Introduction
Human Resource Essentials for Delivery System Reform
Key Roles: Below is a description of key roles as described by Maryland, Pennsylvania, and Vermont. Depending on the size of the state, scope of reform, and resources, one individual may fill more than one role and/or more than one person may fill one role. In addition, some roles may be filled by contracts with external vendors.Key Roles:
| Role | Description | Considerations |
| Owner/ program management | • Provides leadership and direction to the effort • Project management • Creative problem solving • Coordination across agencies |
Depending on design, may be: • Consolidated in one person • Distributed to project managers in various agencies or at local level |
| Policy | • Identifies goals • Pursues needed federal and state authority • Negotiates with federal government • Engages state legislature |
• May include staff at a central organization as well as subject matter experts from other parts of the state |
| Stakeholder engagement and convening | • Brings together providers, payers, government partners • Brings voices of impacted partners, consumers, and other advocates |
• May be independent or embedded in state government • Especially important for recruiting providers |
| Data | • Data management • Data analysis • Attribution • Financial modeling • Interpretation and communication • Shares data with providers |
• May be in-house and/or through a vendor • A key way to support rural and/or less resourced providers |
| Quality improvement | • Oversight and monitoring of quality improvement programs • May include implementing performance payments • May provide support, training, and technical assistance to providers to reach goals |
• Depending on the design, may already be built in to managed care |
| Reporting | • Manages federally and/or legislatively required reporting • Ongoing communication with federal/legislative contacts • Tracks spend and identified outcomes over time • Shares reporting back with providers |
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| Billing | • Manages billing for the program and outgoing payments to providers | |
| Rate setting | • Periodically sets and adjusts fixed rates for a defined package of benefits | • May not be needed, if the state is not creating their own global budget. • Medicaid agencies will already have a rate setting function that may be sufficient. |
| Other functions | • Contracting • Business office • Information technology • Human resources |
• States may be able to use existing infrastructure. • External organizations will have to build or contract for these functions. |
Key Skills for Staff and Contractors
To be the most successful, the individuals who fill the necessary roles for delivery system and payment reform have a combination of the skills listed below in addition to the specialized skills needed to fill their roles.
Governance Structures
In addition to staff and contractual relationships, large-scale payment and delivery reform also benefits from thoughtful governance structures. As described in NASHP’s January 2024 blog post, Thinking Ahead on the AHEAD Model: Governance, states must consider governance requirements (in federal models and/or state legislation), while simultaneously positioning themselves well to implement the reform and other state priorities.
The three states interviewed all described a variety of committees, workgroups, and advisory groups that bring together impacted parties to provide input, make decisions, and implement changes. In some cases, the governance structures were laid out in statute (such as for Vermont’s Blueprint for Health). In all cases, the governance structures include a combination of health of health and human service agencies; payers; hospitals, health systems, and/or other relevant providers; and other impacted partners.
