rwjf-tag: Delivery system reform and payment models

Young, G.J. (2017, February). Hospitals in the post-ACA era: Impacts and responses. New York, NY: Milbank Memorial Fund.

This brief looks at the ways the Affordable Care Act sought to change hospitals, how hospitals are responding to these pressures, and resulting considerations for state policymakers. Of particular interest are increased hospital-provider consolidation activity, hospital participation in value-based care arrangements, and expectations for hospitals to play an increasing role in improving community health. This… Read more »

Tanenbaum, S.J. (2017). Can payment reform be social reform? The lure and liabilities of the “Triple Aim.” Journal of Health Politics, Policy, and Law, 42(1), 53-71.

This article analyzes the potential of the health care system to achieve the triple aim and, specifically, the attempt to improve population health by rewarding providers who contain costs. The first section of the article considers the task of improving population health through the health care system. The second section discuss the Center for Medicare… Read more »

Solomon, L.S., & Kanter, M.H. (2018). Health care steps up to social determinants of health: Current context. Permanente Journal, 2018(22), 18-139.

This article provides an overview of what the role for the United States’ health care system is in addressing the social determinants of health, how to create the right policy context for innovation, and how healthcare can partner more effectively with providers of social services to meet patients’ most pressing needs given the fragmented, typically… Read more »

Sharfstein, J.M., Gerovich, S., Moriarty, E., & Chin, D.C. (2017, August 16). An emerging approach to payment reform: All-payer global budgets for large safety-net hospital systems. Washington, DC: The Commonwealth Fund.

This article assesses the feasibility and likely outcomes of implementing global all-payer budgets in hospital systems in the United States, particularly in large safety-net hospital systems. The article reviews this concept based on the experiences of global hospital budgeting programs implemented in Maryland and planned for Pennsylvania. The article concludes that to be successful, all-payer… Read more »

Robert Wood Johnson Foundation. (2019, February). Medicaid’s role in addressing social determinants of health (Briefing series: Key Medicaid issues for new state policymakers). Princeton, NJ: Author.

This brief discusses three issues for state policymakers to consider as they implement strategies to address social determinants of health and aim to integrate such efforts into delivery of health care. Namely, state officials should consider: 1) covering selected non-medical services; 2) integrating social supports into health plan care management; and 3) using value-based payments… Read more »

McGinnis, T., Crumley, D., & Chang, D. (2018, May). Implementing social determinants of health interventions in Medicaid managed care: How to leverage existing authorities and shift to value-based purchasing. Washington, DC: Academy Health.

This brief illustrates how states can use existing Medicaid authority to finance innovative upstream prevention and population health initiatives. In 2017, Nemours Children’s Health System contracted with the Center for Health Care Strategies (CHCS) to work with the PacificSource Columbia Gorge Coordinated Care Organization (CCO), a regional Medicaid payer operating as the sole managed care… Read more »

Machledt, D. (2017, November 29). Addressing the social determinants of health through Medicaid managed care. Washington, DC: The Commonwealth Fund.

This brief explores the impact of several provisions of the Centers for Medicare and Medicaid 2016 updated Medicaid managed care rule’s influence states’ ability to address social determinants of health through managed care. Several provisions in the new Medicaid managed care rule signal CMS’s intent to increase access to high?value nonmedical interventions. For instance, the… Read more »

Hostetter, M., Klein, S., & McCarthy, D. (2018, May 20). Vermont’s bold experiment in community-driven health care reform. Washington, DC: The Commonwealth Fund.

This article describes how OneCare, a large accountable care organization (ACO) in Vermont, addresses the social needs of its beneficiaries, under Vermont’s Blueprint for Health. The Blueprint for Health, a statewide initiative, compels public and private payers to support nurses, social workers, community health workers, and others working to help patients manage their chronic conditions,… Read more »

Heeringa, J., Lipson, D., Machta, R., Lane, K., & Vogt, R. (2018, January). Designing Medicaid Delivery System Reform Incentive Payment demonstrations to reward better performance. Baltimore, MD: Centers for Medicare and Medicaid Services.

This brief describes differences in incentive design features of six Delivery System Reform Incentive Payment (DSRIP) demonstrations and assesses their strengths and limitations in promoting provider participation in delivery system reform and value-based payment (VBP) arrangements. While the effects of DSRIP incentive designs on outcomes are not yet known, this study finds that differences in… Read more »

Georgia Health Policy Center & Robert Wood Johnson Foundation. (2016, October). Financing population health: abridge version. Atlanta, GA: Andrew Young School of Policy Studies, Georgia State University.

This report describes innovations in financing that can be used to improve population health. Eight innovations are described, with examples of each provided: 1) capture and reinvest; 2) blending and braiding; 3) community development financial institutions; 4) hospital community benefits; 5) low-income housing tax credits; 6) new market tax credits; 7) social impact bonds; and… Read more »

Felland, L., Lipson, D., & Heeringa, J. (2018, April). Examining New York’s Delivery System Reform Incentive Payment demonstration: Achievements at the demonstration’s midpoint and lessons for other states. Baltimore, MD: Centers for Medicare and Medicaid Services.

This brief examines New York’s Delivery System Reform Incentive Payment (DSRIP) demonstration. This demonstration, authorized by a Medicaid section 1115 waiver, is an ambitious and complex effort to transform the health care delivery system, reduce cost growth, and improve care outcomes for Medicaid beneficiaries and uninsured individuals. The demonstration involves thousands of health care providers… Read more »

Daniel-Robinson, L, & Moore, J.E. (2019, January). Innovation and opportunities to address social determinants of health in Medicaid managed care. Washington, DC: Institute for Medicaid Innovation.

This article identifies opportunities within the Medicaid program to identify and address the unmet social needs and risk factors that have a significant impact on health outcomes and costs. With access to enrollee health data, Medicaid managed care organizations (MMCOs), with the support of state Medicaid agencies and community-based organizations (CBOs), are well positioned to… Read more »

Crumley, D., Lloyd, J., Pucciarello, M., & Stapelfield, B. (2018). Addressing social determinants of health via Medicaid managed care contracts and section 1115 demonstrations. Hamilton, NJ and Washington, DC: Center for Health Care Strategies, Inc. & the Association for Community Affiliated Plans.

This report examines Medicaid managed care contracts or requests for proposals (RFPs) in 40 states, in addition to 25 approved section 1115 demonstrations. Incentives and requirements related to the social determinants of health (SDH) are compiled, common themes in the states’ approaches are identified, and recommendations are developed for federal policymakers, including the Centers for… Read more »

Cantor, J., Mikkelsen, L., Simons, B., & Waters, R. (2013, January). How can we pay for a healthy population? Innovative new ways to redirect funds to community prevention. Oakland, CA: Prevention Institute.

In this brief, four promosing approaches for sustainably generating resources to pay for community prevention within and outside the health care system are described: wellness trusts, social impact bonds/health impact bonds, community benefits from non-profit hospitals, and Accountable Care Organizations. These approaches represent those that stood out based on a broad scan of the academic… Read more »

Bush, M. (2018). Addressing the root cause: Rising health care costs and social determinants of health. North Carolina Medicine Journal, 79(1), 26-29.

This article describes how North Carolina plans to use its Medicaid expansion to address social determinants of health. The expanded Medicaid is designed to convert North Carolina’s fee-for-service program into a managed care health delivery system, with managed care organizations (MCOs) controlling costs by managing overall population health for beneficiaries through lump sum payments that… Read more »

Bachrach, D., Guyer, J., Meier, S., Meerschaert, J., & Brandel, S. (2018, January 31). Enabling sustainable investment in social interventions: A review of Medicaid managed care rate-setting tools. Washington, DC: The Commonwealth Fund.

This article explores practical strategies that states can deploy to support Medicaid managed care plans and their network providers in addressing social issues using a literature review, interviews with stakeholders, and analysis of federal regulations. The following strategies were identified: 1) classify certain social services as covered benefits under the state’s Medicaid plan; 2) explore… Read more »

Artiga, S., & Hinton, E. (2018, May). Beyond health care: The role of social determinants in promoting health and health equity. Menlo Park, CA: The Henry J. Kaiser Family Foundation.

This brief provides an overview of social determinants of health and emerging initiatives to address them. It shows: 1) social determinants of health include factors like socioeconomic status, education, neighborhood and physical environment, employment, and social support networks, as well as access to health care; 2) there are a growing number of initiatives to address… Read more »

American Hospital Association. (2019, January). Medicaid financing for interventions that address social determinants of health. Chicago, IL: Author.

This paper is intended to inform hospitals and health systems about these opportunities as they work with state Medicaid agencies, policymakers and health plans on ways to make financial support available for promising interventions. Medicaid financing can be an important source of support, though it is only one part of the puzzle. This paper identifies… Read more »

Onie, R. (2018). Integrating social needs into health care: A twenty-year case study of adaptation and diffusion. Health Affairs. 37(2): 240-247.

The US health care system has recently begun to account for patients’ unmet social needs in care delivery and payment reform. This article presents a twenty-year qualitative case study of five stages of diffusion—testing and learning, standardization, replication, shifting from doing to enabling, and catalyzing broad adoption—of a practical approach for integrating social needs into… Read more »

Dzau, V.J., McClellan, M.B., McGinnis, J.M., Burke, S.P., Coye, M.J., Diaz, A., … Daschle, T.A. (2017). Vital directions for health and health care: Priorities from a National Academy of Medicine initiative. Journal of the American Medical Association, 317(14), 1461-1470.

This article sought to review the most salient health challenges and opportunities facing the United States, to identify practical and achievable priorities essential to health progress, and to present policy initiatives critical to the nation’s health and fiscal integrity. Through a qualitative synthesis of the National Academy of Medicine white papers, authors found that the… Read more »

Gray, E.M., & Aronovich, R. (2016, April). Producing an ROI with a PCMH: Patient-centered medical homes can deliver high-quality care and produce a healthy ROI for organizations that are willing to invest the time and effort required to plan for the transition and maintain the model. Healthcare Financial Management, 70(4), 7479.

This article examines how patient-centered medical homes (PCMH) can produce a return on investment (ROI). As organizations transition to and engage in this model of care, it is imperative that they fully consider all the financial and temporal requirements that must be addressed to successfully develop and operate a PCMH. Organizations also should explore the… Read more »

Moody, G. (2012). Ohio Health and Human Service Transformation. Presentation to the Center for Evidence Based Practice, Case Western University.

This presentation outlines Ohio’s plan for health and human service transformation under the ACA. Ohio’s vision includes: creating a person‐centered care management approach – not a provider, program, or payer approach; services are integrated for all physical, behavioral, long‐term care, and social needs; services are provided in the setting of choice; services are easy to… Read more »

Goolsby, L., & Levin, B. (2012). A framework for alternative human service financing. Policy & practice, 70(5).

This article describes how leaders from the American Public Human Services Association (APHSA) are examining ways to move human services away from its current unsustainable trajectory and toward viable new funding options, including blending or braiding program funds; supplementing public funds with investments from the private and philanthropic sectors; and other funding alternatives that would… Read more »

Golden, O. (2013, June). New perspectives on transforming states’ health and human services: Practical commentaries on the first year of the work support strategies initiative. Washington, DC: Urban Institute.

In this commentary collection, twelve authors – national, state, and county leaders along with research and policy experts — offer perspectives on lessons from the first year of Work Support Strategies (WSS). WSS is a multi-state initiative to design and test cutting-edge improvements in policy, service delivery, and technology to help low-income working families get… Read more »

Golden, R., & Shier, G. (2012). Innovating for improved care transitions. Journal of the American Society on Aging, 36(4), 91-93.

This report describes the Community-Based Care Transitions Program (CCTP) which was created to involve social services or home and community providers in providing transition services for patients as they move from one setting to another. Examples of successful partnerships including links to websites of each for more detailed information are provided as well as description… Read more »

Boris, E.T., de Leon, E., Roeger, K.L., & Nikolova, M. (2010). Contracts and grants between human service nonprofits and governments. Washington, DC: Urban Institute.

This brief summarizes results of the 2010 National Survey of Nonprofit-Government Contracting and Grants, a study of human service organizations designed to document the extent of nonprofit-government contracting, processes and problems. It also examines the impact of the recession on these organizations and the cutbacks they have made to keep their programs operating. While contracting… Read more »

Bachrach, D., Pfister, H., Wallis, K., & Lipson, M. (2014). Addressing patients’ social needs: An emerging case for provider investment. New York, NY: The Commonwealth Fund.

This report explores the impact of social factors on patient health and health care costs, and the growing relevance of such factors in today’s health care environment. Informed by published research and interviews with more than 25 experts, we point out the direct and indirect economic benefits that may inure to providers who address patients’… Read more »

The Menges Group. (2014, June). Positively impacting social determinants of health: How safety net health plans lead the way. The Association for Community Affiliated Plans.

This report seeks to follow the five key areas of social determinants as outlined by Healthy People 2020, an initiative by the Department of Health and Human Services. The report describes programs in which the Association for Community Affiliated Press (ACAP) health plans are innovatively and positively impacting the other key areas of social determinants… Read more »

Prevention Institute. (2013, February). Opportunities for advancing community prevention in the State Innovation Models initiative [Memo]. Oakland, CA: Author.

This memo argues that State Innovation Models (SIM) represent an opportunity for states to refocus their healthcare systems in ways that reduce costs and improve outcomes, with a focus on prevention at the population level. To do so, the following are needed: data collection tools; expanded workforce capacity, including the training and incorporation of “navigators”… Read more »

Sandberg, S.F., Erickson, C., Owen, R., Vicerky, K.D., Shimotsu, S.T., Linzer, … DeCubellis, J. (2014). Hennepin Health: A safety-net accountable care organization for the expanded Medicaid population. Health Affairs, 33(11), 1975-1984.

This article examines Hennepin Health, a health system which place places all participants in a full risk-sharing agreement. Key to Hennepin’s success (improved health outcomes, reduced costs) was their investment in their healthcare workforce; leadership and collaboration; and a favorable policy environment within the state. Medicaid program rules limited what Hennepin is able to fund… Read more »

Ormond, B., Richardson, E., Spillman, B., & Feder, J. (2014). Health homes in Medicaid: The promise and the challenge. Washington, DC: Urban Institute.

This article examines potential benefits and challenges with the Medicaid health homes model. Challenges include: short time frames to see reform efforts; meaningful cultural change needed among providers in order for collaboration to be successful; communication is technically, legally, and operationally complex; and information-technology systems to facilitate meaningful information sharing require capital and human resource… Read more »

Klein, S., McCarthy, D., & Cohen, A. (2014). Health Share of Oregon: A community-oriented approach to accountable care for Medicaid beneficiaries. New York, NY: The Commonwealth Fund.

This report describes Health Share, a Coordinating Care Organization (CCO) in Oregon, which distributes capitated payments to member organization, which have agreed to bear the risk in providing services and access to a given population. Health Share earned 100% of its incentive pool, suggesting a very successful effort and can be considered as a model… Read more »

Galloway, I. (2014). Using pay-for-success to increase investment in the nonmedical determinants of health. Health Affairs, 33(11), 1897-1904.

This article discusses how fee for service models encourage treating illness and discourage spending to address social determinants of health. Social Impact Bonds and similar mechanisms can help bring dollars into the sector while ensuring that public reimbursements only go to successful programs. However, public agency data sharing is needed to support these efforts.

Crawford, M., McGinnis, T., Auerbach, J., & Golden, K. (2015). Population health in Medicaid delivery system reforms. New York, NY: Milbank Memorial Fund.

This issue brief focuses on strategies that inform Accountable Care Organization (ACO) design and governance structures, program components, metrics, and information-sharing mechanisms—and it includes some promising early examples of states working to embed population health strategies in Medicaid ACOs. It highlights both the challenges states have faced and the strategies that have been used. It… Read more »

Abrams, M., Nuzum, R., Zezza, M., Ryan, J., Kiszla, J., & Guterman, S. (2015). The Affordable Care Act’s payment and delivery system reforms: A progress report at five years. New York, NY: The Commonwealth Fund.

In addition to its expansion and reform of health insurance coverage, the Affordable Care Act (ACA) contains numerous provisions intended to resolve underlying problems in how health care is delivered and paid for in the United States. These provisions focus on three broad areas: testing new delivery models and spreading successful ones, encouraging the shift… Read more »

New York Department of Health Medicaid Redesign Team. (2015). A path toward value based payment: New York state roadmap for Medicaid payment reform. Albany, NY: New York Department of Health.

This report examines the New York DSRIP process. This roadmap is a multiyear plan for comprehensive Medicaid payment reform including how the State will amend its contracts with Managed Care Organizations. This Roadmap was developed as a living document. It is not a blueprint; but rather attempts to demonstrate the State’s ambition and the elements… Read more »