REPORT JANUARY 2018 Enabling Sustainable Investment in Social Interventions: A Review of Medicaid Managed Care Rate-Setting Tools Deborah Bachrach, Jocelyn Guyer, Sarah Meier, John Meerschaert, and Shelly Brandel ABSTRACT KEY TAKEAWAYS ISSUE: It is widely recognized that social factors, such as unstable housing Social factors like unstable and lack of healthy food, have a substantial impact on health outcomes housing and lack of healthy food are widely known to affect health and spending, particularly with respect to lower-income populations. care outcomes and spending. For Medicaid, now dominated by managed care, this raises the question While Medicaid traditionally has of how states can establish managed care rates to sustain investments in not covered or reimbursed for social supports. social interventions, it offers more practical options for doing GOAL: To explore practical strategies that states can deploy to support so than is commonly recognized. Medicaid managed care plans and their network providers in addressing social issues. With the predominance of Medicaid managed care, states METHODS: Literature review, interviews with stakeholders, and analysis require new contract and rate- of federal regulations. setting strategies to enable plan FINDINGS AND CONCLUSIONS: We identify the following options: and provider investment in social interventions. 1) classify certain social services as covered benefits under the state’s Medicaid plan; 2) explore the additional flexibility afforded states through Options available to address Section 1115 waivers; 3) use value-based payments to support provider social drivers of health include: investment in social interventions; 4) use incentives and withholds to classifying certain social services encourage plan investment in social interventions; 5) integrate efforts to as covered Medicaid benefits, address social issues into quality improvement activities; and 6) reward using value-based payments to support provider investment plans through higher rates for effective investments in social interventions. in social interventions, and More needs to be done, however, to assist interested states in using these rewarding managed care plans options and identifying pathways to braid Medicaid dollars with other with higher payment rates. social services funding. Sustainable Investment in Social Interventions: Medicaid Managed Care Rate-Setting Tools 2 INTRODUCTION strategies do not represent a comprehensive solution to It is now widely recognized that social factors, such the issue of Medicaid’s role in addressing social issues, they as unstable housing, lack of healthy food, unsafe are an essential building block. neighborhoods, and unemployment, have a substantial impact on health care outcomes and spending, BACKGROUND particularly with respect to lower-income populations.1 States face several questions about what role they want Moreover, there is an emerging body of research on which Medicaid to play in addressing social issues that directly interventions are most likely to result in better outcomes affect the health of Medicaid beneficiaries and the cost and reductions in spending.2 As the nation’s largest payer of serving them. Do they want to move their Medicaid for health care services for low-income populations, many programs beyond paying for medical services to of whom have substantial social service needs, Medicaid tackling affordable housing, economic insecurity, unsafe is front and center when it comes to these issues. State neighborhoods, and access to adequate and healthy Medicaid agencies are increasingly focusing on how food? In some states, the priority is finding more effective the program can cover and reimburse for nonclinical ways to deliver traditional medical care. Other states, interventions, particularly in managed care, now the particularly those that have implemented an expansion dominant service delivery model in Medicaid. of coverage to low-income adults or are adopting a This report identifies practical strategies that states can population health approach to their Medicaid programs, deploy to support Medicaid managed care plans and their look to their managed care plans and providers to address network providers in addressing social issues. Based on a such issues (Exhibit 2). In all cases, states must evaluate the literature review and on interviews with state officials, extent to which federal Medicaid rules permit coverage health plan leaders, actuarial experts, and other stakeholders, and payment for discrete nonclinical services. we identify options for states to consider if they are interested in incorporating the cost of social interventions Rate-Setting Tools in Context into Medicaid managed care rates (Exhibit 1). While the A Medicaid managed care financing and payment strategy is an essential element, but far from the only required element, of any approach to use Medicaid as a vehicle Exhibit 1 for addressing social determinants of health. During STATE OPTIONS AND CONSIDERATIONS our interviews, we consistently heard that while there is strong interest in innovative rate-setting options, 1. Classify certain social services as covered states have many other challenges they need to tackle benefits under the state’s Medicaid plan for Medicaid to play a role in addressing social issues. 2. Explore the additional flexibility afforded states These other challenges include the need for more staff through Section 1115 waivers with different skills, such as social service experience or 3. Use value-based payment to support actuarial proficiency; a data infrastructure to identify and investment in social interventions address social factors; and sufficient time and resources for plans and providers to prepare to address social issues 4. Use incentives and withholds to encourage plan (see Appendix D). While these are important issues, they investment in social interventions are not the focus of this report, which addresses options 5. Integrate efforts to address social issues into available to states for creating a payment and managed quality improvement activities care contracting strategy that supports investments in social interventions. 6. Reward plans with effective investments in social interventions with higher rates commonwealthfund.org January 2018 Sustainable Investment in Social Interventions: Medicaid Managed Care Rate-Setting Tools 3 Exhibit 2 MEDICAID EXPANSION: IMPLICATIONS FOR THE IMPORTANCE OF ADDRESSING SOCIAL DETERMINANTS OF HEALTH In the states that expanded their Medicaid programs reinforced the importance of Medicaid addressing social to all adults with incomes below 138 percent of the issues: first, because of the relatively high prevalence federal poverty level (31, plus the District of Columbia), of mental illness and substance abuse among the newly eligible adults often have extensive social needs. population,b and second, because of Medicaid’s According to research from the Medicaid and Children’s increasingly important role in the coverage and care of Health Insurance Program Payment and Access low-income families. Finally, interviewees noted that, Commission, 70 percent are below the federal poverty as Medicaid coverage became more stable and states level, but, even so, only about half receive benefits from and managed care plans began to implement value- the Supplemental Nutrition Assistance Program.a In our based payment policies, plans and providers were better interviews with Medicaid directors in expansion states, positioned to address the social needs of their enrollees they reported that gaining these new enrollees has and patients. a M. Heberlein, “New Findings from the Health Reform Monitoring Survey,” Presentation at the Medicaid and CHIP Payment and Access Commission (MACPAC, March 24, 2015). b Medicaid and CHIP Payment and Access Commission, “Chapter 4: Behavioral Health in the Medicaid Program—People, Use, and Expenditures,” in Report to the Congress on Medicaid and CHIP (MACPAC, June 2015). Medicaid Managed Care Rate-Setting: Rules, In other words, states cannot directly build the cost of Policies, and Procedures social support services not covered under the state plan The question at the center of this analysis is how states can into their capitation rates (Exhibit 3).4 support plan investment in social services that improve health outcomes and are cost-effective. In states with The regulations also specify that rates should reflect Medicaid managed care, this translates into a question of reasonable nonbenefit expenses associated with how to set Medicaid managed care capitation rates in such providing the covered benefits and meeting mental health a way that plans are incentivized or required — and, even parity requirements. These nonbenefit expenses include more importantly, have the resources — to address social administrative costs; taxes, licensing, and regulatory issues that directly affect the health outcomes of their fees; contribution to reserves; profit or risk margin; the members. cost of capital; and other operational costs. As further discussed below, quality initiatives can be considered The starting point for answering this question is the part of operational costs, potentially creating a vehicle federal Medicaid managed care rules that require states for covering social interventions that are part of a plan’s to ensure that capitation rates are actuarially sound. This quality initiatives. means that rates must be sufficient to cover the costs that plans incur to provide covered benefits to their enrollees, A distinct but related issue is that states also must set their as well as related administrative and operational capitation rates at a level that results in plans, on average, expenses. Notably, capitation rates must be based only being projected to incur a medical loss ratio (MLR) of on services covered under the state plan and services at least 85 percent.5 The MLR calculation is designed to necessary to achieve mental health parity requirements.3 ensure plans are spending a sufficient amount of their commonwealthfund.org January 2018 Sustainable Investment in Social Interventions: Medicaid Managed Care Rate-Setting Tools 4 Exhibit 3 VALUE-ADDED AND “IN-LIEU-OF” SERVICES Under the federal Medicaid managed care rules, plans covered in a state plan because they are a cost-effective may cover value-added services, which are services alternative. For example, a state could allow plans to that are not covered under the state plan, but that a provide medically tailored meals as a substitute for a managed care plan chooses to spend capitation dollars home visit by an aide in selected circumstances. The on to improve quality of care and/or reduce costs.a For actual costs of providing the in-lieu-of service are example, a managed care plan might elect to provide included when setting capitation rates, and they also supportive housing for a beneficiary with a mental count in the numerator of the MLR.b In-lieu-of services,   illness who otherwise would cycle between hospital however, can only be covered if the state determines the stays and homelessness. The cost of value-added service or alternative setting is a medically appropriate services cannot be included in the capitation rates; and cost-effective substitute or setting for the state plan it can, however, be included in the numerator of the service; if beneficiaries are not required to use the in- medical loss ratio (MLR) if it is part of a quality initiative. lieu-of service; and if the in-lieu-of service is authorized and identified in the contract with Medicaid managed States and plans also may elect to cover “in-lieu-of” care plans. services, which substitute for services or settings a 42 CFR § 438.3(e)(1)(i). In some states, value-added services are required in the contract between a state and managed care plans even though value-added services are optional. In these instances, plans may offer to cover some value-added services when they bid to participate in a state’s managed care program, and then these services are enshrined in the contract. Even though the services are part of the contract, plans are not necessarily paid to provide them. By definition, value-added services are not covered benefits under a state plan, so the cost of providing them cannot be built into the capitation rate for managed care plans, leaving plans to pay for them out of profits. b See 42 CFR § 438.3(e)(2). capitation funds on services for beneficiaries, rather than rates could be lower if social interventions are effective administrative costs, profits, or other similar expenses in driving down use of medical care. In our interviews, (Exhibit 4). This means it is key to assess where the cost some actuarial experts and plans questioned whether of social interventions fits into the MLR calculation; if this issue, often referred to as “premium slide,” should investing in social services helps plans to meet an 85 be a significant concern. They point out that plans ought percent MLR threshold, they will be more likely to make to be able to accept lower rates provided they have a such investments. If doing so harms their ability to reach source of funding for social interventions and receive an 85 percent threshold, such investments are likely to a reasonable profit margin. Indeed, these experts note remain small and/or short-lived. Although they are not that a key purpose of managed care is to better manage required to do so by federal regulations, some states also costs, making it a sign of success if premiums decline or recoup money from plans that fail to meet a minimum grow at a slower rate than they otherwise would. Even so, MLR. If states elect to do so, federal regulations require others suggested that concerns about premium slide could that the MLR they establish must be 85 percent or higher. nevertheless dampen plan interest in aggressively tackling social factors, especially if plans are not provided with Finally, from a plan perspective, these rules and funding for the cost of the interventions. requirements also raise the prospect that future capitation commonwealthfund.org January 2018 Sustainable Investment in Social Interventions: Medicaid Managed Care Rate-Setting Tools 5 Exhibit 4 FORMULA TO CALCULATE THE MEDICAL LOSS RATIO The medical loss ratio (MLR)a is calculated by summing spending that is included in a plan’s numerator, the the cost of claims for services covered by Medicaid, higher its MLR. If a plan cannot consider investments quality improvement expenses, and fraud prevention in social services as part of the numerator, such expenses.b The sum of these elements, often referred investments drive down the plan’s MLR. In effect, if to simply as “the numerator,” is divided by a plan’s investments in social interventions are treated in the capitation revenue minus taxes and fees, which is same way as profits and administrative costs, it creates a referred to as the “denominator” of the MLR. The more disincentive for plans to make such investments. Quality Fraud Claims + improvement + prevention expenses expenses Medical loss ratio = Taxes Premiums – and fees See 42 CFR § 438.8(d). a See 42 CFR § 438.8(e-f). b Value-Based Payment: A Jumping-Off Point The release of the Medicaid managed care rule in the Over the past decade and certainly since passage of the spring of 2016 has accelerated states’ use of value-based Affordable Care Act in 2010, state Medicaid agencies payment.6 The rule provides authority for states to require have sought to move away from fee-for-service payment plans to engage in value-based payments and other structures to more value-based payment strategies — delivery system reforms, as well as allowing states to from volume to value (Exhibit 5). Initially the focus was use payments or withholds to incentivize plans to meet on the relationship between states and providers, with such goals or mandates (Exhibit 6). For example, the rule states increasing reimbursement for providers that met highlights that states can require plans to participate patient-centered medical home standards and sharing in a patient-centered medical home initiative, which, savings with providers that could meet minimum quality depending on the state, could include a strong emphasis standards and bring down costs. However, states that on connecting beneficiaries to social supports. Moreover, deployed managed care delivery models did not have the rule grants states some authority to directly shape direct payment relationships with providers. Thus, payment arrangements between plans and their network the question became how to inject these new provider providers. Certain guardrails apply, including that the payment strategies into Medicaid managed care. state cannot direct the value or the frequency of the payments to individual providers, cannot condition payments on intergovernmental transfers, and must link the requirements to the state’s Medicaid quality strategy.7 commonwealthfund.org January 2018 Sustainable Investment in Social Interventions: Medicaid Managed Care Rate-Setting Tools 6 Notably, value-based payments — including state MLR and so are part of the numerator.8 With the managed performance bonus payments and shared-savings care rule’s changes and clarifications, it is now easier for payments to providers — are built into capitation rates states to pay for value through managed care, including and considered “claims” for purposes of calculating the when value can be obtained through cost-effective investments in social services. Exhibit 5 WHAT IS VALUE-BASED PAYMENT? Value-based paymenta,b — that is, payment based on the Medicaid, Medicare, and commercial markets. For the value (i.e., quality and cost) of care, rather than example, a Medicaid managed care plan might pay a exclusively on the quantity of services provided — bonus to providers for strong performance on outcome incentivizes better care, better outcomes, and lower measures and allow providers to share in the savings if costs, and it is increasingly being used among payers in costs are kept below a target level. See 42 CFR § 412.160. a Note that states can develop their own definitions for value-based purchasing, which may be broad or narrow. b Exhibit 6 STATE OPTIONS TO INCENTIVIZE PLANS TO MEET VALUE-BASED PAYMENT REQUIREMENTS The Medicaid managed care rule gives states the related to social issues and/or that make use authority to require plans to use value-based payments of value-based payments. These payments are and offer fiscal incentives to meet the requirements.a excluded entirely from MLR calculations. • Incentive payments are a payment mechanism • Withhold arrangements are any payment under which plans receive additional funds — over mechanism under which a portion of a plan’s and above their capitation payment — for meeting capitation payment is withheld unless a plan meets targets in the contract. Such arrangements can be performance targets. States can use withhold up to 5 percent of a plan’s capitation revenue, an arrangements to incentivize plans to meet metrics amount that could total tens of millions of dollars. linked to social supports. Withhold payments States can elect to use incentive payments to returned to plans are considered part of revenue reward plans that perform well on quality metrics and so are included in the denominator of the MLR.b a When states design incentive payments or withhold arrangements, federal regulations require that they are designed to support the goals of their managed care quality strategy. b See 42 CFR § 438.6 for additional detail. Several additional requirements and caveats apply, including that withhold and incentive arrangements must be linked to a state’s quality strategy. Moreover, arrangements that withhold a portion of a capitation rate for noncompliance with general operational requirements are considered a penalty, not a withhold arrangement. In addition, contracts that provide for a withhold arrangement must ensure that the capitation payment, minus any portion of the withhold that is not reasonably achievable, is actuarially sound. The total amount of the withhold, achievable or not, must be reasonable and take into consideration the financial operating needs of participating plans. commonwealthfund.org January 2018 Sustainable Investment in Social Interventions: Medicaid Managed Care Rate-Setting Tools 7 STATE OPTIONS FOR INCENTIVIZING OR Option 1: Classify Certain Social Services as Covered REQUIRING PLAN INVESTMENT IN SOCIAL Benefits Under the State’s Medicaid Plan INTERVENTIONS States have some discretion to classify a range of social supports as Medicaid plan benefits.9 By doing so, states For states interested in using their Medicaid payment can include these services in plans’ benefit packages and and managed care contracting strategies to support build their cost into the states’ Medicaid managed care investments in social interventions, we identify six rates in the same way as hospital services, physician options that could provide plans with the resources and services, or other “traditional” medical services. flexibility to so invest. In general, the options are not Moreover, plan payments to providers for these services mutually exclusive and likely would need to be combined are classified as part of “claims” (i.e., included in the in order to develop a comprehensive strategy that both numerator) for purposes of the MLR calculation and so provides plans with the resources to finance social do not count against plans when it comes to future rate- interventions and moderates the impact on future rates if setting. The allowable services include connecting people they are effective in driving down medical costs. Indeed, it to housing, food assistance, and peer support services is not unusual for states to rely on a multipronged strategy (Exhibit 8). to address social issues (Exhibit 7). Exhibit 7 ARIZONA’S MULTIPRONGED APPROACH TO ADDRESSING SOCIAL ISSUES States interested in tackling the social issues of Medicaid • Reinvestment requirements. Arizona requires beneficiaries are likely to require a range of strategies, RBHAs to reinvest 6 percent of their profits back into sometimes relying on Medicaid and sometimes the community. Some plans directly fund housing going outside of Medicaid. Arizona has adopted a or food banks, while others set up mini-competitive multipronged approach, serving those with serious grant programs to finance community-based mental illnesses through Regional Behavioral Health organizations. Authorities (RBHAs). • Leverage equity requirements. Arizona allows • Maximize use of Medicaid coverage for plans to use a share of their equity as a line of nonclinical services. Arizona includes several credit to invest in low-income housing. One plan nonclinical services in its Medicaid benefit package, partnered with a nonprofit organization to purchase including respite services and care management. large housing complexes, with a requirement that a portion of the units are set aside for Medicaid • State and local funding for nonmedical beneficiaries. services. Arizona provides approximately $35 million in state-only grants for housing to RBHAs. • Value-based payments. Arizona’s value-based The money is used to create partnerships with payment strategy allows for plans and providers to housing authorities and secure housing subsidies provide a continuum of health and social services. for members. By design, there is only one RBHA for each geographic region in the state. commonwealthfund.org January 2018 Sustainable Investment in Social Interventions: Medicaid Managed Care Rate-Setting Tools 8 Exhibit 8 SOCIAL INTERVENTION SERVICES COVERED BY MEDICAID AS MEDICAL ASSISTANCE BENEFITS a • Linkages to social service programs that offer • Assistance in finding and retaining help with food assistance, rent, childcare costs, employment, particularly for people with heating bills, and other major household expenses. disabilities, including ways to prepare to enter the job market or to find and keep jobs. • Stable housing support provided through services that help people find and remain in homes, • Peer support offered by individuals who come including assistance locating a home, assistance from a beneficiary’s community or who have had making home repairs, and training in navigating similar experiences and can offer counseling, advice, relationships with landlords or other tenants. and other support. D. Bachrach, J. Guyer, and A. Levin, Medicaid Coverage of Social Interventions: A Road Map for States (Milbank Memorial Fund, July 2016). a Considerations In addition, some of the Medicaid benefits that offer While Option 1 represents a straightforward way to a vehicle for addressing social needs carry unique build the cost of social interventions into a managed care requirements and obligations. For example, states could strategy, there are some issues to consider. First, if a state opt to classify the cost of connecting families to the elects to cover a social service as a Medicaid benefit, it Supplemental Nutrition Assistance Program (SNAP) is subject to the same requirements as other Medicaid or other help finding adequate food as part of “case benefits, including “statewideness,” which requires that management” or “targeted case management,” which the benefit generally must be provided on a statewide are both optional Medicaid benefits. But if they do, they basis, and “comparability,” which requires that a benefit must ensure that their managed care plans meet federal be provided on a comparable basis to nearly all Medicaid requirements, such as offering yearly assessments for beneficiaries regardless of their pathway to Medicaid each beneficiary receiving the service and developing eligibility.10 In our interviews with plan officials, some individualized plans.12 suggested that this poses a bigger problem for a social Finally, whatever the benefits of this approach, it is not a intervention than a medical need, because social service full solution. Some key social supports simply cannot be needs and resources are highly community-specific. classified as Medicaid benefits. These include the direct For example, one community might have a strong costs of essentials such as food and housing. Federal peer support program because of the efforts of a local laws and regulations are clear that such services cannot community leader, but other parts of a state might be be considered part of the Medicaid benefit package or devoid of such resources. States may prefer to target their directly paid for with Medicaid funds. social support services toward specific high-need areas or subpopulations, but the Medicaid rules generally would require statewide coverage for all members.11 commonwealthfund.org January 2018 Sustainable Investment in Social Interventions: Medicaid Managed Care Rate-Setting Tools 9 Option 2: Explore the Additional Flexibility Afforded that affect health.13 The health-related services offered States Through Section 1115 Waivers by CCOs include short-term housing for individuals States also have the flexibility to pursue 1115 waivers, discharged from the hospital who otherwise would be which offer broad authority to waive provisions of the at risk for readmission, as well as home improvements Medicaid statute and to provide financing for services that can make it more viable for people to remain in the not otherwise included in Medicaid. They must further community (installing handrails, for example) or that can the purposes of the Medicaid statute and be budget- reduce unnecessary hospitalizations (such as use of air neutral to the federal government. Unlike the other conditioners to reduce asthma attacks). In its 1115 waiver, options discussed, 1115 waivers can require considerable Oregon secured clarification of how it can encourage negotiation with the Centers for Medicare and Medicaid CCOs to provide such services and build their cost into Services (CMS), but they have the advantage of offering capitation rates (Exhibit 9). sweeping authority for states to experiment with greater support for social interventions. Considerations The process of negotiating a Medicaid 1115 waiver can In recent years, 1115 waivers frequently have been used be time-consuming and complex, requiring extensive for Medicaid delivery system reform and, in this context, discussions with CMS. Moreover, such demonstrations some states have sought to encourage investments in are intended to test out new ideas, not to serve as the social interventions. Oregon, the best-known example, permanent vehicle by which a state operates its Medicaid has established Coordinated Care Organizations (CCOs) program. For example, delivery system reform waivers, that are given a global budget to provide physical health, such as the one secured by Oregon, are expected to phase behavioral health, and “health-related” services, which out over time. Indeed, a number of the waivers already is to say services not otherwise covered by Medicaid Exhibit 9 OREGON’S SECTION 1115 WAIVER: USING MEDICAID TO PROVIDE “HEALTH-RELATED” SERVICES Using a Section 1115 waiver, Oregon operates its Medicaid adjunct to covered benefits) and “community benefit program through coordinated care organizations initiatives” (community-level interventions focused on (CCOs), which are community-based partnerships of improving population health and health care quality). managed care plans and providers that manage physical, They can include, for example, short-term housing behavioral, and oral health services for a defined Medicaid assistance post-hospitalization or a public education population. Like managed care plans, CCOs take on risk campaign to increase vaccination rates. and are paid rates developed in accordance with the Oregon secured clarification in its 1115 waiver that it can Centers for Medicare and Medicaid Services’ rate-setting put the cost of such services in the numerator of the requirements for Medicaid managed care. MLR if the services are related to a quality initiative (see A major goal of Oregon’s initiative is to “address the Option 5 below). Moreover, Oregon incentivizes plans to social determinants of health and improve health equity offer health-related services by rewarding high-quality across all low-income, vulnerable Oregonians.” To this and relatively efficient plans with a higher profit margin. end, Oregon encourages its CCOs to offer “health- To date, CCOs have dedicated a relatively small share related services,” which include “flexible services” (cost- of their capitation funds to such services, but the state effective services offered voluntarily to individuals as an continues to encourage them to do so. commonwealthfund.org January 2018 Sustainable Investment in Social Interventions: Medicaid Managed Care Rate-Setting Tools 10 in place explicitly require that some of the innovation investments even beyond those included in the Medicaid taking place will gradually be built into a state’s Medicaid benefit package. Of course, this assumes the provider managed care contracting strategy, creating a long-term, is persuaded that investment in social interventions sustainable approach to financing that can outlive the will have a positive impact on health outcomes and waiver. its performance under the value-based payment arrangement. The Trump administration has suggested that under certain circumstances it will permit waivers to continue Arizona offers an example of how value-based payments indefinitely. Still, it has restricted some of the tools used can be integrated into a Medicaid managed care in the past to help finance waivers.14 And, as with prior contracting strategy that supports plans in addressing administrations, it does not appear willing to authorize social issues. The state requires managed care plans to Medicaid coverage of significant social interventions. ensure that a specified share of payments to providers are made under value-based payment arrangements. It Option 3: Use Value-Based Payments to Support reinforces the requirement by withholding 1 percent of Investment in Social Interventions premiums and allowing plans that meet the value-based Value-based payments create an opportunity to address payment threshold to compete against each other to earn social issues when doing so would deliver value to a share of the withheld funds based on their performance Medicaid and improve health outcomes. Historically, on quality metrics. In response, plans have established Medicaid has been a program that pays for Medicaid- shared-savings arrangements with Medicaid providers covered benefits — for the most part clinical services — that deliver an array of medical and nonmedical services delivered to Medicaid-eligible beneficiaries. It has not (Exhibit 10). been in a position to cover social interventions, even when it would be cost-effective to do so, unless they Considerations could be squeezed into the Medicaid box. Because value- First, value-based payments offer a helpful tool for based payments — whether paid by the plan or the financing the cost of social interventions, but they do Medicaid agency — are not linked to providing specific not automatically solve the issue of premium slide. Plans medical services, they can be used by providers for social may remain concerned that future rates will be based on Exhibit 10 USING VALUE-BASED PAYMENTS TO PROVIDE A CONTINUUM OF HEALTH AND SOCIAL SERVICES: AN EXAMPLE IN CIRCLE THE CITY Medicaid managed care plans establish shared-savings hospital or living on the street with acute conditions, arrangements with organizations such as Circle the City, primary care at an outpatient clinic, and mobile medical a nonprofit community health organization in Maricopa services. The shared-savings payments made by plans County, Arizona, that works with people who have been to Circle the City and other such organizations, which or are currently homeless.a It provides a continuum of can be used to finance the full array of services that they health care and related social services that helps people provide, are considered part of a plan’s medical claims to remain outside of a hospital or nursing home and and are built into capitation rates and the numerator of reside in the community. These services include medical the MLR. respite care for people recently discharged from the For more details, see the Circle the City website. a commonwealthfund.org January 2018 Sustainable Investment in Social Interventions: Medicaid Managed Care Rate-Setting Tools 11 lower medical costs without including the costs of social already incorporate value-based payments into the claims investments that helped achieve those lower medical data used for rate-setting, typically by identifying these costs. One state has said that it attempted to address payments separately in the reporting template they use to this issue by telling plans that it will continue to include collect financial data from managed care plans. value-based payments in the rate calculations even if Finally, shared-savings models run the risk of incentivizing medical utilization declines over time. As nonclinical providers to cut costs without delivering value, making interventions become more effective, states and plans it important to have a robust set of quality metrics to will need to identify more formal long-term strategies for measure performance. Indeed, there is a risk that shared- providing plans with sustainable funding streams for their savings models could be vulnerable to many of the same nonclinical interventions. concerns that plagued the initial rollout of managed care Second, value-based payment requires states and plans to into Medicaid in the 1970s and 1980s, when news stories have an effective way to measure and reward performance surfaced of plans pocketing capitation funds without outcomes. To date, most quality metrics used in value- providing services. To prevent such concerns from arising based payment strategies are focused on process or in the context of shared-savings models, states can establish specific clinical outcomes, such as inpatient utilization, strong oversight mechanisms prior to implementation. readmission rates, diabetes and asthma management, and delivery of preventive services (e.g., immunization Option 4: Use Incentives and Withholds to Encourage rates, well-child visits). Some of these metrics do likely Plan Investment in Social Interventions incentivize investments in social interventions. For As a fourth option, states can make incentive payments or example, there is solid evidence that diabetics are more use withholds to reward plans for improving outcomes likely to be hospitalized at the end of a month when for beneficiaries, including outcomes linked to improved SNAP benefits are running short, making food security social circumstances. Incentive payments are excluded an important issue if plans are paid to lower hospital from the MLR calculation entirely, while withhold utilization rates or reduce emergency department visits.15 payments are treated as part of plan revenue and are included in the denominator of the MLR.16 But states interested in encouraging plans and providers to address social issues will want to explore whether While states cannot direct plans to invest in non-Medicaid there are additional or alternative metrics aimed more social supports, they can indirectly encourage such squarely at these objectives. For example, they could investments by linking incentive and withhold payments establish a measure that looks at the extent to which to outcomes that can be improved by offering social high-risk individuals complete a health risk assessment, supports. For example, a state might make such payments are provided with a housing plan, and, ultimately, are to plans that succeed in reducing unnecessary use connected with and able to remain in housing. of medical care by connecting beneficiaries to social supports; addressing food security, social isolation, or Third, interviewees noted that states and plans need an housing issues; or reducing disparities in outcomes. In accounting system to track, monitor, and build shared- addition, incentives and withholds can be combined with savings and other value-based payments to providers Option 3 to reinforce plan incentives to participate in into their Medicaid managed care rates. The claims-based value-based purchasing arrangements. system used for clinical encounters is not appropriate because value-based payments, by design, often are not Considerations linked to specific services provided but rather to a plan From a state perspective, a major issue with incentive or provider’s success in keeping costs below target levels payments is that they are an “add-on” to capitation while maintaining or improving quality. Several states payments and require additional funding. For states commonwealthfund.org January 2018 Sustainable Investment in Social Interventions: Medicaid Managed Care Rate-Setting Tools 12 dealing with a budget squeeze or simply committed to Option 5: Integrate Efforts to Address Social Issues into minimizing Medicaid expenditures, the additional cost Quality Improvement Activities could be prohibitive. From a plan perspective, this reality States have the authority to include the cost of quality may mean that incentive payments are considered an improvement activities in the nonbenefit portion of unreliable or short-term source of revenue, dampening their Medicaid managed care rates. In addition, the cost plan interest in making longer-term investments in of quality improvement activities is considered part of social supports. Similarly, withhold arrangements are the numerator of the MLR (Exhibit 11). This means that not necessarily considered by plans a reliable funding states can incorporate into their managed care rates the mechanism for sustained social investments, because cost of social investments that are considered quality such arrangements depend on plans meeting targets improvement activities. The issue, of course, is whether a and in some cases are only available to those plans that particular social intervention can be considered a quality outperform other plans. improvement activity. As with the value-based payment option, discussed Considerations above, much of the success of an initiative rooted in using While it is clear that the cost of quality improvement incentive or withhold payments will depend on a state activities can be taken into account in rate-setting and selecting appropriate quality metrics. To incentivize considered part of the numerator of the MLR, the extent investments in social supports, the metrics need to to which CMS will allow states and plans to classify encourage plans to take a whole-person approach to initiatives aimed at social issues as part of quality care, providing not only medical services but also social improvement activities remains uncertain.17 States supports when appropriate. Exhibit 11 ACTIVITIES THAT IMPROVE HEALTH CARE QUALITY: WHAT COUNTS? a States can include the costs of activities that improve readmissions through a comprehensive discharge health care quality in the numerator of the MLR. In program; improve patient safety, reduce medical errors, general, federal regulations require that such activities and lower infection and mortality rates; implement, be designed to improve health quality; increase the promote, and increase wellness and health activities; likelihood of better outcomes in ways that can be enhance the use of health care data to improve quality, “objectively measured” and produce verifiable results; transparency, and outcomes; or support meaningful be directed toward individual enrollees (or, if directed use of health information technology. There are also more broadly, result in no additional costs); and be activities that cannot be considered quality activities, grounded in evidence-based medicine, widely accepted such as setting up a network of providers, combating best clinical practices, or criteria issued by recognized fraud, and conducting utilization reviews. professional medical associations, accreditation bodies, States interested in classifying some of their activities government agencies, or other nationally recognized as health care quality improvement activities will want health care quality organizations. to review these various requirements closely. For more States also must ensure that the activity is primarily details, see 45 CFR § 158.150. designed to improve health outcomes; improve hospital See 42 CFR § 438.8(e). a commonwealthfund.org January 2018 Sustainable Investment in Social Interventions: Medicaid Managed Care Rate-Setting Tools 13 certainly do not have carte blanche to characterize Considerations anything that their plans and providers are doing as While this option helps to address premium slide, it could part of quality improvement activities. However, they pose both operational and political issues. States will need may be able, for example, to classify efforts to connect to design criteria to establish which plans should receive individuals with serious mental illnesses to housing as a higher profit margin — or, in the variation, relief from part of a quality initiative aimed at reducing unnecessary the MLR standard — and determine how best to monitor readmissions. On the other hand, they presumably will and evaluate plan compliance with the criteria. For not be able to classify activities such as paying for rent as example, they could require plans to make a certain level part of a quality initiative. of investment in social interventions as part of quality initiatives and to provide evidence of the impact of those While there is some literature describing such possibilities, interventions on medical utilization. From a political we have not yet found states that are taking advantage of perspective, it could prove challenging to publicly justify a this option to support social interventions. In addition, higher profit margin for selected Medicaid managed care classifying too many activities as part of “quality” could plans even if the basis is lower medical utilization because undermine more broadly the effectiveness of the MLR, of social interventions. Similarly, plans are likely to push which is designed to ensure that issuers do not use an back on MLRs greater than 85 percent. undue amount of their capitation funds for administrative costs or profits. CONCLUSION Option 6: Reward Plans with Effective Investments in State Medicaid programs are increasingly looking for Social Interventions with Higher Rates ways to improve health outcomes using both clinical and The options above would offer plans some resources to nonclinical interventions. Managed care plans typically finance the cost of social interventions, but they do not are willing partners in such efforts, but they often face squarely address concerns about premium slide. States, a rate-setting process that discourages sustainable however, have some options for providing plans that investments in social interventions. In this analysis, we invest in social interventions with a cushion against the have outlined several options available to states to modify impact on their rates if the interventions drive down costs. their approach to Medicaid managed care rate-setting Specifically, as noted above, Medicaid managed care rates to send clear signals that they value such investments include a nonbenefit component, which, in turn, includes and want them to continue over time. None represents a profit margin or, for nonprofit plans, a risk margin. States a perfect or comprehensive response to the challenge of can elect to provide a higher profit and risk margin to incentivizing social investments. Together, however, they plans that demonstrate they have lowered medical costs offer each state the opportunity to design an initiative through investments in social interventions. consistent with its goals and priorities. A related strategy is for the state to establish an MLR above Indeed, as we found when speaking with some of the the 85 percent required in regulation for rate-setting states that are furthest along, it almost surely will take purposes, then offer relief from this higher standard a broad array of strategies to significantly increase the to those plans that invest in social interventions and role of Medicaid managed care plans in addressing the succeed in driving down medical utilization as a result. social factors that affect health. In the months and years For example, a state might generally require plans to ahead, it will be important to support states not only in meet a MLR of 88 percent, but then allow plans that invest pursuing such options, but also in identifying the limits in social interventions and thus lower medical costs to of these strategies and finding ways to combine them receive an MLR of 85 percent. with non-Medicaid initiatives to address the social and economic issues that can drive poor health outcomes and inefficient care. commonwealthfund.org January 2018 Sustainable Investment in Social Interventions: Medicaid Managed Care Rate-Setting Tools 14 Notes B. C. Booske, J. K. Athens, D. A. Kindig et al., Different 1 10 Selected eligibility groups are not subject to the Perspectives for Assigning Weights to Determinants of comparability requirement, such as those who Health (University of Wisconsin Population Health qualify for Medicaid because of medical bills that Institute, Feb. 2010). allow them to “spend down” to eligibility (i.e., the medically needy). States also can elect to disregard L. M. Gottlieb, A. Quiñones-Rivera, R. Manchanda et al., 2 the “statewideness” and comparability requirements “States’ Influences on Medicaid Investments to Address in certain circumstances, such as if they are using the Patients’ Social Needs,” American Journal of Preventive authority provided in the Medicaid statute to offer an Medicine, Jan. 2017 52(1):31–37. alternative benefit plan. See 42 CFR § 438.3(c)(ii). 3 D. Bachrach, J. Guyer, and A. Levin, Medicaid Coverage 11 of Social Interventions: A Road Map for States (Milbank In a typical process, a state would work with an 4 Memorial Fund, July 2016). actuarial firm to review its recent claim experience (including fee-for-service and other non-claim- 12 One exception is that states can provide targeted case based payments to providers); apply appropriate management to a subset of Medicaid beneficiaries, trend adjustments to reflect anticipated price and including beneficiaries living in a particular geographic utilization changes; reflect the impact of any program area. In addition, states can provide alternative design changes; add in administrative expenses, benefit plans without regard to “statewideness” and profit margin, and other “nonbenefit” expenses; make comparability requirements, as discussed further in other reasonable adjustments; consider historical and D. Bachrach, J. Guyer, and A. Levin, Medicaid Coverage projected medical loss ratio (MLR); and, finally, apply of Social Interventions: A Road Map for States (Milbank any risk-adjustment factors. Memorial Fund, July 2016). See 42 CFR § 434.4(b)(9). 5 13 The state also distributes incentive payments based on each CCO’s performance on 17 different performance Based on the Medicaid managed care rate as of June 6 metrics. 2017; note the delayed provision date. Some provisions of the new regulations went into effect immediately, 14 On Dec. 15, 2017, the administration issued a Dear State while others are effective for plan years beginning in Medicaid Director letter that phases out expenditure July 2017 or later. See Center for Medicaid and CHIP authority for Designated State Health Programs in Services, “Medicaid and CHIP Managed Care Final Rule Section 1115 demonstrations, a strategy used by several (CMS-2390-F) Implementation Dates,” Presentation states to finance the nonfederal share of the cost of (Centers for Medicare and Medicaid Services, n.d.). waivers. See https://www.medicaid.gov/federal-policy- guidance/downloads/smd17005.pdf. Ibid. These provisions went into effect for contracts 7 starting on or after July 1, 2017. 15 D. Bachrach, J. Guyer, and A. Levin, Medicaid Coverage of Social Interventions: A Road Map for States (Milbank See 42 CFR § 438.8(e). 8 Memorial Fund, July 2016). D. Bachrach, J. Guyer, and A. Levin, Medicaid Coverage 9 16 Withhold payments that are not made because a plan of Social Interventions: A Road Map for States (Milbank has failed to meet a standard are excluded entirely from Memorial Fund, July 2016). the MLR calculation. 17 See 42 CFR § 438.8(e). commonwealthfund.org January 2018 Sustainable Investment in The Commonwealth Fund Social Interventions: Medicaid Managed Care Rate-Setting Tools Care Cost Burden? How High Is America’s Health 15 APPENDIX A. BIBLIOGRAPHY State Innovations in Rate-Setting State Innovations in Value-Based Payment and Social Intervention Investments J. J. Bartholomew, L. Coyner, T. M. Doyle et al., “Payment Reform and Medicaid Rate Development, Session 33 L,” M. Crawford and R. Houston, State Payment and Financing Panel at 2016 Society of Actuaries Annual Meeting and Models to Promote Health and Social Service Integration Exhibit (SOA, Oct. 2016). (Center for Health Care Strategies, Feb. 2015). Center for Health Care Strategies, Developing Capitation L. M. Gottlieb, A. Quiñones-Rivera, R. Manchanda et al., Rates for Medicaid Managed Long-Term Services and “States’ Influences on Medicaid Investments to Address Supports Programs: State Considerations, Technical Patients’ Social Needs,” American Journal of Preventive Assistance Brief (CHCS, Jan. 2016). Medicine, Jan. 2017 52(1):31–37. Center for Health Care Strategies, “Rate-Setting Strategies R. Mahadevan and R. Houston, Supporting Social to Advance Medicaid Managed Long-Term Services and Service Delivery Through Medicaid Accountable Care Supports Goals: State Insights,” Webinar (CHCS, Aug. 16, Organizations: Early State Efforts (Center for Health Care 2016). Strategies, Feb. 2015). Medicaid and CHIP Payment and Access Commission, R. Manchanda, S. Ackerman, and L. Gottlieb, Building “Section D: Payment Policy in Medicaid Managed Care,” in Medicaid Managed Care Systems That Address Social Report to the Congress: The Evolution of Managed Care in Determinants of Health. A Case Study Synthesis (University Medicaid (MACPAC, June 2011). of California, San Francisco, and Health Begins, Feb. 2016). Oregon Health Authority, Application for Amendment and New York State Department of Health, Medicaid Redesign Renewal, Oregon Health Plan 1115 Demonstration Project, Team, A Path Toward Value Based Payment: Annual Medicaid and Children’s Health Insurance Program (OHA, Update, New York State Roadmap for Medicaid Payment Aug. 2016). Reform (NYS DOH, June 2016). Oregon Health Authority, CCO Rate Development E. Rogan and E. Bradley, Investing in Social Services for Actuarial Certification, January 1, 2017 – December 31, 2017 States’ Health: Identifying and Overcoming the Barriers Capitation Rates (OHA, Oct. 2016). (Milbank Memorial Fund, May 2016). Oregon Health Authority, Concept Paper on Increasing A. Spencer, J. Lloyd, and T. McGinnis, Using Medicaid Use of Health-Related Services and Value-Based Payments Resources to Pay for Health-Related Supportive Services: (OHA, n.d.). Early Lessons (Center for Health Care Strategies, Dec. 2015). Oregon Health Authority, Office of Health Policy and Medicaid Managed Care Regulation and Rate-Setting Analytics, Where We Are and Where We’re Going: Rate Guidance Setting for Coordinated Care Organizations (OHA, April 2015). Actuarial Standards Board, Actuarial Standard of Practice No. 49: Medicaid Managed Care Capitation Rate Development and Certification, Doc. No. 179 (ASB, March 2015). Centers for Medicare and Medicaid Services, 2017 Medicaid Managed Care Rate Development Guide: For Rating Periods Starting Between January 1, 2017 and June 30, 2017 (CMS, n.d.). commonwealthfund.org January 2018 Sustainable Investment in The Commonwealth Fund Social Interventions: Medicaid Managed Care Rate-Setting Tools Care Cost Burden? How High Is America’s Health 16 APPENDIX B. LIST OF INTERVIEWEES Catherine Anderson, national vice president, strategy Richard Kronick, professor of family and preventive and positioning — Medicaid and Medicare, medicine and adjunct professor of political science, UnitedHealthcare Community and State University of California, San Diego Arlene Ash, professor and division chief, biostatistics and Stacey Lampkin, commissioner, Medicaid and Children’s health services research, University of Massachusetts Health Insurance Program Payment and Access Medical School Commission, and actuary and principal, Mercer Tom Betlach, director, Arizona Health Care Cost MaryAnne Lindeblad, Medicaid director, Washington Containment System State Stephen Chakmakian, chief medical officer, Pamme Lyons Taylor, vice president of advocacy and UnitedHealthcare Community Plan, Arizona community-based programs, WellCare Health Plans Lori Coyner, Medicaid director, Oregon David Mancuso, director, Research and Data Analysis Division, Washington State Department of Social and Leonardo Cuello, director of health policy, National Health Health Services Law Program Shawn Nau, CEO, Health Choice Integrated Care Toby Douglas, senior vice president for Medicaid solutions, Centene Heather Petermann, division director, health care research and quality, Minnesota Department of Human Services Sabrina Gibson, vice president and chief Medicaid actuary, WellCare Health Plans Michelle Raleigh, vice president of actuarial services, Centene Jim Golden, director, Division of Managed Care Plans, Centers for Medicare and Medicaid Services Mathew Spaan, manager, care delivery and payment reform, Minnesota Department of Human Services Norbert Goldfield, medical director for clinical and economic research, 3M Health Information Systems Jonathan Weiner, professor, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Daniel Harris, actuary, Magellan Public Health Don Killian, vice president of actuarial services, Centene Charlton Wilson, chief medical officer, Mercy Care Plan/ Deborah Kilstein, vice president for quality management Mercy Care Advantage and operational support, Association for Community Ross Winkelman, principal, Wakely Consulting Group Affiliated Plans commonwealthfund.org January 2018 Sustainable Investment in The Commonwealth Fund Social Interventions: Medicaid Managed Care Rate-Setting Tools Care Cost Burden? How High Is America’s Health 17 APPENDIX C. LIST OF ADVISORY COMMITTEE MEMBERS Tom Betlach, director, Arizona Health Care Cost Stacey Lampkin, commissioner, Medicaid and CHIP Containment System Payment and Access Commission, and actuary and principal, Mercer Lori Coyner, Medicaid director, Oregon MaryAnne Lindeblad, Medicaid director, Washington Toby Douglas, senior vice president for Medicaid State solutions, Centene Sara Rosenbaum, J.D., professor, health law and policy, Sabrina Gibson, vice president and chief Medicaid actuary, Department of Health Policy, Milken Institute School of WellCare Health Plans Public Health, George Washington University Sherry Glied, Ph.D., dean and professor of public service, Marjorie Rosenberg, Ph.D., professor, Department of Risk New York University Robert F. Wagner Graduate School and Insurance, Wisconsin School of Business of Public Service Laura Gottlieb, M.D., assistant professor, Department of Family Community Medicine, University of California, San Francisco School of Medicine commonwealthfund.org January 2018 Sustainable Investment in The Commonwealth Fund Social Interventions: Medicaid Managed Care Rate-Setting Tools Care Cost Burden? How High Is America’s Health 18 APPENDIX D. ADDITIONAL CHALLENGES STATES FACE IN USING MEDICAID TO ADDRESS SOCIAL ISSUES • State staffing and expertise. New (or redirected) plans; it also can make it easier to track and build staff resources are needed to develop Medicaid on social investments. Similarly, states, plans, and managed care policies and contracting requirements, providers need systematic data and tools to evaluate identify appropriate performance standards, and the effectiveness of social interventions. Do they engage in other tasks discussed in this report. Several see declines in hospitalizations among diabetics if interviewees highlighted agency staffing and expertise individuals have a steady source of food and some as a potential impediment to advancing new managed extra help at the end of a month when SNAP runs care payment strategies. out? How cost-effective is it to provide housing to individuals with serious mental illnesses? In the • Data infrastructure. States will need a data absence of such resources, it will be difficult to sustain infrastructure that allows them (or plans or providers investments in social interventions over time. acting on their behalf) to identify the social and economic issues confronting Medicaid beneficiaries, • Lead time for managed care plans and providers. as well as to monitor and track the effectiveness of Managed care plans and providers will require time their efforts. Although some providers and plans to identify and enter into agreements with social already gather such information, we consistently service organizations or to build additional in-house heard that there is a need for a systematic approach capacity or infrastructure to track and offer social to gathering and sharing the data, for example, which service options. Many plans and providers are not beneficiaries are struggling with housing, facing accustomed to working directly with social service employment challenges, recently leaving a jail or organizations, and they need to develop those prison, or confronting domestic violence. A common relationships as well as conduct the “nuts and bolts” mechanism for sharing data can allow Medicaid work of setting up contractual arrangements with managed care plans to avoid the need to collect all social service providers. the same data again when a beneficiary changes commonwealthfund.org January 2018 Sustainable Investment in Social Interventions: Medicaid Managed Care Rate-Setting Tools 19 ABOUT THE AUTHORS population health from the University of Wisconsin- Deborah Bachrach, J.D., a partner with Manatt, Phelps Madison and an M.Sc. in health economics, policy, and law & Phillips, has more than 25 years of experience in health from Erasmus University in the Netherlands. policy and financing in both the public and private sectors John Meerschaert, F.S.A., M.A.A.A., a principal and and an extensive background in Medicaid policy and consulting actuary at Milliman, has a diverse background health care reform. She works with states, providers, in health insurance and managed health care programs. plans, and foundations in implementing federal health He has advised state government agencies, health systems, care reform and Medicaid payment and delivery system insurance companies, health maintenance organizations reforms. Most recently, Ms. Bachrach was Medicaid (HMOs), and other health care clients. His experience director and deputy commissioner of health for the with commercial, Medicare, and Medicaid coverage from New York State Department of Health, Office of Health the perspective of insurers, providers, and government Insurance Programs. She has previously served as vice stakeholders allows him to provide unique insight on president for external affairs at St. Luke’s-Roosevelt a wide range of issues. He received his B.B.A. from the Hospital Center and as chief assistant attorney general and University of Wisconsin and is a fellow of the Society chief of the Civil Rights Bureau in the Office of the New of Actuaries and member of the American Academy of York State Attorney General. Ms. Bachrach received her Actuaries. B.S. from the University of Pennsylvania, Wharton School, and her J.D. from New York University School of Law. Shelly Brandel, F.S.A., M.A.A.A., a principal and consulting actuary at Milliman, has expertise in both Jocelyn Guyer, M.P.A., a managing director with Manatt, managed and traditional health care programs, with more Phelps & Phillips, provides policy expertise, strategic than 15 years of experience in these areas. She has assisted advice, and technical support to states, foundations, and various entities, including health plans, employers, a range of clients on the implementation of the Affordable insurance companies, and Medicare/Medicaid programs. Care Act, delivery system reform, Medicaid, and the She has helped clients with product development and Children’s Health Insurance Program. She has served as pricing, experience analysis, valuation of reserves, and an advisor to the National Governors Association Center financial reporting. Ms. Brandel received her B.S. from for Best Practices, the National Academy for State Health the University of Miami and is a fellow of the Society Policy, and the American Academy of Pediatrics, among of Actuaries and member of the American Academy of others. Ms. Guyer received her B.A. from Brown University Actuaries. and her M.P.A. from Princeton University Woodrow Wilson School of Public Policy and International Affairs. ACKNOWLEDGMENTS Sarah Meier, Ph.D., is a research health economist at RTI The authors would like to thank the many individuals International. She was previously a manager at Manatt who provided their time and insights to this effort through Health and a research associate at Mayo Clinic. Dr. Meier interviews (Appendix B) or by serving on the report’s specializes in research and policy issues in the areas of advisory committee (Appendix C). health care coverage and access and delivery system and payment model reform. Her background includes experience implementing select Medicaid provisions Editorial support was provided by Jennifer Rubio. of the Affordable Care Act while interning in the Office of Health Policy at the Assistant Secretary for Planning For more information about this report, please contact: and Evaluation of the Department of Health and Human Deborah Bachrach, J.D. Services, as well as evaluation of Wisconsin’s BadgerCare Partner, Manatt, Phelps & Phillips, LLP Plus and Core expansions. Dr. Meier holds a Ph.D. in dbachrachmanatt.com commonwealthfund.org January 2018 About The Commonwealth Fund The Commonwealth Fund, among the first private foundations started by a woman philanthropist—Anna M. Harkness—was established in 1918 with the broad charge to enhance the common good. The mission of The Commonwealth Fund is to promote a high performance health care system. The Fund carries out this mandate by supporting independent research on health care issues and making grants to improve health care practice and policy. An international program in health policy is designed to stimulate innovative policies and practices in the United States and other industrialized countries. Support for this research was provided by The Commonwealth Fund. The views presented here are those of the authors and not necessarily those of The Commonwealth Fund or its directors, officers, or staff. 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