Delivery System Redesign

The term "super-utilizer" describes individuals whose complex physical, behavioral, and social needs are not well met through the current fragmented health care system. As a result, these individuals often bounce from emergency department to emergency department, from inpatient admission to readmission or institutionalization -- all costly, chaotic, and ineffective ways to provide care and improve patient outcomes. To explore how Medicaid could best advance models for this high-need group of patients, the Center for Health Care Strategies, in partnership with the National Governors Association, hosted a Super-Utilizer Summit in February 2013. This report presents the Summit's common themes and key recommendations for building better systems of care for high utilizers.

The Federally Qualified Health Center Urban Health Network is a coalition of 10 federally qualified health centers (FQHCs) in the Minneapolis–St. Paul area that pursued an accountable care organization (ACO) through a Medicaid demonstration project with Minnesota. This case study explores: the state context under which the ACO contract emerged; origins of the coalition; the members’ motivations to participate; strategies and processes established to work toward cost and quality benchmarks; challenges faced in pursuing accountable care; and the organizational strengths that facilitated the health centers’ shift from competition to collaboration.

NCQA’s 2013 State of Health Care Quality Report summarizes Healthcare Effectiveness Data and Information Set (HEDIS) results from calendar year 2012 from health plans covering a record 136 million people, or 43 percent of the US population. The 2013 report’s key findings include: stagnant or declining performance in appropriate use of antibiotics; continued improvement in childhood obesity measures; mixed results regarding childhood immunization; sustained decline in initiation of alcohol and drug treatment; and better experience of care in Medicaid HMOs.

The Centers for Medicare and Medicaid Services and states are partnering to transform health care systems by creating and testing new models of care delivery and payment. Interviews with officials from states participating in the State Innovation Models (SIM) Initiative reveal that the readiness of providers and payers to adopt innovations varies, requiring different starting points, goals, and strategies. State governments also have policy levers to encourage efficient deployment of a diverse health care workforce. As federal officials review states’ innovation plans, set timetables, and provide technical assistance, they can also take steps to accommodate the budgetary, political, and time constraints that states are facing.

As part of the Agency for Healthcare Research and Quality (AHRQ)'s Infrastructure for Maintaining Primary Care Transformation initiative, NASHP worked with four states (Idaho, Maryland, Montana, and West Virginia) that sought to adapt aspects of North Carolina’s nationally recognized model of primary care practice transformation. This report summarizes the value of primary care transformation for the states, describes the North Carolina model, and outlines states' successes, challenges and lessons learned.