Policy Breakfast: State Innovations to Address High-Cost/High-Needs Populations

Tuesday, February 6 | 7:00 - 8:45 a.m.


  • AcademyHealth Members: $25
  • Non-Members: $50

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Event Description:

States are increasingly focused on how to support their high-cost/high-needs populations, especially those they are serving through the Medicaid program. Nationally, that population accounts for approximately 50 percent of Medicaid spending while representing only 5 percent of those enrolled. These state initiatives and interventions target “super-utilizer” Medicaid enrollees who are the most frequent users of costly sites of care, such as emergency departments and inpatient settings, but often have non-clinical social service needs that are provided in community settings. This policy breakfast will feature innovative efforts to address these populations in the District of Columbia, Pennsylvania, and West Virginia.

District of Columbia

The District of Columbia has launched a care coordination benefit for Medicaid beneficiaries with multiple chronic conditions embedded in the primary care setting.  Recognizing the workflow challenges providers face implementing these types of programs, the District designed a unique incentive payment approach, developed innovative health information exchange tools, and financed ‘on the ground’ practice transformation support.  The District will discuss the care delivery reforms that have been incentivized by their support for this program, and progress to date.

West Virginia

Recognizing the capacity constraints on primary care clinics, especially in the many rural areas, West Virginia has enlisted its academic medical centers and their health plan partners to serve as centers for regional pilots and provide evidence-based interventions for Medicaid enrollees with complex care needs. The state is enhancing providers’ existing complex care initiatives and fostering a collaborative working relationship among participating providers, managed care organizations, and social services providers.


Pennsylvania will showcase its efforts to address the most costly 5 percent of Medicaid beneficiaries. That population primarily has Serious Mental Illness (SMI) with some having co-occurring substance use disorder diagnoses. Several years ago, Pennsylvania Medicaid worked with their managed care organizations to develop an integrated care program that was piloted in a couple of regions across the state. Following impressive results, the pilot was expanded statewide in 2015. The current effort includes additional data analyses for population stratification, requiring an integrated care plan across behavioral and physical health plans and service providers, and the use of quality metrics upon which to base certain incentive payments.

Register for the policy breakfast >>