Delivery System Redesign

Narrow networks contain a smaller number of providers and in-network facilities than traditional provider networks, typically resulting in lower premiums. This paper assesses the benefits and risks of a range of policy and regulatory options available to federal and state policy-makers on these narrow networks. The development, review and oversight of health plan networks involves trade-offs between premium costs and consumers’ access to and choice of providers. This paper makes clear that there is no current regulatory approach that can satisfy all stakeholders, but with the right balance between consumer choice and cost containment, consumers can receive quality care at an affordable price through narrow networks.

The growing adoption of electronic medical records and advances in health information technology are fueling an explosion of new health data. Expectations are high that new data resources will guide the transformation of the health care industry and positively influence population health. There have been challenges and opportunities at every turn, and progress has been slow, but mounting evidence suggests that better use of data is moving health care in the right direction.
 

Case studies of three U.S. regions that ranked relatively high on the Commonwealth Fund’s Scorecard on Local Health System Performance, 2012, despite greater poverty compared with peers, revealed several common themes. In these communities, multi-stakeholder collaboration was an important factor in achieving community health or health system goals. There were also mutually reinforcing efforts by health care providers and health plans to improve the quality and efficiency of care, regional investment and cooperation to apply information technology and engage in community outreach, and a shared commitment to improve the accessibility of care for underserved populations. The experiences of these regions suggest that stakeholders can leverage their unique histories, assets, and values to influence the market, raise social capital, and nudge local health systems to function more effectively.

States are increasingly turning to Medicaid managed care as a key strategy to manage costs and encourage innovation in health care delivery. This report examines health care providers’ perspectives on the role of managed care in improving health services for low-income adults in four communities: Milwaukee, WI; Oakland, CA; Seattle, WA; and Washington, D.C. It finds that providers do not generally perceive Medicaid managed care as a catalyst for delivery system reform. Fragmented delivery systems, limits on the types of services for which managed care organizations are at risk, and the volatility in managed care markets all present challenges to improving care delivery. Policy and operational changes could enhance the role of Medicaid managed care in promoting patient-centered, coordinated, and high-quality care.

As states develop managed care programs for individuals who are dually eligible for Medicare and Medicaid or who use long-term services and supports, it is important for states to engage medical, behavioral health, and home- and community-based service providers, as well as hospitals and nursing facilities. Providers can serve as an important channel for communication with state policymakers and administrators about how the managed care program is faring, and they can help highlight best practices and identify problems before they occur. This brief, developed through support from The Commonwealth Fund and The SCAN Foundation, provides tips to help states engage providers in designing, implementing, and overseeing a managed care delivery system for individuals with complex care needs.
 

This report highlights leading states’ approaches to support community-based prevention initiatives by bridging health care delivery and public health systems. It examines various mechanisms – both previously existing and those created through health reform – that states can leverage to implement sustainable community-based prevention programs. They include Medicaid waivers, federal grants, accountable care and medical home models, pooled funding, and new federal requirements for nonprofit hospitals. The report includes opportunities and lessons from featured states (California, Maryland, Massachusetts, Minnesota, North Carolina, Oregon, Texas, and Vermont).
 

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.
 

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.
 

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.