This June 2009 report from the National Academy for State Health Policy examines collaborative arrangements in 10 states designed to improve health care quality.

From the National Academy for State Health Policy:

This report focuses on 10 leading state quality improvement partnerships – interrelated broad-based partnerships, mostly with public and private sector representation, which have long-term, statewide, systemic quality improvement strategic intent, and transparent agendas. They are:

• The Center for Improving Value in Health Care (CIVHC), Colorado
• The Kansas Health Policy Authority (KHPA);
• Partnership of the Maine Quality Forum, Quality Counts, and the Maine Health Management Coalition;
• The Massachusetts Health Care Quality and Cost Council (HCQCC);
• The Minnesota Health Care Value Exchange (HCVE);
• Partnership of the Oregon Quality Corp, the Oregon Patient Safety Commission, the Oregon Health Policy Commission, and the Oregon Health Fund Board;
• The Pennsylvania Governor’s Office of Health Care Reform (GOHCR);
• The Rhode Island Quality Institute (RIQI);
• The Vermont Blueprint for Health (Blueprint); and
• The Washington Quality Forum (now an informal partnership of the Washington State Health Care Authority and the Puget Sound Health Alliance).

These partnerships vary along a continuum of formality and scope. They build on varying histories of collaboration in each state and arise from different needs and aspirations. Nevertheless, they share a longterm commitment to multi-pronged, strategic, broad-based, and systemic improvements. Many of the partnerships are linked to broader state health reform initiatives, and most explicitly or implicitly focus on improving quality of care and improving value in the health system.  These 10 state quality improvement partnerships provide a way for their states to streamline quality improvement efforts so that they are efficient and not duplicative. The partnerships attempt to be strategic, comprehensive, and long term in their planning, but also to identify “quick wins” – pr oven initiatives that provide concrete results in a relatively short time. Partnerships take advantage of successful models in other states, which provide lessons learned along with ideas for quick wins. In their efforts to improve quality and system performance, partnerships tend to employ five broad interrelated strategies:

• Data collection, aggregation, and standardization for performance measurement;
• Public reporting and transparency of quality and/or cost data to drive accountability and improvement;
• Consumer engagement to drive change and encourage care self-management
• Provider engagement through evidence-based practice improvement tools and guidelines; and
• Payment reform and alignment of financial incentives to encourage value-based purchasing

Full report: http://www.nashp.org/files/Quality_Improvements_FINAL.pdf

This June 23 report for the Commonwealth Fund examines the prospect of building Medical Home programs within state Medicaid and SCHIP programs. 

From the Commonwealth Fund:

With 47 million uninsured Americans, double digit inflation in medical spending and health outcomes that lag far behind other nations, comprehensive health care reform that addresses access, cost and quality issues is a national priority. A primary-care-oriented system may have benefits for population health, equity in health, and cost containment and has been shown to reduce racial and ethnic disparities, and result in significantly lower health care costs and improved life expectancy diseases for those with chronic diseases.

A medical home is an enhanced model of primary care in which care teams attend to the multi-faceted needs of patients and provide whole-person comprehensive and coordinated patient-centered care. First advanced by the American Academy of Pediatrics in the 1960’s for certain pediatric populations, the medical home concept has evolved to embrace all populations. In 2007, four major physician groups agreed to a common concept of the patient centered medical home (PCMH) defined by seven "Joint Principles." Supporters of the PCMH model have joined together to form the Patient Centered Primary Care Collaborative (PCPCC) that represents employers, medical specialty societies, health plans and other organizations.

Since 2006 more than 30 states have initiated projects to improve Medicaid and Children’s Health Insurance Programs (CHIP) to advance medical homes. Several states also are driving state-wide transformation by using their purchasing leverage to make changes in state health benefits plans and in the private sector. This paper summarizes these activities and provides state policy makers with examples of promising practices, lessons learned and ideas they can adapt to work in their state.

This paper was informed by research that started with a brief survey of Medicaid and CHIP directors and targeted Internet research. A working meeting of eight leading states (Colorado, Idaho, Louisiana, Minnesota, New Hampshire, Oklahoma, Oregon and Washington) convened in July 2008 provided for a significant amount of NASHP's research. These eight states—in addition to North Carolina and Rhode Island which have well-developed medical home initiatives—helped us identify five major strategies for other states to consider in developing their own plans:

1. Forming partnerships with key players (including patients, providers and private sector payers) whose practices the state seeks to change.
2. Defining medical homes to help establish provider expectations and implementing processes to recognize primary care practices that meet those expectations.
3. Aligning reimbursement and purchasing to support and reward practices that meet performance expectations,
4. Supporting practices to help advance patient-centered care.
5. Measuring results to assess whether their efforts are succeeding in containing costs, improving quality and patient experience. Forming key partnerships.

Full Report: http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report/2009/Jun/Building%20Medical%20Homes%20in%20State%20Medicaid%20and%20CHIP%20Programs/medicalhomesfinal_revised.pdf 

This study found that children in families where siblings are eligible for different public insurance programs are less likely than other children to be insured, even when all children are eligible for public coverage.  The paper finds that recent policies to encourage enrollment have not improved coverage of this “mixed eligibility” population and further finds that states where the State Children’s Health Insurance Program (SCHIP) is separate from Medicaid have higher mixed eligibility uninsurance rates that states in which SCHIP is part of the Medicaid program.

Hudson, J. L. (2009). Families with mixed eligibility for public coverage: navigating Medicaid, CHIP, and uninsurance. Health Affairs, 28(4), w697-709. DOI: 10.1377/hlthaff.28.4.w697 http://content.healthaffairs.org/cgi/content/abstract/hlthaff.28.4.w697v1 

Author: Julie L. Hudson.

This report by the Kaiser Family Foundation's (KFF) Commission on Medicaid and the Uninsured, released May 2009, explores the use of Medicaid as a health reform vehicle to expand access and quality of care to high-need and low-income populations. 

From KFF:

As debate on national health reform moves forward, expanding coverage to the uninsured as well as addressing health care cost and quality issues have emerged as the dominant drivers for system reform. Extensive research shows that coverage is key to securing access to needed health care services. Leading health reform proposals rely on a combination of public and private approaches to expand coverage, control costs and improve quality with shared responsibilities across employees, employers, government, consumers and insurance markets. 

• Two-thirds of the 45 million uninsured are low-income individuals (below 200% of the poverty level or $36,620 for a family of three in 2009), and many have significant health needs.
• Many low-income individuals do not have access to employer coverage and cannot afford or access private coverage through the individual market.
• Medicaid already serves 60 million Americans and provides a base of affordable and comprehensive coverage that is well suited for low-income and high-need populations. The costs of private health care and Medicare premiums are lessened by having Medicaid insure these highneed populations and provide key services not covered by private plans or Medicare.
• Most Medicaid enrollees receive care through private managed care plans that are designed to promote access to care, enhance quality and control costs. Medicaid also helps support community health centers and other safety-net providers in medically underserved areas.
• Medicaid enrollees fare as well as the privately insured populations on important measures of access to primary care even though they are sicker and more disabled. Accounting for the health needs of its beneficiaries, Medicaid is a low-cost program with lower per capita spending than private insurance; thus covering Medicaid enrollees in private coverage would be more costly.
• Medicaid has a well developed administrative structure in every state that has enabled it to be a cornerstone in federal and state efforts to expand coverage. Medicaid plays an important role for some disadvantaged populations and the program has broad public support.
• Expand Medicaid’s reach to more low income individuals by basing eligibility on income alone with federal minimum standards and making additional progress to increase participation rates.
• Ensure that current and new enrollees receive Medicaid’s benefit and cost-sharing protections, and promote better access by addressing payment rates to help boost provider participation.
• Provide adequate Medicaid financing by having the federal government assume the costs of expanding Medicaid coverage or by shifting some current Medicaid costs to the federal government; and provide stable financing by establishing a countercyclical financing mechanism during economic downturns.
• Bolster Medicaid with broader efforts to contain costs across the health system (public and private) to help ensure long term sustainability; develop strategies to expand the primary care workforce to provide better access to primary and preventive care, and establish system-wide quality standards along with the implementation of health information technology to promote an efficient health care system based on positive outcomes.

Full Report: http://www.kff.org/medicaid/upload/7898.pdf

This June 1 Urban Institute report, “Health Care Reform for Children with Public Coverage: How Can Policymakers Maximize Gains and Prevent Harm?,” examines the effect of health care reform on children enrolled in Medicaid and SCHIP.  The report suggests that such children would benefit from increased health coverage for their parents.  The brief also notes that effects of proposals to move the children into health insurance exchanges will vary by the characteristics of those exchanges.  The change may cause them to lose benefits and/or legal protection; however, if reimbursement rates in the exchanges are higher than in public programs, children’s access to care will improve. 

Full Report: http://www.urban.org/UploadedPDF/411899_children_healthcare_reform.pdf 

The Kaiser Family Foundation’s (KFF) Commission on Medicaid and the Uninsured released a policy brief examining private long-term care insurance.  The brief also outlines the results of a study that analyzed the long-term care insurance market and discusses policy challenges for the field.

From KFF: the report found that:

• Cost remains a key barrier to expanding the role of private insurance
• Health risk can deny consumers coverage
• Buyers face complex product design issues
• Time lag between purchase and use of benefits creates problems in service use
• Employer-based market offers promise but adequacy of coverage is a concern
• Medicaid Partnership Program will shape products and the market

Full Report: http://www.kff.org/insurance/upload/Closing-the-Long-Term-Care-Funding-Gap-The-Challenge-of-Private-Long-Term-Care-Insurance-Report.pdf