Delivery System Redesign

This brief describes global and episodic bundling and outlines considerations for state Medicaid agencies when evaluating potential implementation, including the relevance of these strategies for Medicaid agencies employing managed care strategies.

Today, there are roughly 750 ACOs across the nation serving 23.5 million people insured by Medicare, Medicaid, and commercial insurance. This evolving model strives to fulfill the Triple Aim of better health, improved patient experience, and lower costs by shifting more accountability for health outcomes to providers. While not all ACOs have been able to deliver better outcomes at lower costs, many have been able to realize these goals. This brief explores promising trends, emerging opportunities, and potential barriers identified by ACO stakeholders across the country. It also examines how ACOs can build upon initial successes and informs policymakers, researchers, and foundations about key considerations to further the development of effective ACO approaches across the health care market.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) creates strong incentives for physicians to participate in Alternative Payment Models (APMs), and it specifically encourages the development of “Physician-Focused Payment Models” in order to address the many problems with current payment systems that Merit-Based Incentive Payment Systems cannot solve. This report explains the provisions of MACRA relating to APMs and describes the actions HHS should take in the following areas: the regulations defining APMs and alternative payment entities; the processes for soliciting, reviewing, and approving Physician-Focused Payment Models; and the systems and resources to implement Physician-Focused Alternative Payment Models.

The Centers for Medicare and Medicaid Services (CMS) is implementing the Bundled Payments for Care Improvement (BPCI) initiative to test four different alternative payment models based on episodes of care that involve an inpatient hospital stay. One model focuses on care provided during the hospital stay, while the other three models include post-acute care provided once the patient is released from the hospital. CMS hopes that by paying for related care as part of a broad payment bundle, different providers who treat a patient during a single episode will have incentives to better coordinate care, avoid unnecessary services, and improve patient health. This brief describes the different models being tested and CMS’s experience with the project to date.
 

With rapid health care transformation efforts underway across the nation, there is increasing attention on improving outcomes and reducing avoidable health care costs for the small subset of individuals who account for the majority of health care spending. Significant gaps in understanding remain—including how to identify and engage individuals, segment populations into meaningful subgroups with tailored interventions; measure quality outcomes, and align financial incentives across systems. This report aims to identify those opportunities that warrant further exploration, with hopes of targeting future investments and pilot activities to help fill the gaps that remain.

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.

There is widespread agreement that changes in healthcare payment systems are needed to achieve higher quality, more affordable healthcare. To date, however, most payment reform initiatives have had relatively little impact on either healthcare spending or quality.  This report describes seven different alternative payment models that can enable physicians in every specialty to redesign the way they deliver care in order to control spending and improve quality for their patients.

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.