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GEAR Group 3 Information
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Generate, Educate, Activate, Respond (GEAR) Groups

 Group 3: GEAR Up for Understanding Healthcare Payment Reform

 

 

This group will aim to address how public health needs to understand payers and payment reform in the context of population health management. This includes a review of common language, understanding the public payers, commercial payers, what is driving the reform and how the payment system is changing to accommodate this, as well political and financial challenges. The team will discuss how public health can get to the table and contribute to the dialogue including how to engage with health systems and payers. Open to states with innovation-type awards (SIM, TCP, DSRIP, etc.).

 

Domains Addressed: 3, 4

 

Learner Objectives:

  1. Team members will gain leadership skills in working with their peers to identify and share public health and health system goals that are mutually beneficial and that improve chronic disease related health outcomes. 
  2. Team members will have an increased understanding of the current landscape of payment reform.
  3. Team members will learn more about payment reform innovations and initiatives that are designed to address population health.

 

Update April 2016:

Gear Group #3 is addressing how public health needs to understand payers and payment reform in the context of population health management. This includes a review of common language, understanding the public payers, commercial payers, what is driving the reform and how the payment system is changing to accommodate this, as well political and financial challenges. The team is discussing how public health can get to the table and contribute to the dialogue including how to engage with health systems and payers. Membership was open to states with innovation-type awards (State Innovation Models (SIM), Transforming Clinical Practice (TCP), Delivery System Reform Incentive Payment (DSRIP), etc).

 

Payment Reform in the Context of Public Health

Health policy expert, Ken Thorpe, stated, “transforming our overpriced, underperforming health care delivery system demands bold initiatives that are based on the best evidence available and swiftly implemented. The Patient Protection and Affordable Care Act provides a strong base for change by, among other things, specifying innovative, sustained actions in the areas of payment and prevention, and by moderately expanding efforts to explore the best ways to improve care coordination. Fortunately, a large and growing body of research identifies effective approaches for improving quality and slowing the growth in spending—including changes in payment, care delivery, and prevention—which can be put to immediate use….” (1)

 

GEAR GROUP INTERIM OUTCOMES

NACDD GEAR Group #3 members are bringing a variety of excellent experiences in this area to the group.  One member reported that the public health department in Georgia is working with a local Accountable Care Organization (ACO) to develop shared savings models – an asthma coordination model and a diabetes care coordination project. The Centers for Medicare and Medicaid Services (CMS)-funded State Innovation Models (SIM) provides new opportunities to integrate prevention into the transforming health systems.  A group member reported, “our SIM Grant has provided our state an opportunity to have serious conversations about offering the diabetes prevention program as a covered benefit to our Medicaid population.” Another member indicated that ACOs are beginning to recognize the value of public health surveillance data in monitoring the health of the population, not just those who walk through a clinic’s doors. 

 

The second series of calls have been held throughout April. On the recent GEAR Group #3 call, they discussed the process Indiana has gone through to get an 1115 Medicaid waiver to integrate behavioral health into primary care. (For more info on 1115 waivers: https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/Section-1115-Demonstrations.html.)

The group also discussed a number of initiatives Nevada is involved in, highlighting the work they recently did to achieve parity between Medicare and Medicaid to reimburse for diabetes self-management education—an effort that required an internal policy change but not legislation.

This topic of payment reform is red hot and in the nexus between health care and public health. The GEAR Group will be valuable in identifying learnings that can be disseminated to NACDD members throughout the organization who work in a variety of settings.

 

The CDC has summarized this opportunity well:

“The American healthcare system is in the midst of unprecedented change, and the Triple Aim, —achieving better care for patients, better health for communities, and lower costs through healthcare system improvement—is becoming a widely accepted framework for the desired outcomes of the evolving system. Key elements emerging in this transformation include new structures for integrating and coordinating services, a renewed focus on patient engagement and patient-centered care, and new payment models based on the value of population-based health outcomes rather than the volume of services delivered”. (2)

 

  1. Kenneth E. Thorpe and Lydia L. Ogden, The Foundation That Health Reform Lays For Improved Payment, Care Coordination, And Prevention, Health Affairs 29, no.6 (2010):1183-1187.
  2. Hester JA, Stange PV, Seeff LC, Davis JB, Craft CA. Toward Sustainable Improvements in Population Health: Overview of Community Integration Structures and Emerging Innovations in Financing. Atlanta, GA: CDC; 2015. CDC Health Policy Series, No. 2.