TEN TRANSFORMATIVE TRENDS 2021 On the Policy Front, Lots of Action at the
State Level Several states are joining Vermont and Maryland in long-term ambitious efforts to transform care and control costs By David Raths
to issues where there is bipartisan agree- ment over the next few years. But state governments are being more active in innovating in their Medicaid programs and in seeking to control total cost of care at the state level, and that work is expected to accelerate. Jay Want, M.D., executive director of the New York-based Peterson Center on Healthcare, says his organization’s phi- losophy is that while they like to see work at the state level, there’s a role for the federal government to enable state action. “If we’re not going to have a sweeping kind of reform across all 50 states, at least make it easier for states to act,” he says. Previously, the federal government has used State Innovation Model (SIM) grants that allowed for experimentation
W
ith the U.S. Senate evenly divided, federal-level healthcare policy legislation may be limited
continue, or that it shouldn’t continue,” Hughes says. States have quite a few levers that they may not fully appreciate, she adds. One is around their conven- ing ability. “If it’s a governor’s priority or a really prominent agency’s priority to drive change, that’s a powerful tool to bring people to the table to work together.”
On the other hand, Hughes notes, state governors have four-year terms and that is a short window to implement a policy and see change. Stakeholders may won- der if the next administration will have the same priorities. Also, if legislative or regulatory change is required to support a new payment and delivery model, that’s going to take a long time. When it comes to converting policy design to operation- alization at the state level, Hughes says, leadership, resources and time are all necessary to get something off the ground,
“If we’re not going to have a sweeping kind of reform across all 50 states, at least make it easier for states to act.” —Jay Want, M.D.
disparities and population health needs. As the Peterson Center looks for states to work with on payment innovation, data assets are important. “If you have an all- payer claims database (APCD), that’s ideal. It doesn’t exclude you from working with us if you don’t, but without one it’s a lot harder to,” Want says. (Approximately 20 states have APCDs currently, he adds.) “We also look for leadership from the governor or somebody in the governor’s office. There has to be state leadership that has its own reasons for trying to examine this, and then we look for places that have to have some history of col- laborative action in the past. Colorado is an example of a state where it’s a pretty small healthcare community — every- body pretty much knows everybody else. Rhode Island, where we’ve done recent work, is that way, too.”
and infrastructure building. In addition, Medicaid Section 1115 waivers are use- ful jn terms of allowing experimentation, Want adds. Lauren Hughes, M.D., is state policy
director of the Farley Health Policy Center at the University of Colorado Anschutz Medical Campus and associate professor of family medicine in the University of Colorado Department of Family Medicine. She says states serve as valuable health policy laboratories. “That’s where the innovation has been taking place and I don’t see any reason why that won’t
as well as a culture of collaboration. In a previous position, Hughes helped set up the Rural Health Model in Pennsylvania, an alternative payment model transitioning rural hospitals from a fee-for-service model to a global budget payment. “There are no other models like it, and innovation in rural communities is perhaps more difficult than in urban settings, in large part because your risk calculation is very different — you have smaller populations over which to spread risk,” she says. Also, there is a digital divide, and greater underlying health
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The New England States Consortium Systems Organization (NESCSO) is seeking to standardize measurements of primary care spending across six states, taking advantage of the APCDs in those states. One goal is to build on early evi- dence that an increased percentage of total payments invested in primary care is associated with improved quality, uti- lization and cost outcomes.
A focus on equity in Pennsylvania In Pennsylvania, an Interagency Health Reform Council (IHRC) recently rec- ommended the creation of a Health Value Commission that would set cost benchmarks and monitor payer and provider performance relative to those
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