While almost all states have begun Medicaid delivery system transformation, initiatives and programs geared toward upstream prevention and population health are limited and many are untested, especially in the area of payment strategies. AcademyHealth’s Payment Reform for Population Health project is working with Nemours to assist Maryland, Oregon and Washington in exploring possible pathways to Medicaid payment for upstream prevention strategies. This work builds on a previous Nemours project funded by the Robert Wood Johnson Foundation called the Pathways through Medicaid to Prevention: Realizing the Promise of Population Health.

Maryland

Nemours and Maryland will collaborate to research, develop, and test two upstream prevention-related interventions and the associated payment mechanisms at two Head Start centers: 

  • Field a social determinant of health screener for families of Medicaid/CHIP-eligible children to: 1) understand how to leverage Head Start infrastructure to scale up connections to upstream services; and 2) research the feasibility of and facilitators for connecting Medicaid managed care organizations with Head Start programs.
  • Embed dietician services in the Head Start center for families of Medicaid children to provide lessons on how to scale up and replicate payment for clinical services in a non-clinical setting such as local health departments and school-based health centers. Lessons also will inform prevention strategies that rely on non-traditional providers to help mitigate credentialing and billing barriers.

Oregon

The state’s Oregon Health Authority (which includes the Medicaid agency) encourages Care Coordination Organizations (CCOs) to use a portion of their per-member-per-month global capitation payment to provide patients with non-medical services, or “flexible services.” Such upstream services can lead directly to improved health outcomes and lower costs. The Columbia Gorge CCO is launching a pilot community health worker (CHW) program that links to the Pathways Hub, a system designed to connect patients to non-medical, upstream services that can promote health and prevent the use of otherwise avoidable health care services.  While Pathways is presently funded through a one-year grant, Nemours will provide technical support to help the Columbia Gorge CCO develop a sustainability plan that outlines viable funding options and implementation strategies that align with the CCO’s goals and create operationally sustainable funding for CHWs and select Pathways Hub services beyond the one-year grant period.

Washington

Washington State’s Accountable Communities of Health (ACHs) are regional, multi-sector coalitions that work to improve population health. A key responsibility of the ACHs is to facilitate and coordinate projects that bring together multiple sectors to address health priorities collectively within their region. Nemours will provide technical support to help promote and develop ACH transformation projects specifically related to chronic disease prevention and control. Transformation projects also will focus on increased use of value-based payment models that reward providers for quality of care. Specifically, Nemours will assist the Washington Health Care Authority develop resources to assist ACHs with understanding issues related to  investing in non-clinical prevention strategies, including the opportunity to reach non-Medicaid populations. In addition, Nemours will provide direct technical support to one ACH to facilitate and accelerate the development and implementation of an identified upstream prevention investment.