Transforming State Systems to Improve Population Health

By Larry Hinkle
December 2012
Many state officials are turning their attention to the most neglected leg of the Triple Aim: improving the health of populations, which along with improving the experience of care, and reducing per capita costs of health care, is essential for system transformation efforts. The critical need to integrate population health strategies into systems transformation was a central theme that emerged during the presentations and discussions of a National Academy for State Health Policy Preconference: Improving Population Health Outcomes: Creating a Truly Comprehensive System.

During the preconference, attendees considered strategies and models that states are developing to address population health goals. Examples include:
Oregon’s Coordinated Care Organizations (CCOs). The Oregon CCO model seeks to achieve the Triple Aim by improving care coordination across the system with an emphasis on primary care. Linkages between health care systems and communities are critical to the CCO model, with the recognition that medical care is a small component of the determinants of health. In order to become a CCO an entity must meet a number of criteria related to accountability. These include: coordinating physical, mental health, chemical dependency, and oral health care services; encouraging prevention and health through alternative payments to providers; engaging community members/providers in improving the health of the community; and addressing regional, cultural, socioeconomic and racial disparities in health care.
Oregon’s CCOs are governed locally, but state law mandates that governance must include the major components of the health system – in addition to risk sharing financial entities, teams must include at least two providers who actively practice primary care and mental health or chemical dependency treatment, and at least two community members, as well as a member of Oregon’s Community Advisory Council.  The Council is responsible for, among other duties, developing and reporting progress on Community Health Improvement Plans. Oregon also features non-traditional health workers (NTHWs) as a vital part of the coordinated care model and the state is investing in training 300 NTHWs over the next 5 years. Health promotion and care coordination are among their key competencies. Overall 90 percent of Oregon’s Medicaid population is in CCOs and a third party analysis estimates major savings for the state: $1 billion over three years, and $3.1 billion over five years. This is an eye-catching potential result for state policymakers seeking ways to improve care and health while achieving cost savings.
Oklahoma’s Health Access Networks (HANs). Oklahoma’s HANs enhance the Medicaid patient-centered medical home (PCMH) by creating community-based integrated health networks designed to achieve the triple aim. In order to become a HAN, the network must meet two of the following three objectives:

• Reach a formal affiliation agreement or partnership at the community level with traditional and non-traditional providers;
• Include programs that address public health principles – including community development. This also includes local educational programs designed to meet the challenge of reaching rural and underserved populations;
• Be a 501(c)3 non-profit.

Examples of HAN community development to date include community events focused on healthy living and showcasing community resources and partnerships with community organizations (e.g. Coalition for Children and Families, community- based substance abuse prevention, County Board of Health). The components of Oklahoma’s HANs also include: Electronic Medical Records (EMRs), access to specialty care, community resources, telemedicine, quality improvement, and care coordination for complete needs.
Maryland’s State Health Improvement Process provides “a framework for accountability, local action, and public engagement to advance the health of Marylanders.” A set of 39 critical health measures guide the state’s work. Local Health Improvement Coalitions (LHICs) focus on improving the health of communities using local level data for these measures. Having identified health outcome goals, Maryland is highlighting innovative models that align financial incentives with health outcomes. The state is focusing on the creation and support for integrated programs, which are programs or projects that combine clinical innovations (e.g. medical homes, integration of primary and behavioral health, care transitions) with supportive financing mechanisms that reward providers for keeping their patients healthier. The state also incentivizes wellness strategies (e.g. shared savings, bundled payments, readmission revenue) to meet the goals of the Triple Aim.
Another model discussed at the preconference that attempts to integrate population health goals and health care delivery is the Accountable Care Community (ACC), which differs from an ACO in that it includes grassroots community stakeholders and community organizations as well as medical care systems. The ACC is responsible for health outcomes for the entire population of a geographic region, which requires a focus on health promotion and disease prevention; the coordination and integration of public health, social services, and health systems; and payment reform initiatives (e.g. global budgeting, cost accountability, shared risk arrangements, etc.).
The meeting yielded some great ideas and examples of how systems transformation can engage both public health and health care officials and help achieve shared goals to create truly comprehensive reform. If your state is doing something to foster this type of integrated systems work, or if you have ideas on how NASHP can support such efforts, please let us know in the comments!