Delivery System Redesign

Medicaid health homes, made possible through the ACA, provide states with a mechanism to support better care management for people with complex health needs with the goal of improving health outcomes and curbing costs. As of March 2014, 15 states have 22 approved state plan amendments to implement Medicaid health homes. Six "early adopter" states – Iowa, Missouri, New York, North Carolina, Oregon, and Rhode Island – have collectively enrolled more than 875,000 Medicaid beneficiaries in health homes.  This brief draws from the experiences of early health home adopter states to outline elements critical to implementation and sustainability of this new model.
 

As part of the federal Financial Alignment Initiative, states have the opportunity to test care models for dual-eligibles that integrate acute care, behavioral health and mental health services, and long-term services and supports, with the goals of enhancing access to services, improving care quality, containing costs, and reducing administrative barriers. One of the challenges in designing these demonstrations is choosing and applying measures that accurately track changes in quality over time—essential for the rapid identification of effective innovations. This brief reviews the quality measures chosen by eight demonstration states as of December 2013.
 

Public payers are moving to implement payment strategies that reward value in the health care system by linking payment to quality. This report—the third in a series supported by The Commonwealth Fund to explore opportunities for improvement in federal and state policy— highlights quality measurement strategies underpinning value-based purchasing initiatives at the federal and state level. It also describes opportunities for federal-state alignment identified during a Commonwealth Fund-supported discourse among high-level state and federal officials hosted by NASHP.
 

This report summarizes the current state of knowledge about value-based purchasing (VBP) based on a review of the published literature, a review of publicly available documentation from VBP programs, and discussions with an expert panel composed of VBP program sponsors, health care providers and health systems, and academic researchers with VBP evaluation expertise. Three types of VBP models were the focus of the review: (1) pay-for-performance programs, (2) accountable care organizations, and (3) bundled payment programs. The authors report on VBP program goals and what constitutes success; the evidence on the impact of these programs; factors that characterize high- and low-performing providers in VBP programs; the measures, incentive structures, and benchmarks used by VBP programs; evidence on spillover effects and unintended consequences; and gaps in the knowledge base.

Many individuals receiving care for behavioral health conditions also have physical health conditions that require medical attention, and the inverse is also true. Unfortunately, our physical and behavioral health care systems tend to operate independently, without coordination between them, and gaps in care, inappropriate care, and increased costs can result. This brief examines five promising approaches currently underway in Medicaid to better integrate physical and behavioral health care. They can be arrayed along a continuum that ranges from relatively modest steps to coordinate care between the two systems, to more ambitious efforts to implement a single integrated system of care.