VISIT STATE HEALTH COMPARE
Blog & News
New SHADAC Issue Brief Highlights Lessons Learned from SIM States Working to Align Quality Measures
March 21, 2019:In an effort to improve quality and contain the growing cost of health care, states are increasingly undertaking a shift away from fee-for-service reimbursement models that reward quantity and moving toward alternative payment models that reward value.
Many of the states leading the way in payment and delivery system reform have received State Innovation Model (SIM) awards from the Center for Medicare & Medicaid Innovation (CMMI) that have aided in accelerating that work.
A new issue brief from SHADAC researcher Colin Planalp examines the work of five SIM states to develop common measure sets that align quality measures across private and public payers—a strategy aimed at reducing administrative burdens on providers and giving focus to quality improvement efforts. Drawing from the experiences of Connecticut, Massachusetts, Minnesota, Rhode Island, and Washington, the brief outlines a framework for other states to undertake quality measure alignment projects in the future.
This paper was produced by SHADAC with support from the CMMI. SHADAC is part of a team led by NORC at the University of Chicago that serves as the SIM Resource Support Contractor. SHADAC and other technical assistance partners support states and the Innovation Center in designing and testing multi-payer health system transformation approaches.
Strategy: Voluntary or Mandatory Alignment
One of the first key decisions made by states undertaking multipayer quality measure alignment is the choice between adopting a mandatory approach—requiring private payers to use the measure set—or voluntary alignment approach—encouraging stakeholder buy-in via engagement and needs prioritization. The issue brief examines both methods and highlights important considerations of each using examples of voluntary alignment from Connecticut and Washington, and examples of mandatory alignment (e.g., statutory and regulatory authorities) in Massachusetts, Minnesota, and Rhode Island.
Alignment Adoption Techniques
Each state referenced in the brief emphasized stakeholder engagement (i.e., establishing workgroups with representatives from state agencies, commercial health plans, health care providers, consumer advocates and other stakeholders) to ensure that the common measure sets met important priorities and to develop buy-in for adopting measures. The brief examines states’ stakeholder engagement strategies, as well as other techniques employed by the states to bolster their new common measure sets such as Washington’s adoption of the measures in its Medicaid and state employee health plans.
Measure Set Development: Priorities and Goals, Measure Evaluation, and Selection
The issue brief also lays out a roadmap for other states to develop their own common quality measure sets, pulling lessons from the processes employed by the five study states. The state workgroups tasked with selecting metrics for their common measure sets reported that their responsibilities generally entailed identifying and incorporating shared priorities and goals in selecting common measures, cataloguing measures currently in use within the state, selecting criteria for systematically evaluating potential measures, and evaluating and selecting measures according to those agreed-upon criteria.
Measure Set Sustainability
As a final step, the states profiled in this brief also have created and implemented processes to ensure their common measure sets will remain effective and relevant by periodically updating the measure sets by either removing measures where provider performance has topped out and/or adding new measures to address evolving quality priorities.
Lessons Learned
Ultimately, what conversations with these states revealed was a common set of lessons that can be utilized by other states planning to undertake quality measure alignment moving forward. Articulated at various points within the issue brief are recommendations for states to focus on:
- Including workgroup members from all stakeholder groups: commercial, public, state agencies, providers, consumers, and any other key groups.
- Encouraging stakeholder engagement in all aspects of selecting and implementing common measure sets.
- Strongly defining a rationale to promote stakeholder involvement, buy-in, and engagement.
- Selecting measures that are meaningful and practically applicable for providers and payers alike.
- Adopting a common measure set in public programs in order to promote mirrored alignment in commercial programs.
- Continuing to review measures after they have been set, and updating or modifying if necessary.
Read the full issue brief for more details on aligning quality measures in states.
Suggested Further Reading
Quality Measurement for HCBS and Behavioral Health in Medicaid: What’s Happening and What’s Missing
Blog & News
Tiered Provider Cost-Sharing: Improving Efficiency through Consumer Choice and Provider Incentives
September 24, 2018:The Minnesota State Employee Group Insurance Program (SEGIP) has covered Minnesota state employees and their dependents using a tiered provider model since 2002. A recent SHARE-funded analysis led by Dr. Bryan Dowd (University of Minnesota) examined the SEGIP tiering model as well as patient and clinic responses to this tiered provider network approach. The following blog provides a high-level overview of findings from this analysis.
Background: Tiered Provider Cost-Sharing
The Problem
Efforts to reduce health spending often fail to provide consumers with both (a) information on price and quality and (b) an incentive to take action. For example, high-deductible health plans give the consumer an incentive to seek more efficient providers but no information about more affordable options.
The Solution
Tiered provider networks offer a solution to this problem by giving consumers information about the price and quality of health care providers and creating an incentive to choose providers that are more efficient. In this model, a provider's past total cost of care performance is compared against other providers in an ordered tiers system. This apples-to-apples comparison easily lays out out-of-pocket costs--copayments, coinsurance, deductibles, and maximum out-of-pocket expenses--allowing consumers to see which tier option works best for them and their family.
Advantages of Tiered Provider Cost-Sharing
- To Consumers
Tiering can be implemented within existing, broad networks and preserve the consumer's choice of provider. - To Providers
Tiering helps retain high cost providers by requiring consumers to pay more to access them than they do to access a low-cost clinic. Cost tiers also help consumers control their out-of-pocket costs. Providers benefit because they can choose their own approach to improved efficiency since tiering is based on total cost of care, rather than on the cost of a single procedure (as with bundled payments). - To Payers
Tiering can be implemented fairly easily by an payer that has access to their own medical and pharmacy claims data, including a self-insured firm.
What We Know: The SEGIP Experience
SEGIP has covered Minnesota state employees and their dependents since 2002 using a tiered provider model.
- Primary care clinics in the SEGIP network are sorted into one of four cost-sharing tiers based on the clinic's past total cost of care (adjusted to account for the risk profile of the provider's patient population).
- Clinics can move to a lower tier by better controlling costs, agreeing to lower their fees, or participating in a risk-sharing arrangement with SEGIP.
- There is substantial variation in cost-efficiency across participating providers, with the average total cost of care for the lowest-cost Tier 1 clinic being roughly half that of the highest-cost Tier 4 clinic.
- Consumers can choose any in-network clinic, but consumer costs increase as the clinic's tier increases. For example, annual deductibles in 2016 ranged from $300 for family coverage in Tier 1 to $2,500 in Tier 4. Office copays ranged from $30 to $85 per visit.
What We Learned from SEGIP
The research team found that:
- Customers prefer clinics that are in lower tiers. When a clinic is in a lower tier, it is more likely to be chosen by consumers.
- Clinics want to be low-tier. Many clinics have expressed support for the SEGIP model but are concerned that being placed in a higher tier will impact their reputation, resulting in potentially losing patients. Many clinics address this concern by reducing fees in order to move to a lower tier, leading to gains in their market share. Clinics also report that they would be more interested in moving to a lower tier if more of their non-SEGIP patients participated in tiered cost-sharing models like SEGIP's.
Tiered Provider Cost-Sharing: Options for Scaling the Model
- Self-insured employers are well-situated to implement the tiered model as keeping costs down is in their best economic interest. These employers already have access to the necessary claims data required to establish a tiered provider model for their network clinics.
- Health insurers could develop more tiered network products, especially for the small group and the individual markets that lack the size, data, and resources necessary to implement a tiered cost-sharing model on their own.
- States could leverage existing claims and quality data resources (e.g., in Minnesota, the All-Payer Claims Database (APCD) and the Statewide Quality Reporting and Measurement System (SQRMS)) to inform implementation of tiered provider networks among payers with more limited data resources.
Blog & News
Now Available: SHADAC Presentations from the 2018 AcademyHealth Annual Research Meeting
July 19, 2018:SHADAC presentation materials from the 2018 AcademyHealth Annual Research Meeting (ARM) are now available. Click on the presentation titles below to view and download the materials.
- “The Intersection of Structural Risk Factors and Insurance-Based Discrimination on Healthcare Access Inequities”
Presenter: Kathleen Call
Co-Authors: Rhonda Jones-Webb, Brooke Cunningham, Giovann Alarcón, Sarah Hagge, Alisha Simon - “Who Gets It Right? Characteristics Associated with Accurate Reports of Health Insurance Coverage”
Presenter: Kathleen Call
Co-Authors: Angela Fertig, Joanne Pascale, Don Oellerich - “Minnesota LTSS Projection Model: MN-LPM”
Presenter: Giovann Alarcón
Co-Authors: Robert Hest, Lynn A. Blewett - “Modeling Financial Eligibility for Medicaid Payment of LTSS”
Presenter: Robert Hest
Co-Authors: Giovann Alarcón, Lynn A. Blewett - “Modeling State-based Reinsurance: One Option for Stabilization of the Individual Market"
Presenter: Brett Fried
Co-Authors: Lynn A. Blewett, Coleman Drake - “Advancements in Care Coordination: Findings from an Evaluation of Minnesota’s State Innovation Model Initiative”
Presenter: Carrie Au-Yeung
Co-Authors: Christina Worrall, Donna Spencer, Emily Zylla, Kelli Johnson, Lacey Hartman - “Section 1115 Medicaid Expansion Waivers: Implementation Experiences of Arkansas, Indiana, Iowa, & Michigan”
Presenter: Carrie Au-Yeung
Co-Authors: Emily Zylla, Elizabeth Lukanen, Colin Planalp
Blog & News
Minnesota Health Care Home Care Coordination Cost Study: Results Now Available
March 28, 2018:Results from the Minnesota Health Care Home Care Coordination Cost Study are now available. This study was conducted by SHADAC researchers under a contract with the Minnesota Departments of Health and Human Services.
About the Study
This analysis examined the costs of care coordination for adults in Minnesota’s Health Care Homes (HCH) program, which is administered by the Minnesota Department of Health (MDH) and is aimed at developing patient-centered, team-based care that links the medical component of primary care to wellness, prevention, self-management, and community services. In order to estimate the cost of care coordination, SHADAC researchers used a case-study approach and collected information about the costs associated with activities that define care coordination. Six non-acute, primary care clinics were evaluated.
Study Findings
SHADAC found that the costs for care coordination varied considerably across sites, from $1 to $12 per HCH adult panel in a typical month, but staff at all sites reported that care coordination had a high value to patients. Many noted that care coordination improved the efficiency of care delivery and likely saved costs and resources.
The following are additional key findings from the study:
- Mental health diagnoses and/or multiple chronic diseases seem to drive care coordination costs. Clinic staff report that a wide variety of nonclinical patient characteristics (most related to socioeconomic status) also drive care coordination costs. These included language barriers, homelessness or poor housing, food insecurity, and lack of transportation.
- Clinics appreciated the flexibility afforded by the HCH model design to operationalize certification standards according to clinic and patient needs.
- All of the clinics in the study describe their entire patient panel as being “part of the HCH,” and they reported spending time across the whole panel to identify potential candidates for care coordination. They focus care coordination activities (defined for this study as care coordination outside of usual, quality care delivery) on the higher-need segment of the panel.
- Common approaches to HCH care coordination activities include relying on informal, provider-driven referral to care coordination services; using a team-based care coordination approach; integrating care coordination into pre-defined clinic workflows; and placing importance on demonstrating the value of care coordination to providers.
- Across the board, staff reported the high value of care coordination to the patients. Many noted that care coordination improved the efficiency of care delivery and likely saved costs and resources.
The researchers note that the case study methodology used in this study (selected because of variation in clinic structure, patient population, approach to HCH design, etc.) restricts the ability to generalize findings across sites and primary care clinics in Minnesota more broadly. Accordingly, findings should not be used to determine reimbursement rates, but rather to provide additional context for the ongoing discussion about modifying and improving reimbursement for HCH services.
SHADAC researcher Christina Worrall will be discussing these results on April 3, 2018 during the HCH Learning Days conference in Saint Paul, MN. See her presentation slides here.
Publication
Minnesota's Accountable Communities for Health: Context and Core Components
Minnesota's Accountable Communities for Health, or ACHs, are community-led models of delivering medical and non-medical care and services to improve the health of a target population with substantial health and social needs. This brief provides the context surrounding the development and implementation of Minnesota's ACHs and describes key components of ACH models implemented across the state.
Project overview
In 2013, Minnesota was awarded a cooperative agreement by the Center for Medicare and Medicaid Innovation (CMMI) to implement and test a State Innovation Model (SIM) of state care delivery transformation and payment reform. Minnesota's SIM initiative, called the Minnesota Accountable Health Model, is a joint effort between the Minnesota Department of Health (MDH) and the Minnesota Department of Human Services (DHS). SHADAC is conducting the state-level evaluation of SIM in Minnesota.
Evaluation Approach
SHADAC collects and analyzes new and existing data to report on the implementation and outcomes of five primary “drivers” designed to achieve State reform aims. Qualitative data sources include ongoing document and literature review and semi-structured interviews with state leadership and staff and SIM program participants across the state. Quantitative data sources include two initiative monitoring databases, organization and provider surveys, and All-Payer Claims Database (APCD) data. SHADAC delivers both interim and annual reports to the state.
Other Publications
Final Evaluation Report on the SIM Initiative in Minnesota (January 2018)
Evaluation of the Minnesota Accountable Health Model: Final Report - Executive Summary (September 2017)
Evaluation of the Minnesota Accountable Health Model: First Annual Report (May 2016)
Implementing Multiple SIM Initiatives through One Local Agency: The Effect of "Stack" in Otter Tail County, Minnesota (December 2016)
State Evaluation of the Minnesota Accountable Health Model: Results from the First Year - Presentation (June 2016)
Minnesota Accountable Health Model Continuum of Accountability Assessment: Evaluation Data Source and More - Presentation (March 2016)
