View
216
Download
0
Category
Preview:
Citation preview
7/30/2019 Using State Health Insurance Exchanges to Drive Better, Most Cost-Effective Care
1/8
Using State Insurance Exchangesto drive better, more cost effective care
Patient Centered Primary Care Collaborative
Updated April 2012
The Homer Building | 601 13th Street, NW | Suite 430 North | Washington, DC | 20005
7/30/2019 Using State Health Insurance Exchanges to Drive Better, Most Cost-Effective Care
2/8
2 Patient-Centered Primary Care Collaborative
Executive Summary
2S@SDRjMCSGDLRDKUDR@SSGDBDMSDQNEL@MXDEENQSRSNQDCTBDSGDEQ@FLDMS@SHNMHMDEj -
BHDMBX@MCBNRSNEB@QDHMSGDGD@KSGRXRSDL@MC2S@SDONKHBXL@JDQRG@UDSGDONSDMSH@K
SNOK@X@RHFMHjB@MSQNKDHMSGHRSQ@MRENQL@SHNMRSGDXCDUDKNOSGDHQ2S@SD'D@KSG(MRTQ-@MBD$WBG@MFDR2S@SDONKHBXL@JDQR@QDDMBNTQ@FDCSNATHKCGD@KSGB@QDO@XLDMS@MC
CDKHUDQXQDCDRHFMCHQDBSKXHMSNSGDHQ$WBG@MFDRAX@CU@MBHMF@O@SHDMSBDMSDQDCLDCHB@K
GNLDLNCDKENQGD@KSGB@QD4RHMF$WBG@MFDRSNANSGDWO@MC@BBDRRSN@EENQC@AKD
GD@KSGHMRTQ@MBD-#OQNLNSD@U@KTDA@RDCGD@KSGCDKHUDQXRXRSDLL@JDRDBNMNLHB
RDMRDENQ2S@SDRDLOKNXDQRBNMRTLDQR@MCOQNUHCDQR
AcknowledgementsThis publication was developed by the Patient Centered Primary Care Collaborative (PCPCC) with funding support
IURP3]HU,QF
:HZRXOGOLNHWRDFNQRZOHGJHDQGWKDQNPHPEHUVRIWKH3&3&&pV6WDWH([FKDQJH:RUNJURXSZKRRIIHUHGYDOXDEOH
LQVLJKWVLQWRGHYHORSPHQWRIWKLVGRFXPHQWDVZHOODVLQSXWIRUWKHVHOHFWLRQRIFDVHH[DPSOHV6SHFLDOWKDQNVDUHRI-
fered to the workgroups leadership:
s -DVRQ%X[EDXP3ROLF\$QDO\VW1DWLRQDO$FDGHP\RI6WDWH+HDOWK3ROLF\
s $P\*LEVRQ&KLHI2SHUDWLQJ2IFHU3&3&&
s 6KDZQ0DUWLQ'LUHFWRURI*RYHUQPHQW5HODWLRQV$PHULFDQ2VWHRSDWKLF$VVRFLDWLRQ
s 'XDQH3XWQDP'LUHFWRURI(PSOR\HUV&RDOLWLRQV$VVRFLDWLRQVDQG2UJDQL]DWLRQV3]HU
s $XUHD9D]TXH]6HQLRU'LUHFWRURI&RUSRUDWH$IIDLUV863ROLF\3]HU
s 'DQLHO9LJLO6HQLRU0DQDJHU6WDWH3ROLF\3]HU
s -R\:LOVRQ6HQLRU)HGHUDO$IIDLUV&RXQVHO+HDOWK3ROLF\'LUHFWRU6WDWH)HGHUDO5HODWLRQV'LYLVLRQ1DWLRQDO&RQ-ference of State Legislatures
)RUVHUYLQJDVFRDXWKRUVZHZRXOGOLNHWRHVSHFLDOO\WKDQN0DUFL1LHOVHQ([HFXWLYH'LUHFWRURIWKH3&3&&DQG.D\OD
6FKXVWHU0+6$8QLYHUVLW\RI.DQVDV'HSDUWPHQWRI+HDOWK3ROLF\DQG0DQDJHPHQW
,QDGGLWLRQZHZRXOGOLNHWRDFNQRZOHGJHDQGWKDQNWKH3&3&&VWDIIPHPEHUVDQG3&3&&%RDUGRI'LUHFWRUVZKR
SURYLGHGYDOXDEOHLQVLJKWLQWKHGHYHORSPHQWRIWKLVSDSHU
7/30/2019 Using State Health Insurance Exchanges to Drive Better, Most Cost-Effective Care
3/8
Putting Theory into Practice 3
Introduction
4MCDQSGDEENQC@AKD"@QDBS2S@SDR@QD@BSHUDKXCDUDKNOHMFGD@KSGHMRTQ@MBD$WBG@MFDR
SNL@JDGD@KSGBNUDQ@FDD@RHDQ@MCLNQD@EENQC@AKD2S@QSHMFHM$WBG@MFDRVHKK
@KKNVHMCHUHCT@KR@MCRL@KKATRHMDRRDRSNBNLO@QDGD@KSGOK@MRFDS@MRVDQRSNPTDRSHNMRjMCNTSHESGDX@QDDKHFHAKDENQS@WBQDCHSRENQOQHU@SDHMRTQ@MBDNQGD@KSGOQNFQ@LRKHJDSGD
"GHKCQDMR'D@KSG(MRTQ@MBD/QNFQ@L"'(/@MCDMQNKKHM@GD@KSGOK@MSG@SLDDSRSGDHQ
MDDCR'NVDUDQ2S@SDRB@MTRDSGD(MRTQ@MBD$WBG@MFDRSNCNDUDMLNQD2S@SDRB@M
TRDSGDHQ$WBG@MFDRSNATHKCO@SHDMSBDMSDQDCLDCHB@KGNLDRSG@SB@MHLOQNUDGD@KSG
@MCR@UDLNMDX
/@SHDMS"DMSDQDC,DCHB@K'NLD/",'HR@LNCDKENQGD@KSGB@QDCDKHUDQXSG@S
E@BHKHS@SDRO@QSMDQRGHORADSVDDMHMCHUHCT@KO@SHDMSRSGDHQODQRNM@KOQNUHCDQR@MCVGDM
@OOQNOQH@SDSGDO@SHDMSRE@LHKX(SHMUNKUDR
r Support for whole person care.7KLVFRPSUHKHQVLYHDSSURDFKWRKHDOWKFDUHGHOLYHU\UHFRJQL]HVWKDWSDWLHQWV
DQGWKHLUIDPLOLHVDUHFHQWUDOWRWKHLURZQFDUHDQGHQFRXUDJHVSDWLHQWHQJDJHPHQWDQGVHOIPDQDJHPHQW,WDOVR
LQFOXGHVDIRFXVRQSURPRWLQJZHOOQHVVGLVHDVHSUHYHQWLRQDQGSRSXODWLRQKHDOWK
r Delivering high quality health care services through team-based care. Primary care clinicians and other
KHDOWKSURIHVVLRQDOVLQFOXGLQJQXUVHVFDUHPDQDJHUVSKDUPDFLVWVVRFLDOZRUNHUVEHKDYLRUDOKHDOWKVSHFLDOLVWV
and others) practice team-based care and develop an on-going relationship with the patient in order to manageWKHSDWLHQWpVKHDOWKFDUHQHHGV
r Incentivizing care coordination and improved access.)XQGDPHQWDOWRWKHSULQFLSOHVRISULPDU\FDUHWKHKHDOWK
care team aligns and integrates appropriate resources and services for the patient within a medical neighborhood
WRLQFOXGHVSHFLDOLVWVKRVSLWDOVORQJWHUPFDUHHWF,WGRHVWKLVWKURXJKHQKDQFHGDFFHVVWRFDUHVXSSOHPHQWLQJ
WUDGLWLRQDOGHOLYHU\PHWKRGVWKURXJKRSHQVFKHGXOLQJH[SDQGHGKRXUV WHOHSKRQHKHDOWKLQIRUPDWLRQOLQHVDQG
HPDLOFRPPXQLFDWLRQ
r Enhanced focus on quality and safety. 3&0+VSURPRWHDFFRXQWDELOLW\IRURXWFRPHVXWLOL]LQJHYLGHQFHEDVHG
PHGLFLQHDQGKHDOWKLQIRUPDWLRQWHFKQRORJ\WRLGHQWLI\RSSRUWXQLWLHVIRULPSURYHPHQWDQGPHDVXUHSURJUHVV
r Support for payment reform that rewards value.1HZSD\PHQWPHWKRGVWKDWUHZDUGSHUIRUPDQFHDQGFDUHFR -
RUGLQDWLRQDQGVXSSRUWLQQRYDWLRQLQKHDOWKFDUHWUHDWPHQWVZKLOHDGGLQJYDOXHWRWKHKHDOWKFDUHGHOLYHU\V\VWHP
DUHFULWLFDOIRUWKHVXFFHVVRIWKH3&0+1
What is a Patient Centered Medical Home?
7/30/2019 Using State Health Insurance Exchanges to Drive Better, Most Cost-Effective Care
4/8
4 Patient-Centered Primary Care Collaborative
&RORUDGRLVWKHKRPHRI+HDOWK7HDP:RUNVDPXOWL
VWDNHKROGHU3&0+FRYHULQJSDWLHQWV7KH
practice relies on a well-rounded team of primary
FDUHSK\VLFLDQVVSHFLDOLVWVDVZHOODVRWKHUKHDOWK
providers including mental health specialists and
VRFLDOZRUNHUVSD\HUVDQGSDWLHQWV6WUXFWXULQJ
the practices to expand access and incorporate
FRRUGLQDWHGWHDPFDUHUHVXOWHGLQDQSHUFHQW
reduction in hospital admissions and decreased
(PHUJHQF\'HSDUWPHQW('XWLOL]DWLRQE\SHU-
FHQW11
1HZ-HUVH\WHDPLQJXSZLWK+RUL]RQ%OXH&URVV
Blue Shield brought together a wide range of pro-
YLGHUV WRSURPRWH SUHYHQWLYH FDUH UHGXFLQJ XQ-
QHFHVVDU\ KRVSLWDO DGPLVVLRQV 1RW RQO\ KDV
WKLV 3&0+ SURGXFHG IHZHU KRVSLWDO DGPLVVLRQV
DQG LQFUHDVHG FRVWVDYLQJVEXWERWKSK\VLFLDQV
and patients are grateful for the extra time spent
JHDUHG WRZDUG PDQDJLQJ HDFK SDWLHQWpV KHDOWK
7KLV SLORWpV VXFFHVV HQFRXUDJHG +RUL]RQ WR H[-
SDQGWKH3&0+WRWKH0HGLFDLGSRSXODWLRQRI1HZ
-HUVH\UHDFKLQJPRUHSDWLHQWVPDQ\ZLWKPRUHFRPSOH[PHGLFDOFDVHV7KHSURJUDPKRSHV
to translate similar cost savings to the Medicaid
SRSXODWLRQ
$UL]RQD 8QLWHG+HDOWKFDUH DQG ,%0 GHYHORSHG
D 3&0+ SLORW SULPDULO\ LQ 3KRHQL[ DQG 7XFVRQ
FRQVLVWLQJ RI VHYHQ SUDFWLFHV 8QLWHG+HDOWKFDUH
partnered to help these seven practices develop
the infrastructure and technology necessary for a
VXFFHVVIXOYHQWXUH6LQFHWKHSURJUDPKDV
EHHQ UHFRJQL]HG IRUIRFXVRQ KHDOWK FDUH VDIHW\
DQGTXDOLW\ZKLOHGULYLQJGRZQWKHFRVWVRIKHDOWK
FDUH
5KRGH ,VODQGFROODERUDWHGZLWK %OXH &URVV %OXH
6KLHOGWR GHYHORSD WKUHH\HDU SLORW3&0+ %OXH
&URVV %OXH 6KLHOG RI 5KRGH ,VODQG WHDPHG XS
ZLWKSULPDU\FDUHSURYLGHUVWRSULPDLUO\IRFXV
RQERRVWLQJTXDOLW\RIFDUH $VVLVWDQFHZLWK LP-
SOHPHQWLQJDQHOHFWURQLFKHDOWKUHFRUG(+5QRW
RQO\ LPSURYHGIDPLO\DQGFKLOGUHQpVKHDOWK E\
SHUFHQW EXW DOVR ZRPHQpV FDUH LPSURYHGE\
SHUFHQW DQG LQWHUQDO PHGLFLQH TXDOLW\ LQGLFDWRUV
LPSURYHGSHUFHQW 7KLV LQFUHDVH LQTXDOLW\ LV
staggering especially when coupled with the 17
WRSHUFHQWFRVWUHGXFWLRQQRWDFKLHYHGDPRQJ
QRQSDUWLFLSDWLQJVLWHV
'NVB@M2S@SDRADMDkSEQNL
promoting PCMH principles in
their Health Insurance Exchanges?
Colorado Arizona
Rhode Island
New Jersey
2S@SDR@KK@BQNRRSGDBNTMSQXG@UDADDMOHKNSHMFSGD/",'SN@BGHDUDBNRS
R@UHMFR@MCHLOQNUDGD@KSGRXRSDLCDKHUDQX$W@LOKDRHMBKTCD
7/30/2019 Using State Health Insurance Exchanges to Drive Better, Most Cost-Effective Care
5/8
Putting Theory into Practice 5
Ohio
Minnesota
8WDKDGGUHVVHGWKHULVLQJFRVWVRIKHDOWKFDUHE\LPSOH-
menting a free-market approach in an attempt to reduce
FRVWV ZKLOH LQFUHDVLQJ DFFHVV WR KHDOWK LQVXUDQFH :LWK
WKH FRQVXPHUDV DNH\ IDFWRU RI WKH HTXDWLRQ WKH 8WDK
+HDOWK,QVXUDQFH([FKDQJHZDVFUHDWHG7KHSURJUDPZDV
GHVLJQHGWRSURYLGHDFFXUDWHWUDQVSDUHQWDQGFRQVLVWHQW
information connecting the consumer to the necessary in-
IRUPDWLRQWRSXUFKDVHKHDOWKLQVXUDQFH9DOXLQJSHUVRQDO
UHVSRQVLELOLW\ 8WDKGHYHORSHGD WHFKQRORJLFDOSRUWDO IRUconsumers to access information about health insurance
WRPDNHLQIRUPHGFKRLFHVDERXWWKHLUKHDOWKLQVXUDQFH6
:KDWPDNHVWKH8WDK+HDOWK,QVXUDQFH([FKDQJHXQLTXH
LVQRWRQO\WKDWWKHV\VWHPEXLOGVXSRQH[LVWLQJWHFKQRORJ\
but now several key players within the health care system
DUHQRZFROODERUDWLQJZLWKRQHDQRWKHU7KHFDSDELOLW\IRU
HPSOR\HUVWRPDNHDGHQHGFRQWULEXWLRQWRWKH([FKDQJH
and the consumers capacity to access reliable and trans-
SDUHQW LQIRUPDWLRQ DOPRVW VPDOO HPSOR\HU JURXSV
KDYHSDUWLFLSDWHGLQWKHH[FKDQJHSDUWQHULQJZLWKSURYLG-
HUVDQGSDWLHQWVWRFRYHUPRUHWKDQEHQHFLDULHV7
2Q WKH RWKHU HQG RI WKH VSHFWUXP WKH 0DVVDFKXVHWWV
+HDOWK &RQQHFWRU DGGUHVVHV WKH UDWH RI XQLQVXUHG DQG
reduces the costs of health insurance with an active pur-
FKDVHUPHFKDQLVPLQSODFH7KHVWDWHVHOHFWVSDUWLFLSDW -
LQJLQVXUDQFHSODQVWKDWPHHWWKH&RQQHFWRUpVq6HDORI$S -
proval to offer a wide range of plans and options to both
LQGLYLGXDOFRQVXPHUVDQGVPDOOEXVLQHVVHV
%DVHG RQ VWDQGDUGL]HG EHQHW SODQV KHDOWK SODQV PXVW
VXEPLWIRXUWLHUVRIKHDOWKLQVXUDQFHEHQHWVGULYLQJGRZQ
FRVWVLQWKHSURFHVV$GGLWLRQDOO\WKURXJKWKHFHUWLFDWLRQ
SURFHVVWKH&RQQHFWRUERWKUHGXFHVRYHUDOOSUHPLXPELGV
ZKLOHDFFHSWLQJSODQVWKDWPHDVXUHZHOOLQTXDOLW\RIFDUH
$V D UHVXOW FRQVXPHUV FDQ HYDOXDWH LQVXUDQFH RSWLRQV
FRPSDULQJEHQHWIHDWXUHVGHGXFWLEOHVDQGSUHPLXPV
(MBQD@RDO@SHDMSBNMRTLDQR@SHRE@BSHNM
@MCRG@QDCCDBHRHNML@JHMF/@SHDMSR
@MCSGDHQE@LHKHDR@QDJDXLDLADQRNESGD
OQNBDRR/@SHDMS@MCE@LHKXDMF@FDLDMS
@HLRSNHLOQNUDO@SHDMSRTMCDQRS@MCHMF
NESGDHQGD@KSG@MCQDK@SDCBNMCHSHNMRRNSGDXS@JD@LNQD@BSHUDQNKDHMSGDHQ
GD@KSGB@QDSGQNTFGRG@QDCCDBHRHNM
L@JHMF2G@QDCCDBHRHNML@JHMFHR
@BNKK@ANQ@SHUDOQNBDRRSG@SNBBTQR
ADSVDDMOQNUHCDQR@BSHUDKXDMF@FHMFSGD
O@SHDMSHMTMCDQRS@MCHMF@MCL@M@FHMF
GD@KSGNTSBNLDR@MCL@JHMFHMENQLDC
CDBHRHNMRHMSQD@SLDMS10(S@KRNDMBNTQ@FDR
SGDHMUNKUDLDMSNEO@SHDMSRE@LHKHDR@R
L@MXO@SHDMSRCDODMCNMSGDHQRTOONQS18
Comparing
Exchange models
in Utah and
Massachusetts
&XUUHQWO\ D 3&0+ FRQVLVWLQJ RI LQWHUQDODQG
family medicine practices in Cincinnati that reaches
RYHUSDWLHQWVKDVGHYHORSHGDZRUNJURXS
NQRZQ DV$OLJQLQJ)RUFHVWR KHOSIRVWHUVKDUHG
GHFLVLRQPDNLQJ DPRQJ WKHSDWLHQWV SK\VLFLDQV
DQGKHDOWKSODQV7DVNHGZLWKUHYLHZLQJWKHEHVW
practices and implementing a model that was bestVXLWHG IRU WKLV SURJUDP WKH ZRUN JURXSGHYLVHG
a multi-pronged approach to providing tools that
would improve and distribute information to aid in
WKHLUGHFLVLRQPDNLQJ
7KURXJK D MRLQW HIIRUW 0LQQHVRWDpV 'HSDUWPHQW
RI +HDOWK DQG 'HSDUWPHQW RI +XPDQ 6HUYLFHV
KDYHHVWDEOLVKHGDQH[WHQVLYHQHWZRUNRI3&0+VWKURXJKRXWWKHVWDWH$GGUHVVLQJWKHFKDOOHQJHVRI
forming and maintaining relationships between the
FDUHWHDPDQGWKHSDWLHQW0LQQHVRWDUHFRJQL]HG
WKH YDOXH RI FDUH FRRUGLQDWLRQ DQG LQWHJUDWLRQ
&HUWLI\LQJ DOPRVW PHGLFDO KRPHV WKH 0LQQH-
VRWD+HDOWK&DUH3URJUDP0+&3UHDFKHV
HQUROOHHV$WWKHKHDUWRI WKLVODUJHHQGHDYRULVD
VWURQJIRFXVRQFRPPXQLFDWLRQFROODERUDWLRQDQG
LQQRYDWLRQ
7/30/2019 Using State Health Insurance Exchanges to Drive Better, Most Cost-Effective Care
6/8
6 Patient-Centered Primary Care Collaborative
What can States do to support
the creation of Patient
Centered Medical Homes?,NQDSG@MDUDQRS@SDFNUDQMLDMSRMDDCRTRS@HM@AKDRNKTSHNMRSG@S@QDkDWHAKDD@RHKX
RB@K@AKD@MCBNMjFTQ@AKDSNHMSDFQ@SD@ETKKRODBSQTLNERDQUHBDRVGHKDNODQ@SHMFTMCDQ
@SHFGSATCFDS6NQJHMFHMBNKK@ANQ@SHNMVHSGGD@KSGOQNUHCDQRBNMRTLDQRDLOKNXDQR
GD@KSGOK@MR@MCNSGDQRSNCDRHFMSGDADRSLNCDKENQSGDHQNVMRS@SDONKHBXL@JDQRB@M
HMSDFQ@SDJDXED@STQDRNESGD/",'LNCDKHMSNSGDHQ$WBG@MFDRHMDHSGDQ@BNLOQDGDM-
RHUDNQRSDOAXRSDOATHKCHMFAKNBJ@OOQN@BG2S@SD'D@KSG(MRTQ@MBD$WBG@MFDRB@MAD
CDRHFMDCSNQDkDBSSGDTMHPTDMDDCRNESGD2S@SDRRSQHJHMF@A@K@MBDADSVDDMBTQQDMSRXRSDLHMEQ@RSQTBSTQD@MCMDVED@STQDR3GDkDWHAHKHSXNECDRHFMNEEDQDCAXSGD$WBG@MFDR
@KKNVRBTRSNLHY@SHNMSNOQNUHCDRXRSDLRSG@SE@KK@KNMF@BNMSHMTTLEQNLNODML@QJDS
O@RRHUDOTQBG@RDQCDRHFMRSN@BSHUDOTQBG@RDQ@QQ@MFDLDMSR
3GDFDMDQ@KRSQTBSTQDNESGD$WBG@MFDROQNUHCDRRHFMHjB@MSkDWHAHKHSXHMSGDV@XOQNFQ@LR
@QDCDUDKNODC@MCQDFTK@SDCRHKKTRSQ@SDCHMSGDDW@LOKDRNE4S@G@MC,@RR@BGTRDSSR
SGDHMEQ@RSQTBSTQDNE@M$WBG@MFDHRMNS@MDHSGDQNQRHST@SHNM@MCBNLONMDMSRNE@/",'
B@MADHMBKTCDCHMSGDCDRHFM!NSGSGD$WBG@MFD@MCSGD/",'NEEDQHMCHUHCT@KRS@SDR
SGDNOONQSTMHSXSNCQHUDGD@KSGQDENQLDRODBH@KKXSN@CCQDRRSGDTMHPTDBHQBTLRS@MBDSG@SRS@SDRE@BD
q CNOS/",'OQHMBHOKDR2S@SDRB@MVNQJVHSGRS@JDGNKCDQRSN@CNOSOQHMBHOKDRSG@S@QDHM@KHFMLDMSVHSGSGD/@SHDMS"DMSDQDC,DCHB@K'NLDRDSSHMF@OQHNQHSXNMHLOQNUDCNTSBNLDR@MCBNMSQNKKHMFBNRSRVGHKDDWO@MCHMF@BBDRRSN@EENQC@AKDGD@KSGHMRTQ@MBD3GDHMGDQDMSRSQTBSTQDNE/",'RRTOONQSRSGHRFN@K
q CNOSPT@KHSXLD@RTQDR@MCOQNLNSDO@SHDMSR@EDSX2S@SDRB@MQDPTHQDSG@SGD@KSGOK@MRO@QSHBHO@SHMFHMSGD$WBG@MFDHLOKDLDMS@PT@KHSXHLOQNUDLDMSRSQ@SDFXSG@SHMBKTCDROQNUHCDQ
KDUDKPT@KHSXQDONQSHMFB@RDL@M@FDLDMSB@QDBNNQCHM@SHNMOQDUDMSHNMNE@UNHC@AKDGNROHS@K
QD@CLHRRHNMR@BSHUHSHDRSNHLOQNUDO@SHDMSR@EDSX@MC@BSHUHSHDRSNQDCTBDGD@KSGCHRO@QHSHDR
q $MBNTQ@FDO@XLDMSQDENQL2S@SDRB@MDMBNTQ@FDSGDHQ$WBG@MFDRSNO@QSHBHO@SDHMLTKSHO@XDQOHKNSOQNFQ@LRSG@SSDRSMDVO@SHDMSBDMSDQDCLNCDKRNEO@XLDMSENQGD@KSGB@QDCDKHUDQX/@SHDMSRADMDjSLNRSEQNLHMMNU@SHUDO@XLDMSLNCDKRSG@SL@HMS@HM@ENBTRNMPT@KHSXLD@RTQDLDMSOQDRDQUDO@SHDMS@BBDRRSNB@QD@MCHMBDMSHUHYDBNMSHMTDCHMMNU@SHNM
HMGD@SGB@QDSQD@SLDMSR
7/30/2019 Using State Health Insurance Exchanges to Drive Better, Most Cost-Effective Care
7/8
Putting Theory into Practice 7
Spotlight on the States7KH%OXH&URVV%OXH6KLHOG$VVRFLDWLRQ%&%6$LVFROODERUDWLQJZLWKQDWLRQDODQGORFDOLQGXVWU\
stakeholders to enhance the practice and delivery of primary care on a national scale through
WKH3&0+7KLVLQLWLDWLYHLVFXUUHQWO\LQVWDWHVDFURVVWKHFRXQWU\DQGFRYHUVRYHUIRXUPLOOLRQ
PHPEHUVSURPRWLQJJUHDWHUSDWLHQWLQYROYHPHQWZLWKWKHLUSULPDU\FDUHSK\VLFLDQDQGHQKDQFHG
XVHRIKHDOWKLQIRUPDWLRQWHFKQRORJ\
7KH%&%6$ZRUNVqZLWKGRFWRUVDQGKRVSLWDOVQDWLRQZLGHWRGHYHORSQHZZD\VWRLPSURYHWKH
TXDOLW\RIFDUH\RXUHFHLYHDQGDWWDFNULVLQJKHDOWKFDUHFRVWVZLWKLQWKHV\VWHP$VLJQLFDQW
H[DPSOHWKHLQQRYDWLYHZD\V%&%6$VXSSRUWV3&0+VLVWKURXJKDFRQWUDFWPRGHOLQ0DVVDFKX-
VHWWVWKH$OWHUQDWLYH4XDOLW\&RQWUDFW$4&ZKLFKHQFRXUDJHVFRVWHIIHFWLYHSDWLHQWFHQWHUHG
FDUHE\SD\LQJSDUWLFLSDWLQJSK\VLFLDQVDQGKRVSLWDOVIRUWKHTXDOLW\QRWWKHTXDQWLW\RIWKHFDUH
WKH\GHOLYHU7KLVQHZFRQWUDFWPRGHOFRPELQHVDSHUSDWLHQWJOREDOEXGJHWZLWKVLJQLFDQW
SHUIRUPDQFHLQFHQWLYHVEDVHGRQQDWLRQDOO\HQGRUVHGTXDOLW\PHDVXUHVWLHGWRTXDOLW\KHDOWK
RXWFRPHVDQGSDWLHQWH[SHULHQFHr
r Focus on patients.6WDWHVFDQUHTXLUH([FKDQJHVWRLQFOXGHJRYHUQDQFHVWUXFWXUHVWKDWLQFOXGHSDWLHQWVFRQVXPHUVDQGRUWKHLUIDPLOLHV7KLVZLOOHQVXUHWKDWWKHJRDOVRIWKH
Exchange remain responsive to consumer demands as they reach out to new audiences of
LQGLYLGXDOVDQGVPDOOHPSOR\HUVDQGWKHQHHGVRIWKHWD[SD\HUVZKRDUHVXEVLGL]LQJWKH
H[FKDQJHV
r Support for primary care6WDWHVFDQHQFRXUDJH([FKDQJHVWRSURPRWHSULPDU\FDUH
WKURXJKKHDOWKSODQGHVLJQZKLFKZLOOEHDWWKHIRUHIURQWRIVWUHQJWKHQLQJRXU86KHDOWK
V\VWHP8QGHUD3&0+WHDPPRGHORIFDUHDOOKHDOWKSURIHVVLRQVSUDFWLFHDWqWKHWRSRI
WKHLUOLFHQVHrHQVXULQJWKDWFDUHLVGHOLYHUHGLQWKHPRVWFRVWHIIHFWLYHDQGHIFLHQWPDQQHU
r Paying for care coordination.6WDWHVFDQUHTXLUHWKDWKHDOWKSODQVSDUWLFLSDWLQJLQWKH
([FKDQJHUHLPEXUVHIRUFDUHFRRUGLQDWLRQZKLFKZLOOUHGXFHGXSOLFDWLYHVHUYLFHVDQGintegrating the appropriate treatmentsDQGWKXVKHOSWRGULYHGRZQRYHUDOOKHDOWKFDUHFRVWV
$GGLWLRQDOO\VWDWHVKDYHVLJQLFDQWODWLWXGHZKHQGHVLJQLQJLQFHQWLYHVLQWRWKHLQIUDVWUXFWXUH
WKDWPD\DFWXDOO\GULYHGRZQFRVWVRIFDUH
3GD/",'BNMBDOSBNLAHMDRSGDU@KTDRNEOQHL@QXB@QDVHSGMDVSDBGMNKN-
FHDR@MC@OOQN@BGDRSNOQ@BSHBDSNADSSDQRDQUDSGDMDDCRNEO@SHDMSR
3GD/",'FTHCHMFOQHMBHOKDRLTBGKHJDSGNRDNERS@SDGD@KSGHMRTQ@MBDDWBG@MFDR@QDkDWHAKD@MC@KKNVRS@SDRSNS@HKNQOQNFQ@LR@QNTMCRODBHjB
MDDCR@MCBNMCHSHNMR3GD#DO@QSLDMSNE'D@KSG@MC'TL@M2DQUHBDR
''2QDKD@RDC@jM@KQTKHMFSG@SETQSGDQDWSDMCRSGDkDWHAHKHSXENQRDSSHMF
TO$WBG@MFDR3GHREQ@LDVNQJOQDRDQUDR@MCHMRNLDB@RDRDWO@MCR
SGDRHFMHjB@MSkDWHAHKHSXHMSGDOQNONRDCQTKDRVGHBGVNTKC@KKNVSGDRS@SDR
SNHMBNQONQ@SD/",'OQHMBHOKDRHMSNSGDHMEQ@RSQTBSTQD@MCNODQ@SHNMRNE
SGDHQ$WBG@MFD22
Conclusion
7/30/2019 Using State Health Insurance Exchanges to Drive Better, Most Cost-Effective Care
8/8
2012 Patient-Centered Primary Care Collaborative
3GD/@SHDMS"DMSDQDC/QHL@QX"@QD"NKK@ANQ@SHUD@BJMNVKDCFDRSGDkM@MBH@K
RTOONQSNE/kYDQ(MBENQSGHROTAKHB@SHNM
6FKROOH67RUGD33HLNHV'+DQ(*HQHYUR-(Q-
JDJLQJ3DWLHQWVDQG)DPLOLHVLQWKH0HGLFDO+RPH3UHSDUHG
E\0DWKHPDWLFD3ROLF\5HVHDUFKXQGHU&RQWUDFW1R++ -
6$,72$+543XEOLFDWLRQ1R()
5RFNYLOOH0'$JHQF\IRU+HDOWKFDUH5HVHDUFKDQG4XDOLW\
0H\HUV'3HLNHV'*HQHYUR-3HWHUVRQ*UHJ7D\ORU()7LP
/DNH76PLWK.*UXPEDFK.7KH5ROHVRI3DWLHQW
&HQWHUHG0HGLFDO+RPHVDQG$FFRXQWDEOH&DUH2UJDQL]DWLRQV
LQ&RRUGLQDWLQJ3DWLHQW&DUH$+543XEOLFDWLRQ1R0
()5RFNYLOOH0'$JHQF\IRU+HDOWKFDUH5HVHDUFKDQG4XDOLW\
'HFHPEHU
9RON-&RUOHWWH67KHUROHRIH[FKDQJHVLQTXDOLW\
LPSURYHPHQW$QDQDO\VLVRIWKHRSWLRQV*HRUJHWRZQ8QLYHU -
VLW\+HDOWK3ROLF\,QVWLWXWH
.D\H1%X[EDXP-7DNDFK0%XLOGLQJPHGLFDO
KRPHV/HVVRQVIURPHLJKWVWDWHVZLWKHPHUJLQJSURJUDPV
1DWLRQDO$FDGHP\IRU6WDWH+HDOWK3ROLF\
%DFKUDFK'%RR]DQJ3)HGHUDOO\IDFLOLWDWHGH[-FKDQJHVDQGWKHFRQWLQXXPRIVWDWHRSWLRQV1DWLRQDO$FDGHP\
RI6RFLDO,QVXUDQFH
&RUOHWWH6$ONHU-7RXVFKQHU-9RON-7KH0DV-
VDFKXVHWWVDQG8WDKKHDOWKLQVXUDQFH([FKDQJHV/HVVRQV
OHDUQHG*HRUJHWRZQ8QLYHUVLW\+HDOWK3ROLF\,QVWLWXWH
7KH8WDK+HDOWK([FKDQJH2YHUYLHZ5HWULHYHG0DUFK
IURPKWWSZZZH[FKDQJHXWDKJRYDERXWWKHH[FKDQJH
RYHUYLHZ
8UII-+HDOWKUHIRUPWRRONLWVHULHV5HVRXUFHVIURPWKH
0DVVDFKXVHWWV([SHULHQFH%OXH&URVV%OXH6KLHOGRI0DVVD-
FKXVHWWV)RXQGDWLRQ
6WDWHVLQ$FWLRQ0DVVDFKXVHWWV+HDOWK&RQQHFWRU7KH&RPPRQZHDOWK)XQG
:H[OHU56L[VWHSVRIVKDUHGGHFLVLRQPDNLQJ,QIRUPHG
0HGLFDO'HFLVLRQV)RXQGDWLRQ
&HQWHUV-3LORWSURJUDPKHOSVSDWLHQWVQGPHGLFDO
KRPH1RUWKHUQ&RORUDGR%XVLQHVV5HSRUW5HWULHYHG0DUFK
IURPKWWSZZZQFEUFRPDUWLFOH38%/,&$7,21
6"SDJHQXPEHU
)LW]JHUDOG%$QHZZD\RIWUHDWLQJSDWLHQWVDWqKRPHr
1-6SRWOLJKW5HWULHYHG0DUFKIURPKWWSZZZQMVSRW -
OLJKWFRPVWRULHV
8QLWHG+HDOWKFDUH0RUH$UL]RQDFRPSDQLHVWXUQLQJWR
8QLWHG+HDOWKFDUHpV0HGLFDO+RPH3URJUDPWRHPSURYHHPSOR\HH
KHDOWKFRQWUROFRVW5HWULHYHG0DUFKIURPKWWSZZZ
XKFFRPQHZVBURRPBQHZVBUHOHDVHBDUFKLYHPRUHBDUL]RQDB
FRPSDQLHVBWXUQBWRBXQLWHGKHDOWKFDUHVBPHGLFDOBKRPHBSURJUDP
KWP
*DOH/%&%65,3DWLHQWFHQWHUHGPHGLFDOKRPHSLORW
SURJUDPDVXFFHVV&0,25HWULHYHG0DUFKIURPKWWS
ZZZFPLRQHWLQGH[SKS"RSWLRQFRPBDUWLFOHVDUWLFOH
&1&&4XDOLW\PHDVXUHPHQWDQGIHHGEDFNLQLWLDWLYH)LQDO
FKDUWUHYLHZUHVXOWVZLWKEHQFKPDUNV5HWULHYHG0DUFK
IURPKWWSZZZFRPPXQLW\FDUHQFRUJHPHUJLQJLQLWLD -
WLYHVSFPKFHQWUDO
5HLG57KH*URXS+HDOWKPHGLFDOKRPHSLORW3ULPDU\
FDUHRQUROOHUVNDWHV*URXS+HDOWK5HVHDUFK,QVWLWXWH5HWULHYHG
0DUFKIURPKWWSZZZGRKZDJRYFIK0+&ROOSXEOLFD -
WLRQV5RE5HLGSGI
%OXH&URVV%OXH6KLHOGRI0LFKLJDQ3DWLHQWFHQWHUHGPHGLFDOKRPHIDFWVKHHW5HWULHYHG0DUFKIURPKWWS
ZZZYDOXHSDUWQHUVKLSVFRPSFPKSFPKBIDFWVKHHWSGI
7DQJ3/DQVN\7KHPLVVLQJOLQN%ULGJLQJWKHSDWLHQWt
SURYLGHUKHDOWKLQIRUPDWLRQJDS+HDOWK$IIDLUV
+HDOWK,PSURYHPHQW&ROODERUDWLYHRI*UHDWHU&LQFLQQDWL
$OLJQLQJIRUFHVIRUTXDOL W\,PSURYLQJKHDOWKFDUHDFURVVJUHDWHU
&LQFLQQDWL5HSRUWWRWKH&RPPXQLW\5HWULHYHGRQ0DUFK
IURPKWWSZZZWKHFROODERUDWLYHRUJ3RUWDOVGRFV$)4
(QHZVOHWWHU-DQXDU\$)45HSRUWFRPSSGI
%OXH&URVV%OXH6KLHOG$VVRFLDWLRQ7KHSDWLHQWFHQWHUHG
PHGLFDOKRPH([DPSOHVRI%&%63LORW$FWLYLW\5HWULHYHGRQ
0DUFKIURPKWWSSV\FKRUJ0DLQ0HQX$GYRFDF\*RY -
HUQPHQW5HODWLRQV)LQDQFLQJ+HDOWKFDUH7KH3DWLHQW&HQWHUHG0HGLFDO+RPH([DPSOHVRI%&%63LORW$FWLYLW\DVS[")7SGI
%OXH&URVV%OXH6KLHOG$VVRFLDWLRQ%OXH&URVVDQG%OXH
Shield companies support new healthcare models: Collaborations
ZLWKGRFWRUVDQGKRVSLWDOVDUHLPSURYLQJTXDOLW\DQGYDOXHIRU
FRQVXPHUV5HWULHYHG0DUFKIURPKWWSZZZEFEVFRP
healthcare-news/bcbsa/bcbs-companies-support-new-health-
FDUHPRGHOVKWPO
+HDOWKFDUHJRY$IIRUGDEOHLQVXUDQFHH[FKDQJHV&KRLFHV
FRPSHWLWLRQDQGFORXWIRUVWDWHV5HWULHYHG0DUFKIURP
KWWSZZZKHDOWKFDUHJRYQHZVIDFWVKHHWVH[FKDQJ -
HVDKWPO
Endnotes
Recommended