Health Care Spending And Use Among People Experiencing Unstable Housing In The Era Of Accountable Care Organizations.

Provider organizations are increasingly held accountable for health care spending in vulnerable populations. Longitudinal data on health care spending and use among people experiencing episodes of homelessness could inform the design of alternative payment models. We used Medicaid claims data to analyze spending and use among 402 people who were continuously enrolled in the Boston Health Care for the Homeless Program (BHCHP) from 2013 through 2015, compared to spending and use among 18,638 people who were continuously enrolled in Massachusetts Medicaid with no evidence of experiencing homelessness. The BHCHP population averaged $18,764 per person per year in spending-2.5 times more than spending among the comparison Medicaid population ($7,561). In unadjusted analyses this difference was explained by greater spending in the BHCHP population on outpatient care, including emergency department care, as well as on inpatient care and prescription drugs. After adjustment for covariates and multiple hypothesis testing, the difference was largely driven by outpatient spending. Differences were sensitive to adjustments for risk score, which suggests that housing instability and health risk are meaningfully correlated. This longitudinal analysis improves understanding of health care use and resource needs among people who are homeless or have unstable housing, and it could inform the design of alternative payment models for vulnerable populations.

Policy Levers Key for Primary Health Care Organizations to Support Primary Care Practices in Meeting Medical Home Expectations: Comparing Leading States to the Australian Experience.

Several countries with highly ranked delivery systems have implemented locally-based, publicly-funded primary health care organizations (PHCOs) as vehicles to strengthen their primary care foundations. In the United States, state governments have started down a similar pathway with models that share similarities with international PHCOs. The objective of this study was to determine if these kinds of organizations were working with primary care practices to improve their ability to provide comprehensive, coordinated, and accessible patient-centered care that met quality, safety, and efficiency outcomes-all core attributes of a medical home. This qualitative study looked at 4 different PHCO models-3 from the United States and 1 from Australia-with similar objectives and scope. Primary and secondary data included semi-structured interviews with 26 PHCOs and a review of government documents. The study found that the 4 PHCO models were engaging practices to meet a number of medical home expectations, but the US PHCOs were more uniform in efforts to work with practices and focused on arranging services to meet the needs of complex patients. There was significant variation in level of effort between the Australian PHCOs. These differences can be explained through the state governments' selection of payment models and use of data frameworks to support collaboration and incentivize performance of both PHCOs and practices. These findings offer policy lessons to inform health reform efforts under way to better capitalize on the potential of PHCOs to support a high-functioning primary health foundation as an essential component to a reformed health system.

Making multipayer reform work: what can be learned from medical home initiatives.

Multipayer collaboratives of all types will encounter legal, logistical, and often political obstacles that multipayer medical home initiatives have already overcome. The seventeen multipayer medical home initiatives launched between 2008 and 2014 all navigated four critical decision-making points: convening stakeholders; establishing provider participation criteria; determining payment; and measuring performance. Although we observed trends toward voluntary payer participation and more flexible participation criteria for both payers and providers, initiatives continue to vary widely, each shaped largely by its insurance market and policy environment. Medical home initiatives across the United States are demonstrating that multipayer reform, although complex and difficult to implement, is feasible when committed stakeholders negotiate strategies that are responsive to the local context. Their experiences can inform, and perhaps expedite, negotiations in current and future multipayer collaborations.

State strategies to avoid antitrust concerns in multipayer medical home initiatives.

Currently, 20 states have had one or more active multipayer medical home initiatives. As more states convene multiple payers and work to align payment policies, concerns regarding antitrust liability will need to be addressed. This issue brief provides a summary of state strategies to navigate antitrust concerns in multipayer medical home initiatives. Information for this brief was obtained from a survey sent to 14 states combined with a scan of state websites. Nine states have policies in place either through legislation or executive order to provide some legal protection for their efforts to displace competition among payers. Out of concern that legislation was not sufficient, policymakers in one state also conducted oversight activities to reduce the risk of antitrust liability. Six of the 14 states surveyed have engaged in multipayer initiatives without formal antitrust protection.

About half of the states are implementing patient-centered medical homes for their Medicaid populations.

Public and private payers are testing the patient-centered medical home model by shifting resources to enhance primary care as an important component of improving the quality and cost-effectiveness of the US health care delivery system. Medicaid has been at the forefront of this movement. Since 2006 twenty-five states have implemented new payment systems or revised existing ones so that primary care providers can function as patient-centered medical homes. State Medicaid programs are taking a variety of approaches. For example, Minnesota's reforms focus on chronically ill populations, while in Missouri a 90 percent federal match under the Affordable Care Act is helping integrate primary and behavioral health care and address issues of long-term services and supports. These reforms have led to better alignment of payments with performance metrics that emphasize health outcomes, patient satisfaction, and cost containment. This article focuses on trends in Medicaid patient-centered medical home payment that can inform public and private payment strategies more broadly.

Reinventing Medicaid: state innovations to qualify and pay for patient-centered medical homes show promising results.

This article describes patient-centered medical home initiatives that seventeen states have launched. These initiatives use national recognition or state-based qualification standards along with incentive payments to address soaring costs and lagging health outcomes in state Medicaid programs. Even though these initiatives are in their infancy, early results are encouraging. Modest increases in payment to physicians, aligned with quality improvement standards, have not only resulted in promising trends for costs and quality, but have also greatly improved access to care. Several state programs have already demonstrated declines in per capita costs for patients enrolled in Medicaid; increased participation of physicians in caring for Medicaid patients; and high patient and provider satisfaction. These early results give states good reason to continue developing patient-centered medical homes as part of their Medicaid programs. This article provides a closer look at these innovative models, to inform public and private reform efforts.