Delivery System Redesign

Research demonstrates that improving population health and achieving health equity will require broad approaches that address social, economic, and environmental factors that influence health. Reflecting the increased focus and new opportunities provided under the ACA, a growing number of initiatives are emerging at the national, state, and local level to bridge health care and community health. Given Medicaid’s longstanding role serving a diverse population with complex health, behavioral, and social needs, efforts to address social determinants of health are emerging through many Medicaid delivery and payment initiatives. This brief provides an overview of the broad factors that influence health and describes emerging efforts to address them, including initiatives within Medicaid.

Challenges such as geographic isolation, small practice size, heterogeneity in settings and patient population, and low case volume make participation in performance measurement and improvement efforts especially challenging for many rural providers. This report presents 14 recommendations from a multi-stakeholder committee that was tasked to address these and other challenges of healthcare performance measurement for rural providers, particularly in the context of the Centers for Medicare and Medicaid Services pay-for-performance programs. The resulting recommendations can help advance the integration of rural providers into CMS quality improvement efforts. The recommendations also can be used to enhance the quality measurement and improvement efforts of other public- and private-sector stakeholders.

Under the State Innovation Models (SIM) initiative, launched in 2012 by CMS’ Center for Medicare and Medicaid Innovation, CMS has awarded nearly $950 million in grants to states, the District of Columbia, and the territories to design, implement, and evaluate multi-payer health care delivery and payment reforms aimed at improving the quality of care and health system performance while decreasing costs for Medicaid, CHIP, and Medicare beneficiaries. Under the SIM initiative, the Innovation Center has been making two types of grants to states: Model Design grants through which states develop or refine a State Health Care Innovation Plan; and Model Test grants, which provide funding to states to implement their system transformation plans and evaluate their impact. This fact sheet provides information about the recent grants awarded under SIM Round 2, with a focus on Model Test grants.
 

States are developing accountable care organizations (ACOs) for their Medicaid populations to target health care costs and improve health care quality by better coordinating care for high-need, high-cost patients and reducing inappropriate inpatient and emergency department visits. Many high-need, high-cost Medicaid patients have mental health and substance use issues and are often not well-served in the current fragmented health care system. In response, states are increasingly looking to integrate behavioral health into their Medicaid ACO programs to help move the needle on cost and quality. This technical assistance tool examines four broad strategies states can use to integrate behavioral health services into ACOs.

States and the federal government are investing heavily in state demonstrations to reform the health care delivery system, and gauging the impact of these demonstrations through monitoring and evaluation requires time and effort from both state and federal officials. Greater alignment between state and federal evaluation and monitoring activities and across programs could streamline reporting requirements, ease administrative burden, and improve the effectiveness and efficiency of monitoring and evaluation. In June 2015, the National Academy for State Health Policy convened state and federal leaders to identify actionable steps toward a shared federal and state agenda on improving the monitoring and evaluation of state demonstrations. This brief reflects on the convening’s discussion.