Rhode Island – The National Academy for State Health Policy

Rhode Island’s Accountable Entities Emphasize Children’s Health and Social Needs

In the midst of the pandemic, many states are continuing to advance their health system transformation efforts. Rhode Island’s Medicaid Accountable Entities (AE) Program, for example, is shifting to a pay-for-performance model for several screening measures. Under this model, there is an additional financial incentive to screen children and their families for health and social needs, which have taken on new importance due to the added stressors of COVID-19.

Rhode Island’s AE program, now entering its fourth year, makes provider organizations (AEs) accountable for health outcomes of their members as well as the total cost of care of their populations. Using contractual levers in the agreements between AEs and managed care organizations (MCOs), the state requires AEs to integrate strategies to address social needs and social determinants of health (SDOH). The strategies must include assessment of social needs, referral to community resources, and utilizing community partnerships and engagement to address the identified needs.

Read NASHP’s 2018 profile of Rhode Island’s Accountable Entities Program here.

The state developed SDOH screening requirements for the AEs. Screening tools must be approved by the Rhode Island Executive Office of Health and Human Services (EOHHS), and they must include information on the following domains: housing insecurity, food insecurity, transportation, interpersonal violence, and utility assistance.

Screening for a child’s needs can offer insights about what kinds of services, referrals, or wrap-around care are needed to ensure healthy development. Because the ongoing pandemic has required children and families to stay home and spend additional time together, a safe and supportive home environment is especially crucial for children’s health and well-being. The SDOH screening domains that are required by EOHHS overlap with adverse childhood experiences (ACEs), such as poverty, food and/or housing insecurity, neglect, and mental illness — all of which contribute to poor health outcomes for children.

Rhode Island’s AE program takes into account the benefit of a two-generation (2Gen) approach to these issues. Under a 2Gen framework, services are provided to both children and the adults in their lives simultaneously to help families live healthy and productive lives. When screening children under age 12, Rhode Island’s SDOH screening measure can be applied to an entire household instead of to only the individual child. This can provide a better understanding of how to target interventions for the whole family going forward.

This year, a key change is happening within the AE program that may increase the number of children and families served by the program. The state is shifting to pay-for-performance (P4P) for the SDOH screening requirement. Beginning in Project Year 4 (PY4), there is a financial incentive for the AEs to increase their SDOH screening rates among their attributed populations. AEs needed time to develop their screening tools and build capacity around screening for SDOH before shifting the AE incentive metric to P4P. Other measures, including documented developmental screening for children younger than age 3, will also transition to P4P in PY4.

Though the SDOH screening requirements are specific to Medicaid AEs in Rhode Island, state officials expect the screening requirements to have a ripple effect. In primary care settings, for example, if a provider is administering the SDOH to AE-attributed patients, officials expect they are likely integrating the screening into their workflows and administering it to all of their patients. This has proven to be the case with other well-child practices. For example, the AE Coastal Medical, has implemented universal screenings across all of its practices to assess and identify needs around depression, anxiety, and SDOH.

Screening is only the first step in improving health-related social needs for children and families. One of the goals of the AE program is to use screening results and the improved understanding of its members’ circumstances to improve their overall health. Rhode Island is leveraging its Quality Report System (QRS), a tool for data collection, to calculate performance on the quality measure. This tool enables providers to drill down to the patient level to identify patients still in need of screening.

An upcoming strategy to help AEs coordinate better with community partners is the procurement of a community referral system that would help connect individuals to necessary resources. Such a referral network could be linked with the QRS in the future, making data collection, analysis, and referral a centralized process. Ultimately, this initiative may drive a broader conversation about how the state collects screening data across both public and private payers, and how this data can be used to improve the health outcomes of Rhode Island residents.

Nine States Advance Prescription Drug Affordability Board Legislation

March 15, 2021/in Prescription Drug Pricing Arizona, Colorado, Minnesota, New Jersey, New Mexico, Oregon, Rhode Island, Virginia, Wisconsin Blogs, Featured News Home Model Legislation, Newly-Enacted Laws, Prescription Drug Pricing, State Rx Legislative Action /by Jennifer Reck and Trish Riley

More than 200 bills to lower drug prices have been filed across states during this session and nine states are proposing prescription drug affordability board (PDAB) legislation.

PDABs are somewhat analogous to public utility commissions. They investigate high-priced drugs and, when necessary, set more affordable rates for certain drugs for purchasers within a state. Establishing health care provider and hospital payment rates is a common approach states use to ensure services are affordable. State PDABs extend this strategy to a subset of very costly prescription drugs, while avoiding unlawful patent preemption because they establish drug payment rates – not prices. The National Academy for State Health Policy (NASHP) developed model legislation for this approach in 2017 and in 2019 Maryland became the first state in the nation to enact PDAB legislation.

This chart highlights nine states’ bills to create prescription drug affordability boards, including their implementation timelines, funding sources, enforcement, and purchasers impacted.

Nine states (AZ, CO, MN, NJ, NM, OR, RI, VA, and WI) are currently advancing PDAB bills in their legislatures. While a number of these bills are similar to Maryland’s approach that phases in upper payment limits by initially limiting them to public purchasers before potentially expanding them to include private purchasers, the majority of the currently proposed bills map more closely to NASHP’s original model legislation, which implements payment limits across all payers (public and private) in a state in a more expedited fashion.

The bills are generally similar in two approaches:

They use similar price thresholds to identify a drug for investigation by their PDABs, and
They apply the same factors when setting an upper payment limit for drugs found to be otherwise unaffordable – such as weighing the cost of administering the drug and delivering the drug to consumers.

Minnesota’s bill, however, includes unique language that empowers its PDAB to consider both the “the range of prices at which [a] drug is sold in the United States and the range at which pharmacies are reimbursed [for it] in Canada.” This language creates a bridge between the PDAB model and a newer approach in a recently released NASHP model law that creates payment rates for certain high-priced drugs based on Canadian pricing. This approach, reflected in NASHP’s Act to Reduce Prescription Drug Costs Using International Pricing, offers states a more streamlined approach than establishing a PDAB, which requires the complex task of determining the appropriate value of a drug in order to set an affordable payment rate. Five states (HI, ME, OK, ND, and RI) are currently considering international reference rate bills that use (or “reference”) Canadian prices to set more affordable rates.

As states consider PDABs and international reference rate approaches to achieve the goal of setting more affordable payment rates for drugs, there are several key factors to consider.

While international reference rates look to Canada’s drug prices when establishing appropriate payment rates, PDABs keep the task of identifying affordable rates within a state.
While PDABs may be conceptually preferable for this reason, the time and resources required to implement this approach may not make PDABs feasible for all states. For those states, using Canadian prices to set rates may be the most viable option.

Minnesota’s bill, however, points to a third option, a hybrid approach in which a PDAB would consider Canadian pricing as part of its process.

Explore this chart to compare the different state approaches and implementation timelines of the nine PDAB bills proposed as of March 9, 2021.

Federal and State Special Enrollment Periods Increase Access to Insurance Coverage

February 1, 2021/in Policy California, Colorado, Connecticut, District Of Columbia, Idaho, Maryland, Massachusetts, Minnesota, Nevada, New Jersey, New York, Pennsylvania, Rhode Island, Vermont, Washington Blogs, Featured News Home Eligibility and Enrollment, Health Coverage and Access, State Insurance Marketplaces /by Christina Cousart

Five Trailblazing States Consider Legislation to Capture Big Rx Savings Using Canadian Reference Rates

February 1, 2021/in Prescription Drug Pricing Hawaii, Maine, North Dakota, Oklahoma, Rhode Island Blogs, Featured News Home Model Legislation, Prescription Drug Pricing, State Rx Legislative Action /by Jennifer Reck and Trish Riley

Burdened by high US drug prices that average 218 percent more than in Canada, innovative states across the country are exploring a range of approaches to give their residents the same access to affordable drugs Canadians have. To date, six leading states have passed laws that enable them to import drugs from Canada pending federal approval of their programs. Now, a second set of trailblazing states are exploring an alternative approach that does not require federal approval – importing Canadian drug prices.

Lawmakers in five states (HI, ME, OK, ND, and RI) have introduced or pre-filed bills based on the National Academy for State Health Policy’s (NASHP) model legislation to establish international reference rates using Canadian pricing.

Establishing payment rates for hospitals’ and providers’ services is common to ensure access to affordable care. The NASHP model extends that practice to prescription drugs, giving states a powerful tool to limit what payers within a state will pay, without running afoul of patent law by setting prices.

What is international reference rate legislation?

International reference rate legislation authorizes a state’s department of insurance to establish international reference rates for the costliest drugs in that state. The department determines the reference rates based on those drugs’ prices in Canada’s four largest provinces. The lowest price would become the legal upper payment limit for those drugs for participating purchasers in the state.

A savings analysis NASHP facilitated for one state considering this legislative approach, showed annual savings of more than $32 million for just 35 drugs purchased by state employees alone. States are proposing setting reference rates for up to 250 drugs for all commercial payers, including Medicare advantage plans (Medicaid and traditional Medicare would be excluded), so total savings would far exceed that initial estimate.

Under the model legislation, any savings generated must be shared with consumers through mechanisms left to the discretion of a state. Options may vary by payer, ranging from reducing premiums for commercial payers, maintaining or expanding access to Medicaid services, and avoiding tax increases for public payers.

Oklahoma state Sen. Greg McCortney identified the potential for savings as key. “I do not believe that we can fix our broken health care system until we address the cost of care,” he said. “This bill, once fully implemented, should reduce insurance premiums for every person in the state by hundreds of dollars each year.”

The model law’s implementation process is designed to be easy for a state to administer and does not require costly infrastructure at a time when states are burdened by the pandemic and budgetary restraints. As a proxy for all commercial payers, the bill uses a state’s employee health plan to identify the costliest 250 drugs, determined by drug price times utilization.

The state employee health plan shares the list of 250 drugs with the Department of Insurance.
The department then establishes references rates by comparing publicly available data on drug prices in Canada’s four most populous provinces. The lowest price becomes the reference rate for payers within the state.
No commercial payer could pay more than the reference price established by the state’s department of insurance, and a manufacturer that withdrew a drug or refused to negotiate in good faith would be subject to significant penalties.

As states move forward in their legislative sessions, states are adapting NASHP’s reference rate model and making it their own. They’re exploring variations in the roles their agencies would play, as well as possibly limiting the number of referenced drugs to a smaller group that would have maximum impact.

Insurance Rate Review as a Hospital Cost Containment Tool: Rhode Island’s Experience

February 1, 2021/in Policy Rhode Island Blogs, Featured News Home Consumer Affordability, Health System Costs, Hospital/Health System Oversight, Making the Case for Action /by Johanna Butler

For more than a decade, Rhode Island has used a unique insurance rate review approach to keep hospital costs from rising any more than inflation plus 1 percent. As states confront COVID-19 and its accompanying budget crisis, Rhode Island’s approach that allows regulators to oversee hospital costs and requires insurers to invest in the state’s health priorities offers a new model for curbing health care costs.

From Medicare reference-based pricing to cost-growth benchmarks, states are exploring a number of innovative approaches to stabilize health care costs. Hospital costs are a particularly significant driver of insurance premiums rates. As health care consolidation increases, costs rise and insurers may be less likely to exert negotiating power to lower those costs.

As states renew their focus on health care costs, Rhode Island’s affordability standards, which require the inflation plus 1 percent cap in insurers’ negotiated prices with hospitals in order to have their premium rates approved, offers an avenue for health care cost controls. While the degree of regulatory oversight over insurance markets varies across the country, many states may be able to replicate Rhode Island’s approach.

Background on Insurance Rate Review

The insurance rate review regulatory tool gives state insurance departments the authority to examine proposed premium increases charged by health insurance companies that offer plans in a state. Rate review is used both to assure the financial viability of insurers and to ensure that companies have a legitimate reason to raise costs.

While rate review was ongoing on the state-level before the Affordable Care Act (ACA) was enacted, the ACA created a floor for review of “unreasonable” increases or a 10 percent increase in the individual or small-group market. The federal government defers to state review of premium rate changes unless a state doesn’t have an “effective” program, defined by the Centers for Medicaid & Medicare Services’ Center for Consumer Information and Insurance Oversight. Currently only three states (Oklahoma, Texas, and Wyoming) defer to the federal government for rate review. The ACA also added in the medical loss ratio (MLR) requirement, which limits the amount of premium dollars that insurers can spend on administration, marketing, and profits. The ACA requires most individual and small-group market insurers to spend 80 percent of premium income on health care claims and limits other expenses to the remaining 20 percent of premium income.

Rhode Island’s affordability standards successfully curbed hospital costs by:

• Limiting contracted hospital prices from rising any more than inflation plus 1 percent;

• Reducing quarterly per enrollee spending by an average $55 from 2010 to 2016; and

• Lowering patient-cost sharing while not impacting quality metrics or utilization.

The scope of rate review varies across states – some states only have authority over individual and small-group markets while others also have authority over the fully insured, large-group markets as well. Some states have “prior approval” authority, which allows them to reject, approve, or reduce proposed premium rates, while others have “file-and-use” oversight, which gives officials the authority to review, but not reject proposed increases. Whether states have prior approval or file-and-use authority can also vary based on the market – states typically have less oversight over the fully insured, large-group market than the individual and small-group market.

In 2015, Health Affairs reported that adjusted premiums in the individual market were lower in states that had “prior approval” authority along with MLR requirements from 2010 to 2013. While more stringent rate review is shown to keep premiums lower, some states have expanded the scope of their rate review processes to tackle issues of accessibility and affordability. Since 2010, Rhode Island has been using its unique regulatory structure with the Office of the Health Insurance Commissioner (OHIC) to better control rising hospital costs through insurance rate review.

Rate Review as a Cost Containment Tool

In 2004, Rhode Island enacted a law that split the Office of the Health Insurance Commissioner (OHIC) from the rest of its insurance department in order to better understand and oversee the relationship between insurers and providers. In Rhode Island, the health insurance commissioner has oversight over the individual market, the small-group market, and fully insured, large-group markets. Although the ACA required the OHIC to complete a more comprehensive review of consumer protections in the individual and small-group markets, the OHIC has the authority to review and approve rates for all three markets – including for fully insured, large-group plans.

The legislature also charged the newly created health insurance commissioner with promoting greater accessibility, quality, and affordability in the health insurance market – a unique charge compared to other states – that ultimately led insurance regulators to oversee negotiated rates between insurers and hospitals. The OHIC’s work to oversee hospital costs largely relies on a “public interest” criterion in the state’s insurance statutes. The rate review statute requires proposed rates to be, “consistent with the proper conduct of its business and with the interest of the public,” and the public has an interest in affordability. The 2004 statute also created the Health Insurance Advisory Council, which was responsible for making recommendations on a number of issues, including requiring that the market for small businesses be affordable and fair.

The council led efforts to better understand health care cost drivers in Rhode Island and found that hospitals were a main “pain point” for affordability. Insurers argued they did not have the leverage to negotiate lower rates in contracts with providers. In 2009, the council reviewed the state’s options to address these cost drivers and eventually developed the Affordability Standards and Priorities for Rhode Island Commercial Health Insurers, which emphasized the need for reduced insurance costs, and by extension, reduced hospital costs. In 2010, the insurance commissioner documented significant variances between the rates of payment for inpatient costs across health systems in Rhode Island, prompting additional questions about the contracted rates between insurers and providers. This finding, combined with a lack of insurer-motivated payment reforms, spurred the commissioner to adopt a set of four “affordability standards” for insurance rate review.

Rhode Island’s Affordability Standards

With the adoption of the affordability standards, the commissioner directed insurers to comply with four new criteria in order to have their premium rates approved:

Expanding and improving primary care infrastructure;
Spreading the adoption of the patient-centered medical home model;
Supporting CurrentCare, the state’s health information exchange; and
Working toward comprehensive payment reform across the delivery system.

The primary care criteria required insurers to increase their share of medical spending on primary care by 1 percent from 2010 to 2014, while not increasing consumer premiums. The additional investments also couldn’t lead to increased overall medical expenses – and instead were intended to reflect a shift to new payment strategies. Beyond primary care, the standards required insurers to provide financial support for the Rhode Island Chronic Care Sustainability Initiative, the all-payer, patient-centered medical home pilot project, and CurrentCare, the state’s health information exchange

As far as cost containment, the most striking change to Rhode Island’s rate review process was the implementation of the fourth standard – comprehensive payment reform. In order to set measurable goals to hold insurers accountable for this, the commissioner put six conditions into place that insurers had to adopt in their hospital contracts. The conditions included:

1. Paying for inpatient and outpatient services using “units of service” that encourage efficient resource use.
2. Limiting the average annual effective rates of price increase for both inpatient and outpatient services to a weighted amount equal to or less than Centers for Medicare & Medicaid Services’ National Prospective Payment System Hospital Input Price Index (“IPPS”) plus 1 percent for all contractual years.
3. Giving hospitals an opportunity to increase total annual revenue based on meeting mutually agreed upon quality goals.
4. Including contract terms to meet agreed upon obligations for administrative simplification.
5. Including contract terms that promote and measure improved care coordination.
6. Including transparency for these six terms in contracts.

The #2 condition, requiring insurers to limit the average price increases for hospital services, was groundbreaking in its impact on the contractually agreed-upon prices paid by insurers to providers. In addition to tagging rate increases to IPPS, the affordability standards also required that at least 50 percent of the annual hospital rate increases be earned through the agreed-upon quality measures. These hospital contracting provisions were an early and still innovative approach to regulating hospital costs.

Impact of Affordability Standards

A 2019 Health Affairs review found that implementation of Rhode Island’s affordability standards led to a net reduction in per enrollee spending by a mean of $55 from 2010 to 2016. The study showed that outpatient and inpatient utilization did not significantly change, but spending per encounter decreased in Rhode Island compared to a control group. Quarterly fee-for-service spending actually decreased by $76 per enrollee, but the requirement to increase non-fee-for-service primary care spending raised per enrollee spending by $21, netting out to a quarterly savings per enrollee of $55. In addition, patient cost sharing was lower in Rhode Island after the affordability standards were implemented compared to a control group.

Quality metrics did not change with implementation of the standards. In fact, interviews conducted for a 2013 review of the standards found that the “at-least-50-percent” provision for hospital contracting caused a “culture shift” among hospitals by focusing their attention to meeting quality measures.

The one challenge in understanding the impacts of Rhode Island’s affordability standards is that it is impossible to totally untie the provisions around hospital contracting from the primary care investments, making it somewhat difficult to know how a state might fare if it only enacted standards around payment reform without the primary care investment.

Since implementation in 2010, Rhode Island has updated its affordability standards over time to align with other goals, such as further promoting the patient-centered medical home model and alternative payment methods that emphasize value rather than volume. The most recent affordability standards, adopted in 2016, require insurers to spend at least 10.7 percent of their annual medical spend on primary care. Among other requirements, the standards also maintain the hospital contracting provisions. The standards require insurers to limit hospital rate increases so that the average rate increase is no greater than the Urban Consumer Price Index (CPI) (less food and energy) percentage increase plus 1 percent.

Future of Rate Review as a Cost Containment Tool

Rate review is a promising tool for cost containment. As evidence shows it can keep premiums low but can also be used to impact payer-provider negotiations as in Rhode Island. Placing responsibility for hospital cost containment alongside insurance rate review not only allows for coordinated reform across insurers, but also gives an insurance department, like OHIC, insight into where unintended consequences might occur or other costs might pop up as the state works to control other health care cost drivers.

States have begun to mirror Rhode Island’s affordability standards in their insurance rate review process to advance health policy goals. In 2019, Colorado enacted HB 19-1233, which established a Primary Care Reform Payment Collaborative that, among other things, was tasked with creating an affordability standard to require additional investment by insurers in primary care.

The collaborative recommended that commercial payers be required to increase the percentage of total medical expenditures (excluding pharmacy) spent on primary care by at least one percentage point annually through 2022. The collaborative said the Insurance Commissioner will have to address the risk of costs being passed on to consumers when the affordability standards are promulgated. This standard is similar to Rhode Island’s work to invest in its primary care infrastructure. Importantly, the Colorado collaborative noted in its recommendations that the Insurance Commissioner must include this new affordability standard alongside an effort to reduce overall health care spending. Otherwise, health care costs could rise in the state.

Similarly, Delaware enacted SB 116 in 2019 to create an Office of Value-Based Health Care Delivery within its Department of Insurance. The office’s goal is to reduce health care costs by providing high quality, cost-efficient health insurance products with stable, predictable, and affordable rates. To achieve this mandate, the new Delaware office has been working alongside the Delaware Primary Care Reform Collaborative to develop affordability standards and targets for primary care spending for carriers. In November 2020, the office presented draft affordability standards that would set targets for primary care investment, unit price growth for non-professional services, and the adoption of alternative payment models. Modeling Rhode Island’s work, the targets for primary care investment and capping unit price growth would be enforced through insurance rate review. The draft standards recommend using a phased approach to cap unit price growth beginning in 2022 and would decrease over time, eventually reaching Rhode Island’s cap of CPI plus one percent by 2025. According to a timeline in its November presentation, the office plans to publish the draft standards and accept public comments in February 2021.

With the implementation of Rhode Island’s affordability standards, the state was able to successfully cap growth in hospital costs and thereby constrain premium growth. Rhode Island’s use of rate review to control hospital costs can be a model for other states interested in curbing health care costs. The National Academy for State Health Policy will continue to track state efforts to implement affordability standards and will convene states interested in exploring this policy.

Three States’ Strategies to Improve Behavioral Health Services Delivery through Medicaid Accountable Care Programs

October 26, 2020/in Policy Colorado, Minnesota, Rhode Island Featured News Home, Reports Accountable Health, Care Coordination, CHIP, Chronic and Complex Populations, Cost, Payment, and Delivery Reform, Health Equity, Integrated Care for Children, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Physical and Behavioral Health Integration, Population Health, Quality and Measurement, Quality and Measurement /by Neva Kaye

In recent years, Colorado, Minnesota, and Rhode Island began using accountable care programs to improve delivery of behavioral health services. Already, the programs have produced improvements – Colorado reports an increase in the percentage of Medicaid enrollees receiving behavioral health services and Minnesota’s accountable care organization (ACO) providers have performed better than other clinics in screening adolescents for mental health issues. This report examines these states’ policies and experiences in using accountable care programs to improve delivery of behavioral health care.

Background

Medicaid is the largest payer of behavioral health care (mental health and substance use disorder) in the United States.[1] In addition, studies show that behavioral health conditions contribute to a greater cost to treat than other medical conditions.[2] There are great disparities in health outcomes for people with behavioral health diagnoses,[3] individuals with behavioral health conditions are sicker and die younger than those without such conditions. As states grapple with unprecedented budget crises and increased demand for behavioral health services due to the COVID-19 pandemic, there are incentives for them to change how behavioral health care is delivered.

In an accountable care program, groups of providers (called ACOs) share responsibility for the quality of care, health outcomes, and costs for a defined population. These programs emphasize primary care, care coordination and integration, and value-based payment. Payment depends on the ACO’s performance on defined metrics.

There is broad recognition that integrating behavioral and physical health care, and identifying and treating behavioral health conditions early can lead to improved outcomes.[4] States also face severe behavioral health workforce shortages, especially in lower-income areas — where many of those served by the Medicaid program live.[5]

As a result, states have for many years sought to reform their delivery systems to improve identification and treatment of behavioral health conditions, better integrate behavioral and physical health, and increase Medicaid enrollees’ access to behavioral health care. Many of these previous efforts were based in managed care or on a patient-centered medical home (PCMH) model.

A decade ago, state Medicaid agencies began to implement accountable care programs. In early 2020, the National Academy for State Health Policy identified eight states that had begun to use their accountable care programs to improve their delivery of behavioral health care: Colorado, Maine, Massachusetts, Minnesota, New Jersey, Oregon, Rhode Island, and Vermont. The ACOs participating in these programs focus on coordination and integration of care and provide an infrastructure to improve behavioral health services that, due to their focus on primary care, may prove particularly useful for advancing behavioral health integration.

The pandemic is already causing some states to delay delivery system reforms. However, over the longer term, the pandemic may cause more states to turn to accountable care to help them manage behavioral health services. In recent months, state Medicaid officials have had to focus their attention on ensuring that Medicaid enrollees receive the care they need, leaving little time to develop new reforms. Large state budget shortfalls are also projected,[6] which are likely to lead states to implement cost containment strategies. States may turn to accountable care programs, which hold ACOs and their affiliated providers accountable for cost, quality, and health outcomes, as a way to provide quality services while containing cost. The pandemic is also likely to create increased need for behavioral health services.[7] According to a July 2020 Kaiser Family Foundation poll, more than half of the adults reported that “stress and worry related to the pandemic has had a negative impact on their mental health.”[8] State Medicaid agencies may, ultimately, turn to accountable care to address the combined effect of decreased state funding and increased need for behavioral health services.

This report outlines the program policies, implementation experience, and lessons learned in three states that have all used accountable care to improve behavioral health care and contain cost.

How Colorado, Minnesota, and Rhode Island Structure their Programs

The three states structured their accountable care programs in different ways.

Colorado’s Regional Accountable Entities

This report uses “ACO” when describing more than one state’s accountable care organization, as each state has a unique name for its ACO.

Colorado contracts with regional accountable entities (RAEs);
Minnesota contracts with Integrated Health Partnerships (IHPs); and
Rhode Island certifies accountable entities (AEs).

Colorado began its accountable care program in 2011, but the state did not emphasize behavioral health care in the program until it launched the second phase in July 2018. At that point, Colorado folded its specialized managed care program for behavioral health services into its accountable care program. Since 2018, Colorado has contracted directly with seven regional accountable entities (RAEs). Colorado assigns almost all Medicaid enrollees to a RAE (representing about 97 percent of Colorado’s 1.3 million Medicaid enrollees in July 2020).[9] RAEs support a local network of primary care medical providers (PCMPs), deliver behavioral health services, coordinate members’ care across systems, and are accountable for the cost and quality of care delivered to Medicaid members.

RAEs are paid through a combination of per member per month (PMPM) administrative payments, capitation, and incentive payments. RAEs receive $15.50 PMPM as an administrative payment. The Medicaid agency withholds $4 of each $15.50 to fund the Key Performance Indicator (KPI) payments. The Medicaid agency assigns each of seven KPI metrics a specific PMPM amount, and if a RAE produces sufficient improvement on the measure, it receives a payment based on the PMPM amount assigned to the measure. KPI payments are calculated and distributed each quarter. Unearned incentive payments are used to fund a challenge pool that is distributed based on performance in pursuing specified state policy priorities (e.g., collaboration with institutes of mental diseases or achieving progress on other performance metrics. RAEs also receive capitation payments for behavioral health services and are eligible to receive incentives tied to performance on a set of behavioral health measures. These payments are referred to as behavioral health incentive payments.

Both PCMPs and behavioral health providers must contract with a RAE in order to serve Medicaid enrollees. PCMPs receive fee-for-service payments from the Medicaid agency and administrative and incentive payments from the RAEs. Behavioral health providers contract with the RAEs and receive all payments directly from their RAE.

Minnesota’s Integrated Health Partnerships

Minnesota began its accountable care program in 2013. The state considered behavioral health when designing the initial phase of its program, but strengthened its behavioral health focus in Phase 2 of the program (IHP 2.0), which launched in January 2018. As of June 2020, Minnesota Medicaid contracts with 26 Integrated Health Partnerships (IHPs) that, together, serve 430,000 Medicaid and MinnesotaCare (Minnesota’s basic health plan) enrollees. IHPs are provider organizations. They and their associated providers receive payment for services from either the MCOs or the Medicaid fee-for-service system.

In addition, IHPs are paid through one of two payment models.

Track 1 is intended for small, independent provider systems, specialty health care groups that coordinate care for specific groups of individuals, or a specific major portion of services (including primary care), or other systems unable to take on financial risk.
Track 2 is only open to IHPs that serve more than 2,000 members and that are able to take on upside and downside risk (i.e., share in both savings and losses).

All IHPs (both tracks) receive a clinical and social risk-adjusted monthly population-based payment. In exchange, all IHPs must develop and implement specific health initiatives that address certain social risk factors that their patient populations are facing and achieve satisfactory performance on a set of quality and performance measures in order to continue to participate in the program. Both the initiative itself and the measures are negotiated between the individual IHP and the Medicaid agency. IHPs that participate under Track 2 also share in both savings and losses.

Savings and losses are calculated by comparing the actual total cost of care (TCOC) of the members attributed to the IHP with the members’ projected TCOC absent the IHP. If actual TCOC is less than projected, the difference is savings; if actual is more than projected, the difference is a loss. TCOC is defined to include the cost of providing most services. (See page 54 of Minnesota’s Integrated Health Partnerships Contract for a list of included services.)

The calculation of the amount of savings to be paid to the IHP or the amount of loss to be paid to the agency is based on multiple factors. First, the IHP is only eligible to share in any amount of savings or losses that fall within a negotiated risk corridor (e.g., 6 percent). All profit or loss outside the corridor belongs solely to the agency. The exact share of the amount within the risk corridor (e.g., the available savings) each IHP receives depends on two factors — the savings split it has negotiated with the agency and its performance in three domains (care quality, health information exchange, and alerting exchange).

But the share of losses depends only on the losses split negotiated with the agency and not its performance. The standard split is 50/50, meaning that IHPs can earn up to 50 percent of available savings and will pay 50 percent of available losses. But an IHP can secure a different split by entering into an accountable partnership with a community partner (e.g., a community mental health center [CMHC]) and negotiating a different split with the Medicaid agency — typically IHPs with an accountable partnership agree to take up to 70 percent of the available savings and pay 35 percent of available losses.

Rhode Island’s Accountable Entities

Rhode Island Medicaid began piloting its accountable care program in 2016 and launched its full program in July 2018 when it certified six comprehensive accountable entities (AEs). The Medicaid agency does not contract directly with its certified AEs. Instead, it requires Medicaid MCOs to contract with the AEs (and AEs to contract with MCOs). Each AE and MCO negotiate their own payment models within parameters set by the state. State officials shared that they have become more prescriptive on payment model as their and other stakeholders’ experience has grown and as the number of AEs (and thus the number of contracts that must be negotiated between MCOs and AEs and overseen by the state) grows. Both MCOs and AEs agreed on the need for increased standardization. Currently, all payment models must be based in TCOC calculated according to state requirements and MCOs must share up to 50 percent of any savings with AEs. AEs may accept shared losses if the Office of the Health Insurance Commissioner, which licenses commercial health plans, has determined that the AE is qualified to accept that risk. The amount of savings awarded to an AE must depend on the AE’s performance on at least three measures selected from a common measure set. State payment model parameters also govern how people are attributed to AEs.

In 2016, the Centers for Medicare & Medicaid (CMS) authorized the creation of AEs through approval of an amendment to Rhode Island’s Section 1115 Comprehensive Demonstration waiver. This amendment also authorized the state to create the Medicaid Infrastructure Incentive Program (MIIP) as a Designated State Health Program (DSHP). This designation, which CMS stopped awarding in 2017, authorized the state to receive, over the five-year period of November 2016 to December 2020, up to $129.8 million in federal funding to match state expenditures to support AE infrastructure development. In program Year 3, MCOs may earn up to $1.60 PMPM for each member attributed to a qualified AE. AEs may earn up to $8.44 PMPM by developing and completing projects that support the state’s goals, including those related to behavioral health. Actual payment is based on the achievement of performance milestones, most of which are negotiated between each AE and MCO, subject to state approval.[10]

Why States Included Behavioral Health in Accountable Care

“[In Rhode Island] managed care needed to evolve to be responsible for the needs of individuals with chronic conditions and needs. This pushed managed care to be more holistic across the board.”

Colorado, Minnesota, and Rhode Island chose to include behavioral health in their accountable care programs in order to improve chronic care, increase behavioral health integration, and produce cost savings. Officials from both Colorado and Rhode Island reported that that their new accountable care programs built on their previous efforts to strengthen primary care and better integrate behavioral health into primary care. Rhode Island officials explained that the primary care-centered approach worked well for individuals with moderate or low behavioral health needs, but the “needs of the other end of continuum also need to be considered.” Rhode Island believed that the structure of the accountable care program gave the CMHCs, which can better serve high need individuals, more opportunity to leverage their skills and strengths to be a resource for primary care. Eventually, this state would like to bring primary care to CMHCs in at least some of their AEs.

“Due to high spending for behavioral health on high utilizers, there is value in homing in on integrating physical and behavioral health from a savings perspective.” – Colorado official

Both Colorado and Rhode Island emphasize that behavioral health providers are well-positioned to engage patients with complex needs. Colorado officials also believe that RAEs’ structure, which makes them responsible for both primary and behavioral health care, would increase integration between the two types of services. Officials stated that the care coordination provided by CMHCs under its managed behavioral health program was strong. But they believed that folding the behavioral health program (and CMHCs) into their accountable care program fostered whole person care coordination for those with complex needs. They believed that increased integration and more holistic care coordination would lead to less fragmentation of care, create economies of scale, and, in turn, produce cost savings.

Colorado had also hoped that the RAEs would increase access to behavioral health services. This state has seen an increase in the proportion of Medicaid enrollees who receive one or more behavioral health services, and stakeholders are reporting that access and choice are both stronger.

How States Improve Behavioral Health through Accountable Care

All three states through their ACO contracts (Colorado and Minnesota) or certification standards (Rhode Island), consider performance on behavioral health measures in ACO payments. All three states also considered behavioral health in the performance requirements they created for their ACOs regarding network adequacy, care coordination and integration, and health information technology (HIT) supports. One or more of these states also called out behavioral health in the requirements they established in many other areas of performance.

Attribution

Attribution is the process used to identify the members of the defined population for which the ACO is accountable. All attribution processes consider where the patient has obtained care in the past. All three states featured in this brief first attribute Medicaid enrollees to a primary care provider (PCP) or a subset of PCPs who have met state-established qualifications. These states then consider each ACO to be “accountable” for the enrollees attributed to the providers affiliated with the ACO. All three states attribute enrollees with behavioral health conditions to a primary care provider, but only Minnesota currently considers behavioral health in that process. The first step of Minnesota’s process is to attribute Medicaid enrollees who have received services from a behavioral health home (or health care home) to the IHP with which that provider is affiliated.

Rhode Island had implemented a similar policy at program launch but now considers only primary care in attribution. Officials reported that they made this change because they determined that including attribution to an Integrated Health Home as the first step was difficult and time consuming. This, along with member churn impacted the state’s ability to confidently collect performance data. Additionally, Rhode Island found that many of the people served by integrated health homes were engaged in primary care with a separate provider.

Payment Models

As previously described, Colorado, Minnesota, and Rhode Island have each created a unique payment model for their ACOs. All three states, however, consider behavioral health performance in ACO payments and have established policies that foster consideration of behavioral health performance in payments to individual providers.

ACO Payment

Payment is considered to be the driving force to ensure ACO accountability for performance. All three states have tied ACO payment to behavioral health performance. Colorado’s RAEs may earn two types of incentive payments for performance. A RAE may earn incentives of up to $4 PMPM in key performance indicator (KPI) payments, which are primarily tied to the performance of the PCMP network. The RAE may also earn up to 5 percent of its behavioral health capitation rate (about $30 million) in behavioral health incentive (BHI) payments, which are primarily tied to the performance of the behavioral health network.

In both Minnesota and Rhode Island, ACOs may earn a share of the savings they produce — and are sometimes required to also share in any losses. Both of these states calculate savings and losses using a TCOC methodology. Both also include behavioral health services in the TCOC calculation, and Minnesota considers behavioral health services when calculating the monthly population-based payment that each of its IHPs also receives.

Regardless of their specific ACO payment model, all three states tie ACO payment to performance on a set of metrics that includes behavioral health measures, along with measures of other types of performance. In Colorado, performance on the metrics governs the amount of the incentives the RAEs earn. In Minnesota, performance on the metrics governs whether Track 1 IHPs may continue to participate in the program and whether Track 2 IHPs earn the full portion of their contracted share of any savings they produce. In Rhode Island, performance on the metrics governs what portion of savings are paid to the AE and how much the MCO may retain (and for those AEs that have been approved to accept downside risk, what portion of the losses they are required to pay to the MCO).

“Measures [in Rhode Island] were shaped by high-level goals of the organization and we wanted to make sure that there are mechanisms for balanced, useful data.”

There is little commonality between the behavioral health measures these states chose to factor into payment (Table 1). Only one measure is used by all three states – follow-up appointments within X days after an inpatient hospital discharge for a mental health condition, although even on this measure, states have made different choices as to when to specify seven-day follow-up and when to specify 30-day follow-up. Although there was little commonality between the specific measures used, there was some commonality regarding the domains to be measured. All three states included measures of engagement and follow-up.

When asked why they chose their specific measures, state interviewees uniformly reported that the choices were based on their goals for the program and stakeholder input. They also reported that the choices were informed by previous efforts.

Rhode Island, for example, drew its measures from a common measure set created as part of the state’s State Innovation Model (SIM) initiative.
Colorado emphasized that it considered areas that it knew had “room for improvement” and used measurement to create incentives for the RAEs to change that part of the system. For example, the state tied payment to “follow-up after a positive depression screen” in order to incent behavioral health and primary care integration. Further, Colorado sought to align its behavioral health (BHI) and primary care (KPI) payments to incentivize the same behavior across the program. As one official explained, “behavioral health is not in a silo, and requires the engagement of physical health as well.”
Finally, this measure set is not static, Minnesota, for example, is currently phasing out its medication measures.

Table 1: Behavioral Health Measures that Factor into ACO Payments

	Colorado	Minnesota	Rhode Island
Screening and Assessment
Screening for depression and follow-up plan		Some IHPs^*	Optional
Behavioral health screening or assessment for children in the foster care system	BHI
Developmental screening in first three years of life			Optional
Engagement and Follow-up
Initiation and engagement of alcohol and other drug abuse or dependence (AOD) treatment		Required
Engagement in outpatient substance use disorder (SUD) treatment	BHI
Behavioral health engagement: Percentage of members who received a behavioral health service delivered either in primary care settings or under the capitated behavioral health benefit within a 12-month evaluation period	KPI
Follow-up appointment within 7 or 30 days After an inpatient hospital discharge for a mental health condition	BHI; 7-day	Track 1: 7- or 30-day Track 2: 30-day	Required, opt for 7- or 30-day
Follow-up appointment within 7 days after an emergency department (ED) visit for a substance use disorder	BHI
Follow-up after a positive depression screen	BHI	Some IHPs^*
Medication
Antidepressant medication management: acute and continuous		Required
Adherence to antipsychotics for individuals with schizophrenia		Required

Acronyms: BHI=behavioral health incentive payment; KPI=key performance indicator payment; IHP=Integrated Health Partnership.

^*The measure is used if it is appropriate to the topic of the health intervention that the IHP and Minnesota Medicaid jointly select.

Colorado’s RAEs have increased the percent of Medicaid enrollees who receive behavioral health care.

To date, only Colorado has published a summary of ACO performance on the measures that factor into incentive payments. This state has seen some positive results. On the primary care side, payment is tied to behavioral health engagement. During the first year of program operation, the RAEs produced almost a two-percentage point increase in this metric. On the behavioral health side, Colorado established incentives for performance on five measures.

During the program’s first year of operation:

All seven RAEs met performance improvement goals for engagement in outpatient SUD treatment and follow-up after a positive depression screening;
Five met the goal for behavioral health assessment for children in the foster care system; and
Four met the goals for follow-up from mental health inpatient stays and SUD emergency room visits.[11]

Although not yet complete, Rhode Island is conducting an evaluation of its program which, when complete, will shed more light on its program’s impact on behavioral health care.

Minnesota officials report that IHPs perform above average when compared to clinics and/or systems that are not IHPs, on many quality measures, including those related to diabetes, asthma, and vascular care. In terms of behavioral health metrics, IHPs perform better than non-IHPs on ensuring adolescents are screened for mental health issues. Additionally, those IHPs with health interventions with a behavioral health focus have seen some positive results, including high levels of relative improvement across years.

Payment to Individual Providers

Colorado and Rhode Island both sought to ensure that the individual providers, including behavioral health providers, affiliated with their ACOs would benefit from performance payments earned by the ACO. Colorado explicitly requires its RAEs to share any incentive payments the RAE receives with the providers who form the RAE’s health neighborhood, which consists of the providers (including behavioral health providers) and facilities that work with an individual’s PCMP to meet all of the person’s health needs. RAEs are also required to report all payment arrangements, including those with behavioral health providers to the Medicaid agency. Rhode Island does not require its AEs to share savings, but it does require the AEs to have documented relationships with behavioral health provider partners to meet their patients’ needs, and Rhode Island Medicaid envisions that some of those relationships will include shared savings. It also requires the AEs to share 10 percent of any incentive pool payments they receive with a partner organization, which may be a behavioral health provider.

Minnesota encourages its IHPs to implement accountable care partnerships by potentially rewarding the IHP with more favorable financial arrangements. For example, instead of receiving 50 percent of any savings, the IHP might receive 70 percent. An IHP can use this mechanism to also reduce the share of any losses that it must pay, and Medicaid officials report that it is this attribute that is often most attractive to the IHP. The financial arrangements are negotiated with each IHP. Minnesota offered an example of a potential partnership between an IHP and a CMHC. The CMHC agrees to provide behavioral health services to a targeted set of patients who screen positive for a behavioral health need. IHP-affiliated providers will screen patients, refer those who screen positive to the CMHC, and the CMHC will provide any needed services and ‘close the loop’ by providing information back to the referring provider. Minnesota Medicaid also negotiates the specific measures that will be used to judge the success of the partnership. In this case, that might include the number of patients that were screened for behavioral health needs divided by the total number of patients, or it could also include the total patients who received services divided by the total patients referred. Although there is no requirement that partners be paid, eligibility for a more favorable risk arrangement depends on several factors that encourage payment, including how well the partners are working together.

Finally, when it launched its accountable care program, Colorado Medicaid began directly paying PCMPs (i.e., primary care providers) for short-term behavioral health treatment (up to six visits) on a fee-for-service basis. Other behavioral health services are paid for by the RAEs. Colorado Medicaid had anticipated that this change would foster behavioral health integration and support then-existing partnerships between some federally qualified health centers (FQHCs) and CMHCs. As expected, this policy did improve access for patients with more mild behavioral health conditions. However, some FQHCs chose to withdraw from the partnerships and hire staff to provide the short-term services. Colorado Medicaid also found the policy more difficult to implement than anticipated, as the agency had to adjust the payments it made to the RAEs for behavioral health services to reflect that payment for some short-term services that would now be made by the agency.

ACO Performance Requirements

Colorado, Minnesota, and Rhode Island all complemented their payment reforms with performance requirements to help ensure that their ACOs were prepared to deliver accountable care and that savings would be produced by improving care rather than curtailing access. These three states all chose to address behavioral health in their ACO performance requirements governing provider network composition and access to services, care coordination, and health information technology.

Table 2: Performance Area Requirements

Performance Area	Colorado	Minnesota	Rhode Island
Network and access to services	√	√	√
Care coordination	√	√	√
Health information technology	√	√	√
Provider support	√		√
Quality	√		√

Network Composition and Access to Behavioral Health Services

All three states required their ACOs to include at least some behavioral health providers among their affiliated providers, although only two required contracts. Colorado required its RAEs to create a statewide behavioral health network and offer contracts to CMHCs and substance use disorder (SUD) clinics. Similarly, Minnesota’s IHPs must contract with CMHCs “to the extent possible,” and each AE in Rhode Island must demonstrate that they have sufficient partnerships with behavioral health providers to provide the population that the AE plans to serve with access to a range of treatment options that represent a continuum of care. Rhode Island officials reported that in the early years of their program, they required the AEs to partner with CMHCs. Now that many of the AE/CMHC partnerships are well-established, this performance standard has been broadened to count partnerships with all types of behavioral health providers, not just CMHCs. Rhode Island has broadened the requirement to include all behavioral health providers. These three states also established other performance expectations. For example, Rhode Island requires each AE to include a representative of a community-based behavioral health provider within its governance structure.

“Care coordination…with CMHCs was strong, but with the [primary care and behavioral health] combination there is more whole-person care coordination…”

Colorado officials reported that access to behavioral health services increased because those providers who had been delivering care through the specialty managed care program continued to deliver care as part of the RAEs’ networks, but the RAEs had expanded their independent provider network as well. Officials viewed this to be an overall positive outcome because both traditional providers (e.g., CMHCs) and independent providers who had not previously treated Medicaid enrollees were needed to meet the current Medicaid population’s full range of needs. However, some RAEs, especially those that hadn’t established some utilization review requirements, found that utilization of expensive services, such as inpatient services, increased. These RAEs are now working to ensure that the right utilization management is in place, and one aspect of that work is to assess whom the independent provider networks are serving and consider if that is the best place for those enrollees to receive care.

Care Coordination and Population Health Management

One of the hallmarks of accountable care is ensuring that patients’ needs are systematically identified and addressed, and that care is coordinated across systems and providers. All three states established policies for care coordination that addressed behavioral health issues.

Minnesota used its IHP selection process to establish the expectation that IHPs should screen patients for behavioral health and chemical dependency conditions and that care coordination should feature “integration of medical/behavioral-chemical/social service community care coordination and planning.”
Colorado’s contract with its RAEs defines care coordination to include coordination of behavioral health needs and then includes numerous requirements for care coordination. Because this state has also tasked its RAEs with delivering behavioral health care, it has created requirements for that system, including requiring RAEs to fund intensive case management from savings.
Rhode Island’s certification standards require AE’s to have policies and procedures in place that support integration of physical, behavioral, and social supports.

“The important piece is that the expansion of the independent provider network [in Colorado] reshaped the landscape of services being performed while CMHCs remained in the game…”

Colorado and Rhode Island also created requirements to ensure that behavioral health was addressed at the population level by requiring their ACOs to prepare population health plans that address behavioral health issues. Rhode Island also includes requirements designed to ensure that the plan guides each AE’s population health management activities, including behavioral health integration that considers risk factors for poor behavioral (as well as physical) health outcomes.

Health Information Technology (HIT)

Data is key to systematically identifying and managing a population’s health needs, identifying gaps in care, and measuring health outcomes. Colorado, Minnesota, and Rhode Island took slightly different approaches to ensuring that providers had, and could use, data to improve delivery of behavioral health services.

Minnesota provides clinical data, including behavioral health claims data, to IHPs on a monthly basis and requires IHPs to use the data to improve performance.
Colorado also provides claims data to the RAEs and, in addition, emphasizes the use of electronic care coordination and other analytic tools. This state required each RAE to have a care coordination tool to help PCMPs and other providers, including behavioral health providers, coordinate care — and also required that the tool had to support “HIPAA and 42 CFR Part 2 compliant data sharing.” RAEs were additionally required to have other data analytic tools and to support providers use of the tools.
Rhode Island established requirements for using analytic tools (decision-support tools) and is developing a dashboard for AEs that provides information about their performance on quality measures. In addition, this state requires AEs to include behavioral health provider contacts in patient registries.

Provider Support

“More [technical assistance] was needed in the beginning to help behavioral health providers understand workflow and [payment] models.”

Shifting to a new delivery and payment model can be difficult, even when providers voluntarily shift. Changing providers’ approaches to delivering care, including behavioral health care, to enable them to thrive under a new system can be particularly difficult. Colorado and Rhode Island both addressed these concerns in their accountable care programs but took very different approaches.

Colorado required its RAEs to provide the support. Each RAE was required to prepare and implement a provider support plan that addressed the RAE’s plan to help providers work toward behavioral health integration. Under these plans, RAEs offer providers access to care coordinators, practice transformation coaches, and ongoing training. They also offer in-person coaching and online support, including access to tools and resources for provider use.

Rhode Island’s MIIP, which is funded as a Designated State Health Program under the state’s 1115 waiver, paid for projects that support the providers associated with the AEs. Each AE develops projects to help build its capacity in specific areas, including some related to behavioral health, such as implementation of evidence-based behavioral health integration and consultation services.

Through this work, officials found that behavioral health providers, even more so than primary care providers, needed a better understanding of alternative payment methodologies (APMs) and how to manage their practices to thrive under these arrangements. Those that had not previously served Medicaid enrollees (e.g., independent behavioral health providers) had even greater technical assistance needs because they often also had to learn Medicaid policies and create new infrastructure. One state official noted the program would have benefited from a comprehensive assessment of providers’, including behavioral health providers, technical assistance needs well before program launch to identify and address critical gaps in provider understanding before they affected the program’s success.

Quality

One of the aims of accountable care programs is to hold providers accountable for the quality of care they deliver. Colorado and Rhode Island chose not only to hold their ACOs accountable by measuring the outcomes they produce on quality metrics, but also the process each ACO used to achieve quality. Rhode Island requires each AE to establish a quality committee to oversee the AE’s quality assurance and improvement program. This state requires that the committee membership include at least one licensed behavioral health clinician who is an AE participant.

Colorado’s requirements are based in Medicaid managed care requirements. Each RAE must conduct two performance improvement projects each year. One of these projects must address behavioral health, and RAEs may choose to dedicate both to improving integration of physical and behavioral health care. RAEs must also prepare quality plans that address behavioral health.

Lessons Learned and Conclusion

Officials from the three states advised those seeking to use ACOs to improve behavioral health services to seek and use stakeholder input, leverage infrastructure and relationships built during previous initiatives as well as the knowledge and experience of the providers currently serving Medicaid enrollees, and expect growing pains. In addition, an examination of these states’ experience finds three overarching takeaways.

States worked to strengthen the primary care system and integrate primary care and behavioral health before introducing accountability for behavioral health services. State officials in all three states used an iterative process to incorporate behavioral health services into their ACOs. Both Colorado and Minnesota waited to incorporate behavioral health until they had several years of experience operating their programs. Colorado officials stated that even when they were planning the first phase of their program, they knew that they ultimately wanted to include behavioral health. They did not do so at that time because they wanted to first focus on ensuring that the primary care aspects of their program were working well. They also knew that the shift to the new delivery system was going to require the reworking of a long-standing behavioral health services delivery structure and believed that making major simultaneous changes to both primary and behavioral health care would cause too much disruption. Rhode Island included behavioral health in its accountable care program from the beginning, but had a very strong, widespread patient centered medical home (PCMH) program in place prior to launching the accountable care program.

All three states had also previously worked to increase behavioral health integration. Rhode Island, for example, had funded an Integrated Behavioral Health Pilot (IBH) that supported primary care practices in incorporating co-located behavioral health clinicians into their operations. Minnesota had established a behavioral health home program to promote whole-person care. Colorado established learning collaboratives to help primary care and behavioral health providers develop the skills needed to support integration, such as creating a multidisciplinary team.

States adjusted program policies as their own and other stakeholders’ experience grew. Both Colorado and Rhode Island reported that they considered their programs to be iterative after launch. Rhode Island officials shared that, during the third year of the program, they began requiring MCOs to calculate shared savings in a specific way and allowed the AEs to earn up to 50 percent of the savings based on their performance. The Medicaid agency made this change due to feedback from both AE and MCOs about the difficulty of managing a growing number of contracts, each with potentially different financial arrangements. Increased standardization also eased the state’s oversight and monitoring. Rhode Island had anticipated that it would need to adjust its policies as its experience grew because the Medicaid agency was, as one official described, “Designing, building, and flying [the airplane] at the same time.”

A Colorado official similarly reported that, “Our program is iterative, and we continue to tweak and learn from it.” Recently, Colorado is encountering challenges related to COVID-19, including questions about how to integrate specialty providers and behavioral health.

States found that ACO leadership, like their associated providers, benefit from support. Officials recognized and planned for provider support, although some wished that they had offered more support. The states also knew that ACOs would need support in order to achieve success. They found that many ACO technical assistance needs were similar to those of providers. Some ACOs, like providers, needed a better understanding of the type of alternative payment models that could work for behavioral health providers. Rhode Island engaged a contractor to provide individual and group technical assistance to both MCOs and AEs — one focus of which was to support both as they entered into shared-risk contracts.

Colorado reported that some newer RAEs had moved back to fee-for-service reimbursement for behavioral health providers but were now working with CMHCs to develop more value-based payment arrangements. Also similar to providers, ACOs that had not previously served Medicaid enrollees had greater technical assistance needs. In Colorado, new RAEs were less familiar with Colorado Medicaid and its emphasis on community-based services. One official wished that the state had allowed sufficient time during implementation to support peer learning for new RAEs, perhaps through shadowing existing contractors, underscoring that education and collaboration were critical. Although Colorado found that new RAEs needed to improve their understanding of Medicaid policies, experienced RAEs needed to be “shaken up” to encourage continued engagement and innovation. Officials in this state worked to engage both newer and more experienced RAEs in peer learning. As one official stated, “When they [RAEs] first started, it was a competition. Now they meet and learn from each-other.”

Conclusion

In recent years, states have begun to use Medicaid accountable care programs to better integrate behavioral and physical health, improve identification and treatment of behavioral health conditions, and increase Medicaid enrollees’ access to behavioral health care. Examining the strategies and outcomes of three of these states offers others valuable information that they can apply to their own programs. All three states’ Medicaid agencies took different approaches to selecting and paying their ACOs, but all three based ACO payment in performance and established ACO performance standards — and considered behavioral health in both of these aspects of their programs. All interviewees reported that their programs were improving care but, to date, only Colorado has published a summary of ACO performance on the measures that factor into payment. This state has seen some positive results, including a modest increase by all RAEs in the percent of Medicaid enrollees receiving behavioral health services and follow-ups after a positive depression screening.

End Notes

[1] “Report to Congress on Medicaid and CHIP”, Medicaid and CHIP Payment and Access Commission, June, 2015.

https://www.macpac.gov/wp-content/uploads/2015/06/June-2015-Report-to-Congress-on-Medicaid-and-CHIP.pdf

[2] Roeber, C., McClellan, C., and Woodward, A. “Adults in Poor Physical Health Reporting Behavioral Health Conditions Have Higher Health Costs”, Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality, April 26, 2016.

https://www.samhsa.gov/data/sites/default/files/report_2107/ShortReport-2107.html

[3] Roberts, L.W., Louie, A.K., Guerrero, A.P.S. et al, “Premature Mortality Among People with Mental Illness: Advocacy in Academic Psychiatry”, Academic Psychiatry, June 5, 2017. Psychiatryhttps://link.springer.com/article/10.1007/s40596-017-0738-9

[4] Correll CU, Galling B, Pawar A, et al,“Comparison of Early Intervention Services vs Treatment as Usual for Early-Phase Psychosis: A Systematic Review, Meta-analysis, and Meta-regression, JAMA Psychiatry, June 2018. https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2679768

[5] “National Projections of Supply and Demand for Behavioral Health Practitioners: 2013-2025”, Health Resources and Services Administration, November, 2016. https://bhw.hrsa.gov/sites/default/files/bhw/health-workforce-analysis/research/projections/behavioral-health2013-2025.pdf

[6] E. McNichol and M. Leachman. States Continue to Face Large Shortfalls Due to COVID-19 Effects. Center on Budget and Policy Priorities. July 2020. https://www.cbpp.org/research/state-budget-and-tax/states-continue-to-face-large-shortfalls-due-to-covid-19-effects

[7] N. Panchel et al., The Implications of COVID-19 for Mental Health and Substance Use. Kaiser Family Foundation. April 2020. https://www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/

[8] L Hamel, et al. KFF Health Tracking Poll – July 2020. https://www.kff.org/coronavirus-covid-19/report/kff-health-tracking-poll-july-2020/

[9] Colorado Department of Health Care Policy and Fib=nuancing. ACC Operational Dashboard. September 2020.https://www.colorado.gov/pacific/sites/default/files/ACC%20Phase%20II%20Operational%20Dashboard%20September%202020.xlsx

[10] Rhode Island EOHHS. Attachment K – Infrastructure Incentive Program: Requirements for Managed Care Organizations and Certified Accountable Entities. http://www.eohhs.ri.gov/Portals/0/Uploads/Documents/PY3Attach_K_Incentive_Program_Requirements_PY3_Final%20Updated%205.28.20%20for%20Web.pdf

[11] Colorado Department of Health Care Policy and Financing. Behavioral Health Incentive Program https://www.colorado.gov/pacific/sites/default/files/Accountable%20Care%20Collaborative%20Program%20Improvement%20Advisory%20Committee%20BHIP%20Preliminary%20Data%20Handout%20March%202020.pdf

Acknowledgements: The National Academy for State Health Policy (NASHP) would like to thank the state officials from Colorado, Minnesota, and Rhode Island who contributed to this brief as well as Health Resources and Services Administration Project Officer Carolyn Robbins and her colleagues for their feedback and guidance. The author also wishes to thank Trish Riley, Kitty Purington, Jodi Manz, and Kristina Long of NASHP for their contributions to the paper. This project was supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under co-operative agreement number UD3OA22891, National Organizations of State and Local Officials. The information, content, and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the US government.

How States Use Cost-Growth Benchmark Programs to Contain Health Care Costs

August 6, 2020/in Policy Connecticut, Delaware, Massachusetts, Rhode Island, Washington Charts, Featured News Home Consumer Affordability, Health System Costs, Hospital/Health System Oversight, Making the Case for Action, Total Cost of Care Benchmark /by Deborah Fournier and Adney Rakotoniaina

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Governing Accountable Health Entities: Examples from 12 States

March 29, 2019/in Policy California, Colorado, Connecticut, Delaware, Massachusetts, Michigan, Minnesota, New York, Oregon, Rhode Island, Vermont, Washington Charts Accountable Health, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Health Equity, Health System Costs, Housing and Health, Population Health, Social Determinants of Health /by NASHP Staff

More than a dozen states are developing accountable health models to improve population health and control costs by addressing community needs, such as transportation, recreation, and housing. These entities’ mission — to build healthy communities through cross-sector partnerships — is supported by innovative and evolving governance structures. This NASHP chart and a companion blog highlight how states are structuring these entities to keep them accountable and reflective of their communities.
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State	Description, Goals, and Functions of Governing Body	Representation in Governing Body	Community Engagement	Governance Accountability, Incentives, or Milestones	Connection to Other State Initiatives
California Accountable Communities for Health Initiative (CACHI)	“An accountable communities for health (ACH) must establish a sound governance structure that ensures effective decision-making; accountability to the community; representation of stakeholders’ interests; proper fiduciary, fiscal, and social responsibilities; and control over funding and staff.” (ACH Legal & Practical Recommendations, p. 4) An ACH should have a set of rules (bylaws or agreement) to hold stakeholders accountable to their obligations, defined fiduciary duties for the Governing Body, established controls over activities and finances, and a conflict of interest policy and procedure.” (p. 4)	The ACH collaborative must include: “-Health plans, hospitals, private providers or medical groups and community clinics serving the geographic area. -Government health and human services agency/public health department -Grassroots, community and social services organizations that include authentic and diverse representation of residents, particularly from underserved communities.” “It is desirable that every ACH include broad representation of several of the following types of entities: -County and/or city government leadership, including elected officials -Behavioral health providers – Housing agencies -Food systems -Employers and other business representatives -Labor organizations -Faith-based organizations -Schools and educational institutions -Parks and recreational organizations and agencies -Transportation and land use planning agencies -Dental providers -Local advocacy, grassroots organizations or policy-focused organizations.”(RFP, p. 7)	CACHI’s Year 1 request for proposals awarded points for, “Meaningful resident engagement and a process for ongoing engagement throughout the funding period.” (RFP, p. 14)	Recommended key milestone: “By the end of Year 1: Develop a governance plan that includes the following: -A list of community sectors to be represented on the Governing Body of the Wellness Fund. -An outline of key components of bylaws to establish the number of directors, meetings, voting procedures, a community investment committee, and conflict of interest and anti-nepotism policies. -A document outlining how accountability to the community will be achieved and maintained (e.g., by reserving board and committee slots for community residents and providing annual reports on activities and spending).” (ACH Legal & Practical Recommendations, p. 35-36)

State	Description, Goals, and Functions of Governing Body	Representation in Governing Body	Community Engagement	Governance Accountability, Incentives, or Milestones	Connection to Other State Initiatives
Colorado Regional Accountable Entities	“The contractor shall have a governing body responsible for oversight of the Contractor’s activities in relation to this Contract.” (RFP 5.3.5)	“The contractor shall select members of the governing body in such a way as to minimize any potential or perceived conflicts of interest.” (5.3.5.1)	“The regional accountable entities (RAE) will develop mechanisms to engage community partners within the RAE’s region for population health and nonmedical community services.” (3.3.10) The RAE will “promote physical and behavioral health ….[and] the population’s health and functioning, coordinate care across disparate providers, interface with long-term services and supports providers, and collaborate with social, educational, justice, recreational and housing agencies to foster healthy communities ….” (3.3.3)	The contractor shall publicly list information, including, but not limited to, the names of the members of the governing body and their affiliations, on the contractor’s governing body on the contractor’s website.” (RFP, 5.3.6)	“The program will focus on greater coordination with the Colorado Departments of Human Services, Public Health and Environment, Education, and Corrections, as well as initiatives such as Comprehensive Primary Care Plus (CPC+), State Innovation Model (SIM), Hospital Transformation Program, and the Colorado Opportunity Project. The RAE will play key regional roles in these initiatives as they are well aligned with the Accountable Care Collaborative’s goals.” (3.3.11)

State	Description, Goals, and Functions of Governing Body	Representation in Governing Body	Community Engagement	Governance Accountability, Incentives, or Milestones	Connection to Other State Initiatives
Connecticut Health Enhancement Communities (HECs)	“Health Enhancement Communities (HEC) will have a defined structure, with a formal governance structure and community organizing groups. The formal governance structure will have clearly defined decision-making roles, authorities, and processes. The community organizing groups will have ownership and decision-making authority over the things that matter most to them and will lead the identification and implementation of interventions in their communities.” HEC Design Principles (See p. 52-54 of HEC model design draft proposal, Oct. 22, 2018, for chart of other governance requirements.)	“-In addition to community organizing groups, HECs will need to identify multiple methods for gaining meaningful involvement, including in decision-making, as HECs form and operate -HECs will need to include multiple community organizations that directly address root causes of poor health in their communities.” (HEC model design draft proposal p. 52)	“Given their unique and essential perspectives and insights about their communities, HECs’ success depends on the ongoing involvement of community members and community members making decisions about things that matter most to them. In addition to community members being involved in HEC formation and operation, the HEC structure should also support community organizers and locally owned and directed community organizing groups within communities….” (HEC model design draft proposal p. 9-10)	Minimum governance structure elements required by the state and determined by HECs: “-Partnership agreements -Bylaws -Backbone organization -Formal contracts for services.” (HEC model design draft proposal p. 52-53)	State Innovation Model

State	Description, Goals, and Functions of Governing Body	Representation in Governing Body	Community Engagement	Governance Accountability, Incentives, or Milestones	Connection to Other State Initiatives
Delaware Healthy Neighborhoods	Neighborhood task forces: “Create and propose data driven, evidence-based initiatives, request funds…measure outcomes… engage in quality improvement. Local councils “serve as a ‘board’ of the Healthy Neighborhood (e.g. decision making about resource allocation)… [and] approve Task Forces’ requests for resources.” (HMA, Healthy Neighborhoods Model, Dec. 2017, p. 7) The role of the fiscal agent is to: -“Distribute funding to entities implementing Task Force Initiatives (once ‘readiness process’ has been completed) -Collect data/outcomes from each Task Force related to funded initiatives and utilize this practice of continuous analysis as a tool for ongoing learning -Focus on sustainability of the SIM Grant funding (e.g., establishing and managing a community trust) -Serve as a ‘Backbone Organization’ across all Local Councils.”(HMA, p. 4)	Local neighborhood task forces contain: “-Local community stakeholders and leaders that are focused on a priority area -Two co-chairs.” Local councils are made up of: “-At least one representative from each task force -Local leaders with expertise in priority areas -Cross-sector entities and organizations recruited via the Social Network Analysis to ensure representation of all critical entities -Delivery systems as well as community-based organizations -Community advocates from neighborhoods -Community stakeholders.” (HMA, p. 7) “Voting procedures are established in the bylaws of the Local Council.” (HMA p. 18)Local councils are advised by a statewide consortium with: “-Local council co-chairs -Statewide leaders focused on user-friendly community-level data -Statewide leaders focused on sustainability of healthy neighborhoods -Statewide leaders focused on policy -Advocacy organizations from neighborhoods -The statewide fiscal agent.” (HMA p. 8)		“Readiness assessment will assess: -Did the task force use data about community needs to develop the initiative? -Did the task force include representatives from diverse entities who weighed in on the creation of the plan? -Similarly, do you have community buy-in?” (p. HMA 15-16)	State Innovation Model

State	Description, Goals, and Functions of Governing Body	Representation in Governing Body	Community Engagement	Governance Accountability, Incentives, or Milestones	Connection to Other State Initiatives
Massachusetts Accountable Care Organizations (ACOs)	Massachusetts Health Policy Commission (HPC)’s ACO Certification Program assessment criteria includes a “Patient-centered, accountable governance structure.” (ACO Policy Brief, April 2018, p. 3)	“The ACO provides for meaningful participation in the composition and control of the Governing Body for its participants or their representatives.” ACOs must attest that “ACO Participants have at least 75% control of the Governing Body (Proposed 2019 ACO Certification Standards, p. 7). – [ACOs must have] “at least one patient or consumer advocate within the governance structure.” (Proposed 2019 ACO Certification Standards, p. 7-8)	“The ACO governance structure is designed to serve the needs of its patient population, including by having … a patient and family advisory committee.” (Proposed 2019 ACO Certification Standards, p. 7-8)	The HPC requires ACOs to submit an “Organizational chart(s) of the Governance Structure(s) of the Applicant (and Component ACOs as applicable), including Governing Body, executive committees, and executive management, and indicating the location of a patient or consumer representative role within each Governance Structure.” (Proposed 2019 ACO Certification Standards, p. 5-6) ACOs are required to submit a Full Participation Plan that includes “The providers and organizations with which the ACO is partnering or plans to partner, the governance structure … [and] a population and community needs assessment.” (p. 14)	MassHealth Medicaid Section 1115 Demonstration
Massachusetts Accountable Care Organizations (ACOs)	“The ACO Governing Body regularly assesses the access to and quality of care provided by the ACO, in measure domains of access, efficiency, process, outcomes, patient safety, and patient experiences of care, for the ACO overall and for key subpopulations (i.e. medically or socially high needs individuals, vulnerable populations), including measuring any racial or ethnic disparities in care.” (Proposed 2019 ACO Certification Standards, p. 8)			ACOs are required to submit a Full Participation Plan that includes “The providers and organizations with which the ACO is partnering or plans to partner, the governance structure … [and] a population and community needs assessment.” (DSRIP protocol, p. 14)	MassHealth Medicaid Section 1115 Demonstration

State	Description, Goals, and Functions of Governing Body	Representation in Governing Body	Community Engagement	Governance Accountability, Incentives, or Milestones	Connection to Other State Initiatives
Michigan Community Health Innovation Regions (CHIRs)	“Each of the five regions is supported by a backbone organization that serves as a fiduciary and acts as a neutral convener for the CHIR’s governing body.” “CHIR partners are organized by a neutral backbone organization that [serves as a fiduciary and] facilitates the development and implementation of key strategies, creating the necessary capacity to sustain progress on stated objectives. CHIR steering committees provide a clear leadership structure and promote shared accountability among partners for aligning their resources to address priority community health needs.” (SIM, “About CHIRS”)		“CHIR governance facilitates effective collaboration of providers, health plans, community based organizations and individuals to pursue community‐centered solutions to upstream factors of poor health outcomes and health disparities.” (NASHP slides, Aug. 2018)		State Innovation Model

State	Description, Goals, and Functions of Governing Body	Representation in Governing Body	Community Engagement	Governance Accountability, Incentives, or Milestones	Connection to Other State Initiatives
Minnesota Accountable Communities for Health (ACHs)	“The lead organization is responsible for convening a multi-sectoral governing body with representation from partner organizations and the community. ACH projects are exploring and testing a variety of governance approaches such as charters, formal business agreements between partners and use of technical subcommittees …. ACH leadership team structure and makeup differs across ACHs. Some ACHs created an entirely new governance structure while others use existing committees, task forces, or advisory bodies (such as Statewide Health Improvement Program – SHIP – committees) to organize their work.” (ACH: Perspectives on Grant Projects and Future Considerations, Oct. 2016, p. 12). “Besides leadership and governance, the ACH must have a ‘backbone’ or lead organization to serve as convener and integrator.” (p. 35)	“Each ACH has a lead organization (e.g., private foundation, non-profit social service agency, local public health agency or health care system) that serves as fiscal agent and resources manager. The lead organization is responsible for convening a multi-sectoral governing body with representation from partner organizations and the community.” (ACH: Perspectives on Grant Projects and Future Considerations, p. 12) “All health plans and systems serving the population should participate in the ACH. Local public health must be an active partner, and local political leaders, government officials and other leaders should be invited to participate. Most importantly, the governing body should ensure that persons experiencing health disparities are represented in ACH partnerships, mission and vision.” (ACH: Perspectives on Grant Projects and Future Considerations, p. 35)	“Each ACH grant project features … community-led leadership.” (Minnesota Accountable Communities for Health)	Required components of each ACH grant project are: “-Community-led leadership -Care coordination between multi-sectoral partners -Population-based prevention -Measurement and evaluation -Partnership with an Accountable Care Organization -Participation in an ACH learning community -Sustainability planning -Health equity focus.” (Minnesota Accountable Communities for Health)

State	Description, Goals, and Functions of Governing Body	Representation in Governing Body	Community Engagement	Governance Accountability, Incentives, or Milestones	Connection to Other State Initiatives
New York Performing Provider Systems (PPSs)	“The Performing Provider System will need to demonstrate that it has a governance strategy that ensures that participating providers work together as a “system” and not as a series of loosely aligned providers nominally committed to the same goal.” (DSRIP Program Funding and Mechanics Protocol, p. 14)	“Please explain how the selected members provide sufficient representation with respect to all of the providers and community organizations included within the PPS network. Please outline where coalition partners have been included in the organizational structure, and the PPS strategy to contract with community based organizations.” (DSRIP PPS Organizational Application, p. 35)	“Describe how the PPS governing body will engage stakeholders on key and critical topics pertaining to the PPS over the life of the DSRIP program.” (DSRIP PPS Organizational Application, p. 34-36)		Medicaid Section 1115 Demonstration Delivery System Reform Incentive Payment program
	“Describe the decision making/voting process that will be implemented and adhered to by the governing team. Explain how conflicts and/or issues will be resolved by the governing team.” (DSRIP PPS Organizational Application, p. 35.)				State Health Innovation Plan (through the State Innovation Model)
					State Health Improvement Plan (the Prevention Agenda).

State	Description, Goals, and Functions of Governing Body	Representation in Governing Body	Community Engagement	Governance Accountability, Incentives, or Milestones	Connection to Other State Initiatives
Oregon Coordinated Care Organizations (CCOs)	“Coordinated care organizations may be local, community-based organizations or statewide organizations with community-based participation in governance or any combination of the two.” (2017 ORS 414.625) “Each coordinated care organization’s governing body establishes standards for publicizing the activities of the coordinated care organization and the organization’s community advisory councils, as necessary, to keep the community informed.” (ORS 414.625)	“Each coordinated care organization has a governing body of which a majority of the members are persons that share in the financial risk of the organization and that includes: (a) A representative of a dental care organization selected by the coordinated care organization; (b) The major components of the health care delivery system; (c) At least two health care providers in active practice, including: (i) A physician licensed under ORS chapter 677 or a nurse practitioner certified under ORS 678.375 (Nurse practitioners), whose area of practice is primary care; and (ii) A mental health or chemical dependency treatment provider; (d) At least two members from the community at large, to ensure that the organization’s decision-making is consistent with the values of the members and the community; and (e) At least one member of the community advisory council.” (2017 ORS 414.625)	Required to serve on the governing body are: “At least two members from the community at large, to ensure that the organization’s decision-making is consistent with the values of the members and the community; and At least one member of the community advisory council.” (2017 ORS 414.625)Community advisory councils: “A coordinated care organization must have a community advisory council to ensure that the health care needs of the consumers and the community are being addressed. The council must: (a) Include representatives of the community and of each county government served by the coordinated care organization, but consumer representatives must constitute a majority of the membership; and (b) Have its membership selected by a committee composed of equal numbers of county representatives from each county served by the coordinated care organization and members of the governing body of the coordinated care organization.” (2017 ORS 414.627)		Medicaid Section 1115 Demonstration

State	Description, Goals, and Functions of Governing Body	Representation in Governing Body	Community Engagement	Governance Accountability, Incentives, or Milestones	Connection to Other State Initiatives
Rhode Island Accountable Entities (AEs)	“The intent of these requirements include: 1) To ensure multi-disciplinary providers are actively engaged in a shared enterprise and have a stake in both financial opportunities and decision-making of the organization; (2) to ensure that assets and resources intended to support RI Medicaid are appropriately allocated, protected, and retained in Rhode Island; (3) to ensure that the mission and goals of the new entity align with the goals of EOHHS and the needs of the Medicaid population; (4) to ensure a structured means of accountability to the population served.” (AE Certification Standards, 2017, p. 16)	“There shall be an established means for shared governance that provides all AE Partner Providers with an appropriate, meaningful proportionate control over the AE’s decision-making process.” (AE Roadmap, April 2017, p. 42) “Board or Governing Committee Membership. The majority of voting members of the Board or the Governing Committee shall be provider representatives from participating Partner or Affiliate provider organizations, provided that at least three members shall be LTSS providers and one member shall be a behavioral health provider. Minimal representation requirements for each population certified to serve -Children: pediatric representative member of Consumer Advisory Committee, community-based organization (CBO) provider of age-appropriate supports -Adults: representative member of Consumer Advisory Committee, CBO provider of age-appropriate social supports (AE Certification Standards, 2017, p. 45)	Draft certification standards include a requirement for AEs to have a “Community Advisory Committee consisting of at least ten persons who are attributed Medicaid beneficiaries who are representative of the populations served by the AE.” (AE Roadmap, 2.1.8)		Medicaid Section 1115 Demonstration
					State Innovation Model (SIM)

State	Description, Goals, and Functions of Governing Body	Representation in Governing Body	Community Engagement	Governance Accountability, Incentives, or Milestones	Connection to Other State Initiatives
Vermont Accountable Communities for Health (ACHs)	“An accountable community for health is managed through a governance structure that articulates the process for decision-making and outlines the roles and responsibilities of the integrator organization, the steering committee (or other decision-making body), and other collaborative structures or partners.” From Vermont Accountable Communities for Health Peer Learning Lab Report, March 2017	“The governance structure should include a diverse representation of stakeholders, including decision-makers, experts, community members, and leaders from the variety of community organizations that impact health in the region.” (Vermont ACH Peer Learning Lab Report, p. 18).	“The ACH Peer Learning Lab sought to build on this framework and test model implementation while increasing community capacity and readiness across the nine Core Elements of the ACH model.” (Vermont ACH Peer Learning Lab Report, p. 6 )	Governance is one of the nine core elements of the ACH model. (Vermont ACH Peer Learning Lab Report, p. 18)

State	Description, Goals, and Functions of Governing Body	Representation in Governing Body	Community Engagement	Governance Accountability, Incentives, or Milestones	Connection to Other State Initiatives
Washington Accountable Communities of Health (ACHs)	Accountable communities of health must: -Maintain a governance structure that includes balanced cross-sector collaboration and decision-making, including the necessary documented procedures and agreements, e.g. bylaws and a memorandum of understanding. -Ensure that no one sector or organization can control decision-making. -Revisit the process at least annually to determine effectiveness considering the regional landscape and specific governance structure.” (State Innovation Model Contractual Guidelines for Accountable Communities of Health, P. 5)“Minimum expectation: ACHs must develop and maintain a communications framework to keep partners informed and involved in between meetings and events.”(State Innovation Model Contractual Guidelines for Accountable Communities of Health, p. 8).	“Washington’s tribes and urban Indian health organizations (UIHOs) are among the partners ACHs should reach out to for participation in ACH activities, including governance and decision making… Tribal governments are not stakeholders. The state maintains relations with the tribes on a government-to-government basis.” (State Innovation Model Contractual Guidelines for Accountable Communities of Health, p. 7)	“ACHs require governance structures tailored by community leaders to most effectively implement the goals of Healthier Washington at the local level.” (State Innovation Model Contractual Guidelines for Accountable Communities of Health, p. 5). “Because of the unique regional demographics, existing resources, and potential initiatives already under way, the specific community engagement strategies will not be prescribed by the state.” (State Innovation Model Contractual Guidelines for Accountable Communities of Health, p. 8).	“Minimum expectation: ACHs must implement a cascading engagement approach tailored to the local environment that brings the voice of consumers and individual community members to ACH development and decision making, in addition to the balanced multi-sector decision making structure.” (State Innovation Model Contractual Guidelines for Accountable Communities of Health, p. 8) “ACHs are strongly encouraged, under the SIM contract, to maintain open public governing body meetings.” (State Innovation Model Contractual Guidelines for Accountable Communities of Health, p. 8)	State Innovation Model

Q&A: How Rhode Island Tackles Social Determinants of Health through its Accountable Entity Model

November 27, 2018/in Policy Rhode Island Blogs Accountable Health, Blending and Braiding Funding, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Health Equity, Health System Costs, Medicaid Managed Care, Population Health, Quality and Measurement, Social Determinants of Health, Value-Based Purchasing /by Elinor Higgins

Across the country, states are launching new payment models that reward quality, promote care integration, improve access, and address the social determinants of health (SDOH) in an effort to improve population health. One of these ground-breaking initiatives is Rhode Island’s Accountable Entity (AE) Program, created to improve the health of Rhode Islanders enrolled in Medicaid managed care plans.
Rhode Island’s program is designed to encourage Medicaid managed care organizations (MCOs) and providers to deliver more cost-effective care through value-based payments, improve coordinated care delivery, and focus on population health in ways that go beyond traditional clinical care. Rhode Island Health System Transformation Project Director Lauretta Converse and AE Program Director Deborah Correia Morales, members of National Academy for State Health Policy’s (NASHP) State Accountable Health Models workgroup, recently shared how their program is addressing SDOH during the first year of AE implementation.
Could you describe Rhode Island’s accountable entity program and how it fits into your managed care model?
State officials developed the AE program through an amendment to the state’s 1115 Medicaid Demonstration Waiver as a way to move the existing Medicaid MCO model away from fee-for-service and towards value-based care to expand its ability to improve health outcomes and decrease costs. The AEs are provider organizations that once certified by the Executive Office of Health and Human Services (EOHHS ) are eligible to contract with one of the state’s MCOs. Specific contractual requirements set forth by the EOHHS provide guidelines for how MCOs and AEs should proceed in coordinating teams of providers with the goal of aligning financial incentives, improve their capacity to manage complex conditions, and better address social needs. The AEs, through increased delivery system integration and improved information exchange, will enhance the capacity of the MCOs and providers to support and serve high-risk populations. AE participation is voluntary, but once MCOs enter into an AE contract, they are eligible to receive incentive funding from a pool of total incentive dollars. During project Year 1, 15 percent of those dollars is allocated to the MCO incentive pool while 85 percent is allocated to the AE incentive pool.

EOHHS is the certifier not the contractor. The Rhode Island EOHHS certifies AEs, but contracts are developed between the AEs and the MCOs.

How are you incorporating SDOH into the AE model?
AEs are accountable for care coordination for their attributed populations and are required to adopt a defined population health approach. Rather than having individual providers treat patients’ individual health issues one at a time, AEs coordinate a team of providers who take on increasing financial risk for treating the whole person. A central element of the AE model is the required integration of strategies to address SDOH. The strategies must include assessment of social needs, screening and referral to community resources, and using community partnerships and engagement to address identified needs. Rhode Island has taken this on through a three-legged stool approach: certification, payment, and incentives.
How certification works:
In the first year of the program, the EOHHS certified six AEs. The state’s EOHHS uses a set of certification standards that require:

The identification of three key domains of social need
Evidence of capacity to address those domains;
A process for screening, managing referrals; and
Arranging supports for patients who need them.

AEs work with their providers to identify the best points of contact with their patients, and are able to bring aspects of care management to a broader population. AEs must be able to demonstrate clear evidence of their capacity to address the three priority domains, which could be through defined relationships with community-based organizations, in-house social supports, or an agreement with a separate social supports agency.
Possible key domains include housing stabilization and support, education and literacy, food security, safety and domestic violence, employment, and transportation. As expected, the AEs all received conditional certification because they did not yet meet the necessary standards for providing services and supports from within the community or for screening and referring patients based on the SDOH [ ]. Rhode Island state officials recognize that the AEs need support, in this case in the form of incentive payments, to develop their capacity in this area and to reach the goal of emphasizing community-based resources and services in addition to institutional care.
How payment works:
Certified AEs participate in an EOHHS-designed, value-based, Alternative Payment Methodology (APM) and total cost of care (TCoC) model through contractual partnerships with MCOs. EOHHS contracts with MCOs, which then subcontract with the AEs, which makes the MCOs responsible for ensuring AE contractual compliance. These contracts are intended, over time, to move AEs away from shared savings to increased financial risk and responsibility and to move provider payments from volume-based to value-based arrangements. Payments to AEs, made by the contracted MCO, are based in part on the quality of the care they deliver to their members, as determined by the EOHHS Quality Scorecard, which includes an SDOH measure.
How incentives work:
AE infrastructure development and implementation are supported through the Health System Transformation Project (HSTP), an amendment to the state’s 1115 Medicaid Demonstration Waiver. Entering into APM contracts makes AEs eligible to receive incentive payments from their managed care partners, and AEs receive the funds in exchange for meeting milestones established by AEs and MCOs in an individualized HSTP plan. The milestones initially are based on infrastructure and capacity building and will transition to performance-based outcome metrics. well the AEs perform in accordance with the plan dictates the amount of incentive funding earned.
AEs are required to allocate 10 percent of their received incentive funds to establish partnerships between the AE and community-based organizations that support behavioral health care, substance abuse treatment, or SDOH. A key tenet of addressing SDOH is engaging with community supports so that relationships for referral, follow-up, and tracking are established. As such, it is a requirement of the program that the agreements between community partners and AEs be formalized along with the process of identifying partners’ specific service and referral needs.
How do AEs engage with community partners to help reach their goals and address social determinants of health?
EOHHS identified four steps for AEs to use to develop meaningful community-based partnerships in Rhode Island.
First, it is necessary to identify the appropriate partners to assist in addressing SDOH within a particular community. The next step is to formalize the agreement between the AE and the community partner to establish expectations and hold each party accountable for their responsibilities. The third step is to establish bi-directional care management tracking so that all parties, including the MCO, are as up-to-date as possible on the care of patients within the AE. Finally, partners develop metrics for measuring the SDOH efforts and need for any adjustments to maximize the impact of the partnership.
All of these steps are supported through a requirement that the AEs allocate 10 percent of their incentive funding to community-based organizations.
Why are social determinants so integral to new payment and delivery models?
An increasingly familiar statistic — only 20 percent of health outcomes are due to clinical health care — establishes the importance of addressing societal, behavioral, and environmental factors when attempting to improve health. Addressing SDOH not only improves the overall health of a community, it increases the capacity of a system to prevent poor health outcomes and to manage and treat the health needs of the people it serves. A payment and delivery model that holds providers accountable for the full range of factors that influence health outcomes is a model that is likely to decreases costs and improves results.
What are your next steps?
Thus far, AEs have identified housing, food, and domestic violence as their top social determinants. EOHHS hopes to see AEs increasingly engaged in addressing these issues in their communities while taking on additional financial risk and better meeting certification standards in Year 2 of the program.