Quality and Measurement – Page 3 – The National Academy for State Health Policy

How States Use the National Standards for CYSHCN in their Health Care Systems

October 28, 2019/in Policy Charts, Featured News Home, Maps Care Coordination, Children/Youth with Special Health Care Needs, Children/Youth with Special Health Care Needs, Chronic and Complex Populations, Cost, Payment, and Delivery Reform, Integrated Care for Children, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Population Health, Quality and Measurement, Quality and Measurement /by NASHP Staff

States Feature Strategies to Better Integrate Care for Dual-Eligible Beneficiaries

October 21, 2019/in Policy Blogs, Featured News Home Care Coordination, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Eligibility and Enrollment, Health Coverage and Access, Health System Costs, Long-Term Care, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Population Health, Quality and Measurement /by Kitty Purington

Dual Eligible Special Needs Plans (D-SNPs) enroll individuals who are entitled to both Medicare and medical assistance from a state Medicaid plan. States cover some Medicare costs, depending on the state and the individual’s eligibility.

Many states already leverage Dual Eligible Special Needs Plans (D-SNPs ) to better manage care for individuals enrolled in both Medicare and state Medicaid programs. Recent changes to federal regulation, stemming the Bipartisan Budget Act of 2018, are expected to make D-SNPs more attractive for states seeking to better integrate care for this population.

The National Academy for State Health Policy (NASHP), with support from The SCAN Foundation, convened state policymakers at its recent annual conference to explore these new opportunities, highlight Medicare/Medicaid integration efforts in leading states, and explore what internal state capacity is needed to successfully address the needs of dual-eligible beneficiaries across programs.

The session, Maximizing Medicare: New Opportunities to Support State Policy Goals, featured examples of successful D-SNP models in Minnesota and Arizona, and highlighted lessons learned from states, detailing what internal expertise is needed to support these programs.

Individuals covered by both Medicare and Medicaid present unique challenges for state policymakers. This population often has higher health care costs and poorer outcomes, including higher rates of chronic conditions and behavioral health diagnoses. For states, creating well-integrated and coordinated systems of care for this high-needs population can be hampered by the complex interplay of these two programs.

The Bipartisan Budget Act of 2018 permanently authorized D-SNPs, and final regulations require D-SNPs to coordinate Medicaid benefits for duals and assist them in navigating appeals. The new rule also requires D-SNPs – in some circumstances – to provide an integrated appeals process and discharge planning for some high-need members. All D-SNPs must meet certain minimum integration criteria by 2021.

Both Minnesota and Arizona have experienced improved integration of care for duals through use of D-SNPs. Both states leveraged the contracting requirements of the Medicare Improvements for Patients and Providers Act to align administration and improve consumer experience. Wisconsin has structured its program to provide a more integrated experience at every step, including one set of enrollment materials, aligned enrollment dates, and care coordination for primary, acute, and long-term care services. Arizona’s D-SNP plans must be contracted “companion” plans with the Arizona Health Care Cost Containment System (AHCCCS), the state’s Medicaid agency. This and other contract features help encourage member enrollment in the same health plan for both Medicare and Medicaid services.

What internal capacity is needed to make these programs work? Presenters offered the following key takeaways:

Leadership is critical: Strong leadership is an important factor in providing more integrated care for duals. Leadership that understands the complexity of the population, and the need to mobilize specific resources and policies to address their unique issues and make long-term investment in these programs has been an ingredient for success in leading states.
Build and nurture strong managed care organization (MCO) partnerships: Collaborative relationships with Medicaid MCOs are also central to integrating care across programs. To avoid misalignment, presenters suggested working with MCOs to review detailed descriptions of the services to be coordinated by D-SNPs, including behavioral health and long-term services and supports, and discussing enrollment, marketing, and appeals policies with them to identify and resolve issues.
Engage stakeholders: Similarly, states found it helpful to regularly engage a range of stakeholders – providers, members, and advocates – to identify specific needs and areas of disconnect, and to allay consumer and provider concerns who may be impacted by policy changes.
Focus on staff capacity and ongoing training: States emphasized the need to have subject matter expertise within a state Medicaid agency. One presenter noted, “integration is a process and not an event,” long-term capacity is necessary to be able to analyze and respond to the changing state and federal regulatory landscape on an ongoing basis. Having designated staff and facilitating clear lines of communication across offices within Medicaid with an “open door policy” can also help identify and troubleshoot issues. Important areas of expertise include accessing and using Medicare data, understanding covered services and payment, and familiarity with state policy options to better integrate care.

Presenters encouraged policymakers to make full use of available resources to help them better understand the policy issues and needs of dual eligibles. The federal Medicare-Medicaid Coordination Office (MMCO) was noted as an excellent resource. MMCO leaders recently released a State Medicaid Director Letter detailing how states can improve care for dually-eligible beneficiaries. Additionally, the Integrated Care Resource Center website also provides a host of state-specific materials and learning opportunities.

Additional information and copies of slide presentations from NASHP’s 2019 conference is available on this Conference Presentation page.

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.

Webinar for State Officials Only: Innovations in Medicaid Pharmacy Benefit Management Policies – A Look at Three States

September 30, 2019/in Policy Ohio, Washington, West Virginia Webinars Administrative Actions, Cost, Payment, and Delivery Reform, Health System Costs, Prescription Drug Pricing, Quality and Measurement, State Rx Legislative Action, Value-Based Purchasing /by NASHP Staff

Friday, Nov. 1, 2019
3:30-4:30 p.m. (ET)

Faced with rising prescription drug costs, state Medicaid programs are implementing innovative policies to manage their pharmacy benefit and find savings. This webinar, for state officials only, is an opportunity to hear officials from three leading states:

West Virginia carved pharmacy benefits out of its Medicaid managed care program in 2017 and reports that its shift to a fee-for-service model saved the state over $54 million in state fiscal year 2018.
In response to a report demonstrating the cost to the state when pharmacy benefit managers (PBMs) profit from “spread pricing,” Ohio began requiring managed care plans’ contracts with PBMs to include a transparent, pass-through payment model and to prohibit spread pricing as of January 2019. Ohio’s recently passed 2020 budget bill goes a step farther, requiring all managed care plans to contract with a single PBM, which is selected by the Ohio’s Medicaid department.
To lower the cost of drugs and maximize rebate potential, Washington’s Medicaid program implemented a single formulary for all managed care and fee-for-service pharmacy benefits on Jan. 1, 2018.

This webinar is for state officials only and will not be recorded.

Moderator: Trish Riley, Executive Director, National Academy for State Health Policy

Speakers:

Brian Thompson, MS, PharmD, Director of Pharmacy Services, Bureau for Medical Services, West Virginia Department of Health and Human Resources
Vicki Cunningham, PharmD, former Director of Pharmacy Services, Bureau for Medical Services, West Virginia Department of Health and Human Resources
Maureen Corcoran, MBA, MSN, Director, Ohio Department of Medicaid
Donna Sullivan, MS, PharmD, Chief Pharmacy Officer, Washington Health Care Authority

Rural Health Clinics

September 23, 2019/in Policy Reports Chronic and Complex Populations, Cost, Payment, and Delivery Reform, Health Coverage and Access, Health IT/Data, Health System Costs, Primary Care/Patient-Centered/Health Home, Quality and Measurement, Safety Net Providers and Rural Health /by NASHP Staff

Download this report.

Rural health clinics (RHCs) were established through the Rural Health Clinic Services Act of 1977[i] in order to improve access to non-physician practitioners, such as physician assistants and nurse practitioners, in rural areas that lacked an adequate supply of physicians. Today, there are approximately 4,100 RHCs[ii] in 44 states.[iii] To be eligible to become a RHC, a practice must be in a “non-urbanized area,” according to the US Census Bureau, and be located in a health professional shortage area (HPSA), a medically underserved area (MUA), or a governor-designated MUA.

RHCs are certified by the Centers for Medicare & Medicaid Services (CMS) and must meet specific requirements, including specified staffing ratios and available services. There are two types of RHCs, independent and provider-based. Independent RHCs are free-standing practices owned and operated by a provider, group of providers, or health system. Provider-based RHCs are owned and operated most commonly by hospitals, but can also be owned and operated by nursing homes or home health agencies that participate in Medicare.[iv]

RHCs are reimbursed by state Medicaid programs either through the Prospective Payment System (PPS) or through a qualifying alternative payment methodology (APM). Similar to federally qualified health centers (FQHCs), in order for states to pursue a value-based APM with RHCs, individual RHCs must agree to participate, and the APM must reimburse each RHC the equivalent of what it would have received through the PPS.[v]

As states develop and implement value-based purchasing initiatives in their Medicaid programs, engaging safety net providers will help these efforts have the greatest impact on reducing overall health care costs and increasing quality. Value-based APMs, such as pay-for-performance and shared savings, shift practice reimbursement away from a focus on the volume of services billed toward a focus on providing high quality, efficient care.[vi]^,[vii]

While state Medicaid agencies across the country have been moving forward with engaging FQHCs in value-based purchasing initiatives, progress has been much slower with RHCs. The National Academy for State Health Policy (NASHP) has been working with six states through its Value-Based Payment Reform Academy to support them in developing value-based APMs for FQHCs and RHCs. Working with these states and the Federal Office of Rural Health Policy has led to the identification of key infrastructure and capacity barriers RHCs often face when engaging in value-based purchasing:[viii]

• Organizational capacity: Many RHCs do not have the staff or leadership capacity to champion the practice changes necessary to undertake value-based purchasing models. Officials from the six Academy state teams noted that many RHCs in their states struggle with provider recruitment and retention. Additionally, many do not have operating margins to support the data analytics and/or administrative staff that are critical for practices engaged in value-based purchasing. Assessment tools, such as the University of Iowa Rural Health Value Assessment Tool, can help states and RHCs better understand existing capacity for value-based purchasing. While some RHCs may not have the requisite infrastructure and capacity to participate in value-based APMs currently, states may want to consider how they can support and promote practice transformation and a greater emphasis on population health management among RHCs in the near-term.
• Low Medicaid Empanelment: Academy states reported many RHCs have a majority of Medicare and commercial patients, and a minority of Medicaid patients.[ix] Small numbers of Medicaid patients may make it challenging for state Medicaid agencies to accurately set payment rates in a new APM or determine practice performance on quality metrics, particularly those tied to payment. Additionally, states will need to be strategic in engaging RHCs with low Medicaid empanelment who may not have enough patients to incentivize them to participate in any value-based APM.
• Provider-based RHC complexities: Gaining support for value-based purchasing from provider-based RHCs may be challenging, as their participation will likely depend on the overall goals, priorities, and financial environment of the operating hospital. It is important to note that Medicaid reimbursement for services provided by provider-based RHCs owned by hospitals are intertwined with the hospital’s overall revenue.
• Limited quality reporting requirements: RHCs submit cost reports to CMS, but are not required to submit data on quality metrics at this time. Notably, services provided by RHCs that are paid through the Medicare all-inclusive rate methodology are not eligible for the Medicare Merit-Based Incentive System.[x] RHCs’ participation in commercial quality improvement initiatives is not well documented.[xi] As a result, some RHCs may not have experience with quality and process improvement, which could mean these RHCs require greater support to participate in value-based APMs, which are tied to quality measurement and reporting.

Despite these challenges, there are successful examples of RHCs engaging in value-based purchasing and quality reporting and improvement.

• Engage RHCs participating in Medicare ACOs: Presently, almost 15 percent of Medicare Shared Savings Program (MSSP) ACOs include at least one RHC.[xii] Lead researcher Judy Ortiz at the University of Central Florida conducted a study of RHC participation in Medicare ACOs in the southeast United States. This research found that RHCs participating in ACOs tend to be independent, larger, for-profit, and more well established (between 5 to 10 years old).[xiii] States may want to start by targeting these types of RHCs to participate in efforts to design value-based APMs. These RHCs may already have the infrastructure and capacity necessary to participate in these types of models.
• Engage RHCs in Quality Measurement and Reporting: Quality measurement and reporting is a cornerstone of value-based APMs. States may want to start by engaging their RHCs in quality reporting initiatives. For example, the Michigan Center for Rural Health brought together RHCs in the state to identify appropriate quality metrics for them and to serve as a forum for sharing practice-level quality improvement best practices.[xiv]

The Maine Rural Health Research Center piloted a set of primary care-based quality measures with a cohort of RHCs across the United States. A steering committee developed a set of 18 quality measures to pilot with RHCs. The pilot did not achieve the RHC enrollment that it expected, highlighting capacity issues for RHCs. The pilot did find that participating RHCs were interested in technical support on extracting data from electronic and paper records, data analysis and benchmarking, and quality improvement,[xv] highlighting that states may be able to incentivize RHCs to participate in quality reporting and ultimately value-based purchasing efforts by offering technical assistance.

[i] Public Law 95-210.

[ii] Centers for Medicare & Medicaid Services Medicare Learning Network. “Rural Health Clinic.” January 2017. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/RuralHlthClinfctsht.pdf.

[iii] Centers for Medicare & Medicaid Services. “CASPER Report 0006D Name and Address Listing for Rural Health Clinic Based on Current Survey,” May 23, 2017. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/rhclistbyprovidername.pdf,

[iv] Rural Health Information Hub. “Rural Health Clinics (RHCs) Frequently Asked Questions.” Accessed November 20, 2017. https://www.ruralhealthinfo.org/topics/rural-health-clinics#difference.

[v] Centers for Medicare & Medicaid Services, Rural Health Clinic, January 2017. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/RuralHlthClinfctsht.pdf.

[vi] Health Care Payment Learning & Action Network, Alternative Payment Model: APM Framework (McLean, VA: The MITRE Corporation, 2017). https://hcp-lan.org/workproducts/apm-refresh-whitepaper-final.pdf.

[vii] For more information on value-based purchasing, please visit the National Academy for State Health Policy’s Toolkit: State Strategies to Develop Value-Based Alternative Payment Methodologies for FQHCs. **Communications – please LINK TO TOOLKIT WHEN AVAILABLE**

[viii] NASHP Value-Based Payment Reform Academy State-Only Discourse Meeting, Washington, DC, July 26, 2017; and Personal interview with HRSA Federal Office of Rural Health Policy, teleconference, August 15, 2017.

[ix] John A. Gale and Andrew F. Coburn, The Characteristics and Roles of Rural Health Clinics in the United States: A Chartbook (Portland, ME: University of Southern Maine, Muskie School of Public Service, Maine Rural Health Research Center, 2003). https://digitalcommons.usm.maine.edu/cgi/viewcontent.cgi?article=1086&context=facbooks.

[x] Centers for Medicare & Medicaid Services. “Getting Started with the Quality Payment Program: An Overview of MIPS for Small, Rural, and Underserved Practices.” PowerPoint. Accessed November 20, 2017. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/QPP-for-small-and-rural-slides.pdf.

[xi] John Gale, et al., Pilot Testing a Rural Health Clinic Quality Measurement Reporting System (Portland, ME: University of Southern Maine, Muskie School of Public Service, Maine Rural Health Research Center, 2016). https://muskie.usm.maine.edu/Publications/rural/RHC-Quality-Measurement-Reporting.pdf.

[xii] Centers for Medicare & Medicaid Services. “Fast Facts: All Medicare Shared Savings Program (Shared Savings Program) Accountable Care Organizations (ACOs).” January 2017. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/All-Starts-MSSP-ACO.pdf.

[xiii] Judith Ortiz, et al. “RHCs in Accountable Care Organizations (ACOs).” PowerPoint, Rural Health Research Group, University of Central Florida, College of Health & Public Affairs, Sept. 15, 2016. https://www.hrsa.gov/ruralhealth/resources/conferencecall/rhcacoslides.pdf.

[xiv] Michigan Center for Rural Health. “Michigan RHC Quality Network.” Accessed November 15, 2017. https://www.mcrh.msu.edu/programs/RHC/Michigan%20RHC%20QN.html.

[xv] John Gale, et al., Pilot Testing a Rural Health Clinic Quality Measurement Reporting System.

State Medicaid Quality Measurement Activities for Women’s Health

September 18, 2019/in Medicaid Managed Care Maps Cost, Payment, and Delivery Reform, Eligibility and Enrollment, Health Equity, Infant Mortality, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Population Health, Quality and Measurement, Quality and Measurement, Quality Improvement, Special Populations and Services /by NASHP Staff

Minnesota and Indiana Governors Work to Improve Social Equity and Health in Every Zip Code

September 16, 2019/in Policy Indiana, Minnesota Blogs CHIP, CHIP, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Eligibility and Enrollment, Health Coverage and Access, Health Equity, Health System Costs, Healthy Child Development, Housing and Health, Infant Mortality, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Population Health, Quality and Measurement, Social Determinants of Health /by Elinor Higgins

In their 2019 state of the state speeches, 13 governors addressed social equity, acknowledging that reducing inequities and improving opportunities for all residents improves lives and health outcomes. Two of them — Indiana and Minnesota – offer examples of how states are orchestrating their legislative and administrative efforts to reduce health disparities and promote social equity.

Background

Of the many factors that influence health, 80 percent occur outside of the health care system, such as access to safe and affordable housing, high-quality education, and employment opportunities. Across the nation, health disparities persist where racial and ethnic discrimination, gender inequities, class distinctions, and other barriers systemically keep certain people from the opportunities and resources needed to live long and healthy lives.

These health disparities can be observed and tracked by state, county, zip code, or neighborhood. Indiana and Minnesota state policymakers are using budget appropriations, executive orders, and legislation to improve social equity.

Indiana

Gov. Eric Holcomb and a group of Indiana state leaders are tackling disparities in infant mortality under the umbrella of health equity. Their goal is to lower the state’s rate of infant mortality across all zip codes by improving services for expecting mothers.

“Now we’re seeking to implement two more programs that aim directly at reducing infant mortality…. These are the kinds of efforts it will take to get more babies to celebrate their first birthdays, regardless of their zip codes.” – Indiana Gov. Eric Holcomb

In May, Gov. Holcomb signed a bill to address infant mortality and establish a perinatal navigator program. The program engages pregnant women in evidence-based, early prenatal care to improve outcomes regardless of where a woman lives by providing referrals for wraparound services and community-based, home-visiting programs. There is an evidence base to support the positive impact on birth outcomes of community-based programs like these that address social determinants of health. The new law also establishes a program to provide more nurse partners and community health workers to coach, care for, and educate young women during pregnancy.

Across the United States, African Americans experience a higher infant mortality rate than any other racial group — and this is true in Indiana as well. From 2013 to 2015, Indiana’s infant mortality rate averaged 7.13 per 1,000 live births, compared to the 2015 national average of 5.90 per 1,000 live births. The non-Hispanic black population infant mortality rate in Indiana was much higher, at 13.26 per 1,000 live births. Indiana’s plan to boost resources for pregnant women and to engage women sooner in supportive care is designed to make pregnancy outcomes — and overall health outcomes — more equitable for all.

Minnesota

In Minnesota, Gov. Tim Walz and state leaders are using a variety of levers to address the structural components of inequity. The initiatives proposed in the budget or enacted through executive orders are designed to reduce disparities in educational achievement and hiring experienced by racial minorities in Minnesota. Though not directly tied to health, these disparities can lead to income inequality and other stressors that are strongly associated with poor health outcomes — so Minnesota’s upstream approach has the potential to improve health across the state.

“Every student in Minnesota deserves the opportunity to learn in the best schools in the country with caring, qualified teachers. But as I travel around the state, I see how the quality of a student’s education is too often dependent on their race or zip code. …Disparities in our educational system based on geography, race, or economic status hold back not only our students, but our entire state from reaching its full potential. We must make Minnesota the Education State for all children — black, white, brown, and indigenous.” — Minnesota Gov. Tim Walz

Minnesota’s state budget, approved in late May, included a 2 percent increase in per-pupil funding to public schools, which is part of Gov. Walz’s plan to reduce disparities in educational achievement by improving school resources across the state. He also proposed a Community Solutions Fund in his budget that would provide local groups with grants to help them address children’s health care issues in a flexible way.

Gov. Walz also issued an executive order at the beginning of his term creating the Diversity, Inclusion and Equity Council. Headed by Chris Taylor, the state’s new Chief Inclusion Officer, the council will focus in part on diversifying the state workforce as another strategy to address historic structural inequities. The council’s long-term approach to address disparities is designed to level Minnesota’s economic and social playing fields and improve social equity and health outcomes for all.

The approaches taken by Minnesota’s and Indiana’s governors demonstrate how state leaders can push for social equity with targeted or broad systemic changes to improve overall social conditions. As more policymakers adopt an upstream approach to health and address inequities, they can reduce economic, social, and discrimination-based obstacles to generate better health outcomes for all.

State Medicaid Levers to Promote Immunization: California’s Experience

September 9, 2019/in Policy California Reports CHIP, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Eligibility and Enrollment, Eligibility and Enrollment, EPSDT, Essential Health Benefits, Health Coverage and Access, Health Equity, Health IT/Data, Health System Costs, Healthy Child Development, Immunization, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Population Health, Primary Care/Patient-Centered/Health Home, Quality and Measurement /by Rebecca Cooper

Vaccines are a powerful and cost-effective tool to prevent diseases and save lives. Once common, deadly diseases such as polio, measles, and mumps are preventable and smallpox no longer exists outside of a laboratory. According to research estimates, of 4.3 million infants born in the United States in 2009, vaccines will prevent 40,000 deaths and 20 million illnesses over their lifetimes. Vaccinating children is also cost effective, saving $10.20 for every $1 spent on immunizations.

Despite these successes, states are working to improve their immunization rates, which hovered at 68.4 percent nationwide in children ages 19 to 35 months in 2012. California is using an assortment of strategies and inducements to boost its immunization rates.

How Can States Increase Immunization Rates through Medicaid?

Medicaid plays a key role in the delivery of vaccines, especially among vulnerable populations including children and pregnant women. Because Medicaid covers a large percentage of US children (39 percent), increasing childhood immunization rates among Medicaid beneficiaries can generate significant long-term savings. US Centers for Disease Control and Prevention (CDC) officials estimate that vaccinating children born between 1994 and 2018 has saved the United States about $300 billion in direct medical costs and $1.38 trillion in total costs, and protected millions from serious diseases.

State Medicaid programs can employ a variety of levers to increase immunization rates among their beneficiaries, from ensuring access and coverage for vaccines to tracking targeted metrics that inform provider incentive payments and reimbursement. These levers include:

Providing comprehensive coverage: Early and Periodic Screening, Diagnostic and Treatment (EPSDT) is Medicaid’s benefit for children and adolescents younger than 21, as described in Sec. 1905(r) of the Social Security Act. The EPSDT benefit requires that states provide all vaccines recommended by the Advisory Committee on Immunization Practice (ACIP) to all children eligible for EPSDT benefits.
Making vaccine available: Through the Vaccines for Children (VFC) program, the CDC purchases vaccines at a discount and distributes them to state health departments and other local and territorial public health agencies. These entities distribute the vaccines to private and public health providers who are registered as VFC Children are eligible for VFC-funded vaccines if they are younger than 19 and Medicaid-eligible, uninsured, American Indian or Alaska Native, or underinsured and vaccinated in certain settings. VFC-eligible children receive recommended vaccines at no cost when administered by a registered VFC provider.
Using metrics: The US Department of Health and Human Services sets annual Medicaid and Children’s Health Insurance Program (CHIP) health care quality measures to ensure providers deliver appropriate care to their patients. The 2019 Medicaid and CHIP Core Set of Children’s Health Care Quality Measures includes the Healthcare Effectiveness Data and Information Set (HEDIS) Childhood Immunization Status measure.* Monitoring and measuring changes in vaccine delivery through this metric is a critical step to improving targeted immunization rates.
Using incentive measures: State Medicaid programs can use incentive payments to increase immunization uptake. For example, evidence shows that incentive payments to providers through Medicaid pay for performance programs increases childhood immunization rates.
Performance improvement projects (PIPs): State Medicaid programs can encourage managed care organizations (MCOs) to focus on improving immunization rates by including it as one of their PIPs. Medicaid MCOs participate annually in PIPs.
Form partnerships to strengthen immunization efforts: Multiple state agencies play an important role in increasing immunization rates. Medicaid and public health agencies can partner with other stakeholders to address mutual goals.
Data sharing: States have various data sources from different agencies that may include information on vaccination status. This includes immunization information systems (IIS), which are confidential, population-based computerized registries that record vaccination doses and are usually maintained by public health departments, and Medicaid Management Information Systems (MMIS), which contain Medicaid claims data. Data exchanges between IIS and MMIS can help identify missed opportunities for vaccination, monitor gaps in immunization coverage, and improve vaccination rates.

California’s Strategies

A Healthy People 2020 immunization target is to increase the percentage of children ages 19 to 35 months who receive the recommended doses of diphtheria, tetanus, and pertussis (DTaP), polio, mumps-measles-rubella (MMR), Hib (meningitis), hepatitis B, varicella and pneumococcal conjugate vaccine (PCV) to 80 percent, from the 2012 average of 68.4 percent. As of 2017, California’s combined seven-vaccine series coverage rate among children ages 19 to 35 months was 68.6 percent. California’s health-related agencies have been working over the last several years to increase the state’s childhood immunization rates. Medi-Cal, California’s Medicaid Program, covers 43 percent of children in the state, so Medi-Cal has strong incentives to work to improve vaccination rates among its beneficiaries. Medi-Cal uses the following levers to reach this goal.

Comprehensive coverage: The California Department of Health Care Services (DHCS) administers the EPSDT benefits to all low-income youth enrolled in Medi-Cal consistent with the federally mandated benefit. Pregnant women (of any age) and all children younger than 21 are eligible for Medi-Cal if they meet income limits.
Vaccine availability: Medi-Cal participates in the VFC program to ensure that vaccines are eligible at no charge to public and private providers for eligible children. DHCS reimburses enrolled providers the administrative fee per dose of vaccine. In 2018, the California Department of Public Health (CDPH) distributed approximately $665 million worth of ACIP-recommended pediatric vaccines through the VFC program. Immunizations are also a medical and pharmacy benefit for all adult Medi-Cal members, including pregnant women.
Metrics: California’s Medi-Cal program collects the HEDIS measure “Childhood Immunization Status” from all of its MCOs, which requires the administration of the 10 ACIP-recommended vaccines by age two. MCOs are required to meet a minimum performance benchmark on the childhood immunization measure – 50 percent of all Medicaid health plans nationally, as determined by the National Committee for Quality Assurance). When MCOs do not meet the benchmark, quality improvement work is required, sanctions are imposed, and corrective action may be imposed. MCOs are contractually required to document each member’s need for ACIP-recommended immunizations as part of all regular health visits, and to ensure that all children receive ACIP-recommended immunizations at any health care visit.
Incentive measures: California’s Medi-Cal program operates a directed payment Quality Incentive Program (QIP) that directs MCOs to make QIP payments to designated public hospital systems tied to performance on specific performance metrics, including the Childhood Immunization Status and Immunization for Adolescents measures. As part of California’s 1115 Waiver, Medi-Cal provides incentive payments to designated public hospital and district and municipal hospital systems tied to performance on specific performance metrics, including the Influenza Immunization measure for members ages six months and older [California’s Public Hospital Redesign and Incentives in Medi-Cal (PRIME) program]. In addition, California’s Medi-Cal Value-Based Payment Program provides an incentive payment to providers for administration of several vaccinations, including the pertussis vaccine to women who are pregnant (supporting the HEDIS Prenatal Immunization Status Measure), the influenza vaccine to adults 19 years and older, and the last dose of any of the multiple-dose vaccine series given on or before a child’s second birthday (DTaP, polio, hepatitis B, Hib, pneumoconccal conjugate, rotavirus, and influenza), supporting the Childhood Immunization Status measure.
Performance improvement projects (PIPs): In 2016, DHCS identified improving childhood immunization rates as one focus topic for its PIP because less than three-quarters of young children enrolled in Medi-Cal were fully immunized, and immunization is an area with quantified health disparities, especially within the Medicaid program. Between 2015 and 2017, five health plans participated in PIPs to improve immunizations of two-year-olds. In 2018, health plans with low or declining performance on the HEDIS childhood immunization indicator were required to participate in a childhood immunization-focused PIP. Between 2017 and 2019, 15 health plans participated in PIPs to improve childhood immunization rates. Beginning in the fall of 2019, health plans will embark on their third round of PIPs, one of which will focus on childhood and adolescent health. To date, seven health plans have submitted PIP-focused proposals to improve childhood immunization rates. Separate from the PIPs, as noted above, when health plans do not meet the required performance benchmark for the childhood immunization measure, DHCS requires those plans to conduct a rapid cycle quality improvement project to improve their immunization rates. DHCS is striving to increase its overall managed care childhood immunization rate to at least 80 percent coverage.
Partnerships that strengthen immunization efforts: Medi-Cal partners with multiple stakeholders, including CDPH and other state agencies, health care providers, and other private entities. CDPH provides technical assistance to public and nonprofit health clinics, participates in the multi-sector California Immunization Coalition, and assists schools and childcare centers in complying with state immunization requirements.

CDPH continues to develop and support efforts to address disparities in immunizations of minority and uninsured children, including a focus on increasing prenatal immunization with the TDaP vaccine among pregnant Latina women. In 2015, CDPH undertook several initiatives, including the DHCS National Governor’s Association Learning Collaborative, to increase prenatal immunization rates.

Data sharing: California’s IIS – the California Immunization Registry (CAIR) – supports immunization by:
- Providing a comprehensive immunization record that can adapt to changes in the medical home or health insurance;
- Calculating which shots children need and minimizing under- or over-immunization;
- Issuing reminders of upcoming visits; and
- Identifying individuals and populations with low immunization rates.

The Medi-Cal program requires its MCOs to ensure that immunizations are reported to the registry. California physicians’ offices, clinics, families, and schools are estimated to have saved several millions of dollars annually as a result of the registry.**

California uses strategic levers to increase immunization rates in its Medicaid population, including identifying the target populations’ EPSDT benefits, identifying metrics for quality improvement programs, and developing strategies to incentivize providers to improve their immunization rates. These levers enable the Medicaid agency to contribute as a critical partner to a strong state partnership supporting a comprehensive strategy for improving immunization rates.

* Percentage of children age two who received four diphtheria, tetanus and acellular pertussis (DTaP); three polio; one measles, mumps and rubella (MMR); three haemophilus influenzae type B; three hepatitis B, one chicken pox; four pneumococcal conjugate; one hepatitis A; two or three rotavirus; and two influenza vaccines by their second birthday. This measure calculates a rate for each vaccine and nine separate combination rates.

** California Immunization Registry (CAIR) users include health care providers, public health departments, schools, childcare facilities, family child care homes, WIC service providers, foster care agencies, welfare departments, juvenile justice facilities, and other programs that provide, track, or promote immunization.

Acknowledgements: The National Academy for State Health Policy (NASHP) would like to thank Mary Beth Hance at the Center for Medicare and Medicaid Services, Megan Lindley and Aaron Borrelli at the Centers for Disease Control and Prevention (CDC), Sarah Royce at the California Department of Public Health and Linette Scott at the California Department of Health Care Services for their time and insights, which made this blog possible. The author also wishes to thank Trish Riley and Jill Rosenthal for their contributions to this case study. Any errors or omissions are the author’s. This project is supported by the CDC. This information or content and conclusions are those of the authors.

Montana Uses Patient-Centered Medical Homes to Holistically Address Children’s Health Needs

August 30, 2019/in Policy Montana Blogs Care Coordination, Children/Youth with Special Health Care Needs, Children/Youth with Special Health Care Needs, CHIP, CHIP, Chronic and Complex Populations, Cost, Payment, and Delivery Reform, Eligibility and Enrollment, EPSDT, Essential Health Benefits, Health Coverage and Access, 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, Primary Care/Patient-Centered/Health Home, Quality and Measurement /by Emma Watson

Montana recently expanded its Patient-Centered Medical Home (PCMH) program benefits to most children enrolled in Medicaid and the state’s Children’s Health Insurance Program (CHIP). Montana enhanced its PCMH program by:

Expanding the pool of approved providers;
Increasing the number of quality measures that must be tracked; and
Adding complex care management (CCM) – a coordinated care approach designed to help patients and caregivers better manage medical conditions and co-occurring psychosocial factors and reduce hospitalization.

The primary goal of broadening these benefits is to promote the health of children through better preventive care and to appropriately treat chronic diseases by increasing primary care visits and encouraging healthy habits. Over time, the state hopes that this strategy could reduce emergency room visits and drive down costs associated with care.

Montana broadened the eligible providers and services offered to Medicaid and CHIP recipients by integrating the PCMH program with the state’s existing Comprehensive Primary Care Plus (CPC+) initiative that began in 2017. To integrate these programs, Montana aligned its quality measurement and data collection work, so that both initiatives gather and report on the same measures. The state requires that PCMH providers:

Obtain National Committee for Quality Assurance accreditation;
Apply to become a PCMH provider; and
Report on 21 quality metrics. These metrics include management of A1C control in diabetic patients, blood pressure control in hypertension patients, behavioral health screenings and referral to necessary treatment, preventive screenings, and age-appropriate immunizations.

The ultimate goal of PCMHs is to deliver high-quality, cost-effective care by engaging enrollees as stakeholders in their health. The state also recently began building an infrastructure to help ensure the PCMH program is sustainable – these efforts include developing new information technology systems to standardize data collection.

Montana’s work to develop its PCMH model first began in 2009 after the state received a technical assistance grant from the National Academy for State Health Policy (NASHP) to advance the multi-payer Patient-Centered Medical Home Initiative that included Medicaid and CHIP children. Two years later, the state’s PCMH working group was reorganized and is now an official state advisory council comprised of insurance companies, medical providers, public agencies, and consumer advocates.

In 2013, the initiative was enacted with provisions defining expectations and requirements for these medical homes, and a PCMH pilot program was implemented in 2014 that included four federally qualified health centers (FQHCs) and a hospital. That same year, PCMH benefits became available to Medicaid-enrolled children, and in 2017 coverage was expanded to CHIP enrollees. Montana uses a third-party administrator to oversee CHIP members. The third-party administrator uses both the PCMH and CPC+ model, however, they are not the same as the state-run program and do not include the CCM program.

The CCM model engages a comprehensive team of health care professionals. In Montana, the team includes a primary care physician, a licensed nurse, a behavioral health professional, and a social worker in order to treat patients multi-dimensionally. Teams may manage up to 30 members in the CCM program and members must be attributed to the practice through the PCMH model. To be eligible, enrollees:

Must have two or more chronic conditions;
Be open to intense, in-home care coordination; and
Have visited the emergency room multiple times in the last 60 days or had more than one inpatient hospital stay in the last six months.

To access PCMH care, a child’s medical provider must participate in the program.

The non-physician members of the CCM teams try to meet with the member in his/her home and then collaborate with the PCP to design relevant interventions and preventative services based on the teams’ observations. Meeting with the member in his/her home may not happen initially, but it is important to understand the patient’s physical environment to create a holistic treatment plan. These visits must happen at least weekly for the first three months and then at least monthly for the next three months. Visits occur based on the needs of the patient and usually happen more often than required by the program.

The program seeks to engage the member and his/her family in order to meet all of the needs of the household and connect members to appropriate resources. The teams assess other factors affecting the patient’s well-being, such as social determinants of health at the initiation of and conclusion of PCMH appointments to measure the effectiveness of the intervention.

The state’s next steps are to create performance-based incentives for physicians to promote the quality of care, and to continue to refine the PCMH model to address the unique needs of children in Montana.

For more information about states’ efforts to implement patient-centered care models, see more NASHP resources on delivery system reform and primary care and medical homes.

#NASHPCONF19 Presents its Academy Award to Washington State Health Policy Innovators

August 26, 2019/in Policy Washington Blogs Cost, Payment, and Delivery Reform, Eligibility and Enrollment, Health Coverage and Access, Health System Costs, Medicaid Expansion, Medicaid Managed Care, Quality and Measurement, Value-Based Purchasing /by Joe Flores

#NASHPCONF19 Academy Award winners, representing Washington State, are (left to right) Washington Health Care Authority Chief Policy Officer Mich’l Needham, Medicaid Director Maryanne Lindeblad, Senior Health Policy Advisor to the Insurance Commissioner Jane Beyer, Health Benefit Exchange Policy Director Molly Voris accepting the award for exchange CEO Pam MacEwan, and state Rep. and Chair of the House Health Care and Wellness Committee Eileen Cody. Missing is Jason McGill, former senior health policy advisor, Office of the Governor.

On Friday, Aug. 23, 2019, NASHP presented its 32nd Annual State Health Policy Conference Academy Award to a team of Washington state policymakers and legislators who have worked together to implement pioneering policies to improve the quality, cost, and delivery of health care in their state. Below are remarks made by Joe Flores, Virginia governor’s deputy secretary of finance and NASHP executive committee member and chair of its Health Access and Finance Committee, during the award’s presentation.

It is my distinct privilege this afternoon to present NASHP’s highest honor – the Academy Award – recognizing outstanding achievement in state health policy.

For those of you who were here as we kicked off this meeting two days ago, you will remember that we recognized a Rising Star in Health Policy. This afternoon, however, we recognize a group of health policy leaders whose star continues to shine bright, which is a change from our usual practice.

These leaders have been in the trenches for many years, have the battle scars to prove it, but also have gained the wisdom of knowing that lasting change takes time, effort, and persistence. And, we learned this week that a healthy dose of humor doesn’t hurt either.

These leaders understand, like NASHP, that meaningful reform requires setting a big table where different viewpoints can be heard. Whether you’re from the Governor’s Office, the legislature, a state agency, the Bureau of Insurance, or an advocacy group, we need to hear about health policy from different perspectives to be successful. We need to listen and learn from one another, sometimes disagree, and then move forward.

The leaders we honor today – and their peers across their state – have been consistent in promoting important advances in state health policy. This state placed the administration of Medicaid, state employee health insurance, and recently teacher’s health plans under one authority; it led in establishing the Basic Health Plan; created an all-payer claims database to inform policy, and secured Medicaid waivers that established accountable communities for health. Of course, many states have achieved similar successes but today we honor a group of leaders who have worked together, many for decades and some changing positions along the way, who demonstrate what collaboration looks like and what it can achieve.

Most recently these leaders, along with many others, created the first public option plan, including cost containment through reference pricing to Medicare and standard plan design to protect consumers. A very significant achievement, indeed, but in many ways it is just the latest example of progress in the State of Washington and one achieved in no small part from the collaborative work of the leaders we honor today. Let me introduce them and ask them to come forward to accept this award. They are:

State Representative Eileen Cody, Chair of the House Health Care and Wellness Committee;
Pam MacEwan, Chief Executive Officer, Washington Health Benefit Exchange;
Jane Beyer, Senior Health Policy Advisor to the Insurance Commissioner;
Jason McGill, previously Senior Health Policy Advisor, Office of the Governor;
Maryanne Lindeblad, Medicaid Director; and
Mich’l Needham, Chief Policy Officer, Washington Health Care Authority.