State Medicaid agencies, which fund half of all births in the United States, are increasingly looking for ways to improve birth outcomes and maternal health while reducing costs by improving medical care and avoiding medically unnecessary cesarean sections. Two case studies from Wisconsin and Oklahoma show how these states successfully improved health care access and quality by creating pregnancy-focused medical homes and developing provider education and incentives to reduce unnecessary C-sections. The studies were developed in partnership with the National Institute for Children’s Health Quality with support from the Health Resources and Services Administration’s Maternal and Child Health Bureau.
Case Study: Oklahoma’s Cesarean Section Quality Initiative Promotes Improved Birth Outcomes
Case Study: Wisconsin’s Obstetric Medical Home Program Promotes Improved Birth Outcomes
Since 2008, the Bureau of TennCare (Tennessee’s Medicaid agency) has worked with the Tennessee Chapter of the American Academy of Pediatrics (TNAAP) to advance the medical home model in pediatric practices. In 2012, TNAAP launched the Tennessee Medical Home Project, a three-year education and training initiative to increase providers’ medical home capabilities and capacity to coordinate care for children and youth with special health care needs. TNAAP implemented the Tennessee Medical Home Project in partnership with the Tennessee Department of Children’s Special Services and Tennessee Voices for Children through Health Resources and Services Administration grant funding.
Tennessee is pursuing a multi-payer medical home initiative as part of its State Innovation Model Test Award (see below for additional information). According to the state’s proposal, there are more than 500 NCQA PCMH-recognized practices in the state and all of the major health plans have implemented a PCMH incentive program; however, providers have found it difficult to participate in more than one initiative due to the disparate program requirements and incentives set by each plan. TennCare (Medicaid) managed care plans and commercial payers will pilot a new multi-payer initiative with greater alignment across payers in 12 practices in Knoxville and Memphis before the program rolls out statewide.
Participation in Federal Initiatives
State Innovation Models Initiative: In December 2014, Tennessee received a two-year, $65 million Model Test Award to implement and test the Tennessee Health Care Innovation Initiative. Key features of Tennessee’s innovation plan include a multi-payer patient-centered medical home program for adults, a pediatric medical home initiative, and health homes for individuals with severe and persistent mental illness. Tennessee previously received a $756,000 Model Design Award to develop their plan.
Last updated: March 2015
|Forming Partnerships||The Tennessee Medical Home Project, which is primarily focused on children and youth with special health care needs, has been developed in partnership with:
|Defining & Recognizing a Medical Home||Definition:
The Tennessee Medical Home Project refers to both the definition of “medical home” set forth in the American Academy of Pediatrics’ 2009 Policy Statement as well as the Joint Principles of the Patient Centered Medical Home.
The Bureau of TennCare and the Tennessee Department of Children’s Special Services have partnered with the Tennessee Chapter of the American Academy of Pediatrics (TNAAP) and Tennessee Voices for Children to develop educational and training materials to support medical home implementation, particularly to serve children and youth with special health care needs. As part of this work, TNAAP has developed a website with resources and toolkits for practices; TNAAP has also held a series of online and in-person learning events.
Crisis services for behavioral health emergencies have the potential for significant cost savings by reducing inpatient hospitalization and emergency department utilization and encouraging more appropriate use of community-based behavioral health services. Traditionally, individuals experiencing a behavioral health crisis have been initially treated in a general hospital emergency department or admitted to a hospital and then receive limited outpatient treatment. This approach has been neither cost effective nor consistent with clinical best practice. As a result, several states have developed a continuum of crisis intervention services to provide less expensive, community based alternatives. The research base on the effectiveness of crisis services is growing and states now have experience using different payment mechanisms to support a comprehensive crisis system.
This webinar will provide an overview of the evidence base on clinical and cost effectiveness of different types of crisis services, as detailed in a new report from Truven Health Analytics and the Substance Abuse and Mental Health Services Administration (SAMHSA). State officials from Tennessee, Washington, and Wisconsin will then share strategies used to coordinate, consolidate, and braid funding services in order to provide a full continuum of services to individuals experiencing a behavioral health crisis.
- Joyce Allen, Director of the Bureau of Prevention, Treatment, and Recovery, Wisconsin Department of Health Services
- Jane Beyer, Assistant Secretary for Aging and Disability Services, Behavioral Health and Service Integration Administration, Washington
- Suzanne Fields, Senior Advisor to the Administrator on Health Financing, SAMHSA
- Neva Kaye, Managing Director for Health System Performance, National Academy for State Health Policy
- Julie Seibert, Research Leader, Truven Health Analytics
- Mary Shelton, Director of Behavioral Health Operations, Bureau of TennCare
Support for this webinar was provided by the Substance Abuse and Mental Health Services Administration through a contract with Truven Health Analytics.
|Click to Download Webinar Transcript||230 KB|
- All Medicaid services are delivered through TennCare, Tennessee’s Medicaid managed care program. TennCare is one of the oldest Medicaid managed care programs in the country and it enrolls the entire state Medicaid population in managed care. TennCare enrollees are assigned to one of the Medicaid-only Managed Care Organizations (MCOs) operating in the region in which they live (West, Middle, East); these MCOs provide physical and behavioral health benefits. A Prepaid Ambulatory Health Plan also operated under the TennCare program manages dental benefits for TennCare enrollees.
- There were a total of 1,218,676 beneficiaries enrolled in TennCare as of July 2011. TennCare is operated under a Section 1115 Waiver.
- Tennessee provides services including behavioral health, substance abuse, and dental services to all TennCare children through its TENNderCare program (the state’s name for the EPSDT benefit). Tennessee also provides behavioral health services through three different Section 1915(c) Home and Community Benefit Service waiver programs.
Tennessee Code 71-5-144 defines Medical Necessity as follows:
“To be determined to be medically necessary, a medical item or service must be recommended by a physician who is treating the enrollee or other licensed healthcare provider practicing within the scope of the physician’s license who is treating the enrollee and must satisfy each of the following criteria:
Managed care contracts require that if a managed care organization’s EPSDT “screening rate is below ninety percent (90%), as determined in the most recent CMS 416 report, the CONTRACTOR shall conduct New Member Calls for all new members under the age of twenty- one (21) to inform them of TENNderCare services including assistance with appointment scheduling and transportation to appointments.”
|Tennessee is one of only 12 states that require MCOs to be accredited by the National Committee for Quality Assurance (NCQA). This includes the reporting of Health Care Effectiveness Data and Information Set (HEDIS) data, from which several measures in the CHIPRA core set of measures for children are drawn, including adolescent well-care visits and well child visits in the first 15 months of life.|
Managed care organizations must secure services for enrollees from a range of behavioral health providers, including: community mental health agencies; case management agencies; psychiatric rehabilitation agencies; psychiatric and substance abuse residential treatment facilities; and psychiatric and substance abuse inpatient facilities.
Tennessee also has three different Home and Community Based Services Waiver programs that it uses to provide behavioral health services: the Arlington Waiver Program, Self Determination Waiver Program, and Statewide Waiver Program. The Self Determination and Statewide waiver programs include children with developmental delays and intellectual disabilities as part of the target population. The Statewide Waiver Program in particular is explicitly aimed at children. Services provided by Tennessee through these waivers include, but are not limited to:
Support to Providers
Tennessee maintains a TENNderCare provider page that contains information on a number of topics including: provider requirements, screening information, periodicity schedule, screening guidelines, and screening tools. Tennessee also staffs a number of regional and statewide EPSDT Coordinators to assist managed care contractors. Additionally, anyone that works directly with the EPSDT population is required to take the TENNderCare training program offered by the Bureau of TennCare. The training includes a slide show outlining the TENNderCare program, as well as a training video, which covers specific elements of the federal guidelines for EPSDT.
Support to Families
Tennessee’s TENNder Tots and TENNderCare For Teens page includes information for families both on the benefits available to the families, as well as resources on a number of different health areas. The state has also developed a, “Welcome to TENNderCare,” overview for families, which outlines screening/check-up schedules and the different services (including behavioral health and dental) that children receive through the program.
Tennessee has an initiative called TENNderCare Connection, which seeks to ensure coordination of care between the managed care organizations (MCOs) and school-based medically necessary services. This initiative was created through an interagency agreement between the Tennessee Department of Education and the Bureau of TennCare. To assist in this process, Tennessee has developed a form that delineates the responsibilities of TennCare, the MCOs, and the Schools to coordinate care.
Managed care contracts also require that MCOs “shall have written policies and procedures for the TENNderCare program that include coordinating services with child-serving agencies and providers.”
Tennessee provides dental services to children through its TENNderCare (EPSDT) program. The state contracts with DentaQuest to serve as the Dental Benefits Manager Prepaid Ambulatory Health Plan. Services provided to TENNderCare beneficiaries include: six-month appointments, screens and diagnostic tests, topical fluoride treatment, pit and fissure sealants, and substance abuse counseling. Tennessee does not provide orthodontic treatment (braces) unless the child is diagnosed with severe handicapping malocclusion.
For states and their partners seeking a better integrated delivery system through multipayer reform initiatives, effective use of data is the foundation, the “building” itself, and roof above. Easier envisioned than done, data can help participants in multi-payer initiatives offer constructive feedback on performance to providers, distribute rewards in value-based payment systems, and hold system participants accountable for the costs and quality of services delivered. This webinar will explore the types of data multi-payer initiatives need to succeed, where states can get data, and how to use it. It will also highlight approaches to using various types of data from three leading states.
- Lisa Dulsky Watkins, Associate Director, Vermont Blueprint for Health, Department of Vermont Health Access
- Brooks Daverman, Director, Strategic Planning and Innovation, Tennessee Division of Health Care Finance and Administration
- Karynlee Harrington, Executive Director; Dirigo Health Agency; Acting Executive Director, Maine Health Data Organization
|Click here for the Webinar Agenda||140.8 KB|
|Click here for the Webinar Presentation Slides||4 MB|
NASHP’s Accountable Care Activity map is a work in progress; state activity pages will be launched in waves throughout Fall 2012.
At this time, we have no information on accountable care activity that meets the following criteria: (1) Medicaid or CHIP agency participation (not necessarily leadership); (2) explicitly intended to advance accountable or integrated care models; and (3) evidence of commitment, such as workgroups, legislation, executive orders, or dedicated staff.
If you have information about accountable care activity in your state, please email email@example.com.
Last updated: October 2012
This report reflects the discussion of nine states participating in “Transitioning to Managed Care: Medicaid Managed Care in Mental Health.” The symposium was funded by the Henry J. Kaiser Family Foundation and the federal Health Care Financing Administration (HCFA).
Early in 2010, NASHP hosted a webinar that brought together individuals from Massachusetts, Oregon, and Tennessee with experience in collaborating with health centers around Health Information Technology (HIT) activities to discuss ways in which state agencies and federally qualified health centers (FQHCs) are working together to use HIT and health information exchange (HIE) funding opportunities from the American Recovery and Reinvestment Act (ARRA) to achieve mutual goals for health system improvements. This briefing draws from and builds on this webinar to offer an overview of opportunities, explore these states’ experiences, and provide concluding observations. This brief was developed through a National Cooperative Agreement (NCA) sponsored by the Health Resources and Services Administration’s (HRSA) Bureau of Primary Health Care (BPHC).
|HRSA-HIT Collaboration||147.6 KB|
Work groups within Tennessee’s state government and the Finance Work Group of HIP TN are collaborating to develop a sustainability plan. Refer to pages 30-31 of the state Strategic Plan.