When Rhode Island health policymakers read the U.S. Centers for Disease Control and Prevention’s Healthy People 2010 report, they realized their children’s generation could face a shorter life expectancy than their own unless they changed their approach to public health. In response, Department of Health officials doubled down on their commitment to address health disparities and improve the social factors that directly affect health, such as housing and nutrition.
At the same time, they understood they needed a new financial approach to support their growing focus on improving health and health equity and reducing obstacles such as poverty, discrimination, poor education, and unsafe environments. Their solution: braided funding from a number of sources to help realign staff, break down organizational silos, and promote cross-sector collaboration.
The department first tested its innovative, collaborative approach through integrated projects, such as bringing together staff from diabetes, obesity, and maternal and child health programs and recruiting community partners to work on a shared initiative. When those initial projects proved successful, they took stock of their funding sources and looked for opportunities to divest from disease-specific funding sources and invest instead in more community-focused funding.
“Where is the funding for doing this kind of work?” observed Ana Novais, executive director of health in Rhode Island’s Department of Health. “There is no health equity funding being given to us, but nearly every proposal or grant we receive mentions health disparities.”
Rhode Island ultimately designed a method for “braiding” together funds from several sources to support its work to improve health equity. Officials wove together federal funds from the Maternal and Child Health Bureau of the Health Resources and Services Administration, the Substance Abuse and Mental Health Services Administration, the Preventive Health and Health Services Block, and two different chronic disease grants from the U.S. Centers for Disease Control and Prevention. They combined these federal funding streams with state funds, designed their work plan to meet both the department’s health equity goals as well as the various federal grants’ requirements, and then requested proposals from community organizations to improve health equity.
Novais explained the proposal asked communities to define themselves as health equity zones and submit proposals to prevent chronic diseases, improve birth outcomes, and improve the social and environmental conditions of neighborhoods across the state. See NASHP’s In the Zone for more about Rhode Island’s work to advance health equity and community health.
Novais recently shared her expertise and experience when she chaired a session on braiding and blending funds for improved population health at the annual 2017 NASHP state health policy conference held in late October. The session, presented in partnership with the de Beaumont Foundation, also featured state officials from Louisiana, Vermont, and South Carolina. Each state uses innovative braiding or blending models to address non-clinical health needs that affect public health through programs such as supportive housing and nurse home visiting for low-income, first-time mothers.
These innovative strategies may become even more important — and more widespread — in the wake of federal proposals to create block grants and cut state public health funding. A number of state health policymakers expressed concern that the flexibility provided by block grants may not adequately compensate for cuts to already lean public health budgets. To help state health policymakers prepare for and respond to such proposed changes, NASHP, the de Beaumont Foundation, and the Association of State and Territorial Health officials recently convened a group of state health policymakers from 11 states to strategically address opportunities and challenges that may result from potential changes to the federal funding landscape.
A new NASHP report, Blending, Braiding, and Block-Granting Funds for Public Health and Prevention: Implications for States, charts a way forward for states interested in maximizing their abilities to coordinate work and resources across programs. It distils ideas from the recent meeting of state leaders and explores state responses to possible federal funding scenarios. The report also:
- Surveys historic and existing sources of block grants and disease- or condition-specific federal funding;
- Examines how states currently use those funds; and
- Poses key questions for officials to ponder in the months ahead.
In this time of rapid policy changes, it is important to learn from states working to align their funding sources to advance their population health and prevention goals. “This paper is an important and much-needed resource for state officials seeking to improve health and health equity by investing in building stronger, healthier, and more resilient communities during this time of change,” said Novais.
Presented in partnership with the de Beaumont Foundation.
As federal officials hint at overwhelming changes in how state health programs will be funded in the future, policymakers are strategizing how to reconfigure their programs to take advantage of the promised brave new world of flexibility and realigned funding. The National Academy for State Health Policy (NASHP), the de Beaumont Foundation, and the Association of State and Territorial Health Officials recently convened a small group of state health policymakers from 11 states to strategically address opportunities and challenges that may result from changes to the federal funding landscape.
The meeting produced a new paper, Blending, Braiding, and Block-Granting Funds for Public Health and Prevention: Implications for States, that charts a way forward for states interested in coordinating work and resources across programs.
“This paper is an important and much needed resource for state officials seeking to improve health and health equity by investing in building stronger, healthier, and more resilient communities during this time of change,” said Ana Novais, executive director of health at the Rhode Island Department of Health. To learn more about Rhode Island’s innovative financing to advance health and health equity, read this blog.
The 2017 annual NASHP state health policy conference also addressed braiding and blending funds for improved population health. The session, presented in partnership with the de Beaumont Foundation, featured officials from Rhode Island, Louisiana, Vermont, and South Carolina. Each state uses innovative braiding or blending models to address population health and non-clinical health needs through programs such as supportive housing and nurse home visiting for low-income first-time mothers. Read more.
Presented in partnership with the de Beaumont Foundation
|Virologic Suppression occurs when the amount of HIV in the blood is lowered to below 200 copies per milliliter or undetectable levels.PLWH are more likely to achieve and maintain virologic suppression when they have access to high-quality, coordinated and comprehensive care, antiretroviral therapy, and support services. A substantial body of research shows that virally-suppressed people have better health outcomes and are at significantly reduced risk of sexually transmitting HIV to others.
Source: Centers for Disease Control and Prevention. “HIV Treatment as Prevention.” Accessed November 13, 2017. https://www.cdc.gov/hiv/risk/art/index.html.
Research shows that people living with HIV (PLWH) who achieve and maintain virologic suppression at undetectable levels have better health outcomes and reduced risk of transmitting HIV to others. As a result, many states have made increasing rates of virologic suppression in Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries living with HIV a high priority. States are increasingly using data analytics to better understand PLWA’s health care engagement and outcomes in order to improve state policies and programs.
In 2016, Medicaid and health departments from 19 states with diverse geographic regions and varying HIV rates joined the HIV Health Improvement Affinity Group. The states represent more than 50 percent of people living with HIV in the United States as of 2014.
Each affinity group state developed a quality improvement project and received technical assistance to strengthen state strategies that increase virologic suppression for Medicaid and CHIP beneficiaries living with HIV. Overwhelmingly, these states identified the need to understand this population’s service utilization and health outcomes in order to inform policy and program improvements. To do this, states can share and compare data sets from HIV prevention, treatment, and surveillance programs and Medicaid. While data sharing and analysis can be complex — due to federal and state laws and the need for a strong information technology (IT) infrastructure — states in the affinity group are leading the way.
|HIV Health Improvement Affinity Group
The HIV Health Improvement Affinity Group (HHIAG) provided support to 19 state Medicaid and public health department teams (highlighted in blue) working to increase rates of sustained virologic suppression among Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries living with HIV.The HHIAG was a joint initiative of the Centers for Medicare & Medicaid Services, the Centers for Disease Control and Prevention, and the Health Resources and Services Administration, in collaboration with the Health and Human Services’ Office of HIV/AIDS and Infectious Disease Policy, and in partnership with NASHP.
Prior to the Affinity Group, there was a very limited working relationship between the Alaska HIV Program and Medicaid. Their collaboration throughout the affinity group allowed leaders from both programs to establish a data use agreement (DUA), providing the HIV Program access to Medicaid claims data. HIV Program staff have completed a match of HIV surveillance data to Medicaid claims to better understand the utilization of services by people living with HIV enrolled in Medicaid and their HIV viral load. HIV Program and Medicaid staff believe this data analysis will allow them to better target limited resources to PLWH who are not regularly seeking HIV care and/or filling their medications.
Maryland state officials recognized the need for a DUA between the Maryland Department of Health and the Office of Health Care Financing (Medicaid) so that HIV program staff could access Medicaid claims data. They are now in the process of finalizing a DUA that will allow regular transfers of Medicaid claims data to the state’s HIV Program. While the DUA was being written, Maryland created a list of claims-based codes that could indicate if a beneficiary is HIV positive, received HIV testing, or received pre-exposure prophylaxis (PrEP). Once the DUA is in place, these codes will be used by data analytics staff to identify and describe beneficiaries using that criteria. Maryland will also create data files of HIV-positive beneficiaries for future analysis of claims utilization.
Louisiana finalized a DUA in 2014 that allows Medicaid claims data to be shared with the state health department. The state runs quarterly analyses that compare Medicaid claims data with HIV surveillance data to identify Medicaid beneficiaries who have an HIV diagnosis, but are not accessing or engaging in HIV care, and whether or not they are virally suppressed. Medicaid managed care plans in the state receive updates about their enrolled members’ results from each quarterly analysis. Based on these reports, plans can reach out to members who are not yet engaged in HIV care and/or not virally suppressed, and help them access necessary services. Louisiana currently incentivizes plans to increase virologic suppression rates by including viral load suppression as one of nine incentive-based quality metrics. If plans do not achieve an established target for an incentive-based measure, they may be subject to monetary penalties.
More promising strategies, state examples, and technical assistance resources describing how states can improve rates of viral load suppression will soon be published in a NASHP toolkit and explored in a national webinar. Visit NASHP.org and read its weekly e-newsletter for information about the release of the toolkit in mid-December.
To register for the webinar on Dec. 6, 2017, click here.
States have a variety of metrics and data sources that potentially can be used to assess and improve population health outcomes. In order to maximize this potential, states need effective strategies to collect, analyze, integrate, and use data from various sources, and to share it across multiple agencies and health care organizations for activities that drive improvement for all populations.
This webinar features an overview of state opportunities to identify and use data from a variety of sources to examine subpopulations, identify needs, and target interventions to address the needs of distinct populations. The webinar also features a discussion among three states that have taken innovative approaches to using data to drive meaningful changes in health outcomes for various subpopulations with critical needs. Maryland discusses applications of its health information exchange (the Chesapeake Regional Information System for our Patients – CRISP) to identify issues and areas of focus, Ohio describes partnership between Medicaid, managed care plans, and public health agencies to use data to address infant mortality and improve perinatal care quality, and Louisiana highlights how it uses various data sources to create new quality and pay for performance metrics with the goal of improving birth outcomes. Following the panel discussion webinar participants will have an opportunity to ask questions of the presenters.
- Moderator: Sherry Glied, PhD, MA, Dean and Professor of Public Service, New York University’s Robert F. Wagner Graduate School of Public Service
- Mary Applegate, MD, MD, FAAP, FACP, Medicaid Medical Director, Ohio Department of Medicaid
- Rebekah Gee, MD, MPH, MSHPR, FACOG, Medicaid Medical Director, Louisiana; Assistant Professor, Louisiana State University Schools of Public Health and Medicine
- Laura Herrera, MD, MPH, Deputy Secretary of Public Health, Maryland Department of Health and Mental Hygiene
Act 243 of the 2007 Regular Legislative Session, known as the Health Care Reform Act of 2007, directed the state to develop and implement a medical home system of care called Louisiana Health First. The law further stipulated that the medical home system incorporate health information technology (HIT) and quality measures to increase access, improve quality, and provide sustainability in medical care for the Medicaid and low-income uninsured populations. However, the Centers for Medicare & Medicaid Services (CMS) did not approve the Louisiana Health First Section 1115 waiver required to implement the program. Act 243 of the 2007 Regular Legislative Session required the Louisiana Department of Health and Hospitals (DHH) to implement the legislation as feasible if CMS did not approve the waiver.
In April 2011, DHH released two requests for proposals (RFPs) to implement Bayou Health, a redesign of CommunityCare, Louisiana Medicaid’s primary care case management program. DHH anticipates that Bayou Health participants will have access to a medical home, and the networks are required to support and facilitate medical home recognition and/or accreditation. The state rolled out Bayou Health across the state’s three geographical service areas in February, April, and June 2012; the program was implemented statewide as of June 1st, 2012.
- In 2007, the United States Department of Health and Human Services awarded Louisiana a $100 million Primary Care Access and Stabilization Grant (PCASG) to rebuild the greater New Orleans area’s primary care system after Hurricane Katrina. The state provided PCASG funds to 25 outpatient provider organizations. Louisiana used the PCASG as an opportunity to build a foundation for medical homes. Indeed, the Louisiana Public Health Institute (LPHI) notes that the PCASG resulted in 36 sites receiving NQCA medical home recognition.
- The Crescent City Beacon Community serves the Greater New Orleans area.
Last Updated: April 2014
The Louisiana legislature established the Louisiana Health Care Quality Forum (LHCQF) with House Concurrent Resolution 75 of the 2007 Regular Legislative Session. LHCQF was established to convene all public and private stakeholders to advance quality initiatives in the state, including the medical home. In March 2008, LHCQF held a medical home summit.
|Defining & Recognizing a Medical Home||
Definition: Act 243 of the 2007 Regular Legislative Session defined a medical home system as: “a health care delivery system that is patient and family centered and is guided by a personal primary care provider who coordinates and facilitates preventive and primary care that improves patient outcomes in the most cost-efficient manner possible. By providing a coordinated continuum of care, the cost of the current health care delivery system shall be reduced, health outcomes shall improve, and the disparities in access to health care among the state’s populations shall be reduced. The medical home system of care shall consist of an integrated system of public, private, or public and private primary care providers, specialty care groups, and hospital providers that are willing to participate in the integrated system and meet participation criteria.”
In 2008, the Louisiana Health Care Quality Forum’s Board of Directors defined a medical home using an abridged version of the Joint Principles of the Patient-Centered Medical Home: “An approach to providing comprehensive primary care that facilitates partnerships between individual patients, and their personal physicians, and when appropriate the patient’s family.” It is important to note that the Louisiana Health Care Quality Forum stressed that (1) there are times when a medical home need not be physician-led and (2) medical homes should not be restricted to one particular degree or license.
Another definition was included in the 2011 Bayou Health Request for Proposals (RFPs): “Systems of care led by a team of primary care providers who partner with the patient, the patient’s family and the community to coordinate care in all settings, from specialists and hospitals to pharmacies, nursing homes and home health agencies. Primary care providers are inclusive of physician-led and nurse-practitioner-led primary care practices.”
Recognition: The Louisiana Health Care Quality Forum’s spring 2008 report notes that the Forum’s Board of Directors endorsed the 2008 NCQA PCMH standards.
As part of the Bayou Health RFPs, care coordination networks are required to promote and facilitate NCQA recognition or Joint Commission (JC) Primary Care Medical Home accreditation.
Networks must meet the following thresholds:
|Aligning Reimbursement & Purchasing||
Under Bayou Health, the Louisiana Department of Health and Hospitals (DHH) is simultaneously implementing two separate models:
Both RFPs allow networks to develop performance-based physician incentive plans.
The Louisiana Health Care Quality Forum (LHCQF) developed a patient-centered medical home (PCMH) toolkit as a resource for providers. As a Regional Extension Center, LHCQF is currently providing health information technology technical assistance.
Bayou Health care coordination networks are required to develop a PCMH Implementation Plan, which includes a description of the technical assistance that the networks will provide to primary care physicians to support practice transformation and national recognition/accreditation. Technical assistance activities will vary across networks. The networks are required to participate in Patient-Centered Primary Care Collaborative activities.
Beginning in calendar year 2013, Bayou Health networks are required to report clinical and administrative performance data annually.
Required data will include measures from the following sources:
The eight states participating in the Maximizing Enrollment program aimed to simplify and streamline enrollment and renewal policies, systems and processes for Medicaid and CHIP and prepare for ACA implementation. These state profiles offer a snapshot of the states’ work within the program by highlighting the following:
- Where states started;
- Major Simplifications Implemented as a result of Maximizing Enrollment; and
- Lessons Learned
|New York||2.1 MB|
- Medicaid services are delivered primarily through a primary care case management (PCCM) program called Bayou Health, which enrolls beneficiaries into one of five managed care Health Plans. Each of the five Health Plans that have contracts with Bayou Health to provide Medicaid services are accountable to the Louisiana Department of Health and Hospitals (DHH) and the state of Louisiana. Bayou Health was rolled out statewide in June 2012, and DHH anticipates that all Bayou Health participants will have access to a medical home, called Care Coordination Networks (CCNs), as the program continues to grow. There were a total of 1,208,859 beneficiaries enrolled in Louisiana’s Medicaid program as of July 2011. Of these, 789,871 were enrolled in managed care.*
- Louisiana operates Bayou Health under a 1932(a) State Plan Amendment.
- Bayou Health replaced KIDMED, Louisiana’s former EPSDT program, and now coordinates EPSDT services for members. Louisiana also offers two Medicaid Waiver Programs to children with developmental disabilities: Children’s Choice and New Opportunities. Services offered by these waiver programs include: case management, personal care respite support, environmental modifications and equipment.
Louisiana’s definition of medical necessity, as defined in Title 50, Public Health Medical Assistance, Part I, Subpart 1, Chapter 11, §1101 is as follows:
The Medicaid director, in consultation with the Medicaid medical director, may consider authorizing services at his discretion on a case-by-case basis.
Additionally, each of the five managed care plans that contract with Bayou Health have their own policies for referrals and prior authorization for services.
|Initiatives to Improve Access
|Reporting & Data Collection||Louisiana contracts with IPRO to serve as an External Quality Review Organization (EQRO) to monitor the different managed care plans. The results form IPRO’s analysis are available on the Louisiana Department of Health and Hospitals Bayou Health page. IPRO tracked plan compliance with contract requirements including those related to care coordination, screening and referral services for EPSDT beneficiaries, and the integration of behavioral health and referral services as defined by the EPSDT benefit. Additionally, each CCN operating under the managed care plans are required to report on different performance measure sets including AHRQ and CHIPRA measures.|
Behavioral health services are integrated into the services provided by the managed care plans. Louisiana also has two waiver programs that they use to provide services to individuals with developmental disabilities within a home or community-based setting.
The New Opportunities Waiver (NOW) provides: individualized and family support services, center-based respite, community integration and development, supported living, skilled nursing services, and others. To qualify for NOW the child must meet financial criteria and be three years and older and have a developmental disability that manifested prior to age 22.
The Children’s Choice Waiver (CC) offers support to children with developmental disabilities who currently live at home with their families, or who will leave an institution to return home. Services provided under this waiver include: all medically necessary Medicaid services, case management, family support, center-based respite, and family training. To qualify for CC the child must meet financial criteria, be age birth through 18 years, meet certain medical and/or psychological criteria, and meet the federal definition for developmental disability.
|Support to Providers and Families|
Under Bayou Health, the Louisiana Department of Health and Hospitals is simultaneously implementing two separate payment models designed to encourage care coordination.
The first is a prepaid model; in which three managed care plans (Amerigroup Louisiana, Amerihealth Mercy of Louisiana, Inc. and Louisiana Health Care Connections, Inc.) receive monthly risk-adjusted capitated payments. The plans also receive lump sump payments for obstetrical delivery to cover the cost of prenatal and post-partum costs. Networks are liable for 100% of any costs above the capitation rate.
The second is the shared savings model; in which two managed care plans (Community Health Solutions, Inc. and United Healthcare of Louisiana) receive per-member per-month (PMPM) enhanced primary care case management fees and, if earned, lump sum shared savings payments. The CCNs are required to pay a portion of these fees to primary care providers as a PMPM care coordination payment. The network’s fee is also subject to certain performance and savings benchmarks being met.
The Louisiana Department of Health and Hospitals recently completed a competitive procurement process to select Managed Care of North America Dental (MCNA) to provide dental services to Medicaid and Louisiana Children’s Health Insurance Program (LaCHIP) enrollees. The anticipated start date for this program is July 1, 2014.
- A prepaid risk bearing managed care organizations model, and
- A coordinated care network with a shared savings model (CCN-S)
The coordinated care network with a shared savings model meets NASHPs set of three core characteristics and capabilities for inclusion under this map. The state defines coordinated care networks as organized health care delivery systems designed to improve access to care and the quality of services, as well as to promote healthier outcomes for Medicaid recipients through the establishment of a medical home system of care. Each CCN-S is required by state regulations to develop and maintain effective continuity of care activities, which ensure a continuum of care approach to providing health care services to members. The CCN-S can share in up to 60 percent of savings if the aggregate costs of authorized services are less than a risk-adjusted Per Capita Prepaid Benchmark (contingent upon meeting clinical quality performance measure benchmarks).
The state Department of Health and Hospitals put out Requests for Proposals for the CCN-S in April 2011. The Department announced in July 2011 that two entities, UnitedHealthcare of Louisiana, Inc. and Community Health Solutions of America, Inc., would be participating in the shared savings CCN model.
To learn more about Louisiana’s medical home initiatives, including the coordinated care networks, visit the Louisiana page of NASHP’s medical homes map.
Last updated November 2013.
Patient population: Participation in coordinated care networks in Louisiana is mandatory for categorically needy children up to 19 years of age and their parents; pregnant women; aged, blind, and disabled adults; uninsured women under the age of 65 who have been identified as being in need of treatment for breast and/or cervical cancer; uninsured women eligible through the Louisiana Children’s Health Insurance Program Prenatal Option; and medically needy individuals and families.
Participation is voluntary for Native Americans/Alaskan Natives and foster care children.
Covered services: A coordinated care network with a shared savings model (CCN-S) provides enhanced primary care case management in addition to contracting with primary care providers for primary care management. The CCN-S is also responsible for coordinating services outside of primary care including, but not limited to:
Attribution: As part of the eligibility determination process, Medicaid and LaCHIP applicants shall receive information and assistance with making informed choices about the CCNs in their area of residence and the availability of choice counseling. These individuals will have the opportunity to talk with an enrollment broker who shall provide additional information to assist in choosing the appropriate CCN.
Each new recipient is given at least 30 calendar days from the postmark date of an enrollment form mailed by the enrollment broker to select a CCN and primary care provider (PCP). Recipients who fail to choose a CCN will be auto-assigned.
The Centers for Medicare & Medicaid Services approved a State Plan Amendment to implement Coordinated Care Networks as part of a new Medicaid managed care program, Bayou Health. The State Plan Amendment took effect on February 1, 2012.
Coordinated care networks contract with Louisiana’s Department of Health and Human Services.
Requirements for the makeup of the coordinated care network shared savings (CCN-S) entities are not specified, but the Request for Proposals released by the Louisiana Department of Health and Hospitals establishes that on-site readiness reviews of the CCN-S will focus on the performance of the governing body, among other areas.
|Criteria for Participation||
State regulations require that a Medicaid-participating entity operating under the coordinated care network shared savings (CCN-S) model be a successful bidder, awarded a contract, and pass a readiness review. A CCN-S must:
Under a fee-for-service with coordinated care networks shared savings (CCN-S) model, the CCN-S receives monthly enhanced primary care case management fees, as well as lump sum savings payments if it is eligible. The CCN-S in turn reimburses primary care providers a monthly case management fee for each enrollee assigned to the primary care provider.
The state will establish a Per Capita Prepaid Benchmark (PCPB) based on the health risk for Medicaid enrollees in the CCN-S. Periodic reconciliations (for time periods covering at least 12 months of service) are performed by the Department of Health and Hospitals to determine total medical cost incurred by the CCN-S. If the CCN-S exceeds the PCPB, it will be required to refund to the state up to 50 percent of the total amount of enhanced primary care case management fees paid to the CCN-S during the performance period. The CCN-S is eligible to receive up to 60 percent of savings if the actual aggregate costs of authorized services, including enhanced primary care case management fees advanced, are less than the aggregate PCPB.
Due to federally mandated limitations under the Medicaid State Plan, shared savings will be limited to five percent of the actual aggregate costs including the enhanced primary care case management fees paid.
|Support for Infrastructure||
Each CCN-S is required to provide technical support and appropriate incentives to assist primary care practices with their transition to a patient-centered medical home model. The CCN-S is also required to facilitate the data interchange between the network and the department.
|Measurement and Evaluation||
The coordinated care networks with shared savings (CCN-S) are contractually required to establish and implement a quality assessment and performance improvement program.
During the CCN Program’s first two years of implementation, any distribution of CCN-S savings will be contingent upon the CCN meeting the established “early warning system” administrative performance measures and compliance under the contract. After the second year of implementation, distribution of savings will be contingent upon the CCN-S meeting department established clinical quality performance measure benchmarks and compliance with the contract.