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How States Address Social Determinants of Oral Health in Managed Care Contracts

How States Improve Housing Stability through Medicaid Managed Care Contracts

February 19, 2021/in Policy Blogs, Featured News Home Behavioral/Mental Health and SUD, Care Coordination, Chronic and Complex Populations, Chronic Disease Prevention and Management, COVID-19, Health Equity, Housing and Health, Medicaid Managed Care, Medicaid Managed Care, Population Health, Social Determinants of Health /by Ariella Levisohn

In 2019, more than 500,000 individuals experienced homelessness and nearly 20 million renters spent 30 percent or more of their income on housing. These numbers are increasing as the COVID-19 pandemic exacerbates housing insecurity for people of color and low-wage workers. To improve housing stability – a critical social determinant of health (SDOH) – states are using Medicaid managed care contracts to encourage health plans to support members’ housing-related needs and promote coordination between housing providers and health plans.

Background

Housing status is a key social determinant of health. Many individuals experiencing homelessness suffer from diabetes, heart disease, and HIV/AIDS at rates that are up to six times higher than the general population, and are at increased risk for contracting COVID-19. Rates of mental illness and substance use disorders are also significantly higher among individuals experiencing homelessness.

Many individuals experiencing or at risk of homelessness qualify for Medicaid. Medicaid can be a valuable resource for helping individuals facing housing insecurity, and research shows that investing in housing can save states money and improve health. One study found that hospitalization, emergency room use, and total expenditures for individuals experiencing homelessness in Massachusetts were 3.8-times higher than for the average Medicaid recipient.

Increasingly, state Medicaid agencies are focusing on addressing housing-related needs of their enrollees through their managed care contracts.

The National Academy for State Health Policy (NASHP) recently completed its three-year Health and Housing institute. Read its final report, Five States Break Down Interagency Silos to Strengthen their Health and Housing Initiatives, to learn how Illinois, Louisiana, New York, Oregon, and Texas improved their respective health through housing initiatives.

How States Use Medicaid Managed Care Contracts to Address Housing Needs

While Medicaid managed care contract language varies significantly between states, there are some similarities in states’ approaches to addressing Medicaid enrollees’ housing needs, including these managed care organization (MCO) contractual requirements:

Screen enrollees for housing-related needs;
Hire designated housing coordinators; and
Ensure the coordination of care between housing providers or agencies and Medicaid programs.

States working to address housing insecurity and homelessness among Medicaid enrollees, or states that already require plans to focus on SDOH more broadly but wish to tailor initiatives specifically towards improving housing status, can adopt some of the contractual language and initiatives described below.

Screening for Housing Insecurity

According to NASHP’s scan of states’ Medicaid managed care contracts, 16 states (of 38 with publicly available contracts or requests for proposals) require contractors to conduct routine screenings for certain SDOH. Of the 16 states, 14 require their managed care plans to screen members about their housing needs during these assessments. These screenings can occur at any interval from annually to quarterly, with some states specifying that individuals who qualify as high-needs members should be screened more frequently. In New Hampshire, community mental health programs that contract with the state’s Medicaid program are required to conduct quarterly assessments and document all members’ housing status. In Pennsylvania, providers must complete an SDOH assessment that focuses on housing security, among other things, at least annually and more often depending on the individual’s risk level.

While some states require health plans to screen all enrollees, others only require screenings for certain populations. For example, Minnesota’s Medicaid MCO requires outreach and screening for members who have been to the emergency department for services three or more times within four consecutive months. In Alabama, the maternity psychosocial assessment includes questions related to homelessness.

Screening for housing status in order to identify members experiencing housing insecurity or homelessness is an important first step in addressing housing needs. However, in the absence of mechanisms to connect individuals to community resources that can help them find appropriate housing assistance, the impact of SDOH screenings is limited.

Hiring Housing Coordinators

According to NASHP’s analysis, seven state Medicaid MCOs identify a designated, full-time employee exclusively responsible for addressing enrollees’ housing needs – Arizona, Kansas, Louisiana, New Hampshire, New Jersey, New Mexico, and North Carolina. Other states, including Delaware and Pennsylvania, require their plans to hire more broadly defined care coordinators or SDOH specialists. They work on housing as part of their jobs, but are also responsible for addressing other member needs, such as employment, transportation, and education.

Through its contract with Kansas Medicaid, United Healthcare employs a housing navigator, a position added in 2016. The housing navigator develops partnerships statewide to identify resources for providing housing supports – including vouchers, prevention services, public housing, and homeless service agencies – and to help members locate housing. United Healthcare’s housing navigator has assisted more than 200 Medicaid members with housing needs.

The Louisiana MCO contract requires the plan to hire a permanent supportive housing program liaison who works with the Louisiana Department of Health to help implement the PSH program deliverables, which include providing affordable housing and tenancy supports. While hiring housing navigators or specialists requires MCOs to invest financial resources, onboarding navigators to help connect members directly to housing services and supports has been shown to be one effective way to address Medicaid enrollees housing-related needs, especially those identified during SDOH screenings.

Partnering with Housing Providers and Agencies

State housing agencies and local housing providers are also valuable resources for improving both the health and housing needs of individuals. Rather than building new systems, managed care plans can address housing insecurity among members by partnering with existing housing services and working to eliminate siloes between health and housing agencies.

For example, in New Mexico, health plans are required to contract with a federally qualified health center that specializes in providing health care for populations experiencing homelessness. Similarly, in New York, health plans are required to coordinate care with Health Care for the Homeless providers. In Oregon, Coordinated Care Organizations – the state’s Medicaid accountable care organizations – have contracted with community-based organizations to provide housing supports and helped develop a medical respite program to house individuals experiencing homelessness following an inpatient hospital stay.

Initial data from New York’s pilot partnership project between Medicaid MCOs and housing providers to reach individuals experiencing homelessness who are high utilizers of Medicaid services showed a 46 percent reduction in emergency room (ER) visits, a 47 percent decrease in Medicaid costs, and a 99 percent reduction in ER costs for participants.

Some state Medicaid contracts also identify opportunities for MCOs to support housing initiatives run by state or federal housing agencies. In Texas, the Medicaid MCO service coordinator must work with staff from their Section 811 Project Rental Assistance program, a federal program that helps provide supportive housing for individuals with disabilities, to coordinate care for Texans receiving Section 811 services and those leaving nursing facilities. This helps integrate health and housing services for individuals previously identified as having housing needs. In Louisiana, the state housing authority and the Department of Health co-manage the permanent supportive housing (PSH) program. The Louisiana MCO contract outlines a number of ways that MCOs are required to support the PSH program, including:

Provide outreach to members who qualify for PSH;
Help members apply for PSH;
Ensure timely prior authorization for PSH tenancy and pre-tenancy supports;
Refer members approved for PSH to relevant providers; and
Work with PSH program management to ensure an adequate and qualified network of PSH program staff and service providers.

The MCO is also required to contract directly with housing providers approved by the state to provide tenancy and pre-tenancy supports to members participating in the PSH program. One analysis of Louisiana Medicaid recipients pre- and post-PSH showed a 26 percent reduction in emergency room visits, a 12 percent reduction in hospitalizations, and an increased use of behavioral health services among participants. Through partnerships with PSH programs, MCOs can improve integration of health and housing services for members and expand the reach of housing programs by helping to identify Medicaid enrollees in need of housing and connect them directly to resources.

Creative Financing

State Medicaid managed care contracts employ creative ways to use Medicaid funding to support efforts to address housing insecurity among enrollees. Although Medicaid cannot directly fund housing, there are many other strategies to effectively invest in housing services. Oregon’s Coordinated Care Organizations (CCOs) are required to spend a portion of their profits or reserves on health-related services, and specifically on housing supports. Starting January 2021, CCOs are also required to submit annual spending plans to the state, which include the CCO’s spending priorities related to addressing SDOH and health equity, and how they align with the state’s housing-related priorities. In Kansas, the state’s MCO request for proposal calls for alternative payment strategies to incentivize warm handoff transitions for individuals moving from institutions into community-based programs and services.

In Massachusetts, the managed care contract mentions the Social Innovation Financing for Chronic Homelessness Population Program (SIF), a Pay For Success (PFS) initiative that finances PSH. Through the Community Support Program for People Experiencing Chronic Homelessness (CSPECH), Medicaid managed care entities fund support services for PSH tenants in the PFS program. As of October 2020, 860 members have enrolled in CSPECH. Together with the PFS program, CSPECH has improved housing retention, decreased emergency room stays, and saved millions in costs. While the current budget climate arising from the COVID-19 pandemic makes adopting new funding strategies difficult, investing health plan dollars in housing services can not only improve members’ housing status, but also decrease Medicaid spending down the line.

Pilot Programs

In addition to established methods, such as screening for housing needs and partnering with housing service providers, some states are using their managed care plans to launch new initiatives to address their Medicaid enrollees’ housing needs. In Florida, MCOs are participating in a voluntary pilot program to provide behavioral health services and supportive housing assistance directly to Medicaid enrollees who are homeless or at risk of homelessness and who also experiencing either serious mental illness or substance use disorder. The North Carolina managed care contract provides for an Enhanced Case Management Pilot program in up to four areas of the state. MCOs in each area work to determine the most effective, evidence-based interventions to address four priority domains, which include housing. The program also requires each program to evaluate the effect of the interventions on health care costs and outcomes. There is no “one-size-fits-all” approach to addressing housing, but piloting programs like these, or creative financing solutions like those mentioned above, can help MCOs determine which methods are best for reaching housing-insecure members in their state, while also improving health outcomes and decreasing costs.

Conclusion

As efforts to address SDOH become increasingly common among Medicaid managed care plans, many states are narrowing their focus to address housing insecurity and homelessness specifically. By working to identify enrollees’ housing needs and directly connect them to housing and supportive services, health plans can improve housing stability, which in turn improves health outcomes and decreases costs.

During the COVID-19 pandemic, states face budget challenges while their Medicaid managed care plans may experience financial gains from a decline in demand for physical health services. This leaves health plans in a unique position to invest new resources upfront in housing-related services. In 2020, many insurers reported large profits, in part due to the decline in non-COVID-19-related hospital admissions. Medical Loss Ratio rules, however, limit the amount insurers can keep for profit or overhead costs – health plans must either issue rebates or spend more on health-related services, which presents an opportunity to use these additional funds to address housing insecurity and homelessness among enrollees. And, by requiring health plans to indirectly invest in housing by hiring housing coordinators, partnering with existing housing agencies who are already immersed in the work, financing housing-related services, or by piloting new, creative solutions, states can take the lead in guiding Medicaid managed care plans’ work.

This project was supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under grant number U2MOA394670100, National Organizations of State and Local Officials. This information or 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.

States Are Increasing their Use of Medicaid Managed Care for Children and Youth with Special Health Care Needs

September 17, 2020/in Medicaid Managed Care Care Coordination, Children/Youth with Special Health Care Needs, Children/Youth with Special Health Care Needs, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Eligibility and Enrollment, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Population Health, Program Design, Special Populations and Services /by Olivia Randi and Kate Honsberger

A new, 50-state analysis of Medicaid managed care programs by the National Academy for State Health Policy (NASHP) shows that in the past three years, state Medicaid managed care (MMC) programs have:

Enrolled more children and youth with special health care needs (CYSHCN);
Provided more services to them through managed care; and
Launched more specialized initiatives serving CYSHCN in managed care.

These trends deviate from past approaches as, historically CYSHCN have often been exempt from MMC due to the complexity of their needs. CYSHCN represent nearly 20 percent of children younger than age 19 and have chronic and/or complex care needs that require physical and behavioral health care services beyond what children normally require.[1] As states become more proficient in developing MMC programs, they are increasingly incorporating CYSHCN into their program designs in an effort to improve quality and reduce costs.

NASHP has updated a 50-state chart and map, originally published in 2017, highlighting new developments in states’ MMC programs that serve CYSHCN.[2] The 2017 analysis found that 47 states use some form of MMC (risk-based, primary care case management, and prepaid health plans) to serve CYSHCN, a figure that remains true in 2020, with the same number of states and Washington, DC continuing to use MMC to serve some or all CYSHCN.

NASHP’s new analysis found a downward trend in traditional fee-for-service (FFS) models and a shift toward innovative delivery systems. Given that 47 percent of CYSHCN are covered by Medicaid, this analysis provides important insight into how states are designing services to meet the unique needs of CYSHCN.[3]

The use of managed care delivery systems is widespread, with states contracting with managed care organizations (MCOs), which are paid on a per-member, per-month basis, to provide services for people enrolled in Medicaid. Thirty-eight states use a risk-based model to serve CYSHCN, in which the MCO assumes the financial risk. Ten states use a primary care case management (PCCM) model in which states contract directly with primary care providers and pay them a case management fee for each enrollee’s care coordination, and three states have a prepaid health plan (PHP) through which health plans are paid per-member, per-month for a limited set of services.

In this new analysis, NASHP identified several key trends among the 47 states and Washington, DC that use MMC to serve CYSHCN, such as the use of specialized MMC plans, MMC enrollment policies for CYSHCN, behavioral health service delivery systems, and quality assessment standards for CYSHCN.

MMC Contract Language for CYSHCN

Since 2017, six states have added a specific definition of CYSHCN to their managed care contracts – 29 states now clearly describe this population of children within their MMC program. Including a definition of CYSHCN in a managed care contract can support identification of CYSHCN and can be used to determine eligibility for specific services and supports. Some states align their definitions with the federal Maternal and Child Health Bureau, Health Resources and Services Administration definition, while others are based on specific health conditions or Medicaid enrollment categories (e.g., children enrolled in Medicaid through the aged, blind, and disabled eligibility category).[4]

More states are also evaluating the quality of care that MCOs provide to CYSHCN using measures that account for their unique needs, as compared to 2017. States are required by federal Medicaid regulations to develop a quality assessment and improvement strategy and to contract with an external organization to evaluate the quality of care provided by their MCOs. In addition to meeting these regulations, 39 states now include specific language in their contract regarding measuring quality of care provided to CYSHCN through MMC delivery systems, an increase of seven states since 2017.

MMC Enrollment Policies for CYSHCN

CYSHCN may be eligible for Medicaid coverage through specific pathways to coverage, including those who are eligible for Medicaid’s aged, blind, and disabled (ABD) category, those receiving Social Security Income (SSI), and those who are enrolled in foster care or who are receiving adoption assistance. Additional subcategories of CYSHCN who may be enrolled in Medicaid include American Indian/Alaskan Native (AI/AN) children, those enrolled in Medicaid home- and community-based service 1915(c) waiver programs, and those enrolled in state Title V CYSHCN programs. States are increasingly mandatorily and voluntarily enrolling these subpopulations into MMC. The majority of states continue to enroll children that are eligible for Medicaid through ABD, SSI and youth in foster care or receiving adoption assistance in managed care. Over the past three years, the number of states that enroll AI/AN children and those enrolled in 1915(c) waiver programs has increased by more than 10 for each subgroup. Together, these trends may point to an increased understanding among state Medicaid programs of the diverse needs among CYSHCN subgroups.

Specialized MMC Plans for CYSHCN

Several states have developed specialized managed care plans to meet the unique needs of CYSHCN or subgroups. These plans typically offer tailored benefits that are often not available through their standard MMC plan. The number of states that have specialized MMC plans for CYSHCN has nearly doubled over the last three years.

Thirteen states (DC, FL, GA, IL, IN, ND, TN, TX, UT, VA, WA, WI, and WV) operate 12 specialized health care plans to serve some or all CYSHCN, an increase of six states since 2017.
Nine states’ (DC, GA, IL, IN, TN, TX, WA, WI, and WV) specialized plans serve youth in foster care and/or receiving adoption assistance, representing over half of the specialized MMC plans. In 2017, only two such plans existed.
Six states (DC, IN, ND, TX, UT, and VA) have specialized plans that serve children who are eligible for Medicaid through the ABD category.
Five states (ND, TN, TX, VA, and WV) enroll children who are enrolled in 1915(c) waiver programs in their specialized plans.

Behavioral Health Service Delivery for CYSHCN

States have historically been more likely to carve behavioral health services out of their MMC plans and deliver these services through distinct behavioral health organizations (BHO) or through FFS arrangements. As more states are shifting to integrate behavioral health and primary care services, they are increasingly providing behavioral health services through their MCOs. As of 2020, 41 states provide behavioral health services through MMC, an increase of eight states since 2017. Six states continue to provide behavioral health services through carve-out FFS and BHO arrangements.

Table 1: States’ MMC Program Design: 2017 – 2020

The table below summarizes key trends across states’ Medicaid managed care programs that serve CYSHCN, such as increases in the number of states that enroll CYSHCN in MMC, offer specialized health care plans that serve CYSHCN, and integrate behavioral health services with primary care for CYSHCN. These and other insights can be found in NASHP’s updated 50-State Chart and Map.

Feature	Number of States – 2017	Trend	Number of States – 2020
Contract language
Contract provides a clear definition of CYSHCN	23	↑	29
Specific quality measures for CYSHCN	32	↑	39
Subpopulation enrollment in MMC (mandatory or voluntary for at least one plan)
Aged, blind, and disabled	40	↑	42
American Indian/Alaskan Native	22	↑	36
Foster care youth/adoption assistance	39	↑	46
Social Security Income (SSI)	20	↑	33
Title V CYSHCN	14	↑	17
1915(c)	14	↑	25
Specialized plans for CYSHCN*
Total states with specialized plans	7	↑	13
Includes aged, blind, and disabled	3	↑	6
Includes youth in foster care/adoption assistance	2	↑	9
Includes Social Security Income	2	↑	3
Includes CYSHCN	2	—-	2
Includes Title V CYSHCN	1	↓	0
Includes 1915(c)	2	↑	5
Behavioral health service delivery system for CYSHCN**
MCO provides behavioral health services	33	↑	41
Behavioral health services are carved-out into FFS	7	↓	6
Behavioral health services are carved-out of managed care and provided by a behavioral health organization	8	↓	6

*Specialized plans may include more than one subpopulation.

**Some states use more than one approach to provide behavioral health services.

Notes

[1] Children with Special Health Care Needs.” Maternal and Child Health Bureau, December 17, 2019. https://mchb.hrsa.gov/maternal-child-health-topics/children-and-youth-special-health-needs.

[2] See NASHP’s 2017 chart and map here: https://www.nashp.org/state-medicaid-managed-care-program-design-for-children-and-youth-with-special-health-care-needs/

[3] MaryBeth Musumeci and Priya Chidambaram, How Do Medicaid/CHIP Children with Special Health Care Needs Differ from Those with Private Insurance? (Menlo Park, CA: Kaiser Family Foundation, June 2019). https://www.kff.org/medicaid/issue-brief/how-do-medicaid-chip-children-with-special-health-care-needs-differ-from-those-with-private-insurance/

[4] Children with Special Health Care Needs.” Maternal and Child Health Bureau, December 17, 2019. https://mchb.hrsa.gov/maternal-child-health-topics/children-and-youth-special-health-needs

Roundtable Discussion: Driving Quality Outcomes and Managing Cost for Children with Special Needs

June 21, 2019/in Medicaid Managed Care Annual Conference Quality Improvement, Special Populations and Services /by NASHP Staff

States are increasingly using managed care to deliver services to children with complex health needs enrolled in Medicaid. This roundtable discussion features the work of two states that have made innovative efforts in this area. Participants will have an opportunity to raise questions and discuss opportunities and challenges to improving care quality and controlling costs for children with medical complexity in Medicaid managed care.

Which Way Is the Wind Blowing? MCOs at a Crossroads

June 21, 2019/in Policy Annual Conference /by NASHP Staff

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.

Medicaid Managed Care Proposed Rule Would Give States More Flexibility

November 20, 2018/in Policy Blogs CHIP, CHIP, Chronic and Complex Populations, Cost, Payment, and Delivery Reform, Health Coverage and Access, Health System Costs, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care /by Kate Honsberger

The Centers for Medicare & Medicaid Services (CMS) has proposed a new regulation that gives states more flexibility to design and implement Medicaid managed care programs for Medicaid and Children’s Health Insurance Program (CHIP) enrollees. The proposal aligns with the Trump administration’s goal to reduce regulatory requirements imposed on states.
The majority of the proposed changes are policy and technical corrections to the 2016 Medicaid and CHIP Managed Care Final Rule. (The National Academy for State Health Policy has analyzed, and highlighted aspects of the rule relevant to children with special health care needs.) CMS notes the proposed rule addresses state officials’ concerns that existing federal regulations are overly prescriptive and administratively burdensome.
NASHP has performed an initial review of the proposed rule and found the following provisions may require fewer state administrative resources if the rule is finalized:

Rate setting:
- Rather than require states to develop and certify each individual rate paid per rate cell (or population group within certain regions, which can be numerous within Medicaid) to demonstrate actuarial soundness in managed care capitation rates as currently exists, states would have the option to develop and certify a rate range. Prior to the finalization of the 2016 regulation, most states used a rate range to justify managed care capitation rates.
Network adequacy:
- Instead of requiring time and distance standards for provider types within a managed care network, states would be able to implement a combination of “quantitative minimum access standards,” such as:
  - Minimum provider-to-enrollee ratios;
  - Maximum travel time or distance to providers;
  - A minimum percentage of contracted providers who are accepting new patients;
  - Maximum wait times for an appointment; and
  - Hours of operation requirements (for example, extended evening or weekend hours).
- The 2016 final rule required states to set time and distance standards for primary and specialist providers without providing a definition of specialist providers. The proposed rule clarifies that states may define “specialist” in whatever way they deem most appropriate for their programs.
Member information:
- To allow for the printing of shorter member marketing materials, states would only be required to include taglines in prevalent non-English languages and in large print on materials for potential enrollees who “are critical to obtaining services,” instead of all written materials.
- Managed care organizations (MCOs) would no longer have to provide monthly updates to paper provider network directories if they offer a mobile-enabled, electronic directory that is regularly updated.
- Provider directories would no longer have to indicate if an individual provider has completed cultural competency training – only the provider’s cultural and linguistic capabilities would be required, including the languages spoken by the physician or provider.
Quality rating system:
- The 2016 final rule required CMS, in consultation with states and other stakeholders, to develop a Quality Rating System (QRS) framework. States have the option to use the CMS-developed framework or establish their own QRS that contains “substantially comparable information about plan performance subject to CMS approval of the alternative system.” The proposed rule would:
  - Allow states to implement their own QRS as long as it was as “substantially comparable to the extent feasible to enable meaningful comparison across states,” and
  - Require CMS to identify a set of mandatory performance measures to be used in the QRS. A state alternative QRS would have to include the mandatory measures identified.

To submit a comment on the proposed rule, go to https://www.regulations.gov and follow the “Submit a comment” instructions. The public comment period is open through Jan. 14, 2019.

States Explore Strategies to Advance Palliative Care at #NASHPCONF18

September 18, 2018/in Policy Blogs Care Coordination, Chronic and Complex Populations, Chronic Disease Prevention and Management, Community Health Workers, Cost, Payment, and Delivery Reform, Health Coverage and Access, Health System Costs, Long-Term Care, Medicaid Managed Care, Palliative Care, Physical and Behavioral Health Integration, Population Health, Workforce Capacity /by Kitty Purington and Hannah Dorr

States, as regulators, payers, and innovators of health care, are uniquely positioned to improve the lives of Americans with serious illnesses by promoting access to palliative care. The National Academy for State Health Policy (NASHP) is working with state leaders to expand and improve palliative care, explore how these services align with other initiatives (e.g., value-based purchasing and delivery system reform), and identify what states need to effectively advance palliative care services.

What is palliative care?
Palliative care is interdisciplinary, patient- and family-centered health care that addresses the physical, mental, social, and spiritual well-being of seriously ill individuals.

It can be provided in hospital, community, or home settings. While often confused with hospice care, which typically focuses on the last months of life, palliative care can be offered alongside curative care at any time.

Palliative care services can improve care and the quality of life of individuals with serious illness by better managing symptoms and stressors. They can also reduce costs, especially for complex populations with serious illnesses. A 2016 study that examined home-based palliative care found these services generated a 4.2 to 6.6 percent return on investment, primarily by reducing unnecessary hospitalizations.
At NASHP’s recent 2018 State Health Policy Conference, a group of state leaders explored these issues from a policymaker perspective and discussed what it would take to advance palliative care services in their states. Below are some of the key themes and opportunities raised during the session:

States need palliative care definitions and standards: State officials identified the need for tools and resources to help states license, reimburse, monitor, and measure high-quality palliative care. Definitions and standards tailored to state regulatory needs can help jumpstart state efforts. California, Maryland, and Colorado have all implemented regulations defining palliative care, which can serve as starting points for other states.

This work is supported by a grant from
The John A. Hartford Foundation, a national philanthropy based in New York City dedicated to improving the care of older adults.

Workforce shortage is a potential barrier: States report that trained professionals — able to address palliative care needs in primary care and as members of specialized palliative care teams — are in short supply. To address this issue, Rhode Island supports provider education on palliative care as part of its cancer control program, and recently expanded the training to providers who treat other serious illnesses. As part of its State Innovation Model test grant, Rhode Island is also developing patient tools for advanced care planning and is offering education to providers to help them feel better equipped to hold these difficult discussions.
Monitoring utilization and quality can be challenging: State Medicaid agencies can support reimbursement for palliative care in a number of ways, including:
- Through managed care contracting;
- As a distinct state plan option; and
- By leveraging existing physician billing codes.

While these payment mechanisms are readily available, participants noted limitations persist. Even with enhanced reimbursement rates for palliative care, one state official reported that provider uptake was low and that the enhanced payment was underutilized. Other officials from states that had activated specialized billing codes for palliative care expressed concern about the quality of care delivered and adherence to best practice standards. States without specialty codes or a specific benefit noted that it was impossible to gauge utilization or quality given the lack of claims data.
California, which requires its Medicaid managed care plans to cover palliative care services as a package of benefits, is an example of a state that has developed a comprehensive regulatory framework to address some of these issues. Its notice to plans outlines eligibility criteria, describes service components (including advance care planning, palliative care assessment and consultation, access to a palliative care team, and mental health services) and requires plans to monitor and report palliative care utilization and provider data to California’s Department of Healthcare Services.

Stakeholder engagement can help when defining and developing palliative care services. State officials reported that engaging a broad range of agencies and stakeholders to develop palliative care initiatives was helpful. At least 27 states have multi-stakeholder taskforces or councils established specifically to advise on palliative care, and those groups provide a readymade forum for state policymakers.

State policymakers are working hard to move state systems toward more comprehensive and value-driven care, often with a special focus on populations that have chronic, complex, and high-cost care needs. Over the next two years, NASHP will convene a Leadership Council of state officials to identify promising policies and develop state recommendations and an implementation roadmap to increase access to and quality of palliative care.
NASHP will also be providing technical support to 10 states to assist them in advancing palliative care through resources, such as development of model legislation or Medicaid managed care contract language, and review of state regulations of palliative care providers and facilities. Look for announcements about publically-available palliative care resources and the technical assistance opportunities at NASHP’s website.
If your state has implemented or is exploring innovative strategies to support palliative care in Medicaid, please share your state’s experience with NASHP, contact Hannah Dorr.

Washington’s Medicaid Chief Examines the Future of Medicaid and Health Reforms

June 26, 2018/in Policy Washington Blogs Care Coordination, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Essential Health Benefits, Health Coverage and Access, Health System Costs, Medicaid Expansion, Medicaid Managed Care, Population Health, Quality and Measurement, State Insurance Marketplaces, Value-Based Purchasing /by NASHP Writers

MaryAnne Lindeblad oversees Washington State’s Apple Health (Medicaid) program, which serves more than 1.8 million residents. She also chairs the National Academy for State Health Policy’s executive committee and is a National Association of Medicaid Directors board member. Lindeblad took time recently to talk to NASHP about the future of Medicaid and health care reform.
Many state officials are despairing at the prospect of federal cuts to Medicaid, can innovation save the day?
We have no choice but to innovate and find different models for delivering and paying for health care. Historically, Medicaid programs often responded to budget pressures by cutting rates, cutting eligibility, cutting services, or contracting out the management of services to a managed care plan. We have exhausted those approaches. We need to find other tools to cover our (low-income) population in a way that is effective and produces the desired outcomes, and one opportunity is to look at other countries for models.
Which countries?
I recently had the opportunity to participate in a webinar with health officials from Spain. We could learn from their system of treating individuals with chronic care needs, some of which we are beginning to implement in Washington. I also believe we must focus more on the social determinants of health, including housing, employment and food security, and provide more robust behavioral health care.
(Note: Spain’s complex care plan uses interdisciplinary primary care teams to coordinate care among specialists, social workers, nursing facilities, home care aides, mental health providers, caregivers, and the patient, which has generated a marked decrease in hospital admissions. Team member receive bonuses, tied to performance measures, based on individual care plans. It also permits program flexibility across regions to meet specific populations’ health care needs.)
What is Washington doing to reform the health care delivery and payment system?
We have about 85 percent of our enrollment in one of our five managed care plans. In 2016, we began integrating behavioral health services into our managed care delivery system. We started in one region in the state in 2016 and will complete the whole state by January 2020. Already, we have seen improved outcomes and reduced hospitalization by having one care manager serve as a point of entry into the health care system for our highest needs, highest risk individuals. Our integrated systems are more responsive to our members’ needs. We are also beginning to build in social determinants of health into our managed care contracts and delivery systems in order to hold providers more accountable for things that directly affect people’s health, such as housing, food security and job and educational opportunities.
We also implemented a robust health home program and to date, we are seeing improved health outcomes and significant cost savings especially for our dual-eligible population.
How effective is your value-based payment (VBP) initiative, which replaced a traditional fee-for-service model with one that rewards providers for delivering quality care?
As a part of our 1115 Medicaid transformation waiver, we require our health plans serving our Medicaid population to move to VBP arrangements. By the end of 2018, we expect to have at least 50 percent of services paid through a value-based arrangement and our goal is to reach 90 percent by 2021, with commercial markets reaching 50 percent by 2021.
We have 1.8 million people in our Medicaid program, 370,000 state employees and retirees, and we will soon add 250,000 teachers in 2020. When purchasing for this many covered lives, our Health Care Authority is well-positioned to drive innovation across the state in both publically- and privately-purchased health care.
Is VBP delivery reform currently your most potent tool?
It is certainly one of our major tools among an array of options including improved care coordination, chronic care management, and integration to name a few. Because we were able to obtain a 1115 transformation waiver, we have an opportunity to test a number of tools over the course of the next four years. In addition, as a part of our Healthier Washington initiative, we are engaging our nine accountable communities of health to bring together leaders to improve health care resources, population health, and whole-person care. They are a great way to meet local needs and engage individuals from multiple sectors at a community level in identifying community health related needs and local solutions.
What do you think of the Medicaid work requirements?
It is difficult to find and keep a job if you have untreated health issues so I would rather invest in programs that provide access to quality and accessible health care first and provide the supports to maintain health. In addition, as a part of our 1115 waiver, we have added supported employment services for individuals that may need some additional supports to both find and keep jobs.
What keeps you up at night?
Being able to maintain the level of access and health insurance coverage that we currently have.
We still have an uninsured rate of around 6 percent in Washington and continue to have a successful (Affordable Care Act) insurance exchange. Can we maintain that level of insurance coverage? What will happen to Medicaid and our exchange in the future? If those programs are rolled back, we will lose ground and it will be more difficult to maintain the gains we have seen in our state. We will be back to seeing emergency rooms visits going up, hospital bad debt rising again, and fewer individuals having routine access to primary care.
We also need to make sure we have a workforce that can meet the demands of the populations we serve. We have many gaps today, especially in behavioral health and primary care. We need to address these shortages and look to how we can best use mid-levels and work our health care professionals to the top of their license.
This is a pivotal time in health care – we have a tremendous opportunity to change how we deliver health services and improve the health of those we serve. We cannot waste it.
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Hear Lindeblad speak at NASHP’s 31st Annual Health Care Policy Conference, Aug. 15-17, 2018, in Jacksonville, FL
Raising the Bar: Value-Based Purchasing to Address Population Health State health policymakers are identifying innovative mechanisms to address the social determinants of health by including new requirements or incentives within value-based purchasing and contracting arrangements. This session highlights how states are using value-based payment roadmaps and Medicaid managed care contracting as levers to increase health and well-being and to control costs. Officials from three states discuss their models, share strategies, and identify practical ideas to address the social and economic factors that influence health through value-based purchasing.
Also, read more about accountable health models: States Develop New Approaches to Improve Population Health Through Accountable Health Models

How States Can Improve Access to Care for Children Under the Medicaid Managed Care Rule

June 12, 2018/in Policy Colorado, Virginia Blogs Behavioral/Mental Health and SUD, Care Coordination, Children/Youth with Special Health Care Needs, CHIP, CHIP, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Eligibility and Enrollment, EPSDT, Health Coverage and Access, Health System Costs, Healthy Child Development, Integrated Care for Children, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Population Health, Primary Care/Patient-Centered/Health Home, Quality and Measurement /by Kate Honsberger

Next month, states face new federal requirements for establishing and maintaining Medicaid managed care provider networks. As they work to comply with these new rules, states have an opportunity to strengthen access to care for children and youth with special health care needs (CYSHCN).
Medicaid and requirements, which address how enrollees access care and the scope of provider networks, are scheduled to go into effect July 1, 2018. The network adequacy provisions of the rule, in particular, may have implications for how CYSHCN can access care.
As outlined in a recently published NASHP analysis, the rule requires states to develop and implement network adequacy standards in their Medicaid managed care programs, including time and distance standards, for certain types of providers:

Pediatric dental
Pediatric primary care
Pediatric behavioral health, including mental health and substance use disorder services
Pediatric specialist
OB/GYN
Adult primary care
Adult specialist
Adult behavioral health, including mental health and substance use disorder services
Hospital
Pharmacy
Long-term services and supports that require the enrollee to travel to the provider

In requiring network adequacy standards – yet avoiding dictating the specific time and distance standards themselves — the rule recognizes that states differ in their geographic conditions and provider capacity. It thereby gives states flexibility to establish standards in a way that fits their unique needs.
Many CYSHCN, especially those with complex needs, typically use multiple specialty providers and home- and community-based providers. By including these provider types in network adequacy standards, states can help ensure access to pediatric and specialty services for CYSHCN.
NASHP recently analyzed how states provide managed care services to CYSHCN enrolled in Medicaid. Several states have implemented network adequacy policies in their Medicaid managed care programs. Of the six states NASHP studied, all of the states include time and distance standards for generalist, specialist, and behavioral health care providers. These standards varied for urban, rural, and frontier areas in geographically diverse states. For example:

Colorado’s Accountable Care Collaborative Phase II program specifies that enrollees must have access to primary care providers (PCPs) within 30 miles or 30 minutes in urban areas, 45 miles or 45 minutes in rural areas, and 60 miles or 60 minutes in frontier areas.
Texas requires MCOs to establish networks in its STAR Kids program so that enrollees have access to two age-appropriate PCPs within 30 miles (or 20 miles in more densely-populated areas). Texas also requires that managed care organizations (MCOs) contract with telehealth providers to ensure access to specialty care in rural areas.
In Virginia’s CCC Plus program, MCOs must offer enrollees a choice of at least two providers of each provider service type located within 60 minutes of their residences, and a choice of at least two specialists within a 30-mile radius in urban areas and no more than a 60-mile radius in rural areas.

In addition to network adequacy requirements, state Medicaid agencies and MCOs use other strategies to ensure that CYSHCN have access to specialty providers. One approach is an analysis of fee-for-service claims data to identify the providers that enrollees have used in the past. The state then makes efforts to enroll those providers who have a history with these children in MCO networks. This strategy is employed by MCOs in Ohio and by the Texas Medicaid agency, which has used the method to help ensure that “significant traditional providers” are included in its MCO networks. Virginia’s Medicaid agency works with the state’s 13 hospital health systems to ensure that they contract with at least three of the participating Medicaid MCOs in the hospital system’s geographic area.
As states work to comply with the network adequacy requirements spelled out in the managed care final rule, they have an opportunity to strengthen access to care among all of their CYSHCN.
For more information about how states are organizing their Medicaid managed care programs to ensure access to care for CYSHCN, visit NASHP’s recent analysis of six state programs.