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Integrated Health Partnerships—Minnesota’s Medicaid Accountable Care Organization Model
August 16, 2024:Minnesota's Integrated Health Partnerships (IHPs) have pioneered a new approach to implementing accountable care organizations (ACOs) for the Medicaid population. Initially launched in 2013 by the Minnesota Department of Human Services (DHS), these partnerships are voluntary agreements between health provider groups and DHS. Health provider groups partner directly with DHS in multi-year contracts to both improve the quality of and reduce the total cost of care for specified patient populations using a shared savings/shared risk financing model.
When IHPs were first established in Minnesota, there were six provider groups participating. A little more than 10 years later, the number of IHPs in Minnesota has more than tripled, with 25 total partnerships covering more than 505,000 beneficiaries, as of July 2024.
DHS released the 2025 Request for Proposals (RFPs) (which recently closed) hoping to expand the program to more interested organizations and to allow current organizations to continue their partnership with the agency.
In order to better understand potential expansions and changes that may be implemented through Minnesota’s IHPs, we must first understand the foundation, function, and purpose of these partnerships.
In this blog, SHADAC staff will explore:
- What is the purpose of an Accountable Care Organization (ACO)?
- How do IHPs relate to ACOs?
- How have IHPs been established in Minnesota and how have they evolved?
- How can IHPs advance health equity for included populations?
- What are some future considerations that could help in better understanding the effect of IHPs?
Keep reading to start learning about the IHP program and how it impacts communities in Minnesota.
ACOs in Medicaid
Accountable Care Organizations (ACOs) are groups of health care providers that agree to take financial responsibility for the quality and cost of care they deliver to a defined patient population. There are national, state, and regional ACO models, and they may support multiple insured populations, i.e., Medicare, Medicaid, commercial, and self-insured.
ACOs often operate alongside Managed Care Organizations (MCOs), offering additional avenues for health care reform and focusing increasingly on advancing health equity. ACOs are a pivotal tool in promoting access to care, investing in population health, and addressing social determinants of health that affect health equity.
Since the enactment of the Affordable Care Act (ACA) in 2010, the Center for Medicare and Medicaid Innovation (CMMI) has supported state initiatives like Minnesota's State Innovation Model (SIM) to test and expand ACO models within Medicaid, and Medicaid-specific ACOs have now been established in nearly a dozen states.*
These programs vary by state in terms of delivery system reform, payment expectations, and in the authorities needed to administer them, but all such Medicaid ACO alternative payment models (APMs) are standardized through classification under Categories 2, 3, and 4 of the Health Care Payment – Learning Access Network (HCP-LAN) APM framework.
IHPs are Minnesota’s Medicaid ACO model. In 2008, the Health Reform Law of Minnesota included recommendations for statewide quality reporting, payments for coordinated care services provided in health care homes (HCHs), and encouragement to participate in bundled payment demonstrations. The law was then amended in 2011 to require DHS to develop a program to “test alternative and innovative health care delivery systems, including ACOs that provide services to a specified patient population for an agreed-upon total cost of care or risk/gain sharing payment arrangement”, leading to the creation of IHPs.
In 2017, SHADAC had the opportunity to conduct an evaluation of early Minnesota IHP implementation as part of Minnesota’s SIM cooperative agreement with CMMI, which documented IHP expansion and evolution, helpful data analytics, and importance of ongoing monitoring of the effects of the IHP program on health care utilization, cost, and quality.
Minnesota's Integrated Health Partnerships Today
As noted earlier, Minnesota’s IHP program began over 10 years ago in 2013. In 2018, the program was updated with various enhancements and changes in order to place a stronger focus and effort on health equity, enhance the risk arrangement incentives, and provide a population-based payment. This led to the implementation of a new overall IHP model (Integrated Health Partnerships 2.0) with two possible tracks for Minnesota IHPs to operate under (see figure below). These two distinct organizational design tracks are tailored to both provider capabilities and population needs.
For full details and requirement on IHP design tracks, please reference the Minnesota Department of Human Services 2025 Request for Proposals for IHP Program
On top of improving care quality and reducing the total cost of care, IHPs on both tracks are also required to design interventions that address specific health disparities across their target population. IHPs in both tracks receive a quarterly risk-adjusted population-based payment (PBP) which is intended to contribute to care coordination and other investments for the population served. IHPs are also assessed based on quality, utilization, and health equity measures. This population-based payment is flexible, adjusting to reflect changing numbers of the included population specified by the IHP’s intervention plan, as well as changing risk factors due to medical and social complexities in the population makeup.**
IHPs are measured through quality and data metrics (e.g., comparing percent change between performance years), as well as a calculation of standards across five domains for those in the shared-risk model - Quality Core Set, Care for Children and Adolescents, Quality Improvement, Closing Gaps, and Equitable Care - a process which is described in further detail in the following section.
Ultimately, IHPs have proven quite successful in Minnesota, with significant savings and quality improvements. Since their inception, IHPs have yielded nearly $546 million in total savings through 2022.
Emphasis on Advancing Health Equity
In response to evolving health care needs and feedback suggesting that the timing was right to build on prior successes of the original IHP program, DHS introduced an improved program, IHP 2.0, enhancing its focus on health equity. The IHP 2.0 program, included modifications to allow the program to more directly address social determinants of health (SDOH) and incentivize partners to reduce racial, geographical, and/or other disparities.
The Minnesota Department of Health describes health equity as “addressing health disparities as part of a broad spectrum of public investments in housing, transportation, education, economic opportunity and criminal justice.” By implementing changes and integrating health equity goals into core operational frameworks, the hope with the IHP 2.0 program is to overcome the limitations of traditional health care approaches in addressing SDOH and health disparities that arise as a result.
In fact, recent case studies on Medicaid payment reforms conducted by the Urban Institute directly referenced and cited Minnesota’s IHPs, describing their influence on health equity along with the overall changes made to the program in 2018 in order to continue to advance equity in Medicaid.
The table below from the Urban Institute identifies and describes the core features of the IHP 2.0 program designed to both focus on and advance equity for beneficiaries.
Source: Allen & Willis, “Can Medicaid Payment and Purchasing Strategies Advance Health Equity?” The Urban Institute, December 2023, https://www.urban.org/sites/default/files/2023-12/Can%20Medicaid%20Payment%20and%20Purchasing%20Strategies%20Advance%20Health%20Equity_0.pdf
As described above, the success of IHPs is evaluated based on performance in health care quality, utilization, health equity, and total cost of care (TCOC). When monitoring quality for those in risk arrangements where quality has an impact on shared savings and losses, the quality-related assessments are organized into five domains.
As a reminder, those domains are as follows:
- Quality Core Set
- Care for Children and Adolescents
- Quality Improvement
- Closing Gaps
- Equitable Care
Two of these domains, “Closing Gaps” and “Equitable Care,” specifically target health equity through tailored clinical and utilization measures aimed at reducing and eliminating disparities among specific Medicaid populations. IHPs can also receive ‘bonus points’ on their overall quality score for creating additional initiatives under the Quality Improvement, Closing Gaps, and Equitable Care domains.
Recent Health Equity Interventions
As a part of the enhanced focus on health equity, IHPs are encouraged to design interventions to address targeted populations’ health equity challenges.
Target populations may differ among the IHPs, with some initiatives aimed at supporting the entire IHP patient population and some designed to serve a more specific sub-population. A summary list of common target populations of Minnesota’s 25 IHPs include:
- Children, adolescents, families, and new mothers
- Justice-involved individuals
- Patients with a mental illness or individuals living with a family member with a mental illness
- Patients that are food insecure
- Adults with substance use disorder
- Individuals experiencing challenges accessing care, including Black, Indigenous, and people of color
A summary list of common social risk factors across Minnesota’s 25 IHPs include:
- Housing instability
- Food insecurity
- Social isolation
- Transportation
- Difficulty paying bills
- Education
- Employment
- Mental health needs
- Access to care
- Language barriers
- Income
- Childcare
IHPs must first identify the population or populations that they are serving, and then they must design, develop, and implement targeted intervention efforts based on those populations, risk factors, and SDOH to advance equity for those groups. IHPs are encouraged to identify an intervention that will meet the needs of their specific population given their knowledge of their community. Examples of these efforts include community partnerships, screening initiatives, referrals to community resources or other needed programs, and care coordination for social needs. The following is a summary list of common interventions currently being used to address health equity across Minnesota’s 25 IHPs:
For a full list, the Health Equity Interventions Summary at this link provides the specific target population, social risk factors, interventions, and milestone components for each IHP in Minnesota.
Closing Thoughts
As DHS’ IHP Program continues to evolve, its focus on data analytics and population health management remains pivotal for achieving comprehensive care delivery and advancing health equity statewide. The IHP 2.0 Program exhibits the importance of translating equity-focused policy goals into actionable requirements and programs. DHS’ work to monitor and disseminate the outcomes of the health equity initiatives and interventions implemented by IHPs will continue to provide valuable insights into their effectiveness and impact on Minnesota's health care landscape.
One potential dissemination method would be to make the Population Health Reports from IHPs publicly available. This would not only increase transparency around the data collected by IHPs and the lessons learned from putting interventions into practice, but also aid in our understanding of the effectiveness of IHPs in addressing SDOH, improving access to care, and eliminating health disparities.
Continue learning about health equity in Medicaid and beyond with the following SHADAC products:
Notes
Publication
Reproductive Oppression in Health Care: Underlying Factors of Medicaid Inequities Annotated Bibliography
*Click here to jump to the 'Reproductive Oppression in Health Care' annotated bibliography*
The State Health Access Data Assistance Center (SHADAC) with support from the Robert Wood Johnson Foundation (RWJF) and in collaboration with partner organizations is exploring whether a new national Medicaid Equity Monitoring Tool could increase accountability for state Medicaid programs to advance health equity while also improving population health.
During the first phase of this project, a conceptual wireframe for the potential tool was created. This wireframe includes five larger sections, organized by various smaller domains, which would house the many individual concepts, measures, and factors that can influence equitable experiences and outcomes within Medicaid (see full wireframe below).
While project leaders and the Advisory Committee appointed at the beginning of the project all agree that the Medicaid program is a critical safety net, they specifically identified the importance and the need for an “Underlying Factors” section of the tool. This section aims to compile academic research and grey literature sources that explain and provide analysis for the underlying factors and root causes that may contribute to inequities in Medicaid.
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- Historical context of Medicaid inequities
- Information on how underlying factors perpetuate inequities in Medicaid
- Potential solutions for alleviating inequities within Medicaid
Once selected, researchers compiled sources in an organized annotated bibliography, providing a summary of each source and its general findings. This provides users with a curated and thorough list of resources they can use to understand the varied and interconnecting root causes of Medicaid inequities. Researchers plan to continually update this curated selection as new research and findings are identified and/or released.
Sections of the full annotated bibliography include:
- Systemic Racism
- Systemic / Structural Ableism
- Sexual Orientation, Gender Identity, and Gender Affirming Care Discrimination
- Reproductive Oppression in Health Care
- Impact on Vital Community Conditions (webpage forthcoming)
This page is dedicated to a single section from the full annotated bibliography:
Reproductive Oppression in Health Care
![reproductive oppression definition in white text on a teal box](https://www.shadac.org/sites/default/files/publications/Reproductive%20Oppression%20in%20Health%20Care%20Definition%208.8.24.png)
Underlying Factors Annotated Bibliography: Reproductive Oppression in Health Care
Have a source you'd like to submit for inclusion in our annotated bibliography? Contact us here to propose a source for inclusion.
Click on the arrows to expand / collapse each source.
Crear-Perry, J., Correa-de-Araujo, R., Lewis Johnson, T., McLemore, M. R., Neilson, E., & Wallace, M. (2021). Social and Structural Determinants of Health Inequities in Maternal Health. Journal of Women's Health (2002), 30(2), 230–235. https://doi.org/10.1089/jwh.2020.8882
Author(s): Joia Crear-Perry, National Birth Equity Collaborative, Washington D.C.; Rosaly Correa-deAraujo, Division of Geriatrics and Clinical Gerontology, National Institute on Aging, National Institutes of Health; Tamara Lewis Johnson, Office of Disparities Research and Workforce Diversity, National Institute of Mental Health, National Institutes of Health; Monica R. McLemore, Family Health Care Nursing Department & Advancing New Standards in Reproductive Health, University of California San Francisco; Elizabeth Neilson, Office of Disease Prevention, Office of the Director, National Institutes of Health; Maeve Wallace, Department of Global Community Health and Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine
Article Type: Peer-reviewed Journal
The authors of this article make a distinction between structural and social determinants of health, describing structural determinants as the “cultural norms, policies, institutions, and practices that define the distribution (or maldistribution)” of social determinants of health. The authors explore these concepts in the context of social determinants of maternal health. They present a theoretical framework of determinants of Black maternal health called “Restoring Our Own Through Transformation” (created by Jessica Roach, 2016) to illustrate a “web of causation” between structural and social determinants of health and wellness. Crear-Perry et al. explore structural determinants of maternal health that are features of the U.S. health care system including financial barriers to care, a shortage of primary care providers, and gaps in quality, while also considering policy levers that might improve structural factors to support better maternal health outcomes, like paid family leave, access to affordable and comprehensive health care (which could be measured using exposure to Medicaid expansion, having Medicaid coverage through 12 months postpartum, etc.), access to culturally appropriate care (e.g., with clinicians that have received education on structural determinants of health and health inequities—i.e. “structural competency” education), and investments in community-oriented primary care for diverse women of reproductive age (e.g., midwifery maternity centers, nurse practitioner practices, maternal and child clinics, etc.).
Morcelle, M.T. (2022). Reforming Medicaid Coverage Toward Reproductive Justice. American Journal of Law & Medicine, 48, 223–243. https://doi.org/10.1017/amj.2022.27
Author(s): Madeline Morcelle, Senior Attorney in the National Health Law Program's (NHeLP) Washington, D.C. Office
Article Type: Peer-reviewed journal
The author of this journal article argues that while Medicaid presents a powerful vehicle for reproductive justice, especially for Black people and people of color, its structure allows for discriminatory eligibility and coverage policies that worsen health inequities for adults and their children. Historically, women and people of color have been advocating against reproductive oppression and advocating for “...universal, comprehensive, and affordable health coverage and access, with strong nondiscrimination protections, for everyone.” However, the author describes how voices of those experiencing oppression need to be centered or part of an “open source” framework rather than a “bottom to the top” engagement to dismantle oppressive systems. The author explains how Medicaid was designed by whites in power to only provide access to health coverage for some, “...the ‘worthy poor’,” and that these discriminatory practices continue today through policy decisions, like making Medicaid expansion a choice, for example. The author also describes the lack of adequate benefits for certain populations. While advances have been made recently, namely the Medicaid postpartum coverage extension opportunity and options to cover some immigrant groups, reproductive justice voices and frameworks should be at the center of Medicaid reform efforts to stop reproductive oppression and advance health equity for all.
Thompson, T. M., Young, Y.-Y., Bass, T. M., Baker, S., Njoku, O., Norwood, J., & Simpson, M. (2022). Racism Runs Through It: Examining The Sexual And Reproductive Health Experience Of Black Women In The South. Health Affairs, 41(2), 195–202. https://doi.org/10.1377/hlthaff.2021.01422
Author(s): Terri-ann Monique Thompson & Yves-Yvette Young, Ibis Reproductive Health, Tanya M. Bass, North Carolina Central University, Stephanie Baker, Elon University, Oriaku Njoku, Access Reproductive Care–Southeast, Jessica Norwood, The Runway Project, Monica Simpson, SisterSong Women of Color Reproductive Justice Collective
Article Type: Peer-reviewed journal
This article details a community-based participatory research approach to focus groups with nearly 50 Black women living in both Georgia and North Carolina (states chosen for having relatively restrictive reproductive health policies) to understand their experiences interacting with reproductive health care. The research team focused on three aspects of the participants’ experiences: access to health care, use of health care, and experience in health care – and how these experiences were connected to structural (summarized here) and individual racism. In terms of structural factors and access to adequate care, findings include that reproductive health clinics were often located outside of participants’ communities, making accessing care difficult. Focus group participants covered by Medicaid experienced issues with copayment being too burdensome. Lack of abortion coverage in some states was also a major concern for participants. In terms of structural racism and service use, authors report inconsistencies in what services are covered by different plans (both private and Medicaid coverage are mentioned), which impacted utilization. Focus group participants also reported that being a Black woman or living in a predominately Black community and receiving public assistance (or being uninsured) negatively impacted their health care experiences. Further, there was a perception that facilities caring for primarily publicly-insured individuals were lower quality. The authors urge for policy actions that alleviate these structural barriers, such as expanding federally funded Medicaid coverage, requiring abortion coverage, increasing reimbursement for doulas and midwives, and investing in hospitals that provide uncompensated care.
Ogunwole, S. M., Karbeah, J., Bozzi, D. G., Bower, K. M., Cooper, L. A., Hardeman, R., & Kozhimannil, K. (2022). Health Equity Considerations in State Bills Related to Doula Care (2015-2020). Women's Health Issues: Official publication of the Jacobs Institute of Women's Health, 32(5), 440–449. https://doi.org/10.1016/j.whi.2022.04.004
Author(s): S Michelle Ogunwole, Department of Medicine, Johns Hopkins University School of Medicine & John Hopkins Center for Health Equity; J’Mag Karbeah and Katy Kozhimannil, Division of Health Policy and Management, University of Minnesota School of Public Health; Rachel Hardeman, Center for Antiracism Research for Health Equity & Division of Health Policy and Management, School of Public Health, University of Minnesota; Debra G Bozzi, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health; Kelly M. Bower, Johns Hopkins University School of Nursing, & Johns Hopkins Center for Health Disparities Solutions; Lisa A. Cooper, Department of Medicine, Johns Hopkins University School of Medicine, Departments of Health Policy and Management, Health, Behavior, and Society, and Epidemiology, Johns Hopkins Bloomberg School of Public Health
Article type: Peer-reviewed journal
This article presents findings from a landscape analysis of state legislation related to doula care, including Medicaid coverage and reimbursement, with specific attention to whether legislation addresses racial health equity. It is well known that disparities in birth outcomes disproportionately affect Black and Indigenous birthing people. And evidence suggests that doula care is associated with improved birth outcomes. Authors draw on reproductive justice and public health critical race praxis frameworks in formulating study questions and methods. Reproductive justice refers to women having autonomy over their own bodes and the right to have and parent children safely and with access to community supports to realize optimal reproductive health. Public health critical care praxis theory acknowledges the legacy of white supremacy and racism as a root cause of health inequities in public health research. Authors draw on this theory to develop criteria for assessing whether doula care legislation is designed to address racial health equity. Criteria included reimbursement with plans to provide a living wage, collaboration with community-based doulas, training and certification requirements and funding, and emphasis on workforce diversity, promising practices, and metrics. Authors found that of the 73 bills introduced by 24 states between 2015 and 2020, just over half focused on Medicaid reimbursement for dual care. (Twelve bills in seven states became law.) However, only two states that passed Medicaid reimbursement for doulas also met some of the authors criteria for racial equity in their laws. Authors conclude that while proposals for increased access to doula care have increased over time, a racial equity lens is lacking. Authors suggest engaging doulas and considering racial equity policy assessments in the legislative drafting process.
[1] Women's Leadership and Resource Center. (2023). Reproductive Oppression Against Black Women | Women’s Leadership and Resource Center | University of Illinois Chicago. Wlrc.uic.edu; University of Illinois Chicago. https://wlrc.uic.edu/reproductive-oppression-against-black-women/