An increasingly common feature of health care payment models is the transfer of financial risk from payers to providers for health care services delivered to a defined population of patients. In these “value-based payment” models, providers accept financial responsibility should spending for most, or all, services for an attributed patient population exceed targeted levels. This financial liability is often shared with payers, and maximum risk exposure is typically capped. This issue brief explores options for states as they consider oversight of risk-bearing organizations, with a focus on states that have elected to act to protect against provider insolvency.
State Health and Value Strategies hosted a companion webinar, Safeguarding Financial Stability of Provider Risk-Bearing Organizations, based on the issue brief that provided an overview of options for states as they consider oversight of risk-bearing organizations (RBOs) as well as a deeper dive on the Massachusetts approach.
As state policymakers seek to identify strategies to deliver higher-quality care at lower costs, payment reform efforts have largely centered on moving from a fee-for-service health care system based on paying for volume, to one based on paying for value. More recently, payment models including prospective episode-based payment, hospital global budgets and per member per month global capitation arrangements have gained attention. This issue brief provides an overview of hospital global budgeting, which represents a middle-ground approach between the narrow bundling of services and global capitation that transfers higher levels of financial risk to a hospital.
States continue to identify and pursue strategies to further reduce the number of uninsured, to make coverage more affordable for consumers and to improve access to care. Several proposals have been introduced at both the federal and state levels that would permit people above Medicaid eligibility levels to “buy in” to Medicaid or would leverage the Medicaid program to strengthen coverage across the individual market and Medicaid. This issue brief presents two possible models for a Medicaid buy-in program for states, and details the design considerations and authorities needed to implement each model.
CHIP covers nearly 9 million children and is a key contributor to record-low levels of uninsurance among children. However, Congress only provided funding for CHIP through FY 2017, which ended September 30. After a series of short-term patches that left states with a great deal of uncertainty, Congress passed a six-year extension of CHIP in January. Three weeks later, on February 9, Congress extended the program for another four years, reauthorizing the program through FY 2027. This issue brief summarizes key features of the 10-year CHIP extension.
The nation’s opioid epidemic claimed more than 42,000 lives in 2016, and more than 2 million people in the United States have an opioid use disorder (OUD)—with nearly another 10 million at risk due to misuse of these drugs. Yet, only 1 in 5 people suffering from an OUD receive treatment. Today, Medicaid covers more than 1 in 3 people with an OUD, and program spending for people with an OUD in 2013 (before Medicaid expansion in many states) was more than $9 billion. In this issue brief, data from three states—New Hampshire, Ohio and West Virginia—highlight Medicaid’s role as the linchpin in states’ efforts to combat the opioid epidemic.
Categorizing Value-Based Payment Models According to the LAN Alternative Payment Model Framework: Examples of Payment Models by Category
As the movement from volume to value-based payment progresses, more state purchasers are requiring their contracted health plans to implement alternative payment models (APMs) with the goals of improving the quality of care and reducing costs for taxpayers. The LAN APM Framework is an increasingly common method being used by states to measure plan progress toward implementation of APMs. This brief provides real-world examples of APMs within the LAN categories and can help states and other interested purchasers develop a common understanding of what types of payment models fit within the framework categories.
State Medicaid Approaches for Defining and Tracking Managed Care Organizations Implementation of Alternative Payment Models
As state Medicaid programs emphasize a focus on value-based payment, they are increasingly requiring their Medicaid managed care organizations to implement alternative payment models (APMs). This brief focuses on different ways in which states may set standard APM definitions to a) track MCO progress toward meeting state APM goals, and b) support comparison of APM implementation within a state and nationally.
In response to President Trump’s October 12 executive order (EO), the U.S. Department of Labor (DOL) has published proposed rules to expand the availability of health coverage sold through associations to small businesses and self-employed individuals. The public has until March 6, 2018 to submit comments on these proposed rules and this brief provides state health officials with a review of the content of the proposed rules and examines the implications for those interested in commenting on the rule.
Value-Based Innovation by State Public Employee Health Benefits Programs provides an overview of three areas of value-based innovation and then affords a deeper examination into specific examples of state employee purchaser activity in California, Connecticut, Massachusetts, Minnesota, Tennessee, and Washington. Despite their differences in size and scope, these state health care purchasers found they could learn from their colleagues in other states as they strive to improve the value of care. For a summary of the examples from the six states, we have also published an Overview that highlights policy innovations and findings to date.
With three states using Section 1332 waivers to help fund reinsurance programs for the 2018 plan year, many more state officials are considering the model for their state in future years. Having worked directly with the 2018 reinsurance states, State Health and Value Strategies is pleased to present the following to-do list for states as they consider reinsurance for 2019.