Lawrence, Massachusetts, a city that has struggled with poverty and poor health, is now a Culture of Health Prize winner due in part to state policies that bolster the city’s efforts to advance health equity and address social needs. These supportive state policies include guidelines governing the local hospital’s community health needs assessments, its community benefits investments, and its determination of need spending. The Mayor’s Health Task Force works closely with community partners and braids funding from a variety of sources to improve the social and economic factors that affect health. The city’s innovative work and longstanding partnerships offer a blueprint for cities and states interested in unlocking the potential of community-centered, multi-sector partnerships.
Download: Keeping the Community at the Center of Community Benefits Programs: Lessons from Lawrence, Massachusetts
Support for this work was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the foundation.
Greg Moody, director of Ohio’s Office of Health Transformation, has quietly spearheaded one of the most effective redesigns of a state health care payment system in the country, generating cost savings and improving public health by showing providers how the cost and quality of their care compares with their peers.
This value-based cost-savings and quality improvement approach, embraced by Ohio’s employers, insurers, and Medicaid managed care plans, pays for health care value instead of volume by analyzing two factors — how much it costs a provider:
- To provide high-quality comprehensive primary care, and
- To treat an “episode of care,” such as treating an acute asthma episode.
Providers are given a report card that assesses their charges, quality of care, and patient outcomes. If they deliver value-based care, they are financially rewarded with a $4 per patient per month bonus. If their care is over-priced and poor quality, compared to their peers, they get bad reviews and no rewards.
This value-based payment approach with its financial inducements has reduced acute asthma treatment costs by 21 percent and acute COPD treatment costs by 18 percent in 1 million Medicaid enrollees over a two-year period. Not only are the state’s Medicaid and employer plans saving money, patients are healthier because doctors are doing more to keep them well, which benefits overall population health.
“We can spend time fighting about health care coverage, like the federal government has for the last few years, or we can address the underlying health care costs,” observed Moody, a member of the National Academy for State Health Policy’s executive committee. “Today, I think it’s up to states to experiment and explore how to create sustainable health care costs.”
How Ohio Launched Value-Based Payment Reform
Ohio, which has been conducting its health care payment delivery reform experiment for eight years, is finding success with a value-based approach that replaces a pay-per-visit system with one that promotes comprehensive primary care and rewards providers who deliver efficient episodes of care. The state focused on improving care coordination, integrating physical and behavioral health, rebuilding behavioral health system capacity, strengthening home- and community-based services, improving community services for the disabled, and modernizing its Medicaid administration.
To date, a handful of states have taken small steps to develop a value-based payment system, but early results have not yielded dramatic, financial successes and many state policy makers are still casting about for a system that quickly delivers cost savings and quality care. According to Moody, Ohio found it and has spent more years implementing and refining it than any other states.
Moody, who worked for then-Congressman John R. Kasich researching Medicaid funding while staffing the US House Budget Committee, was appointed by newly-elected Governor Kasich to Ohio’s new Office of Health Transformation in 2011.
“Governor Kasich did something I never saw anyone do and it is key to how we got it done,” he explained. “About 18 months before he became governor, he assembled a health care team and told us, ‘I’m not running for governor unless we have ideas to propose.’ Now normally, you start recruiting and developing policy proposals after you get elected, but on his third day in office in January 2011, we had already done our homework and released our strategic plan. Now, eight years later, we are using the same plan.”
Ohio modernized its Medicaid system by creating a stand-alone Medicaid department with a new claims payment system and it provided an online eligibility tool to residents who no longer had to travel to county offices to apply. It also consolidated mental health and addiction services as the state’s opioid epidemic exploded and expanded Medicaid.
State leaders also began engaging partners, including provider groups, health plans, and Medicaid managed care organizations, to identify public health priorities that their payment reforms – in this case applying the episodes-of-care payment system – could support. “The starting point,” Moody explains, “is to be clear about our population health priorities – or in payment terms, define what we want to buy.’”
Ohio decided it wanted to prioritize improvements in three main health care areas:
- Mental health and addiction, addressing depression, suicide, drug dependency, and drug overdoses;
- Three chronic diseases: heart disease, diabetes, and asthma; and
- Maternal and infant health.
Shaping Physician Reimbursements to Improve Population Health
Next, Moody’s office asked high-performing primary care practices what they did to keep patients well. “The problem is none of these activities [recommended by doctors] are properly reimbursed under fee-for-service – for example, holding time for same-day appointments, providing 24/7 access to care, risk stratification of patients, and scheduling based on risk.” Moody knew that a new value-based care system had to reward providers who delivered those successful — though uncompensated — services.
To achieve these goals, Ohio created a Comprehensive Primary Care Model that enrolled 161 primary care practices to serve 1 million patients. Ohio collected and evaluated 1,800 performance reports that included patient cost and care quality measures. It also provided $3 million in “enhanced payments” to providers who delivered value-based care. To qualify for the $4 PMPM bonus, providers had to keep patients well by meeting the new quality requirements, including the same-day appointments, team-based care, patient outcomes, and reduced hospitalizations and emergency department use.
In December 2014, Ohio won a federal State Innovation Model test grant to implement an episode-based payment model statewide. The timing of the grant was perfect, Moody noted. It allowed Ohio to expand the state’s limited data analytic capacity, and create new insights about how best to improve health outcomes while holding down the total cost of care. Ohio could now pull in all insurance claims related to certain episodes of care for its value-based analysis.
For example, to assess a joint replacement episode of care cost, Ohio combined the total cost of the surgeon, implanted device, hospitalization, medication, and rehabilitation, and used the data to compare providers’ cost-effectiveness across the state. “We then take back money from the rates of the high-cost providers (in red) and share savings with the high-value providers (in green),” Moody explained.
To qualify for bonuses, providers had to meet both cost and quality targets. “This creates a powerful incentive for the principal accountable provider to pay attention to the total cost of the episode,” Moody explained, “[which is] very different from fee-for-service, which pays the surgeon the same regardless of other costs.”
In January, 2018, Ohio started paying the 161 practices that participated in Ohio’s comprehensive primary care pilot program $4 PMPM for meeting the basic efficiency and quality targets. “In addition, practices that meet quality targets while holding down the total costs of care compared to peers and based on self-improvement earn a significant annual performance bonus,” Moody explained.
Similar initiatives in other states are starting to yield substantial savings and care improvements. Minnesota achieved cost savings and an 89 percent improvement in quality measures and one regional initiative in northeast Pennsylvania achieved an 83 percent improvement in quality measures.
With this performance data, primary care providers are able to make value-based recommendations when referring patients to specialists, and insurance plans can also promote providers who receive high value-based rankings to their members.
Using Episodes of Care Costs to Tackle the Opioid Epidemic
By breaking down costs within each episode of care, Ohio has also been able to address another population health-related problem – opioid over-prescribing – by analyzing claims information to see which providers over-prescribe. The analysis, for example, revealed a provider who prescribed opioid painkillers 100 percent of the time for ankle sprains — meanwhile the state average hovered below 18 percent. More careful opioid prescribing data collections and oversight has produced a 28.4 percent decline in the number of opioid doses prescribed in Ohio between 2012 and 2017.
While the cost-savings opportunities generated by this value-based system appear tailor-made for simple procedures like joint replacement, its application to more complex care, such as perinatal episodes of care, is not currently clear. While acute COPD and asthma episodes of care costs dropped markedly 2014 and 2016, perinatal costs increased 3 percent, about what Moody would have expected in a conventional fee-for-service environment. “At this stage, these results create new questions,” he said, “for example, how do we make complex episodes more sensitive to value-based results? How do we identify the greatest sources of value in complex care and share that information with providers who can use it to improve?”
Ohio recently expanded its episodes of care data collection from three episodes to 43, which include many opioid clinical and quality measures. “Eventually, all of this needs to be transparent to the public and easily available online — it’s what we need everyone to see to make real progress on population health priorities,” he said.
Moody considers his work in Ohio as the pinnacle of his professional experience. He encourages other states to replicate Ohio’s approach. “You don’t wake up one morning and do this, it took years for us to get buy-in to make this happen,” he said. “This is something any state can do, but it takes time. We spent a lot of time defining the key health care delivery problems in Ohio, inventorying existing resources, and identifying the two to three policy changes that would leverage change, it’s a fairly rigorous process.
“There are now more than 30 states with gubernatorial elections in November, those candidates should start now to develop their policies and approaches,” said Moody, who will step down from his job in December when Gov. Kasich leaves office. “Ohio has created a blueprint to make these reforms. There are other ways to do this and be successful, but it’s critical that candidates start thinking and planning now.”
Read Ohio’s Health Transformation report, Moving Ohio’s Health Care Payment System Upstream.
Thursday, August 16th
1:30pm – 3:00pm
State health policymakers are identifying innovative mechanisms to address the social determinants of health by including new requirements or incentives within value-based purchasing and contracting arrangements. This session highlights how states are using value-based payment roadmaps and Medicaid managed care contracting as levers to increase health and well-being and to control costs. Officials from three states discuss their models, share strategies, and identify practical ideas to address the social and economic factors that influence health through value-based purchasing.
SpeakersRyan Ashe, Director, Medicaid Payment Reform, New York State Department of Health
Ryan is a passionate champion of healthcare transformation and payment reform. He believes in aligning incentives that support public sector domains to fundamentally improve people’s quality of life. Prior to leading NYS’ Medicaid payment reform efforts, Ryan advised State governments on major health & human services transformations, including Affordable Care Act implementation and developing integrated service delivery capabilities. Ryan is a veteran of NYS policy, having advised on a number of issue areas in the NYS Legislature.
MaryAnne Lindeblad, Medicaid Director, Washington State Health Care Authority
MaryAnne Lindeblad brings a broad health care and administrative background to the Washington Medicaid program. She has been an active health care professional and leader spanning most aspects of health care including acute care, long-term care, behavioral health care, eldercare and services for people with disabilities. MaryAnne served for two years as Assistant Secretary for Aging and Disability Services Administration with the Department of Social and Health Services, and Director of the Health Care Services Division with the Health Care Authority. Lindeblad has held a variety of leadership positions, including Assistant Administrator of the Public Employees Benefits Board, and Director of Operations for Unified Physicians of Washington. In 2010, she was selected for the inaugural class of the Medicaid Leadership Institute. MaryAnne currently chairs the executive committee for the National Academy for State Health Policy, serves on the boards of the National Association of Medicaid Directors and Olympia Free Clinic. Lindeblad holds a bachelor of science in nursing from Eastern Washington University, and master’s in public health from the University of Washington.
Marie Zimmerman, State Medicaid Director, State of Minnesota
Marie Zimmerman State Medicaid Director has devoted over a decade to public-sector health care in Minnesota, spearheading critical reforms and innovations that have been watched and emulated nationally. Appointed Minnesota’s Medicaid director in 2014, Marie oversees the strategic policy direction and the core business functions of Medicaid and the Basic Health Program (BHP), called MinnesotaCare. The combined budgets of Medicaid and MinnesotaCare topped $11.5 billion in 2016 and provide health coverage to 1 in 5 Minnesotans, delivering health care, behavioral health services and long-term services and supports to more than one million people.
During Marie’s tenure, the state has saved over $1.5 billion through managed care reform and purchasing innovations. Savings include $213 million related to improved health outcomes for Medicaid enrollees through an accountable care model called Integrated Health Partnerships; a collaborative, patient-focused approach to delivering care while lowering cost. In addition, Marie has managed a successful Basic Health Program that provides affordable and comprehensive coverage for lower-income Minnesotans who do not qualify for Medicaid. Prior to her service as Medicaid director, Marie acted as health care policy director for the Minnesota Department of Human Services, where she led early efforts to reform health care purchasing for Medicaid, moving the state toward a pay-for-value model.
Marie is a recipient of the Women in Health Care Leadership Award from Women’s Health Leadership TRUST. She serves on the boards of the National Academy for State Health Policy and the National Association of Medicaid Directors.
Marie lives in Minneapolis with her family. She holds a Master of Public Policy from the University of Minnesota’s Humphrey School of Public Affairs and earned a bachelor’s degree in economics and political science from the University of St. Thomas in Minnesota.
This session was made possible with support from the Robert Wood Johnson Foundation.
Friday, August 17th
10:15am – 11:45am
States are pioneering innovative efforts to integrate or link health and non-health data across agencies to improve health outcomes and population health. Highlights of this session include state presentations about unique projects that work with state and local governments to link administrative data across government agencies that aim to increase collaboration among all sectors that impact health and well-being.
ModeratorLinette Scott, Chief Medical Information Officer, CA Department of Health Care Services
Linette Scott, MD, MPH, is the Chief Medical Information Officer and the Deputy Director of the Information Management Division in the California Department of Health Care Services. In this role she works across the Department and with stakeholders to ensure that reliable data and information are available, and used to drive improvements in population health and clinical outcomes through the Department’s programs and policies. Dr. Scott is a Board Certified Physician in Public Health and General Preventive Medicine. She has a Doctor of Medicine from Eastern Virginia Medical School, a Masters in Public Health from University of California, Davis, and a Bachelors of Arts in Physics from University of California, Santa Cruz. Highlights from her career include serving as a General Medical Officer with the United States Navy, first as squadron physician with the Regional Support Group and later as the military physician for an Active Duty clinic; as a Public Health Medical Officer with the California Department of Health Services; as the California State Registrar and Deputy Director of Health Information and Strategic Planning in the California Department of Public Health, and as the Interim Deputy Secretary for Health Information Technology at the California Health and Human Services Agency.
William Hazel, Senior Advisor for Strategic Initiatives, George Mason University
Dr. Bill Hazel is the Senior Advisor for Strategic Initiatives at George Mason University where he is leading a university-wide effort to address issues related to addiction and opioids.
Kate McEvoy, Director, Division of Health Services, Connecticut Department of Social Services
In this time of changing federal health priorities, state health policymakers play a crucial role in breaking the cycle of poverty and inequity so everyone can live healthy, prosperous lives. Many state leaders, with federal support, are implementing community-wide prevention initiatives that acknowledge that health is affected by factors that extend beyond clinical care. Policymakers are also fostering innovative strategies to promote community engagement so low-income, disadvantaged individuals and families help define community health priorities so all may achieve and maintain health.
|In Brief :
To improve population health and health equity, states are working across Medicaid, public health, and other agencies to develop accountable health structures. State accountable health models — both currently operating and those in development — fall along a continuum. All of them promote healthy communities through community partnerships, but some contract with Medicaid agencies to provide health care services directly to individual Medicaid beneficiaries, while others focus only on community-based interventions.
In October 2017, the National Academy for State Health Policy (NASHP) convened state health officials representing 10 state accountable health models to discuss strategies for using accountable health structures to promote population health. Participants also discussed strategies to assess these structures’ impact on health, determine their return on investment, and develop sustainable funding approaches. The following are some of the key strategies that they identified:
- Use states’ policy and contracting levers to address prevention and health-related social needs in payment and delivery reform. States can leverage Medicaid managed care contracting, build on the flexibility available through Section 1115 demonstration waivers, and maximize State Innovation Model (SIM) investment in population health to focus efforts to improve health.
- Align population health goals, agendas, and, where possible, metrics across communities, payers, and stakeholders. Accountable health structures are most effective in reaching their goals and engaging stakeholders across sectors when they work toward shared goals.
- Use data and measurement to raise the bar on performance, and consider financial incentives to address prevention and health-related social needs. Some policymakers suggest identifying a unified, small set of metrics that can be used across various systems and are tied to payment and accountability and based on community outcomes as well as provider outcomes.
- Work across sectors and agencies to develop a range of financial strategies to support investment in prevention and community health. Identify any gaps and duplication in funding streams. States can bolster the resilience of their accountable health structures by braiding and blending funds across agencies and seeking private sector investment. Cross-sector financial mapping of health-related programs and services can ensure that federal funds support activities that align with state priorities.
- Learn from other states’ value-based payment roadmaps and lessons learned. Instead of reinventing the wheel, state policymakers can adopt and adapt other states’ tools to fit their state’s needs.
As state and federal policymakers seek opportunities to promote good health and its associated benefits, initiatives that enable communities to set public health priorities and maximize resources will be critical. States with active accountable health structures will continue using available policy levers to advance their goals, from improved health and equity to lower medical costs and economic sustainability. Information about the viable strategies and experiences of these states will help policymakers use available funding and policy levers to craft their own sustainable accountable health entities that achieve measurable long-term success to improve population health. NASHP will continue to convene these states, drill down into their experiences, and share lessons so other states may develop accountable health models in the future.
To read NASHP’s in-depth reports on accountable communities for health that explore initiatives in states including California, Minnesota, Vermont, and Washington, please visit:
- State Approaches to Addressing Population Health Through Accountable Health Models
- States Share Innovative Approaches to Improve Population Health through Accountable Health Models
- State Levers to Advance Accountable Communities for Health
- State Levers to Advance Accountable Communities for Health: California State Profile
- State Levers to Advance Accountable Communities for Health: Minnesota State Profile
- State Levers to Advance Accountable Communities for Health: Vermont State Profile
- State Levers to Advance Accountable Communities for Health: Washington State Profile
- Minnesota Accountable Community for Health Saves Money through Local Opioid Prevention Initiative
- Accountable Health Community Models: What’s the State Role?
- Accountable Health Presentation
Support for this work was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the foundation.