During NASHP’s recent state health policy conference, state insurance experts explored the dramatic changes that recent federal action has foisted on their individual health insurance markets. In a second report from this conference session, they highlight strategies they’ve used to stabilize markets and identify lingering challenges to insurance markets’ affordability and choice.
While many state insurance commissioners and Affordable Care Act (ACA) marketplace directors work in tandem with state lawmakers to develop new policies that can support and stabilize markets, several experts noted that state leaders wield significant authority to influence their own markets. For example, through insurance rate review programs, state insurance commissioners have significant influence over the cost of premiums and scope of coverage sold in the markets they regulate.
Pennsylvania, for example, requires insurers to file rates using standard rating factors (a specific percent that all insurers must use to account for cost-sharing reduction calculations). Standard rating factors help the state minimize arbitrary variability between insurers’ rates and encourages competitive pricing practices among insurers.
Panelists also noted the importance – especially this year — of investments in outreach and education to teach consumers about the varying coverage levels of insurance plans now on the market. This is especially important given the expanded availability of short-term and association health plans that may confuse consumers.
Jane Beyer, senior health policy advisor to Washington State’s insurance commissioner, suggested the development of simple tables comparing coverage options (e.g., short-term plans, health care ministries, and broader qualified health plans) as important tools to educate ACA exchange navigators and other outreach workers as they help consumers purchase policies.
States that operate their own state-based marketplaces are uniquely positioned to support their individual markets through effective marketing and innovative consumer tools to help attract consumers.
- Mila Kofman, executive director of Washington, DC’s health insurance marketplace, stressed the importance of a local approach to marketing and outreach. Beyer touted the benefits of Washington State’s new marketplace app and “Smart Planfinder” decision tool that assists consumers in making informed decisions about their coverage options.
- Kate Harris of Colorado’s marketplace explained, “People wildly underestimate what they are eligible for.” She said Colorado is constantly evolving its outreach strategy to find new approaches to expand its reach to uninsured consumers.
- Wes Trexler, Idaho’s Department of Insurance Actuary and Bureau Chief of Product Review, cited his state’s systems control and its ability to create an integrated outreach and enrollment process for its consumers as big factors to its success.
Addressing Affordability through Reinsurance and Other Reforms
Affordability remains a huge threat to stable markets, especially among consumers earning more than 400 percent of the federal poverty level (FPL) and individuals earning less than 100 percent of FPL in non-Medicaid expansion states (see more on Medicaid below), who do not qualify for federal tax credits to purchase individual market coverage. Trexler said states must address the plights of individuals who fall into coverage gaps, including individuals who cannot afford their employer plans but do not qualify for tax credits and individuals who struggle with eligibility for subsidized coverage because of variability in their income throughout the year. As insurance rates rise, these individuals are increasingly priced out of the market and opt for no insurance coverage.
State-based reinsurance programs, instituted through 1332 state innovation waivers, have been successfully leveraged by some states to help reduce premium costs. A state’s reinsurance program pays insurers that take on higher-costs, enabling those insurers to lower their insurance premiums. The payments are funded through a combination of state funds and federal savings achieved from lower tax credit payments paid to subsidize the premiums of coverage sold through the state’s health insurance marketplace.
However, panelists raised concerns about the high costs of implementing state reinsurance programs, the sustainability of these programs, and the political challenge of getting legislation passed to submit a 1332 waiver. Some state officials expressed support for a federally-funded reinsurance program, which could help stabilize state markets and lower federal spending on tax credits.
States, faced with the prospects of market erosion from the emergence of short-term and association health plans, are contemplating options that will balance affordability with the need to keep a robust risk pool that includes healthy and sick; young and old. They are looking into other creative solutions to offer more affordable plans to their consumers.
Colorado recently passed legislation to support a study to use a 1332 waiver to allow for the sale of catastrophic health plans to individuals older than 30. Catastrophic health plans have low premiums, yet high out-of-pocket costs to consumers. Under the ACA, they are only available to individuals under age 30. By adding these plans to its individual market, Colorado plans to offer more affordable options to consumers. The law stipulates that catastrophic plans must be sold through the state’s health insurance marketplace and that Colorado would only pursue the waiver if the study finds that the expansion of catastrophic plans would not lead to overall premium increases OR decreases in tax credits received by consumers.
Under an executive order, Idaho is exploring granting greater flexibility to insurance carriers to sell products that do not comply with federal requirements under the ACA, but would be part of the individual market risk pool. Specifically, these plans would:
- Not meet pre-existing condition protections,
- Allow for a 5-to-1 age rating ratio, meaning that insurers can charge older enrollees up to five times as much for coverage as younger enrollees (the ACA sets this cap at a lower 3-to-1 ratio);
- Allow for annual coverage limits of no less than $1 million; and
- Allow year-round enrollment and not limit enrollment to special time periods).
As envisioned by Idaho’s Department of Insurance, these insurance products, called “state-based plans,” would complement ACA-compliant products. They would bring consumers into the state’s individual market, help to stabilize the risk pool, and force any insurer that sold a state-based plan to also sell a fully ACA-compliant product through the state’s insurance marketplace, thus encouraging product competition through the marketplace.
The Centers for Medicare & Medicaid Services (CMS) rejected the proposal, due to non-compliance with federal law. However, Idaho is continuing conversations with CMS to develop federally-compliant solution for its market.
During the conference session, state officials described a slew of other proposals they plan to explore to help stabilize their markets, including:
- Merging individual and small group markets;
- Forging stronger links between ACA-compliant qualified health plans and public programs (see Washington’s public-employee law described below);
- Providing state-funded subsidies for insurance in addition to federal tax credits; and
- Working with insurers to create more efficient plan design (e.g., changing benefit and network requirements).
Several panelists said it was important to ensure that future solutions do not undercut their individual markets — as new federal policies promoting market segmentation do (e.g., promulgation of short-term plans and health care ministries). Several states have explored implementing a state-based insurance mandate to help ensure that consumers continue to participate in their insurance markets to help stabilize their risk pools for all.
Washington, DC’s new mandate , for example, is modeled closely after the federal mandate, though it made small changes, such as including an automatic exemption for those eligible for Medicaid based on their income even if they were not currently enrolled in Medicaid. Under federal law, these individuals had to actively pursue an exemption, and would often not apply on time if at all. Money collected from the mandate will be used to fund additional affordability programs and coverage outreach initiatives. Washington State leveraged its state purchasing power to require that any insurer offering school or state employee coverage must also offer individual market plans in those counties through the state’s health insurance marketplace.
Medicaid’s Bearing on Individual Market Costs
A few panelists cited the positive effect that states’ decisions to expand Medicaid have had on their individual markets. In Medicaid expansion states, Medicaid eligibility is raised to 133 percent of FPL, meaning that individuals earning between 100 to 133 percent of FPL — who would otherwise be eligible for subsidies for private coverage through the health insurance marketplaces — are enrolled in Medicaid coverage. Studies indicate that Medicaid expansion states have better individual market risk scores than those that have not expanded coverage, suggesting that populations at lower-income thresholds are in poorer health than those at higher-income levels. This suggests that the individual market risk pool in expansion states is healthier, leading to lower overall costs in those markets.
Building on this concept, Idaho, a non-expansion state, explored a dual waiver program in which it would use an 1115 Medicaid waiver and a 1332 state innovation waiver to allow individuals earning below 100 percent of FPL to receive subsidies for coverage through its health insurance marketplace, while enrolling individual earning between zero to 400 percent of FPL with complex medical needs in Medicaid. The program would have enabled more individuals to access coverage, while lowering premiums for marketplace enrollees by taking those with unhealthy risk out of the individual market risk pool.
The proposal was ultimately rejected by Idaho’s state legislature in part due to concerns over costs to the state’s Medicaid program. However, supporters of expansion in Idaho have secured a ballot initiative so residents can vote on whether the state should expand Medicaid in November. Similar initiatives will also be on the ballot in Nebraska and Utah.
Future State Solutions
Challenges remain for states pursuing stabilization strategies. Several officials expressed hope the federal government would refrain from new actions that could de-stabilize markets or reduce state authority over markets, such as restricting state decisions on “silver-loading” to account for CSR losses. Some also expressed a desire for greater flexibility over 1332 waivers that could ease states’ ability to apply for waivers or allow more state experimentation. .
This remains a unique time for states, observed Washington, DC’s Mila Kofman, with consumer groups, insurers, and state policymakers united in their goal to enact policies that create more stable and affordable insurance markets.
NASHP will continue to closely monitor state strategies and report on their efforts to create stable and affordable markets.
In late March, Jessica Altman became Pennsylvania’s insurance commissioner, responsible for protecting consumers in the fifth-largest insurance market in the United States and the 14th-largest in the world.
Altman, who is vice chair of the National Academy for State Health Policy’s (NASHP) Health Care Access and Finance Steering Committee, helped implement the Affordable Care Act (ACA) when she worked at the Department of Health and Human Services’ Center for Consumer Information and Insurance Oversight. She joined Pennsylvania’s Insurance Department in 2015 as its chief of staff and served as acting commissioner since August of 2017.
Altman talked to NASHP recently about the evolving role of health insurance coverage in state and national politics, and how her own career trajectory has followed the evolution of health insurance as the country’s critical health care issue.
Q: How did you come to insurance regulation?
Health insurance is a critical part of the ACA, which fundamentally changed the way the health delivery system works in our country. Working on the ACA demonstrated to me the impact that government can have and the unique and critical role that insurance plays in each of our lives. No one likes to think about insurance – it is strange to invest time and money in something you hope you will never need – but it’s so important for the critical times in people’s lives, whether you need your health insurance for an illness, your car insurance after an accident, or your homeowners insurance following a fire. I have always wanted to be in public service, and when I moved from the federal government to the state level, what especially appealed to me was the consumer protection aspect of this job and the ability to work more directly with consumers and address the issues most important to them.
Q: How has the ACA worked in Pennsylvania?
In many ways, the ACA has been a huge success in Pennsylvania. Our uninsured rate is at an all-time low, and I believe there is a sense of financial security and access to coverage that did not exist before the ACA. When engaging in various communities, I have seen people cry tears of joy because they were able to find better health insurance coverage under the ACA today for thousands of dollars less than ever before. Pennsylvania’s exchange is also among the nation’s healthiest, with five major health insurers insuring about 400,000 residents.
Implementation of such transformative reform has not come without its challenges though, and state regulators are constantly responding to changes directed by the federal government, while implementing policies that we believe will mitigate any potential harm and be in the best interest of the people we serve. One example of our responsiveness is how states around the country recently dealt with President Trump’s decision to stop making payments to fund the cost-sharing reduction program. States found a way (the so-called “silver loading” strategy) to account for these costs by building them into health insurance rates, while actually helping consumers better afford more generous coverage because of the way the premium tax credit structure works.
Q: Does it surprise you that the ACA has had such a profound effect on the country’s health policy dialogue?
Yes and no. I am surprised by the magnitude of the ACA’s impact considering that much of the act focuses on reforming the individual and small group market, while leaving many areas of the system, and in fact the areas where the majority of Americans receive coverage, employer-sponsored coverage and Medicare, relatively unchanged. I think many people have a perception that the ACA reforms are broader than reality. I see this every year when we go through the rate review process, and I hear from many consumers their concerns about requested increases, only to find that most of them will not be impacted because they do not rely on the individual market for coverage. The individual market serves only about 5 percent of Pennsylvanians, and while it is an important and challenging market that we will continue to work to improve, most people are served by other areas of our system that are not experiencing the same volatility that the individual market is today.
Simultaneously, I am not surprised by the profound impact of the ACA because the act represents a fundamental shift in how our government approaches health care. It was a huge step in ensuring health care coverage is a right and not a privilege in this country. There is no doubt that the shift has come with some growing pains, but I believe it has also demonstrated that health insurance is a fundamental right and need, and government should play a role in it.
Q: Did you know how controversial the ACA would be years after its inception?
I was among the first hires to implement the ACA and we had only a few months to make decisions and implement the early regulations while scrambling to set up an organizational structure. When you’re in that environment, you don’t have time to think about how important the work is, but I did have moments when I thought about how friends and family members with pre-existing conditions would finally, for the first time in their lives, get affordable and high-quality insurance. Because of that, I always believed that the ACA would gain acceptance over time. There are many reasons why the ACA remains controversial today, from pieces of the law itself, to changes made to it over time, to just plain politics, but I remain hopeful that we can work together to embrace what is so good about the ACA while looking for solutions to what may not be working.
Q: Is having the country’s persistent debate about ACA important, despite its contentiousness?
Having a national dialogue about our health care system, who that system is working for and who it is failing, is unquestionably valuable. What is important is under the ACA, at the end of the day, is that no one must worry if they can get health insurance if they have a devastating need; it is now there for everyone who needs it. As changes have been discussed and made, I think the dialogue has instilled in people an appreciation for the necessity of coverage from a financial stability perspective, which is why the ACA has made such a difference. My hope is that this dialogue will help move us forward. We need to fix what needs to be fixed, and focus on the many other problems our health care system has, namely cost. The ACA gave us the assurance of coverage, but we have a long way to go to get to the assurance of truly affordable care. Let’s talk about that.
Q: Has it been hard to see the ACA dismantled by the Administration?
It has been incredibly disappointing. What was proposed in the ACA stabilization package (reinstatement of cost-sharing reduction subsidies for moderate- and middle-income residents and creation of reinsurance to help high-risk consumers) would have been a measurable benefit to state insurance markets around the country. I worry about the subset of the population [about 1 to 2 percent of Pennsylvanians] who depend on the individual markets and are not eligible for financial assistance. They’re not protected from decisions that have been made in Washington or from future decisions that may weaken the ACA and increase premium prices. But, I always have hope that those of us who have the privilege of serving the public will do whatever we can to protect insurance coverage and have a positive impact.
Q: What will be the impact of the “thin,” short-term policies that the Administration is proposing on state ACA marketplaces?
There are a number of different plans being talked about that don’t guarantee the comprehensive coverage that ACA provides, for example, coverage of essential health benefits, no discrimination against those with preexisting conditions, no caps on insurance limits, and the right to appeal if coverage is denied. I am working to be a source of accurate information in my state for the public, no matter what insurance choices they ultimately have. We will use the state laws we have to educate and protect consumers.
All insurance regulators around the country are concerned about the overall impact that these short-term policies will have on states’ individual markets if they are able to draw healthier people out of those major markets and drive up costs. Here in Pennsylvania, we don’t have laws or regulations that expressly address these short-term plans, but that will not prevent us from monitoring their impact on the market and looking for ways to mitigate negative impacts on those we serve. In particular, we have already revoked a number of licenses of insurance professionals who misrepresented these plans to consumers and will continue to ensure no consumer is misled about the coverage these plans provide – or do not provide.
Q: Do you have tools and responsibilities you didn’t expect to have as a commissioner given the dramatic changes in the national health insurance landscape?
I came into the job when the ACA already existed, but I know other regulators around the country have seen a huge transition. Insurance has historically, and by law, been a purely state-regulated industry. The ACA introduced a dual role, where the federal government has become a secondary regulator in addition to state regulators, and that has definitely been a challenge. Grappling with that will continue to be a challenge, and not limited to just health insurance – it’s true of other areas of insurance where the federal government plays a significant role, like flood insurance. State regulators are problem solvers and our job is to solve the problems facing our consumers. Because of this dual regulatory framework, we need the federal government to be a partner in solving those problems. Unfortunately, that is not what is happening today.
Q: How hard is it to be an insurance commissioner in this era when you need to quickly respond to sudden federal changes to the ACA coverage?
Insurance regulators have always had to mobilize quickly and respond to emergencies such as floods, fires, or earthquakes by getting on the ground and helping the consumers we are here to protect. However, we would much rather focus on those natural disasters than disasters coming due to eleventh-hour and late-breaking decisions from the federal government.
Historically, before the ACA, we only had state-regulated insurance markets, but with these decisions coming from the federal level where sometimes the only role we are able to play is to mitigate a decision that we were not part of making, it’s very frustrating. But, it is rewarding is to be on the ground and indeed try to mitigate those situations.
Q: Do you see your job changing in the months and years ahead?
We have a lot of work to do to monitor numerous things that are coming our way to shape our markets, for example, the potential proliferation of association or short-term health insurance plans. In addition to consumer protection, my department’s role is to serve as a trustworthy source of information, and we’ve been doing much more to be proactive and inform consumers about these issues. When the federal government curtailed insurance market sign-ups and enrollment time, we launched our own coalition of elected officials, insurers, citizen groups, and health care providers to make clear to consumers what was happening, and what the time limit for marketplace sign-up was. I see that effort continuing.
Q: How does being part of NASHP help you in your job?
I’m a big believer in states learning from each other, from what they have done and brainstorming what we can do. It is invaluable to have credible data and state leaders from around the country get together to talk about different approaches and experiences and do it in a nonpartisan and slightly wonky way. That’s incredibly valuable for us who take the time to take advantage of it.
We insurance regulators have the National Association of Insurance Commissioners that plays an irreplaceable role in convening state regulators and facilitating thought and action on national issues facing the insurance industry and the regulatory community, but to have the additional opportunity to meet and talk with state leaders from departments of human services, Medicaid, and other health care systems who have different perspectives allows us to better engage in a comprehensive discussion of state health care policy.
Q: Your governor is proposing integrating the Department of Human Services with the Department of Health to improve efficiency and innovation. Where does your department fit into improving overall improvement of health care delivery?
I am privileged to serve alongside a group of cabinet members who lead Pennsylvania’s health and human services agencies, including my predecessor Teresa Miller, who value collaboration and are committed to taking a unified and coordinated approach to Pennsylvania’s most pressing health care issues. As we look to combat the opioid crisis, to find value in our health care system, to improve health in our rural communities, and deal with the many other issues all state health officials are facing, having the level of communication and partnership that we do is a major asset. We all have different levers and priorities and strategies for our own agencies or constituencies, but doing that in a way that we are all moving in the same direction and with the same ultimate goals in mind is going to mean we get there faster and, at the end of the day, hopefully achieve better outcomes.
- As of July 1, 2011, there were 2,134,956 individuals enrolled in the state’s Medicaid program, known as Medical Assistance; 1,152,069 of these individuals received physical and dental services through one of 12 Medicaid-only managed care organizations through the state’s managed care program, HealthChoices.
- 302,300 Medical Assistance recipients not served by HealthChoices received physical health services through the primary care case management (PCCM) program ACCESS Plus.
- Mental health and substance use disorder services are provided through 34 prepaid inpatient health plans.
- 454,519 Medicaid beneficiaries also received services through a transportation-only prepaid ambulatory health plan (PAHP).
- Medicaid-eligible children may receive services through the following waiver programs:
- Consolidated Waiver for Individuals with Intellectual Disability, which provides a variety of services to promote community living for individuals over the age of three who would be recommended for an intermediate care facility level of care;
- Infant, Toddlers, and Families Waiver, which provides Early Intervention and habilitation services to children from birth to age three who would otherwise require an intermediate care facility for persons with mental retardation or other related conditions level of care.
Pennsylvania Medical Assistance Regulations define a “medically necessary” service, item, procedure, or level of care as “one that
|Initiatives to Improve Access
||Modified School Health Services
Forty-two school districts in Pennsylvania have modified school health services programs, which allow certified nurse practitioners to be paid directly for EPSDT screens.
|Reporting & Data Collection|
Behavioral health services provided by the Pennsylvania Medicaid program are administered at the county level by Mental Health and Developmental Services (MH/DS) program offices on a fee-for-service basis or by a HealthChoices behavioral health MCO.
Behavioral health plans provide inpatient and outpatient psychiatric care, drug and alcohol treatment, family-based mental health treatment for children, and mental health case management. One behavioral health plan operates in each county in Pennsylvania; contact information for each behavioral health plan is available on the HealthChoices enrollment website.
Guidelines for Best Practice in Child and Adolescent Mental Health Services
The Pennsylvania Medicaid agency published a report, “Guidelines for Best Practice in Child and Adolescent Mental Health Services,” which includes checklists for EPSDT mental health submissions, expected practices, and suggested approaches for obtaining service approvals in managed care.
|Support to Providers and Families||
Support to Providers
Pennsylvania Medicaid operates a Medical Assistance page for providers, which includes information on managed care programs, regulations and handbooks, bulletins, and fee schedules.
HealthChoices plans are required to offer EPSDT training to any provider who serves members under age 21.
Support to Families
HealthChoices operates an enrollment website for beneficiaries that offers information on how to enroll, how to find a provider, and benefits and services.
MCOs participating in HealthChoices are required to “ensure seamless and continuous coordination of care across a continuum of services for the individual member with a focus on improving health care outcomes.”
HealthChoices plans are required to establish Special Needs Units (SNU) and employ a Special Needs Coordinators to deal with issues relating to members with special health care needs, ensure access for these members to PCPs, dentists, and specialists, and coordinate care across settings. Plans must also employ a maternal health/EPSDT coordinator to coordinate maternity, prenatal, and EPSDT services.
Medical Assistance recipients in the ACCESS Plus program are assigned a primary care provider (PCP) who serves as the recipient’s medical home. PCPs coordinate care, direct recipients to specialty services, and provide intensive case management for delivery of disease-specific care and monitoring.
As part of the Chronic Care Initiative (CCI), Pennsylvania launched medical homes in seven regions across the state. In phase I (2008-2011), participating practices were encouraged to focus on diabetes and pediatric asthma.
For more information on medical homes in Pennsylvania, see NASHP’s medical homes map page.
||Pennsylvania Medicaid operates a dental information page for recipients and their families, which includes information on eligibility, when to visit the dentist, and which provider a beneficiary is able to see based on the Medical Assistance program he or she is enrolled in.|
Tuesday, July 29, 2014
1:00 – 2:15 pm ET
View Webinar Here
This webinar explores the leap from health system transformation planning to practice by showcasing four leading states that are designing and implementing multi-payer payment reforms. Through a facilitated discussion, state officials discuss policy levers to shift payment systems away from fee-for-service, offer strategies for sustaining stakeholder momentum and commitment, and share perspectives on promising practices for and operational challenges of turning a plan for multi-payer payment reform into reality.
This webinar is the first in a six-webinar series, supported by Kaiser Permanente Community Benefit, highlighting specific policy and technical issues critical to achieving multi-payer payment reform. It is useful for all states contemplating, designing, or implementing multi-payer payment reforms, particularly SIM Round 2 Model Design applicants.
- Moderator: Anne Gauthier, Senior Program Director, NASHP
- Marcela Myers, Director, Pennsylvania Center for Practice Transformation and Innovation, Pennsylvania Department of Health; Pennsylvania SIM Project Director
- Karen Matsuoka, Director, Health Systems and Infrastructure Administration, Maryland Department of Health and Mental Hygiene; SIM Project Director
- Mark Schaefer, Director, Healthcare Innovation, Connecticut’s Office of the Healthcare Advocate; Connecticut SIM Project Director
- Vatsala Kapur Pathy, Founder, Rootstock Solutions; Colorado SIM Project Director
Primary care practices transitioning to enhanced models of primary care require ongoing support to sustain their transformation efforts. Small and medium-sized practices in particular can benefit from shared resources facilitating care coordination and case management, use of data and technology, and ongoing practice improvement. This State Health Policy Briefing outlines key elements of a shared infrastructure to sustain primary care transformation, identifies policy levers available to federal and state policymakers to support these elements, and highlights relevant initiatives at both levels of government. It also summarizes key areas for policy improvement identified during a meeting of federal and state officials convened by NASHP.
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Primary care extension programs improve the quality of primary care services by educating providers on new and innovative practices in areas such as preventive medicine, health promotion, and chronic disease management. Section 5405 of the Affordable Care Act authorizes the establishment of a national primary care extension program. To pursue this goal, the Agency for Healthcare Research and Quality (AHRQ) established the Infrastructure for Maintaining Primary Care Transformation (IMPaCT) initiative as a pilot to build on states with strong existing extension programs to serve as a potential model for a national extension program.
This webinar will feature a high-level overview from each of the four lead IMPaCT states (New Mexico, North Carolina, Oklahoma and Pennsylvania) that highlights key components of their extension models. Following the overviews, a facilitated discussion with state officials from these states will illuminate the role of, and implications for, state agencies in this work. Following the discussion, participants will have the opportunity to ask questions of the speakers.
- Bob Mcnellis, Senior Advisor for Primary Care, Agency for Healthcare Research and Quality (AHRQ)
- Darren DeWalt, MD, MPH, Associate Professor of Medicine, Division of General Internal Medicine, University of North Carolina – Chapel Hill
- Robert Gabbay, MD, PHD, Chief Medical Officer and Senior Vice President, Joslin Diabetes Center
- Art Kaufman, MD, Vice Chancellor for Community Health; Distinguished Professor, Family & Community Medicine, University of New Mexico Health Sciences Center
- Jim Mold, MD, MPH, Director, Research Division, Department of Family and Preventive Medicine, University of Oklahoma Health Sciences Center
- Chris Collins, MSW, Director, Office of Rural Health and Community Care, North Carolina Department of Health and Human Services
- Marcela Myers, MD, Director of Pennsylvania Center for Practice Transformation and Innovation, Pennsylvania Department of Health
- Garth Splinter, Medicaid Director, Oklahoma Health Care Authority
|Download Webinar Slides||4.7 MB|
Pennsylvania’s Chronic Care Initiative (CCI) began as a project of the state’s Chronic Care Commission, which former Governor Ed Rendell created by Executive Order in 2007. Phase I of CCI (2008-2011), which combines elements of Wagner’s Chronic Care Model and the patient-centered medical home, was staged in seven regional rollouts. The program model varied regionally during Phase I, with differences over requirements to obtain NCQA medical home recognition, payments to practices, and other features. The Southeast Pennsylvania region was the first to launch, beginning with a learning session in May 2008. Six payers participated in the Southeast rollout, and practices were encouraged to focus on diabetes and pediatric asthma. Subsequent rollouts in other regions of the state followed similar models. As subsequent regions launched, the state refined the programs on the basis of lessons learned, and added components, such as shared savings. Four of the seven rollouts featured ongoing enhanced reimbursement from multiple payers. Three offered more limited assistance, without ongoing payment for medical home expenses.
Medicare joined CCI as a payer in two regions through the MAPCP Demonstration on January 1, 2012, launching Phase II of the initiative. Phase II features a single payment methodology for the Northeast and Southeast Pennsylvania regions, as well as coordinated requirements and learning collaborative activities for participating practices. In conjunction with a change in governor’s administration in 2011, oversight of the program has moved to the Pennsylvania Department of Health.
Federal support: Pennsylvania is one of the eight states selected to participate in the Medicare Advanced Primary Care Practice (MAPCP) demonstration program.
Also, 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 Chronic Care Commission, which developed the Chronic Care Initiative (CCI), included representatives from the following groups:
|Defining & Recognizing a Medical Home||
Pennsylvania has adopted the Joint Principles of the Patient-Centered Medical Home as the state’s medical home definition.
The Chronic Care Initiative (CCI) requires practices to achieve National Committee for Quality Assurance (NCQA) Level 1 recognition, as well as certain otherwise optional standards at specified levels of performance. As practices’ NCQA 2008 recognitions expire, they are required to achieve obtain recognition under the NCQA 2011 standards.
|Aligning Reimbursement & Purchasing||
Under Phase I, different rollouts of the Chronic Care Initiative (CCI) in Pennsylvania tested different payment models, including lump sum payments to practices to cover start-up infrastructure costs, per member per month payments, and shared savings. Enhanced payments were stratified by practice recognition, with higher level practices receiving greater enhanced payment than lower level practices. From 2009 to 2011, the state’s contracts with Medicaid managed care organizations (MCOs) required MCOs to participate in CCI; this requirement was removed prior to the start of CCI Phase II in January 2012.
Under Phase II, practices receive per member per month (PMPM) payments from participating payers, including Medicare, Medicaid MCOs, and Medicaid fee-for-service. The amounts of these PMPM payments will vary by initiative year and patient age. Payers are making two PMPM payments to practices:
Year 1: $0.60
Year 2: $0.51
Year 3: $0.43
Year 1: $1.50
Year 2: $1.28
Year 3: $1.08
Year 1: $5.00
Year 2: $4.25
Year 3: $3.61
Year 1: $7.00
Year 2: $5.95
Year 3: $5.06
Practices are eligible for shared savings payments that will take into consideration practice performance on key quality metrics, including diabetes and hypertension management, as well as utilization and cost metrics. As the PMPM amounts decrease from Year 1 to Year 3, practices will be eligible for greater shares of any savings: 40% in Year 1, 45% in Year 2, and 50% in Year 3.
|Supporting Practices||The Chronic Care Initiative (CCI) rollouts have provided for learning collaboratives, including funding to cover lost time and revenue when providers and practice staff were out-of-office. CCI has also provided web-based patient registries and practice coaching. Under Phase II, the Department of Health is leading the learning collaboratives, holding monthly group calls for all practices, and overseeing practice transformation consulting. Practices are asked to regularly submit clinical data for quality improvement purposes. Priorities for further practice transformation have also been identified.|
|Measuring Results||The Commonwealth Fund funded researchers at RAND and Harvard School of Public Health to conduct an evaluation of Phase I of the Chronic Care Initiative (CCI). The Centers for Medicare & Medicaid Services (CMS) is evaluating the impact of the Phase II CCI on outcomes for Medicare patients through a contract with RTI International. NASHP and the Urban Institute are subcontractors to RTI. Final evaluation results are not yet available, but the state has seen promising improvements in process measures as determined by Pennsylvania’s Improving Performance in Practice (IPIP) program.|
Under construction–NASHP is continuing to populate this resource so please check back!
If you have any resources about the Medicaid benefit for children and adolescents in your state that you would like to share, please email firstname.lastname@example.org.
One of the most critical steps in developing and implementing a multi-payer medical home initiative is securing health care payer and purchaser participation. This new NASHP brief discusses five overarching strategies that conveners can use to make the case: building trust among competitors; leveraging existing infrastructure; using the market to drive demand; striking the balance between flexibility and consistency; and illustrating the value of the model. The Commonwealth Fund provided support for the development of this issue brief.
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