with CBOs, dental plans can more easily refer individuals to social and community services to help address members’ needs. Additionally, these partnerships with CBOs allow the state to expand its reach to more Medicaid-eligible children through educational initiatives.

Dental plans can also encourage members to work with CBOs and other public health programs by implementing their own educational programs. Michigan lists community-based public health resources on its website, and requires dental plan contractors to institute educational, public relations, and social media programs to increase awareness of available resources, such as CBOs, that can help reduce the impact of social determinants of oral health.

Data Collection, Tracking, and Reporting

While coordinating with social and community resources is an important step in improving health equity, having strong mechanisms in place to collect and track community data is critical to ensure social determinants are addressed. Michigan stands out in its commitment to require that medical and dental plans collect SDOH-related data.

Michigan requires HKD contractors to collect data on SDOH and utilize enrollment files, claims, encounter data, and utilization management data to improve community collaboration and address oral health disparities. The state specifies that the dental plan must “use social determinants of oral health data provided by [the Michigan Department of Health and Human Services] to analyze member-level data to direct the contractor’s efforts of targeted interventions, outreach, enrollee education and health promotion.” Additionally, the dental plan must report on the effectiveness of its population health management programs, including measures identifying the number of enrollees experiencing a “disparate level of social needs,” such as limited transportation access and housing instability.

Michigan’s data utilization requirements range from addressing individuals’ health-related needs to analyzing population-wide equity issues. Plans are required to gather and utilize this information for finetuning their services, such as care management and referrals. However, given that requirements for health plans to collect SDOH-related data are fairly new, and the state has little funding available for this work, the state’s role in monitoring whether data collection is occurring is currently limited. With adequate funding and personnel, states can take a more active role in tracking and data analysis to better understand the social needs of the population and effectively target SDOH-related interventions.

Quality Assurance and Performance Improvement

Michigan is committed to not only reporting on the effectiveness of SDOH-related initiatives, but also working to improve existing systems to better address inequities in oral health. The HKD contract requires the dental plan to have a Quality Assurance and Performance Improvement (QAPI) plan that includes a description of how the contractor will, “develop system interventions to address the underlying factors of disparate utilization, health-related behaviors, and oral health outcomes, including, but not limited to, how they relate to utilization of dental emergency services,” and “ensure the equitable distribution of dental services to contractor’s entire population, including members of racial/ethnic minorities, those whose primary language is not English, those in rural areas, and those with disabilities.”

SDOH can contribute to variances in utilization of dental services and poor oral health outcomes, with factors such as geographic location and language proficiency playing an important role in driving health care access. In addition to using data to better understand the impact of social factors on members’ oral health and population utilization trends, Michigan requires contractors to continue to find new ways to reach all populations and reduce the effects of SDOH on oral health outcomes.

Medical Contract Language

Much of the language related to SDOH included in the Healthy Kids Dental contract is consistent with the language in Michigan’s Medicaid medical MCO contract, which covers adults and children. Both the HKD and MCO contracts require the plan to collaborate with CBOs to provide physical and oral health education and address SDOH, implement community education campaigns to improve public knowledge of community-based resources, report on the effectiveness of SDOH-related population health management initiatives, and promote equitable access to care using Quality Assurance and Performance Improvement (QAPI) projects.

However, the medical contract also offers additional opportunities for investment in SDOH that states could consider implementing in dental contracts. For example, Michigan requires medical MCO contractors to participate in the Medicaid Health Equity Project, which is a statewide effort to address racial and ethnic disparities. Through this project, Medicaid health plans collect and report on data across multiple quality measures, including access to preventive and ambulatory health services. The state then uses data stratification by race and ethnicity to determine how racial and ethnic discrimination affect each quality measure, with the goal of addressing any disparities.

Additionally, the medical contract requires health plans to enter into agreements with CBOs to coordinate “population health improvement strategies,” which address social determinants such as physical environment and socioeconomic status. These agreements with CBOs must include information on data sharing, each partner’s role in care coordination, reporting requirements, and plans for coordinating service delivery with primary care providers.

What are Key Considerations and Next Steps?

Addressing SDOH is critical to improving oral health, overall health, and health equity. Increasingly, Medicaid dental plans across the country are collecting data on community needs and implementing initiatives to reduce barriers to oral health care. In a recent 50-state scan of Medicaid managed care contracts, NASHP found that out of 19 dental contracts and 38 medical contracts reviewed nationally, 13 and 37, respectively, require the plan to coordinate with community services. Efforts to address SDOH are also underway, though they tend to be further along on the medical side than the dental side. This provides an opportunity for states to apply medical contracts’ language in their dental contracts, or work with health plans to link existing SDOH-related programs with the dental system.

In response to budget shortfalls resulting from the COVID-19 pandemic, Michigan’s Medicaid program now faces potential rate changes, particularly for dental payments. However, program staff report they see opportunities to establish shared performance metrics between Medicaid MCOs and dental plans in the future. The state is considering ways to standardize and refine SDOH-related data collection and analysis, especially related to dental care. Michigan health officials noted the necessity of first ensuring data was valid and reliable before using it to drive decisions or implement capitation withhold incentive programs. The state is also discussing leveraging Michigan’s health information exchange to transmit standardized SDOH screening information to plans and providers.

Through the Healthy Kids Dental and Medical MCO contract, Michigan has demonstrated a strong commitment to addressing social determinants of oral health. The contracts present an opportunity for states to adopt similar language in order to encourage dental plans to coordinate with CBOs, effectively collect and use SDOH-related data, and implement performance improvement projects aimed at reducing disparities.

* NASHP scanned Michigan’s Healthy Kids Dental model contract and the Michigan Medicaid Medical MCO sample contract.

Acknowledgements: This fact sheet was made possible by the DentaQuest Partnership LLC. The author would like to especially thank Trenae Simpson for her guidance and assistance, and state officials in Michigan for their helpful feedback. The information, content, and conclusions are those of the author’s and should not be construed as the official position or policy of the DentaQuest Partnership LLC.

AHRQ Launches Initiative to Improve Heart Health in States with High Rates of Heart Disease and Stroke

March 9, 2020/in Policy Blogs Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Population Health, Primary Care/Patient-Centered/Health Home, Quality and Measurement /by NASHP Staff

The Agency for Healthcare Research and Quality’s (AHRQ) has announced the launch of a new initiative that will invest up to $18 million over three years to help primary care practices prevent heart disease and stroke.

Through this new funding opportunity, the agency is expanding its commitment to ensuring that primary care practices have the support they need to put patient-centered evidence into practice. Building off AHRQ’s EvidenceNOW initiative, this effort focuses on building improvement capacity in states with the highest rates of preventable heart attacks and strokes.

Grantees will form state-based cooperatives that bring together existing state-based organizations to align their efforts to engage primary care practices.

Through these cooperatives, the grantees will build a learning network of primary care practices across their states. The cooperatives and networks will ensure that the latest primary care relevant findings and resources are delivered to primary care professionals to improve the health of their patients and practices. All cooperatives will also conduct a multi-component quality improvement project with at least 50 primary care practices to improve the heart health of their patients. Applicants will also propose evaluation and sustainability plans.

A technical assistance conference call for interested teams will take place at 3 p.m. (ET) Tuesday, March 17, 2020. To register, send an email to Robert.Mcnellis@AHRQ.hhs.gov. Letters of intent are due April 10, 2020 and applications are due May 22, 2020.

State Strategies to Promote Children’s Preventive Services

March 6, 2020/in Policy Charts, Maps Children/Youth with Special Health Care Needs, CHIP, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Eligibility and Enrollment, Health Coverage and Access, Health System Costs, Healthy Child Development, 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, Quality and Measurement, Value-Based Purchasing /by NASHP Writers

Transforming Systems to Improve Health Upstream: Lessons from Washington’s Accountable Communities of Health

January 17, 2020/in Policy Washington Blogs, Featured News Home Behavioral/Mental Health and SUD, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Health Equity, Health System Costs, Healthy Child Development, Maternal, Child, and Adolescent Health, Oral Health, Physical and Behavioral Health Integration, Population Health, Primary Care/Patient-Centered/Health Home, Safety Net Providers and Rural Health, Social Determinants of Health /by Amy Clary

Five years ago, Washington State launched a collaborative regional Accountable Communities of Health (ACH) model to improve the health of communities across the state. These ACHs have evolved into independent organizations that are integral to the state’s health system transformation efforts. A 2019 evaluation by the Center for Community Health and Evaluation found this ACH model has largely succeeded in building robust regional coalitions to improve the health of their communities.

Washington’s ACHs take diverse approaches to improving health through projects such as:

The Pierce County ACH’s Community HUB, which coordinates community health worker services for at-risk pregnant women throughout the county, and
The Olympic Community of Health’s establishment of a regional opiate treatment network.

The ACH projects have aligned with the state’s broader Medicaid transformation effort, which was catalyzed through funding from a four-year State Innovation Models (SIM) test grant.

In their early stages, ACHs prioritized projects designed to improve health-related social and economic conditions. The goals of Washington’s Medicaid transformation demonstration include integrating physical and behavioral health, rewarding outcomes instead of volume in most Medicaid provider payments, addressing the needs of aging populations, and improving health equity.

“A great deal of success locally has been because of the convening role ACHs were able to play. I can’t emphasize enough how important that is in transformation.” – Washington State Medicaid Director MaryAnne Lindeblad

ACH Projects Move Transformation Forward

When Washington’s five-year Section 1115 Medicaid Transformation Project (MTP) was approved in 2017, ACHs designed regional MTP projects that sought to improve clinical care and preventive services while leveraging collaboration across clinical and community organizations to account for social determinants of health. In order to carry out these Delivery System Reform Incentive Payment (DSRIP) projects, ACHs had to build up their organizational infrastructure to the point where they could both develop project plans and distribute the funds to regional partners needed to get the projects off the ground. Given the time-limited nature of these funding sources, sustainability is emerging as a priority for ACHs.

ACHs conduct DSRIP projects on such topics as:

Improving transitional care – when a patient moves from one health care setting to another. The Cascade Pacific Action Alliance is working to coordinate services when patients leave the hospital, in order to improve patient health and reduce preventable hospital utilization.
Improving the integration of physical and behavioral health care. The Spokane region’s ACH, Better Health Together, is working to help patients move between the physical, behavioral, and oral health care systems to receive more integrated care. The evaluation also highlighted the work of the Cascade Pacific Action Alliance, which brings together school districts, physical health clinicians, and behavioral health providers to improve behavioral health coordination for children in the region.
Increasing access to oral health services. North Sound ACH is working to integrate oral health and primary care in community-based settings.

While DSRIP performance accountability focuses primarily on clinical care, the state also encourages ACHs to address health equity, the social determinants of health, and the health of the whole community:

The Greater Columbia ACH created a Community Health Fund with DSRIP dollars to address health-related needs, such as nutrition, transportation, and housing, in its region.
The North Sound ACH requires each MTP partner to participate in an equity and Tribal learning series, and they rotate their meeting locations so that location does not bar any one partner from participating. They also begin each meeting by acknowledging the original inhabitants of the land, according to the evaluation.
The evaluation reported that the HealthierHere ACH established a Community and Consumer Voice Committee, which developed an equity tool to “assess impact and consumer voice.”

Balancing State and Local Roles

As states develop accountable health models that tackle a variety of regional priorities, state agencies often assume the role of key convener for accountable health entities and their local or regional partners. This convening role can help regional entities learn from each other and can inform state approaches so states can balance local or regional goals with broader statewide initiatives.

Just as states convene regional entities, Washington’s ACHs are taking on a critical role in convening their own local partners and supporting efforts to align regional strategies and priorities for much of the state’s health transformation work. The state required ACHs to develop into autonomous nonprofits with the ability to allocate funds and sustain organizational infrastructure. In the process, ACHs have built trusting and collaborative relationships with their regional partners. That successful relationship-building has led to ACHs themselves emerging as key regional players, which effectively positions them to take the lead on other statewide initiatives and activities, according to the evaluation.

As ACHs take the stage regionally, state policymakers are working to balance local expertise with statewide leadership. To allow ACHs to fully capitalize on local and regional knowledge, the state built some flexibility into their structure, such as allowing the ACHs to determine who to include in their governance structures, within state guidelines.

At the same time, the state is responsible for efficiently advancing statewide goals, and certain overarching issues may require a common statewide approach. For example, efficient technology infrastructure or workforce development may call for a statewide solution rather than multiple local approaches. “Consider what would be best served by a statewide coordinated approach to reduce fragmentation, versus a regional approach,” suggested Washington State Health Care Authority Medicaid Transformation Manager Chase Napier.

Conclusion

The recent evaluation of Washington’s ACH model shows the promise of ACHs in moving the state toward health system transformation. While other states’ accountable health models seek to balance local innovation and state coordination, the recent evaluation found that Washington’s ACH model may give states a helpful roadmap for incorporating local and regional voices to improve the health of individuals and communities statewide.

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.

New York Recommends Pediatric Preventive Care Improvements in its First 1,000 Days on Medicaid Report

December 16, 2019/in Policy New York Blogs, Featured News Home Care Coordination, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Healthy Child Development, Integrated Care for Children, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Physical and Behavioral Health Integration, Population Health, Primary Care/Patient-Centered/Health Home /by Elinor Higgins

By age three, a child’s brain has grown to 80 percent of its adult size and experiences during the first 1,000 days are critical to healthy brain development and social, emotional, cognitive, language, and physical development. Preventive measures taken in the first few years of life can have a significant and lasting impact on a child’s future health outcomes and overall success. New York is honing strategies to support healthy development during the first 1,000 days through primary care and trauma prevention strategies.

In October 2019, New York released recommendations from its Final Report of the First 1,000 Days Preventive Pediatric Care Clinical Advisory Group as part of the First 1,000 Days on Medicaid redesign initiative, which was launched in July 2017. It recognizes the critical role that Medicaid can play in the early life of children to help set them up for future success. The initiative also aims to work collaboratively with education programs and other sectors to deliver better results for children in New York.

Later in 2017, a group of stakeholders from different sectors and agencies, including education, child welfare, community-based organizations, public health, and mental health, convened to produce a plan for 10 proposed activities to be part of this initiative. Their first goal was to create a Preventive Pediatric Care Clinical Advisory Group that would develop a framework model for how to organize pediatric care in order to implement the Bright Futures guidelines. The framework model would identify barriers, possible incentives, and new system approaches to deliver the most effective care possible during well-child visits.

The advisory group included members from several child- and family-serving sectors that frequently partner with pediatric primary care, such as education, Early Intervention, and child welfare, and the group also sought feedback and participation from family representatives and community groups. The report, produced in October for the New York Medicaid program, details the group’s Model of Pediatric Population Health, which aims to build on the patient-centered medical home model with higher standards of care and care coordination. The focus of the model is on practice transformation to address the social determinants of health related to poverty, racism, and other environmental influences, and it integrates behavioral health care with traditional clinical care. The model lays out three tiers for integrating behavioral health:

Tier 1: Services received by all children:
- Screening: Age-appropriate screenings for child development, maternal depression, and adverse childhood experiences (ACEs), social-emotional development, social determinants of health, and interpersonal violence
- Culturally sensitive anticipatory guidance focused on social-emotional/family health (e.g., Reach Out and Read, Vroom, lactation counseling, parent access for questions)
- Information about community resources (e.g., Head Start)

Tier 2: Services received when a child or parent has an identified need: (Examples include developmental delay, housing or concrete services need, trauma, or maternal anxiety)
- Short-term counseling by early childhood mental health-trained professionals
- Care coordination by staff knowledgeable about early childhood services to facilitate connection with community resources
- Follow up and escalation to Tier 3 if needed
- Care delivered in a collaborative care model by the primary care provider, with support from mental health professionals either in the practice or remotely via tele-health

Tier 3: Services received when a more complex need is identified for a child or parent
Therapeutic intervention (e.g., dyadic therapy, parental mental health and substance use treatment) in the practice
- Referral to community-based mental health services when needed
- Case management (with early childhood skills) for all needs, including navigation across services

The report recognizes that there will be an increased need for behavioral health staff if the three-tier model is to be implemented successfully. The group envisions that half of the Tier 1 and Tier 2 services could be reimbursed under Medicaid based on diagnoses and fee-for-service payments, but that a capitated payment model might be more effective. For Tier 3 services, the report recommends a parallel to the value-based payment model used to fund collaborative care for adults through Medicaid. Capitated payments through value-based contracts between Medicaid managed care organizations and pediatric practices have been suggested by stakeholders as a potential path for a child-focused, population-based arrangement.

The goal of this model is to achieve health equity for all children and families by addressing systemic disparities, fostering trust between families and medical providers, promoting community linkages, and providing two-generational, trauma-informed, culturally competent, and integrated primary and behavioral health care.

The advisory group also produced a list of recommendations about committing to the Pediatric Population Health model through activities like investment in its core programs, including sustaining the HealthySteps model and sites funded by the NYS Office of Mental Health HealthySteps pilot, and the documentation of progress and outcomes for children as different aspects of the model are piloted. The other planned activities included in the First 1,000 Days on Medicaid initiative include a focus on early literacy, home visiting, development of data systems for cross-sector referrals, and a peer family navigators pilot program.

New York is not the only state focusing on the first few years of a child’s life as a critical period for improving health outcomes across the lifespan. Rhode Island’s First 1,000 Days of RIte Care, the state Medicaid program, aims to improve rates of developmental screening and coordination between pediatric care with family home visiting and Early Intervention. California’s Medicaid program, MediCal, is collaborating with the state’s Office of the Surgeon General to address ACEs with trauma screenings and provider training on trauma-informed care. As states continue to look for ways to improve health at all ages, early childhood is a period where increased coordination across sectors and agencies can lead to preventive strategies that have a lasting impact.

This blog is supported by the David and Lucille Packard Foundation. To learn more about state efforts to promote healthy child development, please visit NASHP’s Healthy Child Development State Resource Center.

Seven Ways State Policymakers Can Promote Palliative Care

November 8, 2019/in Policy Blogs, Featured News Home Care Coordination, Chronic and Complex Populations, Cost, Payment, and Delivery Reform, Eligibility and Enrollment, Health Coverage and Access, Health System Costs, Medicaid Managed Care, Palliative Care, Physical and Behavioral Health Integration, Primary Care/Patient-Centered/Health Home, Quality and Measurement, Workforce Capacity /by Kitty Purington

A patient with chronic obstructive pulmonary disease who was a frequent emergency room (ER) visitor now has a plan to manage his symptoms and now avoids the ER. A family caring for a parent with Alzheimer’s was considering nursing home placement, but after learning how to address challenging behavioral symptoms now feels equipped to continue to care for their loved one at home. A young woman treated for breast cancer had been hospitalized multiple times for pain, but is now managing her symptoms and is back at work.

These and similar stories illustrate why state policymakers are increasingly interested in palliative care and its potential to improve the quality of life of individuals with serious and chronic illnesses, while also reducing unnecessary hospital utilization and cost of care.

Palliative care services are delivered alongside curative treatment and can include pain and symptom management, care coordination, and team-based, multi-disciplinary support. These services 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, fewer than 5 percent of individuals who could benefit from palliative care receive it.

Despite the alignment of palliative care with health policy goals, states face a number of challenges as they work to integrate palliative care across the health care continuum, including:

Stigma that prevents providers, patients, and families from requesting/referring to palliative care;
Workforce and provider capacity issues;
Implementing and then sustaining these services through state health care systems; and
Understanding the overall return on investment associated with palliative care.

In its research into state palliative care activities, the National Academy for State Health Policy (NASHP) has identified an overall lack of policy infrastructure to support state palliative care initiatives. Across the country, few models exist to help states implement and expand uptake of palliative care services.

To address these challenges, NASHP convened a cross-agency group of state policy leaders to provide guidance in developing a framework for how states, as agents of change, can foster access to quality palliative care services. While policy development is always driven by the varied goals and priorities of individual states, the following recommendations offer a roadmap to help policy makers identify state-specific opportunities, areas of alignment, and ideas to aid in future planning.

Recommendations to Promote Access to Quality, Palliative Care

Recommendation 1: Educate policymakers, providers, and the public about the role and value of palliative care across the health care continuum.

Lack of familiarity, discomfort with the topic, and stigma can inhibit providers from offering palliative care, and can prevent families and patients from asking for services that can support their individual goals and quality of life. States can use public health and other health system infrastructures to promote understanding and acceptance of palliative care services. In recent years, many states have created cross-disciplinary task forces and passed legislation to educate providers and the public. Minnesota, for example, has established a palliative care website that offers information and resources to the public about what palliative care is and why is it important.

Other states have instituted policies that require providers to identify and reach out to individuals who may benefit from palliative care. Vermont requires providers to demonstrate competency in identifying and engaging patients who could benefit from palliative care. Educating providers, who often have long-standing relationships with patients and their families and are able to coordinate with other community resources, places them in an ideal position to assist patients at a time when they are especially vulnerable.

Recommendation 2: Use state policies and regulations to help define palliative care services and standards, and distinguish it from hospice services.

While hospice care is offered near the very end of life, palliative care, importantly, can be delivered alongside curative treatment. Statutory or regulatory definitions that limit palliative care to the end of life can prevent access to these services. States can define palliative care in their regulation and licensing requirements to address this. Colorado’s licensing standards for hospitals and providers define palliative care as “focused on providing patients with relief from the symptoms, pain, and stress of serious illness, whatever the diagnosis… Palliative care is appropriate at any age and at any stage in a serious illness and can be provided together with curative treatment.”

States have a range of policy options to define and describe palliative care, including state Medicaid plans, waivers, managed care contracts, and provider reimbursement manuals. In crafting regulations, state policymakers may consider how palliative care services fit into their states’ care continuum and relate to other strategies and initiatives (e.g., enhanced primary care models, long-term services and supports, etc.) States may also need to tailor definitions of palliative care depending on policy goals – some definitions may be fairly detailed (e.g., for a specialty palliative care benefit with an enhanced payment), while other policies are better served by broad guidance (e.g., for public messaging).

State leaders also cautioned that regulating must take into account the evolving field of palliative care, and the need to support growth and workforce. Working with stakeholders to develop capacity may be a necessary first step. As states define their goals related to palliative care, they can then consider how/if current licensure or other regulations support or impede this work.

Recommendation 3: Promote evidence-based standards and practices across a variety of settings and across the lifespan.

Palliative care is an evolving field with diverse services and models for children and adults delivered in home and community settings, hospitals, and nursing facilities. The recently revised Clinical Practice Guidelines for Quality Palliative Care offers a consensus-driven, nationally recognized resource for state policymakers interested in understanding the key features ofhigh-quality palliative care services.

States can foster this high-quality care through policy activities such as disseminating guidance for providers, adopting practice standards in licensing or payment regulation, and embedding palliative care in value-based purchasing models or managed care contracts. New York’s Palliative Care Education and Training Council provides resources and guidance to providers on evidence-based palliative care practices and therapies, and has developed recommendations for provider education and training. Maryland’s hospital licensing regulations outline staffing and other standards that hospitals in that state must adhere to. Regulations require programs to be marketed to patients and families, meet specific staffing and training requirements, develop an inter-disciplinary care plan for each patient, and complete Medical Orders for Life-Sustaining Treatment forms in accordance with state law.

Recommendation 4: Identify quality measures and reporting strategies to improve access to and quality of palliative care.

Effective measurement is an important tool to promote quality and incentivize the delivery of palliative care services. However, comprehensive measurement for palliative care services, at either a practice or systems level, is an emerging area. The National Committee for Quality Assurance has 36 measures relating to serious illness care, measuring domains such as management of physical symptoms, pain assessment and management, and advance care planning. However, these measures may not be validated for all settings or payers, and the organization notes that “most community-based serious illness care delivered outside hospice or home health benefits is not subject to performance measurement designed to address the quality of care.”

Despite these challenges, at least five states currently include palliative care-related metrics or quality improvement requirements in their Medicaid programs. These measures are generally part of targeted initiatives that reach a subset of the total Medicaid populations – Colorado, Illinois, New York, and Rhode Island include at least one palliative care-related quality metric in their financial alignment demonstration or Medicaid long-term services and supports contracts. Both New York and Texas incorporated palliative care into quality improvement strategies in their Delivery System Reform Incentive Payment (DSRIP) waivers. Under Texas’ DSRIP Measure Bundle Protocol, hospitals, physician practices, community mental health centers, and local health departments can elect to report on eight palliative care metrics to earn incentives. The goal of the program is to better coordinate care and transition patients from acute hospital care into home care, hospice, or a skilled nursing facility.

Recommendation 5: Develop strategies to build capacity.

Palliative care access can be limited due to a lack of trained providers, especially in rural areas and in smaller hospitals. To increase availability of services, states may consider a range of options:

Rhode Island and other states require physicians to complete at least four hours of continuing medical education every two years on priority topics that include end-of-life and palliative care.
California recommends its managed care plans contract with Medicaid providers with palliative care training, and partners with California State University’s Institute for Palliative Care to offer palliative training to Medicaid providers and practice staff.

Building on systems that can support palliative care may be another way to foster access. New York’s DSRIP program had an uptake of palliative care services within patient-centered medical homes, a model supported by many states that features team-based, multi-disciplinary care. Health home state plan options for individuals with serious or chronic illness may provide future opportunities. Telehealth in rural or under-served areas can offer another tool to broaden the reach of palliative care services – models and payment strategies for states to support these modalities are still emerging.

Recommendation 6: Develop sustainable reimbursement.

Medicaid programs – bound by state balanced budget requirements – have different approaches to how they pay for palliative care. Sustainable reimbursement can incentivize greater access, and can also provide the state with additional levers to track, understand, and improve the delivery of palliative care services. States can consider using existing fee schedules or codes, creating specialized payment models (e.g., capitation, bundled payment, case rates), or using health plan contracting to promote reimbursement for palliative care services.

In Arizona, a recent Arizona Health Care Cost Containment System (state Medicaid) policy change made palliative care available to most of its Medicaid population, including those enrolled in fee-for-service managed care and managed long-term services and supports plans. California recently established palliative care standards for its Medicaid (Medi-Cal) managed care health plans that provide access for all age groups and include disease-specific criteria to target the benefit (e.g., congestive heart failure, chronic obstructive pulmonary disease, advanced cancer, or liver disease). NASHP’s report, Advancing Palliative Care for Adults with Serious Illness: A National Review of State Palliative Care Policies and Programs illustrates the various ways that states can support palliative care services.

States may also target their limited resources by including palliative care services in more specialized Medicaid policy vehicles, such as Programs of All-Inclusive Care for the Elderly (Florida, Iowa), financial alignment demonstrations for individuals dually eligible for Medicare and Medicaid (Michigan, New York, and South Carolina), and Medicaid managed long term services and supports.

Recommendation 7: Identify opportunities to incorporate palliative care into state health care reform efforts.

State health reform efforts increasingly focus on providing comprehensive and well-coordinated care to high-need populations – such as those with chronic or serious conditions – as a way to improve quality and drive down costs. Palliative care is a natural complement to this work. As payment and delivery system innovations evolve, states can look for emerging opportunities to incorporate and expand palliative care initiatives that:

Value person-centered planning;
Improve care coordination; and
Seek to help older adults and others with significant health care needs remain in their homes and communities.

Next Steps

Palliative care and its whole-patient approach is an evidence-based strategy that improves the care of people with serious illness, often while realizing savings and avoiding unnecessary care. For both states and patients with chronic or serious illness, palliative care adds value. These recommendations offer an initial framework for states to advance the uptake and quality of palliative care services in their delivery systems. In the coming months, NASHP and state policy leaders will showcase successful state strategies to put these recommendations into practice.

Massachusetts Takes a Next Step in Health Reform: Addressing Affordability through Value

October 21, 2019/in Policy Massachusetts Blogs, Featured News Home Care Coordination, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Essential Health Benefits, Health Coverage and Access, Health IT/Data, Health System Costs, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Physical and Behavioral Health Integration, Population Health, Primary Care/Patient-Centered/Health Home, Quality and Measurement, Total Cost of Care Benchmark, Value-Based Purchasing /by Trish Riley

States are incrementalists – enacting laws, amending them, and building on their successes – and that strategy is clearly visible in Massachusetts Gov. Charlie Baker’s bold and comprehensive legislative proposal, An Act to Improve Health Care by Investing in VALUE, announced last week.

Baker’s proposal calls on payers and providers to increase expenditures on primary and behavioral health care by 30 percent systemwide over the next three years while complying with the state’s cost growth benchmarks, administered by the state’s Health Policy Commission. Baker said his proposal “will change the way the system looks, works and operates,” by prioritizing preventative care and early intervention and managing chronic conditions before patients require costly emergency department services.

The proposal includes initiatives to implement those expanded investments, including changes in workforce policies and scope of practice laws. At the same time, the governor proposes strengthening enforcement of cost-growth benchmarks by authorizing financial penalties on those who exceed them.

Additional proposals tackle affordability by:

Prohibiting surprise billing for emergency and unplanned services and establishing an out-of-network default rate pegged at a percentage of Medicare and limiting the use of facility fees;
Advancing insurance market reforms to improve access for small businesses and examining the impact of the state’s law that merges the individual and small group market; and
Building on last year’s efforts to rein in drug prices. The proposal subjects manufacturers of certain high-cost drugs to Health Policy Commission review, requires those manufacturers to participate in cost trend hearings, expands oversight of pharmacy benefit managers, and most significantly, imposes a penalty on manufacturers that increases a drug’s price by more than 2 percent over the consumer price index in any year.

The proposed legislation includes provisions that address telemedicine, the health information exchange, and investments in safety net providers – including plans to stabilize distressed community hospitals and health centers.

Insurers would also be required to maintain accurate provider directories and be required to cover, with no additional costs, same-day behavioral health visits. Urgent care clinics would also be required to offer behavioral health services.

“For far too long, primary and behavioral health care has not been at the forefront of our health care system,” said Marylou Sudders, Massachusetts’ secretary of the Executive Office of Health and Human Services. “While we know that changing the narrative will take time, we are committed to engaging in a multi-year, multi-pronged approach to create a cohesive system of behavioral health care and strong primary care in the Commonwealth.”

The governor’s bill now heads to the state Legislature where debate is expected to be lively. The National Academy for State Health Policy (NASHP) will track and report on developments. To learn more about the plan, NASHP is planning to host a webinar with Sudders, who also sits on the Health Policy Commission board, soon.

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Tennessee’s Care Coordination Tool: Marshaling Data to Help Providers Coordinate Care

AHRQ Launches Initiative to Improve Heart Health in States with High Rates of Heart Disease and Stroke

State Strategies to Promote Children’s Preventive Services

New York Recommends Pediatric Preventive Care Improvements in its First 1,000 Days on Medicaid Report

Seven Ways State Policymakers Can Promote Palliative Care

Recommendations to Promote Access to Quality, Palliative Care

Massachusetts Takes a Next Step in Health Reform: Addressing Affordability through Value

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