TEN TRANSFORMATIVE TRENDS 2021 State Policy continued from page 28
benchmarks. The idea would be to set healthcare cost growth targets annually as well as spending targets for behavioral health, primary care and value-based purchasing, because the focus is on whole-person health reform, says Douglas Jacobs, M.D., the chief innovation officer of the Pennsylvania Department of Human Services.
Pennsylvania already has the Rural Health Model — a global budget model like they have in Maryland, but that’s only in rural settings. “It doesn’t include urban and suburban settings, so we are looking at ways that we can identify urban and suburban counterparts, and eventually perhaps get to a statewide model,” Jacobs says, “but I think we’re not there yet.” The IHRC recommendations include aligning physical and behavioral health measures across state agencies and other payers. In addition to his role as chief innovation officer at DHS, Jacobs still sees patients regularly. “If I see seven patients in my clinic and they all have different insurers, each one of those insurers is focused on different quality measures, and they’re all likely rewarding for differ- ent things,” he explains. “It’s really hard for any provider group to know how they can move forward with population health when they have got one foot in seven dif- ferent canoes. Multi-payer alignment is what really drives the healthcare system forward.”
In working with Medicaid man- aged care organizations (MCOs), the Commonwealth has built in requirements around reducing specific racial inequi- ties and building ties to community- based organizations. “We’ve seen these
to prenatal care and well child visits in the first 15 months of life,” Jacobs says. He adds that addressing issues like food insecurity and housing insecurity can reduce the total cost of care. “It’s not just important to screen for social determi- nants, you have to have community-based organizations that you’re partnering with at the back end to address those issues.
agreement with CMS. The state’s reform goals remain to control healthcare spend- ing; move from a fee-for-service system to one that pays for volume; and to create a value-based system that allows for invest- ments to keep the population healthier. The all-payer model enables Medicaid, Medicare and commercial payers to pay an ACO (called OneCare Vermont)
“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.” —Lauren Hughes, M.D.
So we added those requirements for 2021 to make sure that community-based organizations are part of our healthcare system in a way that they haven’t been in the past.”
The IHRC also recommended creating
“It’s really hard for any provider group to know how they can move forward with population health when they have got one foot in seven different canoes. Multi-payer alignment is what really drives the healthcare system forward.” — Douglas Jacobs, M.D.
disparities, particularly among Black Pennsylvanians, for example, in maternity care, and so we put into our MCO agree- ments for this year equity incentives that have rewards for MCOs that hit certain national benchmarks with their Black membership, specifically in timely access
regional accountable health councils as forums to make health equity a priority. “When you look at maps of Pennsylvania, if you’re born in certain parts of North Philadelphia, your life expectancy is 63 years and if you go just a mile or so to the south, your life expectancy will go up to 86. We see these really profound dif- ferences in geography. That necessitated the need for these regional accountable health councils,” Jacobs says. “The idea is to provide a forum for strategic planning across payers, providers, and community- based organizations. The main goal in the first year is to identify these areas with profound inequities. We’re calling them health equity zones. A subsequent step is to identify strategies to actually combat those equity issues. You can’t just do it with providers and payers. We need everybody at the table to focus on this.”
Ambitious efforts in Maryland and Vermont Several states are engaged in long-term ambitious efforts to transform care and control costs. The State of Vermont is working to combine a global all-payer reimbursement model with community health teams responsible for coordinating care between the medical, social services and public health sectors. The Green Mountain Care Board over- see hospital budgets, commercial payer rates, ACO budgets, and the financial impact of the All-Payer ACO Model
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differently than through fee-for-service reimbursement. Hospitals are starting to receive a fixed, pre-determined all- payer fee for all necessary services, and all Vermont hospitals are voluntarily participating.
In 2014, Maryland implemented a model that shifted the state’s hospital payment structure to an all-payer, annual, global hospital budget that encompassed inpatient and outpatient hospital services. In 2019, the state said that over the first five years of the program, Medicare beneficia- ries had 2.8 percent slower growth in total expenditures ($975 million in savings) during the Maryland All-Payer Model relative to a comparison group, largely driven by 4.1 percent slower growth in total hospital expenditures, according to the report from RTI International. States also are working on integrating primary care and behavioral healthcare. Legislation passed in Washington State in 2014 changed how the state purchases mental health and substance use disor- der services in the Medicaid program. It directed the state to fully integrate the financing and delivery of physical health, mental health and substance use disorder services in the Medicaid program via managed care by 2020. Hughes points to North Carolina as another state that is moving in the right direction. Between Medicaid through the Department of Health Services and the state’s largest insurer, Blue Cross Blue Shield of North Carolina, they cover approximately two-thirds of the state population. “So they are able to make pretty significant changes,” she says, “because they share a similar philosophy of moving from volume to value.” HI
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