Better Health, Better Care, and Lower Costs–One State at a Time

Nov 14, 2016, 12:00 PM, Posted by

While the Affordable Care Act is known for its national reforms, it has given states the opportunity to transform and improve their health systems.

Two doctors standing in a corridor consult together over some paperwork.

The Affordable Care Act (ACA) has drastically accelerated change within the nation’s health care system. While the law is known for ushering in national reforms—policies that aim to better health, improve care, and lower costs across the United States—it has also fostered new opportunities for states to serve as incubators for health care transformation. Valuable lessons can be drawn from these early-innovator states and their commitment to payment innovation, restructuring care delivery systems, and efforts to build healthy communities that extend beyond traditional medical providers. Multi-state health systems are uniquely positioned to facilitate this innovation.

The Centers for Medicare and Medicaid Innovation (CMMI), an office created by the Affordable Care Act to drive change in the health care system, has awarded about $960 million to 34 states, three territories, and the District of Columbia to test comprehensive transformation plans through its State Innovation Model (SIM) initiative. At Trinity Health, we're supporting and studying nine SIM awardees: Connecticut, Delaware, Idaho, Iowa, Massachusetts, Michigan, New York, Ohio, and Oregon. We're committed to sharing early lessons and best practices in addition to obstacles identified within our own health system. This information can help states, CMS, and other stakeholders expedite their own innovation.

Trinity Health is a non-profit Catholic health system present in 22 states across the nation. We're participating in SIM governance structures, encouraging physician partners to embrace practice transformation opportunities, and seeking advanced alternative payment model contracts. Given our system’s experience with these diverse efforts—and our commitment to alternative payment models and population health—Trinity Health is a provider who recognizes the importance of sharing early lessons and best practices to help spread innovation. Here’s what we’ve observed and learned from SIM efforts across the country.

Bold leadership creates results.

Our State Resource Center provides SIM leaders with a one-stop clearinghouse of information. We've found, for example, that success materializes more readily in states where governors or leading health figures have made this work a priority and are regularly engaging on a personal level and insisting on involvement from payer and provider executives. Ohio has been paradigmatic of this approach; the Governor's Office of Health Transformation has demonstrated a relentless commitment to further this work in an inclusive and accountable fashion. Recognizing the need for sustainability, states are building transparent governance structures that include stake-holders outside of government. For example, Delaware elected to pursue a politically-insulated governance structure by establishing the Delaware Center for Health Innovation (DCHI), an independent, non-profit public-private partnership. States should look to their peers and adapt lessons to their unique political and cultural contexts.

Oregon and Minnesota are two of the six original round one testing states. Oregon's Coordinated Care Organization (CCO) model has resulted in almost half of Oregonians benefitting from patient-centered medical homes, fewer ER visits, and fewer hospitalizations. Minnesota's Medicaid Integrated Health Partnerships program includes 19 ACOs covering 350,000 enrollees. In 2014, the program created $61.5 million in savings and exceeded quality targets. For more on what we learned, read our Governors Best Positioned to Improve Health of Residents, Innovate Health Care Delivery and Promote Healthy Living white paper.

Common themes to payment reform and delivery transformation are emerging.

Cross-state commonalities are emerging in delivery system transformation. Shared strategies include advancing health information technology to manage populations; utilizing claims data from all payers and analytic tools to understand that data; developing consistent, common sets of quality and cost measures across payers; investing new resources in practice transformation; addressing changing workforce needs necessary to deliver population health; and expanding access. People-centered starts with people covered.

New York has two initiatives worthy of state replication. Its common set of quality measures is the result of extensive consultation with providers and other stakeholders. Its Payment Reform Scorecard, created in coordination with Catalyst for Payment Reform, is critical for measuring progress toward the state's 80% value-based payment goal.

The premise behind payment reform is that providers should be held accountable for the care they deliver. While the federal government has taken important steps in shifting from “volume to value” in the federal Medicare program, sustainable transformation requires participation by Medicaid and private insurers. States are using a range of alternative payment models to drive reform under their SIM efforts including: accountable care organizations (ACOs) in Massachusetts, Delaware, Connecticut, Iowa, Oregon, and Michigan; patient-centered medical homes (PCMHs) in New York, Ohio, Idaho, Connecticut, and Michigan; and episodes of care in Ohio.

There is growing recognition of the importance of transforming communities into healthier places. 

The value and quality improvement initiatives referenced above hold great promise for providing a seamless, patient-centered experience. Yet, in the midst of this opportunity to improve health care and lower costs, we face a serious challenge that is often overlooked: the largest drivers of poor health and preventable health care costs often fall outside the traditional sphere of health care systems.

States and health care systems have a shared responsibility not only to transform the way we deliver and pay for care, but to transform unhealthy communities into healthier places to live. Health doesn't begin in a hospital or a doctor's office, but in homes and neighborhoods. Health begins in the places we live and work—where our children learn and where we pray. Simply put, where we live impacts how we live, which is why our ZIP code can sometimes be a better predictor of health outcomes than our genetic code. Many states are embracing this concept as integral to their efforts.

Michigan’s health care innovation plan, for example, will include Community Health Innovation Regions (CHIRs) that guide patients to community services relevant to their needs. By partnering with other local stakeholders—schools, charities, faith-based organizations, and others—and providing efficient and effective wrap-around services, CHIRs can help tackle upstream causes of poor health in the region.

We need to look ahead.

The experience of pioneer states should inform the future development of other state models. Multi-state health systems can further this work by aggregating and disseminating key lessons and best practices, as Trinity Health has begun to do. Leading state-level health care transformation and community health innovation is challenging: resources are scarce, internal knowledge is often thin, and political obstacles can seem insurmountable. Still, this work is critical to achieving better health, better care, and reduced spending. Residents in early innovator states will benefit from systems that promote value over volume, provide more care coordination and fewer emergency room visits, rely on evidence-based care decisions with robust consumer engagement, and are improving the health of their communities.

Bechara Choucair is a senior vice president at Trinity Health.