State Delivery System and Payment Strategies Aimed at Improving Outcomes and Lowering Costs in Medicaid
Center for Health Care Strategies, “Medicaid Accountable Care Organizations: State Update,” (Hamilton, NJ: Center for Health Care Strategies, February 2018), https://www.chcs.org/media/ACO-Fact-Sheet-02-27-2018-1.pdf
Michael Wilson et al., “The impacts of accountable care organizations on patient experience, health outcomes, and cost: a rapid review,” Journal of Health Services Research & Policy 25 no. 2 (April 2020): 130-138, https://journals.sagepub.com/doi/full/10.1177/1355819620913141
Office of the Assistant Secretary for Planning and Evaluation (ASPE), Evaluation of the Medicaid Health Home Option for Beneficiaries with Chronic Conditions: Evaluation of Outcomes of Selected Health Home Programs Annual Report - Year Five, Washington, DC: Office of the Assistant Secretary for Planning and Evaluation, May 2017, https://aspe.hhs.gov/basic-report/evaluation-medicaid-health-home-option-beneficiaries-chronic-conditions-evaluation-outcomes-selected-health-home-programs-annual-report-year-five
Office of the Assistant Secretary for Planning and Evaluation (ASPE), Report to Congress on the Medicaid Health Home State Plan Option, Washington, DC: Office of the Assistant Secretary for Planning and Evaluation, May 2018, https://www.medicaid.gov/state-resource-center/medicaid-state-technical-assistance/health-home-information-resource-center/downloads/medicaidhomehealthstateplanoptionrtc.pdf
Kevin Grumbach, Thomas Bodenheimer, and Paul Grundy, “The Outcomes of Implementing Patient-Centered Medical Home Interventions: A Review of the Evidence on Quality, Access and Cost from Recent Prospective Evaluation Studies, August 2009,” (Washington DC: Patient-Centered Primary Care Collaborative, August 2009), https://pcmh.ahrq.gov/sites/default/files/attachments/The%20Outcomes%20of%20Implementing%20Patient-Centered%20Medical%20Home%20Interventions.pdf
Aaron Mendelson et al., “The Effects of Pay-for-Performance Programs on Health, Health Care Use, and Processes of Care: A Systematic Review,” Annals of Internal Medicine 166 no. 5 (March 2017): 341-353, doi:10.7326/M16-1881
California Health Care Foundation, “Making Quality Matter in Medi-Cal Managed Care: How Other States Hold Health Plans Financially Accountable for Performance,” (Sacramento, CA: California Health Care Foundation, February 2019), https://www.chcf.org/wp-content/uploads/2019/02/MakingQualityMatterMediCalManagedCare.pdf
New York State Department of Health, 2017 Quality Incentive for Medicaid Managed Care Plans, Albany, NY: New York State Department of Health, 2017, https://www.health.ny.gov/health_care/managed_care/reports/docs/quality_incentive/quality_incentive_2017.pdf
State fiscal years begin on July 1 except for these states: New York on April 1; Texas on September 1; Alabama, Michigan, and District of Columbia on October 1.
States were asked to indicate whether the following specified delivery system and payment reform initiatives (including multi-payer initiatives that Medicaid is a part of) were in place as of July 1, 2021: patient-centered medical home (PCMH); Health Home (under ACA section 2703); Accountable Care Organization (ACOs); episode of care; and all-payer claims database.
Delaware, Minnesota, New Mexico, and Rhode Island did not respond to the 2021 survey; 2019 survey data and publicly available data were used to identify delivery system and payment reform initiatives in place for these states.
Building off the experience of Health Homes and California’s Whole Person Pilots, the goal of this new benefit is to bring a whole person focus to the care of certain high-need Medi-Cal beneficiaries, e.g., children/youth with complex physical, behavioral, developmental, and oral health needs, individuals who are homeless or at risk of homelessness, among other target populations, to address both their clinical and non-clinical needs. For more information, see:
State of California – Health and Human Services Agency, CalAIM Enhanced Care Management Policy Guide, Sacramento, CA: State of California – Health and Human Services Agency, September 2021, https://www.dhcs.ca.gov/Documents/MCQMD/ECM-Policy-Guide-September-2021.pdf
Centers for Medicare and Medicaid Service, Health Insurance Exchange Quality Ratings System 101, Baltimore, MD: Department of Health and Human Services, August 15, 2019, https://www.cms.gov/newsroom/fact-sheets/health-insurance-exchange-quality-ratings-system-101
Center for Medicaid and CHIP Services, 2020 Medicaid and CHIP Managed Care Final Rule, Baltimore, MD: Department of Health and Human Services, November 9, 2020, https://www.medicaid.gov/medicaid/managed-care/guidance/medicaid-and-chip-managed-care-final-rules/index.html
Under 42 U.S.C. 1396u–2 §(a)(3)
South Carolina Healthy Connections Medicaid, Policy and Procedure Guide for Managed Care Organizations, Columbia, SC: South Carolina Health Connections Medicaid, April 2021, https://msp.scdhhs.gov/managedcare/sites/default/files/MCO%20PP%20April%202021%20Final.pdf
National Association of Medicaid Directors, “Medicaid Value-Based Purchasing: What Is It & Why Does It Matter?” (Washington, DC: National Association of Medicaid Directors, January 2017), http://medicaiddirectors.org/wp-content/uploads/2017/01/Snapshot-2-VBP-101_FINAL.pdf.
For example, in Pennsylvania, the APM target for the HealthChoices physical health MCO program and the behavioral health managed care program is 50% and 20%, respectively, for calendar year 2021. Likewise, Virginia sets a lower percentage (10%) for its MLTSS program, Commonwealth Coordinated Care Plus, than for its Medallion 4.0 Medicaid physical and behavioral health managed care program that serves the state’s low-income children and families and the APM target is set at 25%.
The thirteen states are Arizona, District of Columbia, Hawaii, Louisiana, Michigan, New Hampshire, North Carolina, Oregon, Pennsylvania, South Carolina, Texas, Virginia, and Washington.
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. CMS launched the LAN in 2015 to encourage alignment across public and private sector payers by providing a forum for sharing best practices and developing common approaches to designing and monitoring of APMs, as well as by developing evidence on the impact of APMs.
Under 42 CFR §438.6(c)
Health Care Payment Learning & Action Network, “Alternative Payment Model (APM) Framework: Fact Sheet,” accessed at: http://hcp-lan.org/workproducts/apm-factsheet.pdf. CMS launched the LAN in 2015 to encourage alignment across public and private sector payers by providing a forum for sharing best practices and developing common approaches to designing and monitoring of APMs, as well as by developing evidence on the impact of APMs.
These efforts include the Vermont Medicaid Next Generation Accountable Care Organization (ACO) program under the Vermont All-Payer Accountable Care Organization Model agreement with CMS. Fifty-four percent of Vermont’s FFS Medicaid payments are reported to be in LAN Categories 3 and 4 APM models. For information on Vermont’s All-Payer Agreement with CMS, see:
Centers for Medicare and Medicaid Service, Vermont All-Payer ACO Model, Baltimore, MD: Department of Health and Human Services, last updated August 31, 2021, https://innovation.cms.gov/innovation-models/vermont-all-payer-aco-model
National Committee on Quality Assurance, “Patient-Centered Medical Home Recognition,” (Washington, DC: National Committee on Quality Assurance, accessed October 10, 2019), http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH.aspx
Colorado Department of Health Care Policy and Financing, Accountable Care Collaborative Phase II, Denver, CO: Colorado Department of Health Care Policy and Financing, accessed September 12, 2021, https://www.colorado.gov/pacific/hcpf/accphase2