|Morrison County’s Accountable Community for Health Accomplishments:
*CHI St. Gabriel’s Health Family Medical Center’s Controlled Substance Team in Morrison County
In Minnesota, an innovative approach to improve population health is reducing the opioid crisis and saving taxpayers millions.
In Morrison County, Minnesota, an innovative state approach to improving population health is also helping combat the opioid crisis and saving money. The Unity Accountable Community for Health (ACH) initiative has saved the state’s Medicaid program $3.8 million over three years by reducing claims for prescription opioid and related drugs.
The accountable communities for health initiative, which takes a whole-person approach to prevention, offers a model for state policymakers seeking to develop sustainable, community-based prevention initiatives to combat opioid misuse and promote population health.
Minnesota is one of several states developing accountable health models that emphasize community-based health promotion and cross-sector, cross-agency partnership to address health-related social needs, such as safe and healthy housing and access to wholesome food. Minnesota’s ACHs have the flexibility to implement projects to meet the clinical and social needs of targeted populations. ACHs in Minnesota are locally planned and governed by a leadership team comprised of local providers, community partners, and members of the population served.
Each ACH in Minnesota received $370,000 in federal start-up funding through Minnesota’s SIM grant, and the Unity ACH and five others received additional SIM funding. One of the priorities of the additional funding was to support the ability of the accountable care organizations (ACOs) that partner with the ACHs to collect, analyze, and report utilization and quality data for the populations served by both the ACH and its partnering ACO. ACOs are the only entities with whom ACHs are required by the state to partner. This partnership also enables ACHs, such as the Unity ACH, to develop sustainability models and gain access to crucial health care information such as utilization and cost data.
The Unity ACH Model: How It Works
The Unity ACH includes local health care providers, pharmacies, insurers, local public health and social services agencies, and local law enforcement. The ACH’s lead agency, Catholic Health Initiatives’ St. Gabriel’s Health, uses a controlled substance care team that works closely with providers and patients to coordinate patient care and help patients safely manage their medications. The care team also identifies the health-related social needs of patients and connects them with services for housing, transportation, insurance, and mental health.
The ACH launched medication-assisted treatment (MAT) in May of 2016 to treat heroin and opioid addiction, and expanded MAT into the Morrison County Jail. This initiative — the first of its kind in Minnesota — shows promising results in its first years of operation. Before using MAT (Suboxone [buprenorphine plus naloxone]), 36 people surveyed reported serving an average 17 days in jail. After participating in MAT, participants reported spending less than one day in jail on average. This drop in incarceration for this high-risk population suggests the potential for significant cost savings to county jail systems.
- The Unity ACH reports saving Medicaid $3.8 million as of March 2018, due in part to providers prescribing 540,000 fewer doses of opioids, benzodiazepines, and stimulants, and safely reducing or stopping drug use in more than 450 patients. The ACH gauges savings by measuring reductions in the number of opioid prescriptions filled and tracking emergency department diagnoses for therapeutic drug monitoring. The percent of Medicaid beneficiaries with eight or more opioid claims declined in the area served by the program from 14.8 percent to 12.8 percent in one year’s time.
- Unity ACH has been able to calculate cost savings by leveraging data sharing with its ACO partner, which is contracted to serve Medicaid patients in Morrison County, and therefore has access to cost and utilization data for these patients.
- This cost savings gained the attention of Minnesota’s Congressional delegation. On Sept. 28, 2017, the ACH briefed Senate and Congressional staff about its rural solution to the opioid epidemic. The ACH team had earlier briefed Congressional staff in 2016.
- The Unity ACH model has also led to local policy changes. Providers are now standardizing their screening processes and increasingly accessing the Minnesota Prescription Monitoring Program database, an information-sharing system that helps providers track patients’ prescriptions to inform their own prescribing practices.
- The ACH team won the American Hospital Association’s 2017 NOVA award for its commitment to community collaboration in an innovative solution addressing the opioid crisis. They also won the Rural Health Team Award at the 2016 Minnesota Rural Health Conference.
In 2017, the Minnesota General Assembly appropriated $1 million for accountable community opioid abuse prevention projects, which will allow eight other communities to replicate the Unity ACH model. The ACH’s reach will also grow through the Project ECHO (Extension for Community Healthcare Outcomes) Hub program, supported by the US Substance Abuse and Mental Health Services Administration’s State Targeted Response to the Opioid Crisis. The grants will support weekly eLearning sessions for providers about opioid care and case management.
More broadly, the Unity ACH, in partnership with the state, is considering how savings might be reinvested to support health-related social needs such as transitional housing and healthy food. By incorporating a focus on the opioid crisis and community health within its health care delivery reform, Minnesota provides a model for other states seeking to build community capacity to improve health and lower costs.
Support for this work was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect those of the foundation. Thank you to the Minnesota state officials and ACH leaders who informed this update, and thanks to Felicia Heider for collaborating on an earlier version. All errors or omissions are the author’s.
State health policymakers are eagerly waiting to see if Congress’ omnibus budget bill released this week will attempt to stabilize Affordable Care Act (ACA) insurance markets by reinstating ACA’s cost-sharing reduction (CSR) payments. An early proposal by US Sen. Lamar Alexander would fund the cost-sharing subsidies, which reduce a family’s out-of-pocket health care costs, retroactively from 2017 through 2021.
While this is a potential solution to how the federal government can subsidize health insurance for some consumers who purchase insurance through ACA markets, data collected by the National Academy for State Health Policy (NASHP) illustrates the complex interplay between marketplace subsidies and consumer decisions that states face.
States and insurers demonstrated incredible dexterity in quickly redesigning insurance plans in response to the Administration’s late-in-the-game decision to end CSR payments in October 2017. The result was that consumers faced new confusion as insurance plans were revamped and repriced in 2018, resulting in major enrollment shifts both off and within health insurance marketplaces. Below, NASHP presents 2018 enrollment data collected by state-based marketplaces (SBMs), which closely manage their own exchanges, highlight how state actions to address the loss of CSR funding influenced market decisions in 2018. Key findings indicate:
- Decreased enrollment in marketplace silver plans, especially among consumers who no longer had access to CSR subsidies and who did not qualify for tax credits;
- Enrollment growth in marketplace bronze plans;
- Mixed enrollment growth or declines in gold plans; and
- Mixed growth, and some declines in the total number of subsidized enrollees in the marketplaces.
The findings do not provide a complete picture of what has occurred in markets nationwide, as the data represent only 10 states and do not include complete information about off-marketplace enrollment patterns or full consideration of other factors that may have influenced enrollment during the 2018 enrollment period, including shortened enrollment periods and other factors influencing premium costs. However, they provide a glimpse into how states’ markets reacted to federal policy shifts and the serious ramifications of CSR changes wrought by Washington on consumer purchasing behaviors.
Under the CSR program, insurers are required by federal law to cover certain out-of-pocket expenses (e.g., deductibles, copayments, coinsurance) for enrollees with incomes below 250 percent of the federal poverty level (FPL). CSRs are only available through silver-level health plans purchased on the state or federal health insurance marketplaces. Typically, silver-level plans have an actuarial value (AV) of 70 percent, meaning that the plan must cover in aggregate at least 70 percent of the health care costs received under the plan. CSRs change the AV of plans by varying amounts depending on the income of the qualifying consumer (see Table 1).
|Table 1. Qualifying for CSRs|
|To qualify for the ACA’s CSR program, consumers must purchase silver-level health plans and have incomes between 100 to 250 percent of FPL, which in 2018 ranged from $16,642 to $30,150 for individuals and from $33,948 to $61,500 for a family of four.|
|CSR-Eligible Plan||Standard Silver||Silver 73||Silver 87||Silver 94|
|Income||Any||200-250% FPL||150-200% FPL||100-150% FPL|
The ACA designed the CSR program so that insurers would be reimbursed for expenditures incurred under the program, and would be paid back whatever costs were charged to ensure that consumers who received services were only paying out-of-pocket expenses in line with the AV of their CSR-eligible health plan.
Questions about the exact language of the CSR law spurred litigation over whether it was legal for the government to issue reimbursements without an explicit appropriation for the program. Pending the outcome of this litigation, the Administration stopped issuing CSR reimbursements.
Response to Elimination of Federal CSR Reimbursements
After the Administration stopped CSR payments last October, most state regulators directed their insurance carriers to adjust their 2018 premium rates to account for CSR losses. Not responding to the issue would have left insurers exposed to the lost federal funding, possibly resulting in insurers opting to not participate in markets. As CSR payments most directly affected silver-level plans sold on the marketplaces, most states and carriers opted to load premium increases onto silver-level plans offered through their insurance marketplaces. The Congressional Budget Office (CBO) estimated that silver plan premiums increased by 10 percent on average in 2018 in response to elimination of CSR funding. Among the states that operate their own marketplaces, only three did not load the increases onto their silver plans. These included:
- Colorado, which advised its insurers to distribute premium increases across all metal levels to mitigate the effect on silver-level plans;
- Vermont, which similarly distributed premium increases across all metal levels due to uncertainty over the effects of the changes on its uniquely-merged individual and small group markets; and
- Washington, D.C., which calculated that elimination of the CSR payments would have minimal effect on its market due to low enrollment of CSR-eligible individuals.
CSR Loading Had Differing Impacts on Subsidized and Non-subsidized Consumers
Silver-loaded premiums shifted the affordability and value of plans offered through marketplaces, distorting costs and participation in the markets. For consumers who were eligible for premium tax credits to subsidize their coverage (82 percent of marketplace consumers in 2017), some coverage options became even more affordable. This is because the tax credit is calculated based on the second-lowest-cost silver plan available to a consumer. As a result, as silver premium costs increased in response to CSR elimination, so did the total amount of tax credit a qualifying consumer could receive. This increase in tax credits — combined with more marginal increases in premiums for bronze- and gold-level plans than for silver plans — meant that both bronze and gold plans became more affordable for these consumers. Availability of these more affordable plans may have attributed to the enrollment increases seen in some states’ marketplaces.
While the silver-loading strategy served the important purpose of insulating lower-income consumers from CSR losses, it resulted in increases costs for consumers who were ineligible for tax credits. The increased premiums escalated affordability concerns and forced many of these consumers to seek cheaper options, either by enrolling in lower-value bronze plans or by disenrolling from marketplace coverage entirely. These changes had important repercussions for both consumers and insurers participating in the markets.
- Distorted market competition and enrollment. CSR payment elimination had disproportionate effects on marketplace insurers as they adjusted premium rates differently based on the proportion of CSR-eligible consumers enrolled in their plans. Insurers with a greater proportion of CSR-eligible individuals increased premiums by a higher amount than those with fewer CSR-eligible enrollees. In California, for example, CSR-induced premium rate increases ranged from 8 percent to as much as 27 percent. This lead to a distortion of premium prices between insurers and generated shifts in market share as consumers switched to insurers whose plans had smaller premium growth.
- Increased consumer susceptibility to out-of-pocket spending. The lower-cost bronze plans, which offer less coverage, enticed more consumers to purchase them. While this lowered consumers’ annual spending on premiums, the lower AV of bronze plans means that these consumers are at greater risk of higher out-of-pocket spending. This is especially true for consumers who were once CSR-eligible but switched from silver to bronze plans without considering the resulting out-of-pocket costs.
- Complete disenrollment from individual market coverage. While the total impact of CSR changes on enrollment cannot be known without additional data about off-marketplace enrollment, it is highly probable that premium increases and confusion over the changes in premium costs spurred some non-subsidized consumers to drop insurance coverage altogether. These drops in coverage led to altered market risk pools and premium increases.
Consumers Shifted Purchasing Patterns in 2018
While it is not possible to determine the absolute effect of CSR elimination on consumers’ behavior, initial data collected by the 10 SBM states indicate that state and insurer decisions to silver-load influenced consumers’ choices in 2018. Key patterns that emerged include:
- Disenrollment in silver-level health plans, especially among unsubsidized consumers: While the majority of consumers from these states continued to select silver-level health plans, there was an almost a universal drop in the proportion of enrollees selecting silver-level plans (exceptions include Colorado and Vermont, which did not silver-load, and Minnesota, whose Basic Health Program for consumers earning up to 200 percent FPL offset the effect of CSR losses.) As expected, shifts away from silver plan selections were more common among individuals who did not receive tax credits.
- Growth in enrollment in bronze plans: There was almost universal growth across all states in the proportion of enrollees who selected bronze plans, with the exception of Minnesota and Vermont, which only saw marginal reduction in bronze plan selections.
- Varied growth or disenrollment in gold plans: Changes in gold selections vary across states, from Colorado where the proportion of gold enrollments dropped by nearly one-third to Maryland where gold enrollments increased nearly four-fold.
Different trends in enrollment among subsidized and unsubsidized consumers in these states indicate that CSR policies did not by themselves drive shifts in enrollment. It is also likely that the total effect of the CSR issue varied greatly across all states, depending on several factors including:
- The proportion of unsubsidized marketplace consumers in the state — especially those enrolled in silver plans who were most susceptible to silver-loaded premiums; and
- Baseline premium prices of bronze or gold alternatives for consumers seeking to shift away from silver plans.
Investments in education and outreach also affected how consumers responded to CSR-loading in various states. The Massachusetts’ Health Connector, for example, was among several states that took extensive steps to urge its unsubsidized silver-plan enrollees to seek more affordable options either on or outside the marketplace. Connector officials reported that they were successful in moving 82 percent of affected enrollees into new coverage plans. This meant that 18 percent of unsubsidized consumers remained in silver plans, despite its aggressive outreach efforts to inform consumers about the availability of more affordable options.
Outlook for States and Markets Pending Federal Action
While this information provides a snapshot of enrollment patterns in 2018 from 10 states, it indicates that responses to the CSR funding elimination had diverse effects on states’ markets and consumers. Similarly, if CSR funding is reinstated, the effect will reverberate differently across states’ markets and consumers. Significant changes could mean another year of disruption for insurers, who will need to adapt products and rates based on shifting federal policy, and consumers, who may need to once again actively shop around and switch plans next year. The CBO estimates that 500,000 to 1 million consumers would become uninsured from 2020 to 2021 if CSR funding was reinstated. These would mostly impact consumers with incomes between 200 to 400 percent FPL who would no longer would benefit from tax credits, which are larger than CSR subsidies.
While states and insurers rapidly responded to the Administration’s decision to end the CSR program in 2017, an absence of clear policies and continuous last-minute changes will spur unrest in markets. Without sustainable policies to stabilize the individual market, consumers will face higher costs, confusion, and anxiety about whether insurance coverage will be available when they need it.
While CSR funding remains a concern to some states, states are also seeking solutions that could bring immediate stability to markets, such as federal reinsurance funding. Whatever policies are implemented this spring, time is of the essence as state regulators are already in active negotiations with their insurers for 2019 offerings, with rate filings expected in some states as early as May. Ideally, future federal policies will grant states sufficient time and flexibility to respond to policy changes in a manner most appropriate for their markets.
Click here to view a chart comparing marketplace enrollment by metal level in California, Colorado, Connecticut, Idaho, Maryland, Massachusetts, Minnesota, Rhode Island, Vermont and Washington State.
Uncertainty about the future of health insurance options and concern about the ability of Affordable Care Act (ACA) marketplaces to offer adequate competition and choice have spurred states to look for new coverage approaches. Among the innovative strategies states are proposing are allowing consumers to buy into state Medicaid programs and developing state-specific coverage options within the ACA’s framework.
State Medicaid Buy-In Proposals
A new strategy some states are examining is to allow individuals who are not currently eligible for Medicaid to buy into the program. Cindy Mann of Manatt Health recently explored this proposal at a session at NASHP’s annual health care policy conference. She outlined some of the key issues that states need to consider to implement this approach.
One approach allows states to offer Medicaid as a new “public option” product in their ACA marketplaces, which could help increase affordability and consumer choice, particularly in areas where there are a limited number of participating plans. To be offered on the marketplace, a Medicaid plan would need to match marketplace coverage standards and be certified as a qualified health plan. Some session attendees wondered if a state could “deem” a Medicaid plan as qualified, particularly in bare counties where no insurance product was available.
Another way states could leverage Medicaid to expand coverage would be to permit individuals with incomes above current Medicaid eligibility levels to buy into the program. States could choose to offer this Medicaid buy-in to consumers either with or without subsidies. However, if they offered subsidies, states would need to seek federal approval through a 1332 Waiver or obtain a Basic Health Program (BHP) state plan amendment. Also, in order for the Medicaid plan to be affordable, the benefit package may need to be less robust than traditional Medicaid benefits.
Both strategies would require state Medicaid and insurance agencies to coordinate closely. Key advantages of Medicaid buy-in proposals include:
- The statewide nature of Medicaid’s provider networks;
- The reach of the program overall; and
- States would have the flexibility to set plan rates.
Potential disadvantages include:
- Medicaid’s lower provider reimbursement rates could diminish provider participation; and
- In some states, it may not be politically feasible to broaden the scope of Medicaid, even if individuals are required to pay premiums for coverage.
State and Federal Action on Medicaid Buy-in
Some states have already moved forward on these concepts . In early 2017, Nevada state Rep. Mike Sprinkle introduced and the state Legislature passed AB 374, which offered a public option on the marketplace. The bill directed the state to contract with insurers to provide a commercial health plan based on Medicaid (though without non-emergency medical transportation coverage), and allow eligible individuals to use ACA’s tax credits to purchase this coverage. While the proposal may have required both a 1332 and a Section 1115 Medicaid waivers, the bill was ultimately vetoed by the governor. If re-elected, Sprinkle indicated he will reintroduce the proposal.
In Minnesota, a bill was introduced in January 2017 that would have allowed individuals with incomes above 200 percent of the federal poverty level (FPL) to purchase coverage through MinnesotaCare, the state’s BHP, and they would have received a tax credit subsidy if eligible. The bill did not move forward in the state Legislature.
In Massachusetts, a provision in a recent bill that passed the state Senate in November proposes to allow any individual to purchase coverage through the state’s Medicaid program.
On the federal level, Sen. Brian Schatz (D-HI) and Rep. Ben Ray Lujan (D-NM) in October introduced the State Public Option Act in the Senate and the House, which would allow states to create a Medicaid buy-in program for all residents earning any income level who are not currently eligible for the program.
Idaho’s Health Care Plan
Idaho did not implement the ACA’s Medicaid expansion, but the state has held many meetings since passage of the ACA to explore alternative options to provide coverage to low-income individuals. Most recently, and as discussed at a NASHP conference session, the Governor’s Health Care Advisory Panel has proposed the Idaho Health Care Plan, designed to both stabilize the individual insurance market and offer coverage to some uninsured individuals.
Specifically, one aspect of the plan permits working individuals with taxable income below 100 percent of FPL to purchase subsidized marketplace coverage. The state estimates that 22,000 of the 78,000 uninsured residents with incomes under 100 percent of FPL would be able to purchase coverage.
The other component of Idaho’s proposal creates a new Medicaid Complex Medical Needs program that allows adults and children with certain complex health conditions with incomes up to 400 percent of FPL to be covered by Medicaid. Individuals would qualify if they were not eligible for Medicaid and did not have access to affordable employer coverage.
The state anticipates that moving individuals with high-cost care needs to Medicaid could reduce premiums in the marketplace and would offer these individuals more comprehensive coverage to meet their needs. The draft waiver indicates that the program would cover individuals in need of ongoing medical support for genetic conditions such as hemophilia or cystic fibrosis as well as individuals with end–of-life care needs. Most enrollees with incomes above 150 percent of FPL would be required to pay premiums for this coverage based on a sliding scale.
The two-pronged plan would require federal approval through both a 1332 waiver and a Section 1115 Medicaid waiver. The state held public hearings in December 2017 and is seeking public comments through Dec. 15, 2017. Idaho’s goal is to implement the plan in mid-2018.
Also in 2018, while there may be new efforts in Congress to modify or repeal the ACA, some states are likely to continue to pursue their own options to provide health coverage to residents. NASHP will continue to monitor and share information about these emerging state health policy proposals.
Congressional inaction in funding the Children’s Health Insurance Program (CHIP) has put states – and the children and families CHIP covers– in a cliffhanger scenario. While there have been encouraging legislative steps taken to extend the program, the bill currently appears to be stalled. With the help of temporary, reallocated CHIP funding, states are continuing to support their programs, but these funds are running out. As a result, a growing number of state officials expect they will have to notify families that their children’s coverage is in jeopardy by as early as this month.
To date, 17 states, including Washington, DC, (AZ, CA, CO, DC, DE, FL, HI, ID, MA, MN, MT, NV, OH, OR, PA, UT, and WA) have received redistribution grants from the Centers for Medicare & Medicaid Services (CMS) to continue their programs. Another nine states (AL, AK, CT, GA, KS, KY, NY, VA, and VT) are also expected to receive redistribution grants in the coming days and weeks.
As detailed in a previous NASHP blog, states are eligible to receive redistribution dollars only after spending their available federal fiscal year (FFY) 2017 carryover CHIP funds. The redistribution funds are available as a last resort and nearly $1.2 billion of the total available $2.9 billion has been reallocated to enable states to continue their CHIP programs. In December, Minnesota will be the first state to exhaust all of its federal CHIP funds, including its redistribution grant , and it’s possible that Oregon and Arizona could.do the same.
|Ultimately, timing for notifying families that their children’s coverage could end depends on how long a state can continue its CHIP program while also giving families adequate time to prepare.
Unfortunately, right now some states don’t have much time.
Many states using redistribution grants to fund their separate CHIP programs are watching Congressional activity closely, hoping federal CHIP funding will be extended as part of the continuing resolution (CR) that must pass by Friday, Dec. 8, 2017, to keep the federal government operating. However, reports suggest there will be two CRs – the first by Dec. 8th to ensure the federal government is operational in the short term and another in the coming weeks that will fund the government for a longer term. Congress is most likely to consider adding CHIP funding to the later one. With continued CHIP funding uncertainty, it remains unclear if states can and will put their plans to notify families that their children’s coverage could end on hold until after Congress acts on the second CR. For example, both Colorado and Oklahoma have already sent informational notices to families; Virginia and Connecticut plan to send notices in early to mid-December. Ultimately, timing for notifying families depends on how long a state can continue its CHIP program while also giving families adequate time to prepare — and unfortunately some states don’t have much time.
On Dec. 1, 2017, U. S. Reps. Ryan Costello (R-PA) and Tom Emmer (R-MN) introduced a bill to be included in the Dec. 8 CR that gives CMS greater flexibility to allocate redistribution funding to states that will experience a CHIP shortfall this month. The bill would waive a proration rule in the current statutory formula that dictates the portion of redistribution funds CMS allocates to ensure all states receive some of these funds. If it passes, states that exhaust all of their federal CHIP dollars in December 2017, including those that have already received and used the entirety of their redistribution portion, could receive an additional payment.
It is expected that only Minnesota (and perhaps Oregon and Arizona) will run out of all of their funds in December and would be eligible to receive this additional payment. While the additional redistribution payment will be limited and relatively small, there will be less funds available for other states that are also running out of federal funds in future months. As a result, the urgency for Congress to appropriate new federal CHIP funds for all states remains critical, even with this short-term solution. Even if this short-term fix passes, with a growing number of states expected to exhaust their CHIP funds by the end of January, it does not guarantee there will be no notices going out to families this month.
|Alabama’s notification contingency timeline for its separate CHIP program:
Late December 2017: Send informational notice to families to alert them that coverage may end in February, 2018
January 2018: Freeze enrollment
February 2018: Disenroll children from CHIP
* Alabama expects to exhaust all federal CHIP funds in February, 2017, but needs to initiate notification in December 2017.
Throughout its 20 years, CHIP has enjoyed strong bipartisan support and states, Congress and CMS have enjoyed a productive partnership, sharing the common goal of serving the nation’s children. The House has passed a bill to continue the program for five years and while funding remains a stumbling block, states hope Congress will again find a bipartisan path forward to continue health coverage uninterrupted to the 9 million children who rely on their action.
State policymakers increasingly recognize the need to address the social determinants of health — housing, employment, education, and income — to reduce health care costs and improve population health. Educational attainment, for example, provides dividends for overall health. People with higher levels of education generally live longer and experience healthier lives.
The quality of education a student receives impacts educational attainment and overall health. Evidence shows the overrepresentation of certain groups of students in separate classrooms or other settings of poorer quality overwhelmingly affects students of color. Teachers have identified students of color as having disabilities at higher rates than white students, with research documenting racial bias as influencing their decisions to remove students from the classroom. Students removed from mainstream education settings are less likely to make progress, build skills, and/or return to general educational settings. Black and Latino students are more likely to be affected by disproportionality.
|Disproportionality occurs when any racial or ethnic group’s numbers in special education classes or programs are statistically higher than other students.|
States are uniquely positioned to promote the mental health and educational achievement of all children by addressing the mechanisms that underlie racial and ethnic differences in mental disorder onset and persistence, and the causes and consequences of disproportionality in out-of-regular classroom settings, such as resource rooms, separate schools, or separate facilities. Using the resources of a variety of agencies, including public health, Medicaid, mental health, and education, can address disproportionality. Drawing from interviews with state officials conducted in conjunction with Massachusetts General Hospital’s Disparities Research Unit, the National Academy for State Health Policy (NASHP) identified state policy levers and programs, including mental health consultation, data sharing, convening authority, systemic interventions and supports, that states can use to eliminate mental health disparities.
State Levers to Address Disproportionality in Educational Settings
- Mental health consultation programs: Minnesota, Delaware, Colorado, Ohio and Connecticut utilize mental health consultation programs that can support efforts to address disproportionality. Mental health consultation varies across states, but commonly mental health providers support child care professionals and teachers, including Head Start, Part C Early Intervention Program, and child care workers, to improve their ability to identify and ameliorate mental health issues in children. States are also investing in training resources to improve the skills of early childhood mental health clinicians. Mental health consultants are typically funded by Medicaid agencies, education agencies, state general revenue or federal funds, or grants, and may receive cultural awareness training designed to improve their skills while reducing implicit cultural and racial bias. With leadership from the Substance Abuse and Mental Health Services Administration and other federal health and education agencies, states increasingly expect mental health consultants to carry out their consultative and clinical services in ways that help teachers provide supportive learning environments for all children.
- Data usage: State departments of education are required to monitor, report, and address disproportionality based on race and ethnicity as required by the US Department of Education’s Equity in Individual with Disabilities Education Act final regulation effective July, 1, 2018. Some state officials mentioned having a longitudinal data system to track disproportionality would be helpful, and would provide an opportunity for state health and education agencies to collaborate.
- Advisory groups: Colorado, Minnesota, and Delaware benefit from advisory groups that facilitate interagency collaboration that can address disproportionality. In Minnesota, an interagency task force including the Medicaid agency (Department of Human Services), Department of Health, and Department of Education promotes coordinated efforts to achieve equitable, universal early childhood screening and referrals. Minnesota’s task force laid the foundation to include mental health consultation services within its school-linked grants under its early childhood mental health infrastructure grants. Delaware, Connecticut, and Colorado were able to generate statewide attention to disproportionality by addressing school suspensions and expulsions. Connecticut became the first state to prohibit expulsions in publically-funded preschools and has recently instituted policies to ensure accountability.
- Ohio’s Cultural and Linguistic Competency Plan: Ohio’s Department of Mental Health and Addiction Services instituted a statewide Cultural and Linguistic Competency Plan to promote health equity and eliminate disparities. Ohio provides cultural competence and linguistic trainings to state employees that reference the Culturally and Linguistically Appropriate Services Standards. Additionally, the plan highlights incentives for providing culturally-competent services. Culturally-competent services can result in lowered health care costs stemming from a reduced number of medical errors, unnecessary or avoidable treatments, and lower numbers of missed medical visits. They also can support new business and revenue-generating opportunities, improved performance on quality measures, and alignment with Medicare and Medicaid, which have placed priorities on cultural and linguistic competency. The state also developed a business case for achieving health equity cited in its Cultural and Linguistic Competency Plan.
Mental health inequities can result from disproportionality and are systemic. Addressing this issue involves:
- Unraveling policies and practices that negatively impact students of color of all ages; and
- Implementing systemic interventions and supports to identifying and assisting individual children with specific needs.
As demonstrated by numerous states, state health officials can use several mental health policy levers and strategies to improve students’ overall health and success in school.
This blog was supported by the Massachusetts General Hospital Disparities Research Unit.
1. Green, J.G., McLaughlin, K.A., Alegria, M., Bettini, E., Gruber, M.J., Kwong, L., Sampson, N., Zaslavsky, A.M., Xuan, Z., & Kessler, R.C. (unpublished manuscript). Ethnic/racial inequities in educational placement for youth with psychiatric disorders.
by Jill Rosenthal and Manel Kappagoda of ChangeLab Solutions
The United States ranked 15th among affluent countries in life expectancy in 1980. By 2009, it had dropped to 27th place. Our fragmented health care delivery and public health systems, and the lack of coordination between the two, has resulted in an imbalance of high health spending and poor health outcomes.
A recent report by the Robert Wood Johnson Foundation’s Commission to Build a Healthier America, confirms what we already know: dramatically changing these statistics requires a combined approach that comprises investment in health care delivery and expanding “our focus to address how to stay healthy in the first place.”
This report, developed by the National Academy for State Health Policy and produced by ChangeLab Solutions, highlights leading states’ approaches to support community-based prevention initiatives by bridging the health care delivery and public health systems. It examines various mechanisms – both previously existing and created through health reform – that states can leverage to implement sustainable community-based prevention programs. They include Medicaid waivers, federal grants, accountable care and medical home models, pooled funding, and new federal requirements for nonprofit hospitals. The report includes opportunities and lessons from featured states (California, Maryland, Massachusetts, Minnesota, North Carolina, Oregon, Texas, and Vermont).
|Download the ChangeLab Solutions for the Publication.||5.6 MB|
The Minnesota Department of Health and the Minnesota Department of Human Services are jointly leading Minnesota’s Health Care Homes Project. In 2008, the state enacted legislation requiring that all state-regulated Minnesota payers begin paying for health care homes. The state then worked with a wide range of stakeholders to develop specific criteria for certifying practices as health care homes.
Medicaid received state plan amendment approval from the Centers for Medicare & Medicaid Services (CMS) in July 2010 to begin making health care homes payments. The Health Care Homes program includes 11 participating insurers in addition to Medicaid:
- Medicare, through the Multi-payer Advanced Primary Care Practice Demonstration
- State employee group insurance
- Blue Plus (Blue Cross Blue Shield of Minnesota)
- Itasca Medical Care
- Metropolitan Health Plan
- Preferred One
- Primewest Health
- South County Health Alliance
- UCare Minnesota
According to a January 2014 report to the Minnesota Legislature, as of December 31, 2013, the state’s 322 certified Health Care Homes (HCHs) include 43% of all primary care clinics in the state and serve over 3 million Minnesotans. These practices are geographically dispersed and serve a wide range of patients. Practices receive support through a learning collaborative, practice coaching, and data feedback.
Minnesota’s multi-payer program is unique in several respects:
- Practices are required to have quality improvement teams that include patients/families.
- Enhanced payment is only made on behalf of patients with at least one chronic condition.
- In order to receive enhanced reimbursement for a given patient, the practice must actively identify him or her as qualifying member of their panel. In most other multi-payer initiatives, plans determine patient attribution.
- Minnesota 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. Minnesota received $45 million to implement and test its State Health Care Innovation Plan, which builds on the state’s Health Care Homes program and Medicaid Accountable Care Organizations, profiled on the Minnesota page of NASHP’s State Accountable Care Activity Map.
- Minnesota is one of the eight states selected to participate in the Medicare Advanced Primary Care Practice (MAPCP) demonstration program, though several Minnesota counties are being excluded from MAPCP due to participation in a Medicare 646 Quality Demonstration.
- Minnesota 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. To learn more about Section 2703 Health Homes, visit the CMS Health Homes webpage.
- The state has received a duals demonstration grant from the Centers for Medicare & Medicaid Services (CMS) to “coordinate primary, acute, behavioral and long-term supports and services for dual eligibles.”
- HealthPartners Research Foundation has a grant from the Agency for Healthcare Research & Quality (AHRQ) to study how primary care clinics in Minnesota become health care homes.
- The federal government provides federal financial participation (FFP) for the enhanced reimbursements that Medicaid managed care organizations and Medicaid fee-for-service pay to participating practices.
Last Updated: April 2014
The Minnesota Departments of Health and Human Services hosted many meetings to develop the Health Care Homes Program. Stakeholders in attendance included representatives of:
|Defining & Recognizing a Medical Home||
Definition: According to the Minnesota Health Care Homes website, a health care home is: “an approach to primary care in which primary care providers, families and patients work in partnership to improve health outcomes and quality of life for individuals with chronic health conditions and disabilities.”
Recognition: The state-developed certification standards include expectations related to:
|Aligning Reimbursement & Purchasing||
As per Minnesota law, state-regulated payers (including Medicaid managed care plans) are required to pay for health care home services in manners that are consistent with the Medicaid fee-for-service methodology.
The following payers and purchasers are making enhanced payments:
In order to receive enhanced reimbursement, practices must actively identify patients as qualifying members of their panel. According to the state plan amendment authorizing the Medicaid payment methodology, payments are tiered based on the number of “major condition groups” (i.e., cardiovascular, respiratory, neurologic, renal, etc.) within which a patient has a severe, chronic condition requiring a care team.
The monthly PMPM payment is increased by 15% if a patient’s (or patient caregiver’s) primary language is not English or if the patient (or patient caregiver) has a severe and persistent mental illness. If both of these complexity factors are present, the PMPM is increased by 30%.
Health care homes in Minnesota are receiving a variety of supports:
Payers are providing data feedback to support health care homes in measuring progress and identifying areas for improvement.
Minnesota’s Evaluation of Health Care Homes: 2010-2012, released by the Minnesota Department of Health in January 2014, produced a number of positive findings on the program’s impact on quality of care, utilization, and cost:
Minnesota’s Outcomes Measurement Work Group previously developed recommendations for the state’s evaluation, proposing to focus evaluation efforts on clinical quality (especially care for patients with asthma and vascular conditions), patient access to care and experience of care, and cost (especially rates of hospitalizations, readmissions, emergency department use, and total cost of care).