Delivery System Redesign

Medical home initiatives across the United States are demonstrating that multipayer reform, although complex and difficult to implement, is feasible when committed stakeholders negotiate strategies that are responsive to the local context. Seventeen multipayer medical home initiatives launched between 2008 and 2014 all navigated four critical decision-making points germane to any multipayer payment model: convening stakeholders; establishing provider participation criteria; determining payment; and measuring performance. This brief explores the lessons learned from these experiences.

This report provides a review of safety-net systems across the country, identifying their experiences, lessons, and successes in adapting and responding to health care reform. The purpose is to capture transformations occurring across systems varying financially, while also caring for a large number of low-income patients, to document their actions and innovations as well as implications and potential considerations for the California safety net. As such, this study intends to build on and add a unique dimension to the existing body of work on safety-net hospital systems transformations nationally and in California.

State policymakers increasingly recognize that improving health outcomes is as much about addressing the social determinants of poor health as it is about providing high-quality medical care. Medicaid accountable care organizations (ACOs), or other ACO-like models, offer a prime opportunity to meld population health and payment and delivery system reforms. This brief explores state strategies for promoting population health through Medicaid ACOs. It provides background information on population health approaches and Medicaid delivery system reforms and describes various state strategies to inform ACO design and governance structures, program components, metrics, and information-sharing mechanisms. It also includes some promising early examples from three states — Minnesota, Oregon, and Vermont — working to embed population health strategies in Medicaid ACO program requirements.

DSRIP initiatives are part of broader Section 1115 Waivers and provide states with significant funding that can be used to support hospitals and other providers in changing how they provide care to Medicaid beneficiaries. This analysis provides an early look at the impact of DSRIP waivers on Medicaid payment and delivery systems. It is based on interviews conducted with state officials, providers and advocates in three states that have adopted the Medicaid expansion (California, Massachusetts, and New York) and one state that has not adopted the expansion (Texas).  While each of the four programs is different, a number of major themes emerged across the four states that highlight the opportunities and challenges with DSRIP.

Across the country, states are exploring the viability of Medicaid accountable care organizations (ACOs) that align provider and payer incentives to focus on value instead of volume, with the goal of keeping patients healthy and costs manageable. To date, eight states have launched Medicaid ACO programs, and nine more are actively pursuing them. This fact sheet walks through current progress for Medicaid ACOs. It describes how emerging state programs are seeking to drive accountability through three key activities: (1) implementing a value-based payment structure; (2) measuring quality improvement; and (3) collecting and analyzing data. It also provides a glimpse of some early state successes.

Health disparities persist in the United States, with disadvantaged groups disproportionately bearing the burden of poor health outcomes and shortened lifespans. States cannot effectively control healthcare costs or improve quality without addressing health disparities. Fortunately, state and federal policymakers can work together to build an equitable health care delivery system by aligning payment models, creating new partnerships, and building infrastructure and data systems to reduce health disparities. This brief reflects on a discussion of health equity held at a meeting of state and federal leaders convened by the National Academy for State Health Policy, and includes examples of several states’ efforts to promote health equity.

Policymakers at the federal and state levels are working to develop strategies to address the health disparities that persist in the U.S. and promote health equity across geographic, racial/ethnic, and socioeconomic divisions. This webinar on April 2 will discuss how state and federal policymakers can strengthen their efforts to achieve health equity by coordinating with one another to align payment models, create new partnerships, and build infrastructure and data systems to reduce health disparities. State leaders from Ohio and Louisiana will describe several initiatives supporting health equity and the federal programs they are leveraging to support their efforts. An official from the Centers for Medicaid & Medicare Services (CMS) will describe federal resources available to help states advance health equity and identify opportunities for better alignment of federal and state activities.

States are realizing the potential benefits associated with integrating medical care and social services, and are beginning to take the first steps toward developing financing and payment models that encourage this connection. This brief reviews potential financing mechanisms to facilitate integration, with a particular focus on Medicaid. Drawing from interviews with experts across the country, it offers models ranging from one‐time seed funding for pilot projects to blended or braided financing arrangements that support comprehensive integration. The brief also highlights payment methodologies designed to influence providers to incorporate social services into their care efforts, with a focus on moving away from fee‐for‐service and toward value‐based payment strategies.

Arkansas, Minnesota, Oregon, and Vermont are at the forefront of state efforts to coordinate value-based payment approaches across multiple public and private payers. Each is deploying some combination of payment and delivery system redesign that includes episode-based payment, patient-centered medical homes (PCMHs), and total cost of care arrangements among its Medicaid, Medicare, and commercially insured populations. This report, after describing multi-payer activity generally, examines the extent to which self-insured employers are participating in the kind of delivery system transformation envisioned by the Centers for Medicare & Medicaid Services (CMS) State Innovation Models (SIM) program. The report also provides a summary of current recruitment efforts in each state and synthesizes lessons learned for public officials interested in further outreach to the employer community.