Quality and Measurement – Page 10 – The National Academy for State Health Policy

Health Reform Hub: Repeal, Replace, or Repair?

State Strategies to Address Rising Prices Caused by Health Care Consolidations

September 5, 2017/in Policy Annual Conference, Reports Community Benefit, Cost, Payment, and Delivery Reform, Health System Costs, Population Health, Quality and Measurement /by Erin Fuse Brown, JD, MPH

Foreward by Trish Riley, NASHP Executive Director
The debate over the future of the Affordable Care Act (ACA) and the stability of the individual health insurance markets masks a bigger issue–the underlying cost of health care. From NASHP’s Center for State Rx Drug Pricing to our work on value-based purchasing and alternative payment methods, we support states as they take on this difficult and important work to lower the health care cost trajectory.
We are pleased to release a provocative report we commissioned that addresses a key cost driver in health care–provider consolidation. This paper explores the rapid increase in consolidation of hospitals and provider groups and mergers across geographic markets that have resulted in double-digit price increases in the single largest sector of health care spending.
This is a particularly challenging issue. On the one hand, states have supported provider mergers to create integrated, patient-centered care. On the other hand, these consolidations are clearly driving prices higher with little evidence of improved quality, according to our consultant Erin Fuse Brown, JD, MPH, who introduced this topic at NASHP’s 2015 annual conference.
In this report, she presents a range of strategies states can pursue, including revisiting what we think about certificate of need laws, insurance rate regulation, provider and accountable care organization certification and licensure, and global budgets. She lays out a clear path states can follow to achieve quality care at fair prices.
Please let us know what you think. NASHP will keep this issue on the front burner and wants to hear how we can help your state develop real solutions to the vexing problem of health care consolidation.
Full Report: State Strategies to Address Rising Prices Caused by Health Care Consolidations

Comparison of Estimated Annual Consumer Premiums: In Single County in a State

June 30, 2017/in Policy Charts Cost, Payment, and Delivery Reform, Essential Health Benefits, Health Coverage and Access, Health System Costs, Quality and Measurement, State Insurance Marketplaces /by NASHP Writers

Highlighting State Medicaid Performance Measures, Improvement Projects, & Incentives To Promote Improvement in Women’s Health Services and Perinatal Outcomes

June 26, 2017/in Policy Blogs Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Essential Health Benefits, Health Coverage and Access, Health System Costs, Infant Mortality, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Population Health, Quality and Measurement /by Anisha Agrawal and Derica Smith

Poor birth outcomes, such as pre-term birth, carry substantial human and financial costs and are generally influenced by women’s health and socioeconomic factors such as race, ethnicity, income, health care access, and education. According to the Institute of Medicine, the cost associated with pre-term birth in the U.S. is $26.2 billion each year, with Medicaid covering a higher percentage of pre-term births than private insurance. Since Medicaid plays a major role in financing delivery and other health care for pregnant women with risk factors for poor birth outcomes, state Medicaid agencies have implemented various strategies such as payment reform, performance incentives (provider and patient), and quality improvement initiatives to improve birth outcomes and reduce health care expenditures.
There are a number of coverage, benefit, and delivery system reforms that state Medicaid agencies are implementing to drive improvements in perinatal outcomes. One strategy is holding Medicaid providers or managed care organizations accountable for tracking or reporting their performance on quality measures that drive and support quality of care for women, specifically pregnant women. For example, the Ohio Perinatal Quality Collaborative (OPQC), a partnership between Ohio Medicaid, hospitals, and other stakeholders used various strategies, including revising Medicaid’s elective obstetric delivery reimbursement policy, to reduce Medicaid early elective deliveries with no medical indication from 10 percent to seven percent between 2006 to 2011.
From March to June 2017, NASHP conducted a 50 state scan to identify and confirm those state Medicaid agencies tracking and reporting key perinatal quality measures, as well as those implementing performance improvement projects (PIPs) and incentives to improve birth outcomes. We received responses from 36 states to confirm their activities, and we identified 47 states tracking and reporting on several of the Core Set of Maternity Measures for Medicaid and CHIP and Core Set of Children’s Health Care Quality Measures for Medicaid and CHIP as well as state specific measures to monitor and assess women’s health services to improve perinatal outcomes. Nineteen states have implemented PIPs and performance incentives. Some examples of state activities include:

California Medicaid is tracking substance use (including alcohol) among pregnant women. Although only a small portion were substance use dependent; it was disproportionately higher among Native American women on Medi-Cal.
Three of Oregon’s Coordinated Care Organizations (Intercommunity Health Network, Pacific Source Community Solutions-Columbia George, and Pacific Source Community Solutions-Central Oregon) have implemented performance improvement projects focused on increasing oral health visits among pregnant members.

While quality measures, improvement projects, and incentives are great tools to support states efforts to improve perinatal outcomes, there is a potential opportunity for state Medicaid and Title V programs to collaborate and share data related to services and health outcome goals of mutual interest. Using different but complementary measures, Title V programs also tracks well-woman visits, low-risk cesarean delivery, early elective delivery, and early prenatal care in addition to other perinatal related metrics.
To learn more about state Medicaid agencies’ measures, improvement projects, and incentives, see the new chart and series of maps, and stay tuned for case studies that will take a closer look at efforts to promote improved women’s health and birth outcomes in several of the states!
This blog and related deliverables are joint publications of the National Academy for State Health Policy (NASHP) and the National Institute for Children’s Health Quality (NICHQ). This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) (under grant # UF3MC26524, Providing Support for the Collaborative Improvement and Innovation Network (CoIIN) to Reduce Infant Mortality, $2,918,909, no NGO sources).

State Medicaid Quality Measurement Activities for Women’s Health

June 26, 2017/in Policy CHIP, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Essential Health Benefits, Health Coverage and Access, Health System Costs, Infant Mortality, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Population Health, Quality and Measurement /by Anisha Agrawal

*Maps and Chart updated as of November 3, 2017*
State Medicaid agencies provide a variety of health services to women that promote overall health and well-being and support improved birth outcomes, such as reduction in infant mortality rates. States have the option of implementing performance measurement, incentives or improvement projects, including as part of broad health system transformation, to promote women’s preventive care, chronic disease management, and perinatal care. This series of maps and accompanying chart illustrate state-specific Medicaid measures, performance improvement projects, and incentives promoting women’s health services, such as those recommended by the Health Resources and Services Administration (see more information for details). The series reflects: managed or accountable care performance improvement projects; managed care performance measures; metrics or incentives in statewide Medicaid system transformation (e.g., patient-centered medical home, accountable care initiative); other financial incentives for providers, including pay for performance; and patient incentives. Measures, projects and incentives fall into seven general categories: behavioral health, chronic disease, delivery and postpartum care, general health, prenatal care, reproductive health, and substance use.
Acknowledgement:
This chart is a joint publication of the National Academy for State Health Policy (NASHP) and the National Institute for Children’s Health Quality (NICHQ). This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) (under grant # UF3MC26524, Providing Support for the Collaborative Improvement and Innovation Network (CoIIN) to Reduce Infant Mortality, $2,918,909, no NGO sources).
More Information

• The most common women’s health measures across states are: Postpartum Care (46 states), Timeliness of Prenatal Care/Early Prenatal Care Entry (39 states), STI
Screening/Treatment (39 states), and Frequency of Ongoing Prenatal Care (33 states).
• 46 states plus the District of Columbia have an activity in at least one of the 15 highlighted measures.
• Over 35% of states have implemented at least one improvement project or incentive within managed care (19 states).
• Performance improvement projects are the most common strategy used by state Medicaid agencies to improve quality of care.
The American Congress of Obstetricians and Gynecologists, in partnership with the American Academy of Family Physicians, the American College of Physicians, and the National Association of Nurse Practitioners in Women’s Health, is providing recommendations to update the Health Services and Resources Administration-supported Women’s Preventive Services Guidelines which help clinicians determine the screenings and other health services to routinely offer to patients. The Guidelines include the following services: well woman visits; gestational diabetes screening; sexually transmitted infection (STI) counseling; human immunodeficiency virus (HIV) screening; contraceptive methods and counseling; breastfeeding support, supplies, and counseling; and screening and counseling for interpersonal and domestic violence. For additional information, see the Women’s Preventive Services Initiative website.
We hope these maps and downloadable 50-state chart will be valuable resources to states as they continue to look at strategies to improve perinatal outcomes through women’s health services. Know of something we should add to this compilation? Does your state have a new incentive, measure, or improvement project in place? Your feedback is central to our ongoing, real-time analytical process, so please email aagrawal@oldsite.nashp.org with any feedback, additions, or edits.
The information for these resources was drawn from a number of sources include state websites and reports, and federal data. NASHP made efforts to confirm all information directly with states. The Health Resources and Services Administration supports this work as a part of the Collaborative Improvement and Innovation Network (CoIIN) to Reduce Infant Mortality.

Acronym Key

Estimated AHCA and ACA Premiums and Tax Credits by State, Income, Age, and Select Counties

June 8, 2017/in Policy Charts Cost, Payment, and Delivery Reform, Health Coverage and Access, Health System Costs, Medicaid Expansion, Medicaid Managed Care, Quality and Measurement, State Insurance Marketplaces /by NASHP Staff

These sheets supplement NASHP’s brief, Health Care is Local: Impact of Income and Geography on Premiums and Premium Support. Using data and modeling from the Kaiser Family Foundation, we present estimated premiums and tax credits under current law created by the Affordable Care Act (ACA) and under the American Health Care Act (AHCA), as passed by the House. Estimates are organized by age, income, and select high- and low-cost counties within states.
Note that these estimates only consider premium costs – they do not incorporate any analysis of predicted out-of-pocket expenses due to cost-sharing. Thus, this analysis only provides a partial picture of how consumer costs may shift due to changes incurred under the AHCA. The AHCA’s proposed elimination of Cost Sharing Reduction payments (CSR) and predicted stimulation of high-deductible health plans, for example, are expected to increase out-of-pocket spending, with especially significant increases predicted for consumers in states that opt to waive Essential Health Benefits requirements under the AHCA.
View map of county-by-county premium variation
State Fact Sheets:

Acknowledgements:
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. We are also grateful for the work of the Kaiser Family Foundation whose data we leveraged for this analysis (available at: https://www.kff.org/interactive/tax-credits-under-the-affordable-care-act-vs-replacement-proposal-interactive-map/). We send special thanks to the policy team at Covered California for their analytic assistance, especially Andrew Feher, Isaac Menashe, and Katie Ravel.

CHIP and Medicaid are Essential Partners for Cross Agency Collaboration to Better Serve Children

June 6, 2017/in Policy Massachusetts Blogs Care Coordination, Children/Youth with Special Health Care Needs, CHIP, CHIP, Chronic and Complex Populations, Cost, Payment, and Delivery Reform, EPSDT, Health Coverage and Access, Health System Costs, Healthy Child Development, Integrated Care for Children, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Physical and Behavioral Health Integration, Quality and Measurement /by Olivia Bacon

Increasingly states are focused on the critical role social determinants play in health, and public coverage programs play a key role in this focus. For more than 20 years, the Children’s Health Insurance Program (CHIP) has worked in coordination with state Medicaid programs to serve the health needs of low-income children. States are leveraging Medicaid and CHIP funds to build additional cross agency connections that address the comprehensive care needs of children. Therefore, potential changes in Medicaid and CHIP funding could also affect collaboration efforts with other programs that serve children and families.
State officials report that cross-agency collaborations have increased administrative efficiencies and helped programs become even more effective at serving children. Congressional action however, is needed to extend federal CHIP funding beyond September 2017 and as state officials are considering what proposed changes in Medicaid financing may mean for their programs, they are also weighing how funding changes for coverage programs could affect other state agencies and public programs that are serving children.
Although there is uncertainty about future funding, states are currently continuing to support collaborative efforts in place to serve children. Massachusetts and the District of Columbia offer examples of using their CHIP and Medicaid programs to create improved coordination across multiple state agencies and programs serving youth. In Massachusetts these collaborations work at assuring low-income kids are served by social supports and in D.C., they improve the seamlessness of care provided to kids by improving the exchange of data across agencies.
Leverage Funding Opportunities to Build Partnerships
Health Services Initiatives (HSIs), authorized under Title XXI, provide states the option to use CHIP administrative funds (up to the 10 percent cap) to invest in activities that directly improve the health of children under age 19. Massachusetts, and other states, are using HSIs to leverage their CHIP funding to foster cross agency connections and as an efficient way to support state public health programs serving children’s needs. For instance, currently Massachusetts’ HSI programs include: nutritional programs through schools, smoking prevention and cessation programs, and youth violence prevention through community-based organizations. These activities are primarily funded by state appropriations to the state’s Executive Office of Health and Human Services or the Executive Office of Education with a small portion of CHIP funds used to ensure targeted low-income children are served. In Massachusetts these activities are administered through a variety of state agencies including the Department of Early Education and Care, Department of Public Health, Department of Developmental Services, Department of Elementary and Secondary Education, and Department of Children and Families.
Through the implementation of HSIs, Massachusetts has successfully braided different funding streams to best serve the health needs of children. HSIs have enabled Massachusetts to build interagency connections to support a variety of programs that address an array of children’s health needs by effectively using available state and federal resources. If federal CHIP funding is not extended Massachusetts would lose a crucial funding source that is key to the operation of these initiatives.
Partner to Overcome Coordination Barriers
In the District, the Department of Health Care Finance (DHCF), which administers D.C.’s Medicaid expansion CHIP program, identified a lack of data sharing and collaboration across agencies as a barrier to accurately identifying children with unmet health needs. To address this issue, a cross-agency data sharing partnership with DHCF, the Department of Health (DOH), and D.C. Public Schools (DCPS) was formed. The partnership aims to address the issue of duplicative documentation efforts by the three agencies serving the same child and family population, as well as to provide a more accurate understanding of where there may be a lack of coverage of basic healthcare needs for children. Each of these agencies have different health data mandates including: maintenance of health forms (DCPS), immunization compliance data (DOH), Medicaid status and service utilization (DHCF), and managed care organization assignment (DHCF). In order to share their respective data, the three agencies developed a Memorandum of Agreement. Through this agreement the agencies worked together to effectively address often cited barriers to data sharing, such as the Family Educational Right and Privacy Act (FERPA) and Health Insurance Portability and Accountability Act (HIPAA). By convening stakeholders early, identifying each other’s institutional requirements, and gaining approval from all agencies the partners were able to work around these barriers.
As a result of their collaboration, these three D.C. agencies are able to promote health services outreach and target health resources to the appropriate schools. Sharing DCPS school enrollment data, DOH immunization data, and DHCF Medicaid enrollment data, the agencies can better identify which schools to target with needed services such as oral health care or health education efforts. By building these connections across agencies, D.C. has been able to better serve the health needs of children by increasing efficiencies in coverage and identifying gaps in service utilization.
Conclusion
These examples illustrate two distinct ways states are leveraging their CHIP and Medicaid programs to coordinate across agencies and highlight the important roll partnerships play in providing comprehensive care to children. Given the current uncertainty of federal CHIP funds after September 2017 and state officials’ concerns about the potential ripple effects of proposed funding changes on multiple agencies and programs serving families, it is particularly important to recognize the cross agency structures states have developed to serve vulnerable populations.
To learn more about HSIs: https://www.medicaid.gov/federal-policy-guidance/downloads/faq11217.pdf

NASHP Leaders’ Summit: Views on the Current Congressional Debate

May 23, 2017/in Policy Reports Cost, Payment, and Delivery Reform, Essential Health Benefits, Health Coverage and Access, Health System Costs, Medicaid Expansion, Population Health, Quality and Measurement, State Insurance Marketplaces /by NASHP Staff

In signaling that it will craft its own health reform proposal, the U.S. Senate opens the door for new approaches to address cost, coverage, and access. In tandem, state officials are assessing the impact of potential changes and weighing their options. The National Academy for State Health Policy (NASHP) recently “took the pulse” of state health policy leaders, representing the geopolitical diversity of the states, to collect their thoughts about reform. Through a short survey, meetings, and a focus group of leaders representing insurance, Medicaid, governors’ offices, legislatures, and health insurance exchanges, these states identified both practical approaches and questions regarding the impact of possible Congressional action. This snapshot briefly summarizes the concerns of that disparate group of state officials, all engaged in implementing health reform.
Read full publication here.

Physical and Behavioral Health Integration: State Policy Approaches to Support Key Infrastructure

May 9, 2017/in Policy Reports Behavioral/Mental Health and SUD, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Health Coverage and Access, Health System Costs, Integrated Care for Children, Integrated for Pregnant/Parenting Women, Maternal, Child, and Adolescent Health, Physical and Behavioral Health Integration, Population Health, Quality and Measurement /by Kitty Purington and Charles Townley

Through the State Innovation Model initiative, health home state plan option, and other Medicaid authorities, states have made significant investments to develop and implement payment and delivery system reforms that better integrate the physical and behavioral health systems. Rather than adopting specific integrated care models, states may benefit from taking a broader approach that builds the necessary infrastructure for providers to adopt and adapt integrated care models across the care continuum while meeting their local needs and contexts. In this brief, NASHP reviewed emerging areas of consensus in what makes for a successful integrated care model and highlights how leading states have supported infrastructure development using diverse policy strategies
Read the full brief here.
This work was made possible by The Commonwealth Fund.

How Massachusetts SHOP-ed for a New Small Group Marketplace

May 1, 2017/in Policy District Of Columbia, Massachusetts Blogs Cost, Payment, and Delivery Reform, Eligibility and Enrollment, Essential Health Benefits, Health Coverage and Access, Quality and Measurement, State Insurance Marketplaces /by NASHP Writers

Earlier this spring, the Massachusetts Health Connector (Health Connector), the health insurance exchange of the commonwealth, announced that it would be joining Washington, D.C.’s, exchange, DC Health Link, in a first-of-its-kind collaboration to develop a joint platform for their small business exchanges. This partnership is an exciting example of the collaborative possibilities for states. By building off of DC Health Link’s successful platform, Massachusetts is leveraging expertise and existing infrastructure, while yielding cost-savings for both exchanges. Together Massachusetts and DC will benefit from shared investment in the technology to not only maintain, but also improve the platform in response to evolving customer needs.
The Small Business Health Options Program (SHOP) was created under the Affordable Care Act (ACA) to help small employers (those with up to 50 or, at the discretion of the state, 100 employees) facilitate the enrollment of employees into qualified health plans. Initially, the Health Connector leveraged a “legacy” platform, first built under Massachusetts’ 2006 health reform law, for its SHOP exchange; however, low enrollment meant the Health Connector began to lose money annually on operation of its SHOP. Driven by a desire to make the SHOP more appealing for employers and brokers, yield cost savings, and bring the Connector into ACA compliance, Massachusetts sought an upgrade. After two cycles of reviewing proposals for a new SHOP—none of which achieved its desired targets for financial and technical specifications—the state began to explore a new option, leveraging the SHOP of another State-based Marketplace (SBM).
Massachusetts contacted peer states to gage interest and feasibility of leveraging another state’s system. Each interested state filled out a detailed questionnaire about the capabilities of their SHOP platform, including capacity to support the additional and unique needs of a new state. After considering proposals sent from three states, Massachusetts selected to partner with the District of Columbia, hoping to leverage the flexibility built into its system by using the agility of DC Health Link’s open source code, the marketplace’s proven ability to hold up under high volume, its scalability, and cost effectiveness.
DC Health Link prioritized focus on its small business community early on. Currently, DC has more than three times as many people enrolled through SHOP than through the individual marketplace, with over 4,300 businesses and nearly 70,000 consumers currently participating—a contrast with any other SBMs where enrollment is more heavily concentrated in the individual market (to compare, Massachusetts has 1,435 groups and nearly 6,000 covered persons). Last year, NASHP wrote about how DC Health Link had developed a new agile, open source, cloud-based solution for its small business market—in non-tech terms, an easily adaptable technology built using shared public code. Rather than paying high licensing fees to a software vendor for a commercial off-the-shelf product, DC used local small IT businesses to develop custom open source to create its marketplace. The District was able to leverage this system to streamline their website, improve the consumer experience, and reduce operation and maintenance expenses. DC Health Link has reported significant cost savings as a direct result of its new award winning technology, as well as a reduction in consumer complaints.
Beyond wanting to leverage the efficiencies of DC’s platform, Massachusetts was especially attracted two qualities of the DC SHOP 1) an infrastructure designed to accommodate rapid growth, an important concern as Massachusetts dedicates itself to growing its small group market; and 2) ability of the technology to allow Massachusetts to offer employers “employee choice”, an option by which an employer can set a benchmark contribution and then allow their employees to select from a range of comparable plans. In a presentation to the board of directors in February, Health Connector staff noted employee choice increases carrier competition and estimated that allowing employee choice may reduce costs to consumers by approximately 30 percent. Additionally, assuming current enrollment levels remain constant, the ongoing operational costs for the new platform are estimated to be approximately 50 percent less than the cost of Massachusetts’s previous SHOP. With organic growth anticipated due to the addition of new product offerings, the Health Connector projects that the SHOP market will become totally self-sustaining by its second year of operation.
Massachusetts is intent on minimizing customizations, which will make transition to the joint-platform quick and efficient. DC Health Link, with assistance from IT staff in Massachusetts, will complete the six-month development process in mid-August and conduct an early launch phase for coverage with an October 1, 2017 effective date. The SHOP will be fully operational during this early launch phase, and carriers who are ready to transition to the new platform will be able to do so immediately. The Health Connector will work with its carriers throughout the pilot to help them make a smooth transition before full participation begins in 2018.
States continue to raise the bar as laboratories of innovation. The partnership between the Massachusetts Health Connector and DC Health Link is one example of how states can and are partnering with each other in order to bring the best practices from around the country into their own state. For several years, NASHP has engaged with states to help foster shared resources, services and innovation across states. We will continue to monitor these developments as states strive to implement ground-breaking and sustainable strategies to address coverage needs.

Thank you to the officials from DC Health Link and the Massachusetts Health Connector who generously reviewed and contributed to this work. In particular, thank you to Rob Shriver of DC Health Link, and Jason Lefferts and Jason Hetherington from the Massachusetts Health Connector.
The State Health Exchange Leadership Network is a project of the National Academy for State Health Policy (NASHP), which works to support state officials and staff working on the operation and implementation of health insurance exchanges.