Delivery System Redesign

Youth with complex behavioral health needs face a range of challenges and often receive services from multiple agencies that do not always coordinate services and care plans. Care Management Entities (CMEs) are designed to coordinate services provided by state agencies, and ensure services are comprehensive and not duplicative. This new Implementation Guide provides information about the CME design process for states interested in implementing or improving CMEs for youth with complex behavioral health needs. The guide focuses on experiences of the three CHIPRA quality demonstration states, Maryland, Georgia, and Wyoming, who are using funds to implement or expand CMEs.
 

The federal government, commercial health plans, and other organizations are increasingly using measures of healthcare spending for the purposes of rewarding or penalizing physicians, hospitals, and other healthcare providers, defining provider networks, and encouraging patients to use particular providers. This report describes six fundamental problems with the current attribution and risk adjustment systems that are being used in these measures and explains how these problems could seriously harm both patients and healthcare providers. The report also describes how these problems can be solved using improved methodologies.

This report describes the efforts of 17 different states to transform their primary care delivery systems in order to improve the health of their populations and reduce costs. Since 2009, the Multi-state Collaborative has provided a forum for its members to collaborate across states and with the federal government, sharing data and lessons learned about investment in primary care transformation. The report highlights how these states went about transforming primary care to patient-centered medical homes (PCMH) through aligned payment reform.
 

Provider groups taking on risk for the overall costs of care in accountable care organizations are developing care management programs to improve care and thereby control costs. Many such programs target “high-need, high-cost” patients – those with multiple or complex conditions, often combined with behavioral health problems or socioeconomic challenges. This study compares the operational approaches of 18 successful complex care management programs in order to offer guidance to providers, payers, and policymakers on best practices for complex care management.
 

Across the nation, public and private payers are combining forces to encourage providers in a given health care market to deliver more efficient, higher quality care. Payers can align on several fronts, including payment policies, quality measurement, administrative practices, and data-sharing. Drawing from the efforts of three state innovators (Maine, Vermont, and Wisconsin), this brief outlines promising strategies for quality measurement alignment across purchasers as a means to improving delivery system performance. The lessons can inform Medicaid and private purchasers in advancing a joint quality strategy.

Recognizing that health is determined by a variety of interrelated factors, states are looking to connect health care, public health, and social services to help achieve improved population health, better care, and reduced cost of care. This issue brief describes three essential components for integrating health, including physical and behavioral health, public health, and social services: 1) a coordinating mechanism, 2) quality measurement and data-sharing tools, and 3) aligned financing and payment. It also presents a five-step policy framework to help states move beyond isolated pilot efforts and establish the infrastructure necessary to support ongoing integration of health and social services.

The Agency for Healthcare Research and Quality has published the eighth Evaluation Highlight from the CMS-funded CHIPRA Quality Demonstration Grant Program. This Highlight focuses on how Colorado and New Mexico have helped school-based health centers (SBHCs) strengthen their patient-centered medical home (PCMH) features. It describes what motivated these states and SBHCs to adopt the PCMH model and how other states can support SBHCs in becoming medical homes
 

The health care affordability crisis is causing unprecedented changes in the health care landscape, the most significant of which is the transition from the current volume-based model to myriad models based on measures of value. This white paper outlines the challenges involved with performing population-level analyses, developing cost accounting and profitability analyses across care settings, evaluating care episodes and integrating quality data. It explores the limitations of targeted software solutions to provide cross-enterprise insights. Finally, it provides advice for healthcare executives regarding how to approach gathering quality and cost-related data and leverage technology and analytical expertise to drive risk-based contract success.
 

Physicians’ involvement in accountable care organizations (ACOs) will influence how clinicians and patients perceive the ACO model, how effective these organizations are at improving quality and costs, and how future ACOs will be organized. This first-ever survey of public and private ACOs found that 51 percent of ACOs were physician-led, with another 33 percent jointly led by physicians and hospitals. In 78 percent of ACOs, physicians constituted a majority of the governing board, and physicians owned 40 percent of ACOs. The broad reach of physician leadership has important implications for the future evolution of ACOs. It seems likely that the challenge of fundamentally changing care delivery as the country moves away from fee-for-service payment will not be accomplished without strong, effective leadership from physicians.
 

Despite growing evidence documenting the impact of social factors on health, providers have rarely addressed patients’ social needs in clinical settings. But today, changes in the health care landscape are catapulting social determinants of health from an academic topic to an on-the-ground reality for providers, with public and private payers holding providers accountable for patients’ health and health care costs and linking payments to outcomes. With the confluence of sound economics and good policy, investing in interventions that address patients’ social as well as clinical needs is starting to make good business sense.