As another governor changed his mind on expanding Medicaid coverage last week, the Department of Health and Human Services awarded $300 million in Medicaid demonstration grants to Arkansas, Maine, Massachusetts, Minnesota, Oregon and Vermont -- the last two arguably having the most ambitious redesigned policies.
Each state is getting about $50 million to test several risk-sharing, payment and delivery models, including varieties of accountable care organizations. With a federal waiver, Oregon has created an ACO model using coordinated care organizations -- risk-bearing partnerships of providers, managed care entities, community centers and behavioral health clinics -- with a policy mandate to slow per member Medicaid spending growth by 2 percent.
At the end of last year CMS and Oregon finalized progress metrics for tracking the demonstration's cost, quality and access goals, and local observers see both potential benefits and pitfalls in the CCO system. One Portland physician and medical professor commenting in the New England Journal of Medicine said the move towards aligned incentives was dragging because of slow integration of some CCOs.
Taking a long view, one hospital IT engineer thinks some of Oregon's 15 CCOs may be failing, and be absorbed into those making progress. Oregon health officials intend to bring members of the public employee health plan, Medicare members and potentially commercial markets into CCOs, to expand.
In Minnesota health officials are preparing what will be the country's first state-designed integrated care model, without a federal waiver. The Minnesota Accountable Health Model aims to ensure that every Minnesota resident has the option of team-based, coordinated care between medical care, behavioral healthcare and long-term services, while aligning payments across ACOs, Medicare, Medicaid and commercial insurers.
With a $42 million grant, Arkansas will be trying to incentivize patient-centered health based on population-based delivery strategies and episodes-based payment, in demonstrations launching statewide with both public and private insurers. Under the plan, by 2016 a majority of Arkansans will have access to a patient-centered medical home with comprehensive care focusing on chronic care management and preventive services.
The initiative will begin with conditions like upper respiratory infections, total hip and knee replacements and congestive heart failure, with providers initially paid under existing fee-for-service arrangements and transitioning to shared savings models, based on spending and quality data.
Arkansas' payment model will include performance-based care coordination fees and shared savings for medical homes based on their ability to reduce total cost of care while meeting quality goals. For acute, procedural and ongoing specialty care conditions, Arkansas is going to expand its system of episode-based care delivery with retrospective payment approach rewarding high quality.
Vermont, meanwhile, is on the path to developing a primarily single, public-payer integrated health system that CMS says aims for "full coordination and integration of care throughout a person's lifespan, ensuring better health care, better health, and lower cost." While building an active regulatory health insurance exchange and expanding options under Medicaid and Medicare, Vermont will be testing three Medicaid models -- a shared-savings ACO, a bundled payment model across multiple independent providers, and a pay-for-performance model aimed at individual providers.
Vermont's Blueprint for Health also calls for an advanced "learning health system infrastructure that will support delivery system redesign and state evaluation activities," while the federal grant will help fund clinical and claims data analytics, expanded measurement of patient experience, workforce needs, telemedicine and home monitoring technologies.