Consolidating Key Learnings to Propel Medicaid Transformation Nationwide

From coast to coast, Medicaid is being transformed with the help of 1115 waivers to improve access, quality, and cost effectiveness of health services for the most at-risk residents. These efforts, which are critical to ensure that vulnerable individuals and communities still receive the high quality care they need, are taking place against a backdrop of historical disenrollment from Medicaid, during which approximately 23 million Americans have lost coverage to date.

With 47 states working to evolve Medicaid through their own 1115 waivers, we must find a better way for states to more meaningfully collaborate and learn from one another. While each state has its own program nuances, and population needs, here are a few ways we can consolidate key learnings from state to state, using California’s CalAIM and New York as examples as New York’s leaders prepare to take ambitious steps toward their 1115 Waiver over the next few months. 

California Learnings Can Fuel Implementation, Improvement in New York 

California and New York are both large states with ambitious agendas to transform Medicaid. They are also challenged by significant regional differences, ranging from some of the most densely populated cities to rural areas that have limited access to health care resources. Based on California’s experiences to date, here are a few points New York can apply to its own initiatives.  

• Emphasize technical assistance for Community-Based Organizations (CBOs). Billing for services and exchanging data for care coordination are two areas that typically require technical assistance (TA) to be most effective, particularly given that CBOs often have limited in-house staff. New York should consider holding regional hubs accountable for providing CBOs with access to TA resources across various regions, establishing clear pathways for CBOs and regional hubs to identify gaps in expertise and pair up with the right experts. New York should also hold regional hubs accountable for filling the TA role spelled out in requests for proposals. 
• Make receiving payments as frictionless as possible for CBOs. While less flashy, managing authorizations and billing for social services are critical to care delivery. As was the case in California, this will likely be the first time that many CBOs are being reimbursed through a Medicaid program. In addition, it may be the first time that Social Care Networks need to distribute funds to sub contractors at this scale. Scaling up capacity and developing standards to distribute payments for social services is a substantial undertaking that requires significant new expertise, operational processes, and technology investments. To ensure there are no barriers to scale, Social Care Networks and Managed Care Plans (MCPs) should invest in standardizing the way that payments for Health Related Social Needs (commonly known as HRSN) are distributed to ensure CBOs can receive critical funds for these efforts in a timely and consistent fashion. 
• Enable accountable community governance. California established collaboratives, like this one that brings together the state’s San Luis Obispo, Santa Barbara, and Ventura Counties. These collaboratives serve a critical link between policy and implementation, empowering groups to manage the rollout together. Local delegation has enabled true collaboration between CBOs, MCPs and providers by aligning and orienting incentives toward a population health approach, ensuring benefits are meeting needs. 
• Balance local flexibility with state guidance. In New York, regional hubs are responsible for many implementation details. While this allows for local tailoring, in California, allowing the flexibility allowed to MCPs to implement has also created some confusion and a desire for more prescription from the state. It’s a fine line for New York to walk to successfully anticipate the need for greater definition or clarity for how MCPs, SCNs, and CBOs should collaborate inside or outside of governance activities. Ideally, this would take the form of an effective feedback loop that informs the need for guidance and support.
• Define success with intent. With these goals in mind, data exchange priorities will more meaningfully serve and support better health outcomes. For example, if organizations are expected to track medical costs and clinical outcomes, ensure there is a clear pathway for them to access that data in a usable/aggregated manner. Developing standards for the exchange of social service data is also essential to defining whole person care success and outcomes. 

While New York and California share important similarities, begetting natural opportunities for shared learning, all states with 1115 waivers willing to share and listen to key learnings will help Medicaid evolve meaningfully for patients and the broader health and social services landscape.