Arkansas Health Care Payment Improvement Initiative
In early 2011, Arkansas’s Department of Human Services proposed an initiative they call “Transforming Arkansas Medicaid” (in later documents, “Transforming Arkansas Health Care”). The Arkansas Department of Human Services (which oversees Arkansas Medicaid) has partnered with two large private insurers in the state, Arkansas Blue Cross and Blue Shield and Arkansas QualChoice, to implement this broad payment and delivery system reform initiative.
The alliance, known as the Arkansas Health Care Payment Improvement Initiative, introduced the first phase of reform in October 2012. This model attempts to move away from fee-for-service payments and towards a system that rewards value and outcomes by instituting a shared-savings/shared-risk model based on providers’ average costs for selected episodes of care. To learn more about Arkansas’s Payment Improvement Initiative, visit the Arkansas page on NASHP’s Accountable Care Activity Map.
Arkansas envisions medical homes as a key component of a transformed health care system. Currently, the state is implementing medical homes through CMS’s Comprehensive Primary Care Initiative (CPCi). In the future, the state envisions a voluntary program for interested practices, with plans to grow to include most, if not all, practices in the state.
In April 2013, Arkansas enacted the Health Care Independence Act of 2013, requiring insurers offering plans in the state’s health insurance marketplace to participate in the Health Care Payment Improvement Initiative by supporting medical homes and sharing clinical data with providers.
Arkansas is one of six states selected in February 2013 by the Centers for Medicare and Medicaid Innovation (CMMI) to receive a State Innovation Model (SIM) Model Testing Award. Arkansas received $42 million to implement and test its State Health Care Innovation Plan, which builds on the state’s Health Care Payment Improvement Initiative and emphasizes development of medical homes and health homes in the state.
- Arkansas is one of seven markets participating in CMS’s Comprehensive Primary Care Initiative (CPCi). In this multi-payer initiative, Medicare is collaborating with public and private insurers in the selected states and regions with the goal of strengthening primary care. In Arkansas, CPCi launched in October 2012, bringing together four payers, as well as 69 participating primary care practices with 275 providers across the state.
- Arkansas has received a planning grant from the Centers for Medicare & Medicaid Services (CMS) to develop a state plan amendment to implement Section 2703 of the Affordable Care Act (ACA), establishing health homes for Medicaid enrollees with chronic conditions. For more information on the Arkansas’s application, visit the state’s archive for their health homes planning initiative. To learn more about Section 2703 Health Homes, visit the CMS Health Homes webpage.
Last Updated: April 2014
Arkansas Health Care Payment Improvement Initiative: Arkansas has received input on their payment and delivery system transformation initiative from Arkansans via meetings with key stakeholders, workgroups, webinars and town hall meetings. Project staff have met with a wide range of stakeholders, including:
The state Department of Human Services partnered with Arkansas Medicaid and two large private payers, Arkansas Blue Cross and Blue Shield and Arkansas QualChoice, to form the Arkansas Care Payment Improvement Initiative. This group worked with providers, health administrators, patients and advocacy groups to design the initiative.
For more information, visit the state’s archive for this initiative.
|Defining & Recognizing a Medical Home||
Arkansas Health Care Payment Improvement Initiative: The Payment Improvement Initiative defines medical homes as “a doctor or care team that takes responsibility for the overall health of a patient.”
Comprehensive Primary Care Initiative (CPCi): Practices were selected for participation in CPCi through a competitive application process. Under CMS’s Comprehensive Primary Care Initiative, practices are not required to attain formal PCMH recognition; however, formal PCMH recognition through NCQA, AAHCC, the Joint Commission, URAC, or a state-based recognition program was viewed favorably in practice selection. Additional criteria included:
|Aligning Reimbursement & Purchasing||
Comprehensive Primary Care Initiative (CPCi): This four-year multi-payer initiative, launched in October 2012, includes five payers in the Arkansas market: Medicare, Arkansas Medicaid, Arkansas Blue Cross and Blue Shield, Humana, and Qual Choice of Arkansas.
Medicare pays selected practices a per-beneficiary per-month (PBPM) risk-adjusted care management fee which ranges from $8 to $40. CMS has indicated that it expects care management fees to average $20 PBPM during the first two years of the initiative. In Years 3 and 4, care management fees will average $15 PBPM. Medicare will also introduce a shared savings component beginning in Year 2, calculated at the market level.
The CPCi solicitation for payers indicates that participating payers (non-Medicare) are expected to follow a similar framework, paying per-member per-month (PMPM) care management fees to participating practices on top of fee-for-service and incorporating a shared savings component. Payment amounts will be negotiated individually with participating practices to comply with anti-trust laws.
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Many states began moving forward with their plans to expand Medicaid even before the Supreme Court’s 2012 ruling on the ACA. Other states have more recently decided to pursue expansion, with a number pursuing non-traditional Medicaid alternatives. This webinar will provide a closer look at the various ways states are expanding Medicaid to those who are newly eligible for the program. State panelists will discuss issues related to the expansion, including:
- Coordination with state or federal marketplaces;
- Education and outreach efforts for newly eligible individuals;
- Benefit design and development of the Medicaid Alternative Benefit Plan;
- Provider capacity needs for new and current enrollees; and
- Implications and opportunities for delivery system reform
Please register to join us for this lively discussion.
Alan Weil, Moderator
Executive Director, National Academy for State Health Policy
Policy Specialist, National Academy for State Health Policy
Assistant Director, Arkansas Division of Medical Services, Director of Continuity of Care and Coordination of Coverage Unit
State Medicaid Director, Deputy Commissioner, State of New York Department of Health
Deputy Director, Arizona Health Care Cost Containment System
By Carla Plaza
The start of a new year is a time for reflection and making resolutions. A new year also brings renewed hope, and in 2014, many individuals and families will have access to health insurance coverage, perhaps for the first time. Given all the attention to enrollment and coverage due to the roll out of the Affordable Care Act (ACA), we here at NASHP also hope to continue to help states make progress in reducing the number of uninsured children.
States are currently mobilizing their efforts to provide assistance to individuals who will be able to enroll in coverage through the health insurance exchanges beginning in October. All exchanges will offer some level of enrollment assistance through Navigator, or in some case, In-Person Assistance (IPA) programs, as well as support provided by certified application counselors, exchange call centers and websites, and agents and brokers. This State Refor(u)m webinar will highlight the key features of consumer assistance strategies being employed by exchanges. State panelists from two state-based exchanges and a state partnership marketplace will also address the varying ways that they are coordinating these efforts in their states and some of the implementation issues they anticipate facing when open enrollment begins this fall.
- What is your state’s overall vision or approach to consumer assistance?
- What is the scope and format of training offered for Navigators and in-person assisters?
- How is your state exchange planning to handle consumer assistance hand-offs between call centers, Navigators and IPA programs and state Medicaid agencies?
- How does your state plan to monitor and evaluate the effectiveness of consumer assistance provided?
Heather Howard, Director, State Health Reform Assistance Network
Rachel Dolan, Policy Specialist, National Academy for State Health Policy
Anita Cardwell, Policy Specialist, National Academy for State Health Policy
Sandra Cook, Consumer Assistance Specialist, Arkansas Health Connector
Adela Flores-Brennan, Network Assistance Manager, Connect for Health Colorado
David Van Sant, Navigator and Broker Manager, MNsure
|Download the Presentation Slides (PDF)||5.2 MB|
Through Assuring Better Child Health and Development (ABCD) III, Arkansas, Illinois, Minnesota, Oklahoma, and Oregon have developed and tested models to improve care coordination for children with or at risk of developmental delay. The medical home has been a key mechanism in their improvement efforts. This brief draws from these states’ experiences to outline opportunities and lessons for state policy makers to consider in order to strengthen medical home initiatives by explicitly addressing the needs of children.
Wave 2: in the first 9-12 months of the SIM grant, participating payers intend to implement a modular, scalable infrastructure platform for launching and administering episodes. During this period, the initiative will have 1-2 launches of 5-10 episodes. Episode rollout will occur at a significantly more rapid pace than Wave 1. The launch and administration of these episodes will use the Wave 1 infrastructure platform.
Wave 3: Through mid-2016, the initiative will rapidly achieve scale through quarterly launches of 5-10 sub-waves of episodes. The state expects the scalable infrastructure model will be in place and able to support the rapid launch and administration of these episodes.
Provider Population: The Arkansas Health Care Payment Improvement Initiative includes all providers who provide care for Medicaid, Arkansas BlueCross BlueShield, and Arkansas QualChoice; participation is mandatory. Five episodes are initially included in this initiative; providers who do not provide these services or who have limited case-volume are also excluded.
Patient Population: Arkansans insured by Arkansas BlueCross BlueShield, Arkansas QualChoice and Medicaid are included in the five retrospective risk-sharing payment episodes that have been launched.
In 2013, the initiative will expand to include assessment-based episodic payments. Individual assessments of support and health care needs will determine payment for episodes of care for the developmentally disabled (DD) and long-term services and supports (LTSS) populations. The results of these individual assessments will be used to determine tiered episode funding targets. Initially, all adults in institutional or waiver settings will be included in this approach; children and others receiving care outside of these settings will be included in future iterations.
Scope of Services: The initiative will begin with five episodes of care, though the initiative’s long-term goal for is to have episode-based payment for the majority of episode types within five years. The five initial episodes will be Attention Deficit Hyperactivity Disorder (ADHD), upper respiratory infections, congestive heart failure, hip and knee replacement, and perinatal care. A preparatory phase for these five episodes, which serves as a time for providers to adjust to the new system and for payers to begin collecting preliminary data, launched in July 2012; the performance period began in October 2012.
Episodes are defined differently for each episode type (see slide 10):
In Wave 2 of implementation, under the state’s State Innovation Model grant, episodes around additional health conditions are being added to the initiative:
Attribution: Payers use claims data to designate a principal accountable provider (PAP) (a “care quarterback”) for each episode based criteria for each episode type; the PAP can be a provider, a group of providers, or a practice or hospital. The PAP is identified differently for each episode type; for example, the PAP for a hip or knee replacement (see slide 10) is the orthopedic surgeon. PAPs are responsible for cost and quality of care throughout each care episode, including care provided by other members of the patient’s care team.
The Arkansas Department of Human Services (which oversees Arkansas Medicaid) partnered with two large private payers, Arkansas Blue Cross and Blue Shield and Arkansas QualChoice, to form the Arkansas Care Payment Improvement Initiative. This group worked with providers, health administrators, patients and advocacy groups to design the payment reform that has begun to be put into effect. For more information, visit the state’s archive for this initiative.
|Criteria for Participation||
The Arkansas Health Care Payment Improvement Initiative includes all providers who provide care for Medicaid, Arkansas BlueCross BlueShield, and Arkansas QualChoice; participation is mandatory.
Under the Arkansas Health Care Payment Improvement Initiative, providers will submit claims for all care they deliver and continue to be reimbursed based on existing fee schedules.
Providers are eligible for risk- and gain-sharing based on average cost of care per-episode, assessed yearly based on claims data. Payers are using claims data to assess historical average per-episode costs for each episode type, and identifying thresholds that they believe will maximize provider incentives to provide high quality, cost effective care. For each episode, payers will identify three ranges (see slide 18) against which to assess principal accountable providers’ (PAPs’) average per-episode costs and determine provider eligibility for risk- and gain-sharing:
Gain-sharing is dependent on achievement of “must pass” quality indicators which differ for each episode type; providers who achieve commendable average per-episode costs but fail to achieve these standards will not receive shared savings payments. However, providers who fail to fully report or who do not achieve these standards remain eligible for risk-sharing. A lower gain-sharing limit for each episode and minimum quality requirements disincent under-treatment; stop-loss provisions provide some financial protection to PAPs whose costs are above the “unacceptable” threshold. Risk- and gain-sharing percentages are defined in provider policy manual updates proposed by Medicaid for upper respiratory infections, ADHD, and perinatal care episodes (proposed in June 2012) and for congestive heart failure and total joint replacement episodes (in September 2012).
Payers will make patient- and provider-level adjustments (see slide 20) to ensure fairness to providers.
Regulatory language proposed by Arkansas Medicaid in June 2012 provides more detail on each episode type, including exclusions and proposed payment thresholds, as well as Medicaid’s methodologies for calculating risk- and gain-sharing payments.
|Support for Infrastructure||
The Arkansas Health Care Payment Improvement Initiative has created a HIPAA-compliant online database, the Provider Portal, to provide feedback to principal accountable providers (PAPs). Arkansas providers received a letter in July 2012 explaining the portal and the necessary steps to participate. The letter also explains that providers will gain access to the state’s statewide health information exchange, the State Health Alliance for Records Exchange (SHARE).
For assessment-based episodic payments for developmentally disabled and long-term services and supports populations that will begin in 2013, the state has identified and contracted with an appropriate assessment tool (InterRAI ID), contracted with a supplier to conduct assessments across the state, and contracted with a supporting IT tool for the assessments (CH Mack).
|Measurement and Evaluation||
Providers are required to report on “to pass” quality indicators which differ for each episode type; providers who achieve commendable average per-episode costs but fail to achieve these standards will not receive shared savings payments. In addition, providers will report “to track” quality indicators
Providers will have access to individualized quarterly performance reports through the Provider Portal. Performance reports will include data on quality across episodes, cost effectiveness relative to cost thresholds and other providers, and the provider’s utilization patterns and cost drivers. Reports available through the Provider Portal will draw on claims data as well as clinical data entered into the Portal by PAPs.
Report contents are under development; more information regarding reports can be found here. Providers have access to quarterly reports during the initial preparatory period to gain comfort with this system and assess current performance.
The Affordable Care Act (ACA) offers states multiple policy levers to improve health status and care for racial and ethnic minority populations through delivery system reforms, public health and community interventions, and insurance coverage, as well as provisions specific to disparities reduction. This report synthesizes the experiences of teams from seven states (Arkansas, Connecticut, Hawaii, Minnesota, New Mexico, Ohio, and Virginia) that participated in a learning collaborative to advance health equity using select ACA and state policy levers. The report also presents opportunities for state and federal collaborations to strengthen these efforts, as well as important lessons for advancing health equity.
An accompanying issue brief provides a high-level summary of the full report.