Success Criteria - Health Care Payment Learning & Action Network

Measurement Track: Payment Reform

Capability: Analysis to identify alternative payment model opportunities

Definition:
Establish process to evaluate readiness to enter into alternative payment models. This process should include a financial analysis and business readiness assessment to evaluate likelihood of success and identify gaps for remediation. Identify the stakeholders across the organization who will need to be engaged in this process, such as payer contracting, clinical operations, care management and information technology.

Resources:

Mark Japinga

Mark Japinga is a Research Associate at the Duke-Margolis Center for Health Policy, based out of Washington, DC, and focusing on payment and delivery reform. He has led research initiatives and written issue briefs in areas such as specialty care models, multipayer initiatives, employer-sponsored health care, and state-level transformation. Prior to Margolis, he worked in a variety of positions in and around state politics, including for the Texas Legislature, the Wisconsin Legislature, and Stateside Associates. He is a graduate of Grinnell College and the University of Wisconsin-Madison.

Maria Ramirez Perez

Maria Ramirez Perez is a Program Manager with NC Medicaid’s Healthy Opportunities Pilots program and leads the program’s efforts with Network Leads and community-based organizations. Prior to her work with NC HOP, she also co-led the implementation of NC DHHS’s COVID-19 Support Services Program which helped connect households with social supports to safely quarantine or isolate.

Maria previously worked with Legal Aid of North Carolina where she represented clients in public benefits appeals. She also led regional implementation and outreach efforts to help North Carolinians gain access to clinical care and social supports through the Medical-Legal Partnership and Healthcare Navigator programs.

Maria earned her Master of Public Health from UNC Gillings School of Global Public Health. When she is not focused on addressing healthy opportunities, Maria is trying new recipes or exploring the outdoors. She has logged hundreds of miles hiking in the southeast.

Joe Castiglione

Joe Castiglione is on the Industry Initiatives team at Blue Shield of California, where he works to scale and sustain health care innovation through industry collaboration and policy movement. His work focuses on building strategic partnerships that drive alignment on issues related to payment innovation, primary care, and health equity. Prior to Blue Shield, he led stakeholder engagement, as well as legislative and regulatory advocacy, in Washington, DC for the National Committee for Quality Assurance (NCQA). Joe lives in the Castro District of San Francisco, California. He has an MBA from UC Berkeley Haas School of Business and a BA in International Economics from the University of Texas at Austin.

Tara Smith

Tara Smith is the primary care and affordability director at the Colorado Division of Insurance (DOI), where she helps lead the DOI’s payment system reforms to reduce health costs for consumers by increasing the utilization of primary care. She is responsible for recruiting, convening, and facilitating activities of the Colorado Primary Care Payment Reform Collaborative and for developing affordability standards and strategies to help ensure commercial insurance companies’ investments in primary care drive better value and quality for consumers.

Tara has been actively involved in efforts to reform the state’s health care systems throughout her career, including Colorado’s State Innovation Model (SIM), a four-year, $65 million initiative aimed at transforming health care delivery and payment structures through the integration of physical and behavioral health, along with the implementation of the Affordable Care Act’s health insurance marketplace reforms.

Alicia Berkemeyer

Alicia Berkemeyer is the executive vice president and chief health management officer for Arkansas Blue Cross and Blue Shield. She is responsible for all programs related to provider networks, medical management, provider compensation, quality– and value-based programs, primary care, and commercial pharmacy for Arkansas Blue Cross and Blue Shield, and its affiliates. Alicia joined Arkansas BCBS in 1989 and has held several positions in claims, customer service, sales and marketing, and pharmacy. She has more than 30 years of experience in the health care industry, with a focus on value–based care, primary care, and pharmacy. Alicia played an instrumental role in Arkansas being chosen as one of only seven regions in the United States to participate in the federal Comprehensive Primary Care initiative and assisted the state in receiving significant funding from the CMS Innovation Center in the form of a State Innovation Model grant. Alicia currently serves on the Cystic Fibrosis Board, the University of Arkansas Little Rock Business Advisory Council, and the Divine Mercy Clinic Board.

Kate Davidson, LCSW

Kate Davidson, LCSW is the director of the learning and diffusion group (LDG) at the Center for Medicare and Medicaid Innovation (CMMI), within the Centers for Medicare & Medicaid Services (CMS).  In this role, Ms. Davidson leads CMMI’s team focused on accelerating healthcare system transformation by leveraging improvement science within and across models, as well as leading the multi-payer alignment strategy for the Center through the Health Care Payment Learning and Action Network (HCPLAN). Prior to joining CMS, Ms. Davidson led Policy and Practice Improvement efforts at the National Council for Mental Wellbeing, where she managed payment reform, quality improvement, and workforce development initiatives in mental health and addiction prevention, treatment, and recovery organizations, and provided training and technical assistance to human services organizations, counties, and states. Ms. Davidson began her career in healthcare as a social worker researching, testing, and scaling interventions in community-based settings.  Ms. Davidson has an MSW from Fordham University and a BA from Loyola College in Maryland.

Measurement Track: Quality

Capability: Encourage adoption of pay-for-performance

Definition:
Developing an incentive structure to demonstrate successful achievement of defined process and clinical/preventative measures, as well as earn shared savings and/or reward/bonus payments.

Resources:

Managed Care Data Checklist – Health Information Technology Evaluation and Quality Center

Measurement Track: Quality

Capability: Reporting of quality outcomes (including specialty-oriented)

Definition:
Integration with the Data and Infrastructure Measurement Track for Enterprise Data Warehouse to increase the accuracy of the quality metrics generated and reported to regulators, the practicing providers, and key clients. Includes establishing the importance of data quality in driving business decisions and initiatives undertaken by the provider organization (e.g., communication campaigns to bring patients in for preventive screenings like diabetic eye and foot exams) to improve the outcomes achieved.

Resources:

Measurement Track: Quality

Capability: Provide transparent quality benchmarking methodology

Definition:
Methodology is shared with regulators and providers, and must be adjusted for population mix, risk (including social determinants of health), and market (e.g., mammogram rates may be lower in certain communities with low access to preventative care). Also includes participation in chronic condition clinical registries identifying and tracking care and outcomes.

Resources:

Managed Care Data Checklist – Health Information Technology Evaluation and Quality Center

Measurement Track: Data and Infrastructure

Capability: Develop data strategy structure and governance

Definition:
Relevant data sets across financial, clinical, and operational domains have been identified and are in the process of being ingested into a single enterprise data warehouse or similar solution to enable data from disparate sources to be aggregated and used in analytics. A governance model has been established to drive standardized data definitions as part of a formal data management process and a formal intake process for analytics requests is established.

Resources:

Measurement Track: Data and Infrastructure

Capability: Implement member/patient portal (demographic)

Definition:
Implementation and usage of a patient portal to capture and communicate demographic data between the payer, provider, and member/patient.

Resources:

Managed Care Data Checklist – Health Information Technology Evaluation and Quality Center

Measurement Track: Data and Infrastructure

Capability: Implement member/patient portals (lab, immunization, etc.)

Definition:
Establish an online portal for members and patients to perform basic tasks such as reviewing medical information, paying bills, and other administrative functions. Where applicable, consolidate instances of online portals that exist across the care continuum (e.g., separate portals for inpatient and outpatient services).

Resources:

Managed Care Data Checklist – Health Information Technology Evaluation and Quality Center

Measurement Track: Health Equity Advancements

Capability: Enable access to telemedicine/remote monitoring

Definition:
The ability to monitor and actively manage certain clinical connection points of a patient’s health from their own home (e.g., blood pressure, weight, glucose levels) in order to capture declines in health before they are severe enough to need ER and/or hospital care.

Resources:

Measurement Track: Health Equity Advancements

Capability: Enable mobile/virtual health access outside of acute and ambulatory settings

Definition:
Ability of patients to keep track of their own health, connect with care delivery teams, and support resources by mobile communication channels and network technologies, extending beyond the times when they are in a care setting.

Resources:

Measurement Track: Data and Infrastructure

Capability: Develop technology infrastructure to support advanced consumer tools

Definition:
Ability to capture and incorporate data from remote patient monitoring devices, telehealth services, and consumer wearables (including phones, etc.).

Resources:

Telehealth: Expanding the Boundaries of Patient-centric Care – Healthcare Leadership Council

Measurement Track: Health Equity Advancements

Capability: Longitudinal care management approach inclusive of chronic disease management

Definition:
Holistic and dynamic long-term care management incorporating disease prevention and treatment. Includes digital care support and ongoing monitoring of health status outside of direct patient interventions. Patient values and preferences are incorporated into the care plan.

Resources:

Measurement Track: Health Equity Advancements

Capability: Incorporate member/patient preference to enhance communication engagement

Definition:
Assessing for preferred communication channels during each member/patient interaction and incorporating those preferences into ongoing communications. Engagement can be increased by customizing communications to the cultural norms of the members/patients (e.g., cultural food and social norms).

Resources:

Accelerating and Aligning Population-Based Payment Models: Patient Attribution – Health Care Payment Learning & Action Network

Measurement Track: Health Equity Advancements

Capability: Incorporate propensity for member/patient engagement in the care model delivery

Definition:
Integrated with Data and Infrastructure Measurement Track. Identification of members/patients with higher probability of engagement/participation in care model, which causes patients to seek better quality of care and reduce costs. Knowing the likelihood of a members’/patients’ engagement allows the provider to use lower or higher cost interventions when appropriate (e.g., use text prompts with highly engaged members/patients, versus a face-to-face case manager meeting with a habitually low adherence patient).

Resources:

Accelerating and Aligning Population-Based Payment Models: Patient Attribution – Health Care Payment Learning & Action Network

Measurement Track: Health Equity Advancements

Capability: Provide advanced consumer tools

Definition:
Decision-support tools available to members/patients to help understand essential data/background information, provide evidence-based education, and identify patient values and preferences influencing health care decisions.

Measurement Track: Health Equity Advancements

Capability: Deliver care with cultural competency

Definition:
Effectively deliver health care services that meet the social, cultural, and linguistic needs of members/patients. Contributes to the elimination of racial and ethnic health disparities. Examples include employing community health workers, training on cultural competence and cross-cultural issues, and creating policies that reduce barriers to care and promote engagement across cultures.

Resources:

View from the Field: Recruitment and Retention of African American Men in the Mental Health and Substance Use Workforce – National Council for Mental Wellbeing

Measurement Track: Health Equity Advancements

Capability: Access to nurse line

Definition:
A service for patients to ask basic health questions and address concerns about an illness or injury. Typically, available 24/7/365 as a resource to help decide where to get care and navigate to the right level of care at the right time (e.g., wait for the morning to go to members’/patients’ PCP versus going to the ER).

Measurement Track: Health Equity Advancements

Capability: Development of loyalty programs/incentives

Definition:
Rewards systems that can be used to encourage healthy lifestyle, focus on prevention measures, and navigating toward lower cost/higher quality health care.

Measurement Track: Health Equity Advancements

Capability: Conduct health risk assessments

Definition:
Instrument used to collect health information including biometrics, health status, risks, and habits to understand members’/patients’ needs and possible interventions to help them manage their health.

Measurement Track: Health Equity Advancements

Capability: Conduct member/patient surveys

Definition:
A process or systematic way to capture, document and analyze member/patient feedback or information (e.g., health risk assessments) to inform next phases for program and intervention design (e.g., establishing goals, expanding data collection and resources, etc.).

Measurement Track: Health Equity Advancements

Capability: Awareness of cultural diversity of the population served

Definition:
Includes capturing race, ethnicity, and language (REL) data to allow the customization of interventions to better engage the members/patients in the management of their health.

Resources:

Measurement Track: Health Equity Advancements

Capability: Development of health optimization and wellness initiatives

Definition:
Programs designed to support individuals to achieve the best possible health outcomes while also reducing costs, often with a preventative focus. Examples include smoking cessation, weight loss programs, and preventative health screening.

Measurement Track: Health Equity Advancements

Capability: Provider/payer integration on local, regional, and national community resources

Definition:
Active, bidirectional sharing of promising practices and collaboration on complex patient situations and population trends that need better management (e.g., increase in stent procedures, utilization of a new drug).

Resources:

Flexible Services Program – Community Care Cooperative

Measurement Track: Health Equity Advancements

Capability: Population-specific identification of gaps in equitable access to services

Definition:
Focusing on specific underserved populations or populations with complex needs and conditions that experience the highest disparities in care allows for timely interventions and reduction in overall cost/improvement of outcomes.

Resources:

Measurement Track: Health Equity Advancements

Capability: Screening for social determinants of health barriers during member/patient interactions

Definition:
Incorporating routine health-related social need screening questions (e.g., related to food stability, housing security) during each interaction to assess for potential risks and provide person-centric interventions as needed to remove barriers to care and improved health.

Resources:

Comprehensive Health Integration Framework – National Council for Mental Wellbeing

Measurement Track: Health Equity Advancements

Capability: Stratify and analyze current socioeconomic status data for potential health inequities

Definition:
Close alignment with Data and Infrastructure Measurement Track to ensure proper data is available and analyze that data to identify local populations with potential health inequities and the underlying causes (e.g., transportation, number of providers in market).

Resources:

Measurement Track: Health Equity Advancements

Capability: Longitudinal care management approach inclusive of chronic disease management

Sub-capability: Care management identification and stratification based on predictive analytics

Definition:
Incorporates identification of rising risk populations that have significant potential to decline in health based on predictive factors. Several risk scores are integrated in a composite score to identify the highest need members/patients.

Measurement Track: Health Equity Advancements

Capability: Longitudinal care management approach inclusive of chronic disease management

Sub-capability: Impact based prioritization of care management outreach

Definition:
Supports focusing on patients with modifiable risk factors that if controlled and minimized will improve health outcomes. Focusing on the most immediate and impactful interventions has a higher probability of member/patient’s adherence and health status improvement.

Resources:

Care Transitions Support Services Outcomes and Lessons Learned – National Council for Mental Wellbeing

Measurement Track: Health Equity Advancements

Capability: Identify care management activities and stratification based on clinical, claims, social drivers, and urgency of needs.

Definition:
Using multiple sources of data (e.g., medical, behavioral, and health equity risk scores, as well as recent admissions or ER visits) for a comprehensive 360-degree analysis of a member/patient’s needs and better whole-person care approach.

Resources:

Improve Healthcare Through Value-Based Payment – American Heart Association

Measurement Track: Health Equity Advancements

Capability: Identify care management activities and stratification based on clinical, claims, social drivers, and urgency of needs.

Sub-capability: Incorporate behavioral health, medication management and adherence programs in holistic approach.

Definition:
Team-based care with shared information systems to improve coordination and create individualized, person-centered care. May also include cross screening for common behavioral and physical health conditions to better integrate all care needs.

Resources:

Measurement Track: Health Equity Advancements

Capability: Care management identification and stratification based on claims-based analytics

Definition:
Analyzing healthcare claims and cost data to perform risk stratification. Data used to improve the care management approach by identifying patients and sub-populations that may need additional resources to prevent unintended hospital admissions, readmissions and repeated ED visits.

Measurement Track: Health Equity Advancements

Capability: Care management inclusive of ambulatory/outpatient level of care, specialty health conditions, and readmissions

Definition:
Care management activities include additional focus on the long-term needs of members/patients including preventative care, condition-specific education, and interventions to prevent readmission, help navigate patients to the right care, and empower members/patients to better self-manage their health.

Resources:

Measurement Track: Health Equity Advancements

Capability: Care management approach focusing on inpatient length of stay, level of care, care navigation and transition management

Definition:
Develop both member/patient support and care team education campaigns to reduce hospital admissions and Emergency Department (ED) visits, focus on short-term interventions, and identify the appropriate level of care.

Resources:

Measurement Track: Health Equity Advancements

Capability: Learning to leverage care management utilization metrics outcomes to track discrepancies and inequities for targeted populations

Definition:
Utilization metrics may include average length of stay, readmissions as a percentage of all admissions, range of ED visits/individual, days per thousand, and barriers to discharge, by population.

Resources:

Measurement Track: Multi-stakeholder Alignment & Design

Capability: Development of aligned measurement sets

Definition:
Inclusive of specialty and primary care. Takes into consideration local needs as well as national programs.

Resources:

Measurement Track: Multi-stakeholder Alignment & Design

Capability: Implement interoperable data exchange/electronic clinical quality measures

Definition:
Identify and implement mechanisms, such as health information exchanges, to improve the ability to share data across the care continuum and across independent organizations to enable greater transparency into gaps in care and establish longitudinal patient records. Consider the needs of both employed and affiliated providers in designing potential solutions to enable interoperability across the largest number of stakeholders possible.

Resources:

Measurement Track: Multi-stakeholder Alignment and Design

Capability: Align incentives across organizational leadership and provider network

Definition:
Cascading of incentives down to all providers within the organization supports knowledge of inclusion in quality measurement and performance monitoring. Promotes team-based framework of inter-disciplinary collaboration.

Resources:

Measurement Track: Multi-stakeholder Alignment and Design

Capability: Ability to conduct provider stratification

Definition:
Identification and stratification of providers serving historically underserved patient populations and/or populations with complex needs to find opportunities to target interventions at specific provider locations to maximize impact.

Resources:

Accelerating and Aligning Population-Based Payment Models: Performance Measurement – Health Care Payment Learning & Action Network

Measurement Track: Multi-stakeholder Alignment and Design

Capability: Develop patient-centric coordinated partnerships

Definition:
Collaborate across primary and specialty care on coordinated patient-centered care delivery.

Resources:

Measurement Track: Multi-stakeholder Alignment and Design

Capability: Provider performance incentive alignment

Definition:
Evaluate existing provider compensation models and identify opportunities to establish variable compensation based on metrics other than volume. Socialize plans with provider leadership to gain buy-in and pilot the use of new compensation models with providers who see greater number of patients in alternative payment models. Utilize pilot learnings to develop enterprise-wide approach to transforming provider compensation to be better aligned with the financial and clinical outcomes sought in alternative payment models.

Resources:

Measurement Track: Multi-stakeholder Alignment and Design

Capability: Enhanced provider coordination across levels, intensity, and continuum of care

Definition:
Coordinated patient-centered care delivery incorporating all levels of care including home- and community-based providers.

Resources:

Measurement Track: Multi-stakeholder Alignment and Design

Capability: Identify organizational incentive-based performance

Definition:
Incentivize organizational stakeholders to collaborate and be held responsible for their role in moving towards an accountable care model.

Resources:

Accelerating and Aligning Population-Based Payment Models: Performance Measurement – Health Care Payment Learning & Action Network

Measurement Track: Multi-stakeholder Alignment & Design

Capability: Create accountable care organization (ACO) for defined payment population

Definition:
Initiate a shared risk and incentive model for a specific patient population to facilitate movement toward value-based care payment models.

Measurement Track: Multi-stakeholder Alignment and Design

Investing stage supports investing in multi-stakeholder performance and consensus-generating groups that allow for facilitation, relationship-building, and multi-stakeholder ownership of and accountability for the achievement of health goals.

Measurement Track: Data and Infrastructure

Capability: Sending, receiving, and reconciling data from multiple/aggregated sources

Definition:
Ability to send and receive clinical, claims, and other various data (including SDOH). May also include Health Information Exchange (HIE), usage of APIs to share data between disparate systems, and other interoperable data exchange types.

Resources:

Measurement Track: Data and Infrastructure

Capability: Access to electronic health records (EHR) across and between organizations

Definition:
Ability of multiple types of users across the organization to access clinical data to develop corresponding analytics for care management and reporting.

Resources:

Accelerating and Aligning Population-Based Payment Models: Data Sharing – Health Care Payment Learning & Action Network

Measurement Track: Data and Infrastructure

Capability: Develop integrated electronic health records (EHRs)

Definition:
Inclusion of multiple care types – primary, specialty, behavioral health, acute, etc. – within the EHR for comprehensive member/patient and provider/coordinator view.

Resources:

Measurement Track: Data and Infrastructure

Capability: Create chronic disease registries with electronic health records (EHR) and claims-based data

Definition:
Participation in clinical registries is a critical component of quality outcomes reporting.

Resources:

Accelerating and Aligning Population-Based Payment Models: Performance Measurement – Health Care Payment Learning & Action Network

Measurement Track: Data and Infrastructure

Capability: Develop quality, outcomes, financial, and utilization reporting

Definition:
Includes regular data sharing, of multiple types of data (e.g., clinical, claims, social determinants of health (SDOH)) between organizations throughout the performance year to support accurate and timely analysis for impactable interventions.

Measurement Track: Data and Infrastructure

Capability: Implement performance reporting by individual alternative payment model contract

Definition:
Ability to utilize data captured to see performance measures and metrics of a specific provider contract.

Resources:

Is Data Driving Your ACO Network Composition? – Premier

Measurement Track: Data and Infrastructure

Capability: Leverage quality, financial, and utilization reporting

Definition:
Ability to utilize singular source of data captured for quality, financial, and utilization reporting individually and across contracts.

Resources:

How to Calculate the Elusive ROI for Care Management – Healthcare Innovation

Data Capture and Analytics Subcomponent

Supports the collection and analysis of comprehensive population data for prescriptive analytics, predictive modeling, business intelligence, and risk stratification. Advancement in this area is a foundational dependency to successful progression in other Measurement Tracks.

Measurement Track: Quality

Capability: Encourage adoption of pay-for-reporting

Definition:
Track and encourage participation in pay-for-reporting programs which provide incentives for providers to report quality, cost, or other data to a commercial or government health plan, regardless of performance. Utilize these programs to familiarize providers with the types of measures which ultimately will be tied to payment rates or bonuses in the future and begin to take actions to remediate poor performance. Review performance data received from the Quality Payment Program and other CMS models which have elements of pay-for-reporting.

Resources:

Accelerating and Aligning Population-Based Payment Models: Performance Measurement – Health Care Payment Learning & Action Network

Measurement Track: Quality

Capability: Medical policy transparency

Definition:
Make all medical policies available to the provider community online and in other formats as needed. A member/patient-focused version of the medical policies is available for their review as well.

Measurement Track: Quality

Capability: Improve outcomes through sharing and discussing quality metrics

Definition:
Application of quality performance results with provider groups to drive process and outcomes improvements across clinical, cost, and utilization metrics, and drive improvements with contracted metrics between providers and plans or CMS.

Measurement Track: Quality

Capability: Develop standardized medical policies across population

Definition:
Configuration of medical policies’ guidelines to be applicable for entire population instead of specific sub-populations. Eases burden on providers to determine applicability of medical policies for specific patient types.

Measurement Track: Quality

Capability: Identify low-value care

Definition:
Services that provide little or no benefit to patients, have potential to cause harm, incur unnecessary costs to patients, or waste limited health care resources. The identification of these types of services/care should be a data-driven process.

Resources:

Behavioral Health Practice Assessment Tool – National Council for Mental Wellbeing

Measurement Track: Quality

Capability: Develop organizational quality management program

Sub-capability: Quality improvement assessments

Definition:
Processes that include testing acceptance/adherence to new/revised practices, determining how the new practices are affecting the delivery of patient-centered care, and assessment of how much patient care is improving.

Measurement Track: Quality

Capability: Develop organizational quality management program

Definition:
Standardize processes and structure to reduce variation, achieve predictable results, and improve outcomes for patients, health care systems, and organizations. Structures may include technology, culture, and leadership.

Resources:

Quality Performance Subcomponent

Emphasize ongoing quality monitoring and governance to drive support and a culture of evidence-based, quality-driven decision-making.

Measurement Track: Quality

Capability: Enhanced utilization, financial, quality, and outcomes reporting across sub-populations

Definition:
Aggregated from multiple populations/sub-populations to identify multi-dimensional ties between quality, financial, and utilization results.

Measurement Track: Quality

Capability: Aggregate quality reporting incorporating utilization, sites of service, and patient outcomes

Definition:
Inclusion of multiple sources and types of quality data for well-rounded measurement that captures the impact that quality initiative(s) had on all aspects of care.

Resources:

Building Stronger Business Practices for Value-Based Payment Readiness: Examples from the Field – National Council for Mental Wellbeing

Measurement Track: Quality

Capability: Incorporation of patient-reported outcomes into performance reporting

Definition:
Measures developed to include outcome data collected directly from patients (e.g., patient-reported blood pressure or A1c through monitoring devices and programs).

Measurement Track: Quality

Capability: Collection of patient-reported outcomes (PROs)

Definition:
Report of the status of a patient’s health conditions that comes directly from the patient to a provider or the health plan, without interpretation of the patient’s response by a clinician or anyone else. Examples of patient self-reported data collection tools include Patient-Reported Outcomes Measurement Information System (PROMIS), Medicare Health Outcomes Survey, and FOTO Patient Outcomes.

Measurement Track: Quality

Aligning stage supports benchmarking quality performance results and executing on strategic initiatives to improve outcomes toward person-centered care. Supports aligning to core measure sets across industry/stakeholder groups.

Measurement Track: Quality

Investing stage supports establishing evidence-based quality goals with ongoing data collection for measuring improvement and progress toward goals.

Measurement Track: Payment Reform

Capability: Continuous improvement outputs based on insights and target performance

Definition:
Improvement initiatives are generated from understanding the actual performance to defined metrics and associated targets.

Resources:

Accelerating and Aligning Population-Based Payment Models: Financial Benchmarking – Health Care Payment Learning & Action Network

Measurement Track: Payment Reform

Capability: Financial incentive alignment across organizational leadership and providers focused on accountable care

Definition:
Compensation and/or incentive opportunities align organizational goals to the level of individual provider/practitioner across clinical delivery and leadership teams to optimize improvement capture.

Resources:

Accelerating and Aligning Population-Based Payment Models: Financial Benchmarking – Health Care Payment Learning & Action Network

Measurement Track: Payment Reform

Capability: Collaboration across organizational leadership (e.g., financial, contracting, and operations) to align metrics and performance management

Definition:
Review the existing bundled alternative payment model portfolio and develop performance metrics which take into consideration requirements for quality, cost, and other factors. Performance metrics should be included in organization-wide scorecards or other performance management programs to align incentives and goals. A selection of these measures may also be considered for use in provider compensation models.

Resources:

Measurement Track: Payment Reform

Capability: Leverage reports to identify opportunities to capture shared savings

Definition:
Document detailing focus areas for meeting defined target metrics to achieve shared savings’ potential.

Resources:

Accelerating and Aligning Population-Based Payment Models: Performance Measurement – Health Care Payment Learning & Action Network

Measurement Track: Payment Reform

Capability: Develop financial risk management platform

Definition:
System to organize, track, and monitor organizational financial capture of bonuses to target opportunity for defined performance metrics.

Resources:

Accelerating and Aligning Population-Based Payment Models: Financial Benchmarking – Health Care Payment Learning & Action Network

Measurement Track: Payment Reform

Capability: Management of population-based payment models

Definition:
All or much of a person’s overall care or care for related conditions is encompassed within a single payment. Encourages providers to deliver well-coordinated, high-quality, person-centered care within either a defined scope of practice, a comprehensive collection of care, or a highly integrated finance and delivery system.

Resources:

Accelerating and Aligning Population-Based Payment Models: Patient Attribution – Health Care Payment Learning & Action Network

Measurement Track: Payment Reform

Capability: Create risk adjustment methodologies (risk methodology, benchmarking, etc.)

Definition:
Incorporate social and clinical risk adjustment, including risk methodologies and benchmarking, with clear goals and ability to track desired outcomes.

Resources:

Accelerating and Aligning Population-Based Payment Models: Financial Benchmarking – Health Care Payment Learning & Action Network

Measurement Track: Payment Reform

Capability: Use/application of risk adjustment

Definition:
Adjusts payment incentives and quality performance through risk methodologies. Incorporates social and clinical risk inclusive of goal measurement while monitoring for adverse outcomes.

Resources:

Accelerating and Aligning Population-Based Payment Models: Financial Benchmarking – Health Care Payment Learning & Action Network

Measurement Track: Payment Reform

Capability: Management of performance risk sharing

Definition:
Share bonuses or upside/downside payments across a group of providers, health systems and/or care delivery services.

Resources:

Accelerating and Aligning Population-Based Payment Models: Financial Benchmarking – Health Care Payment Learning & Action Network

Measurement Track: Payment Reform

Capability: Enhance provider contracting (generating transparent model, payment model design)

Definition:
Enable data sharing between payers and providers. May include one-time infrastructure payments for care delivery transformation.

Resources:

Accelerating and Aligning Population-Based Payment Models: Financial Benchmarking – Health Care Payment Learning & Action Network

Measurement Track: Payment Reform

Capability: Enhanced reporting of delegated and collaborative community services on member patient outcomes and plan/provider performance

Definition:
Promotes accountability and transparency of health equity interventions.

Measurement Track: Payment Reform

Capability: Network performance and reporting management

Definition:
Demonstration of a defined provider network’s performance to a set of pre-defined metrics with targets.

Measurement Track: Payment Reform

Capability: Leveraging multiple reports (integrated clinical, claims, quality, and financial data)

Definition:
Reporting includes information captured from electronic health records, claims-based records, quality analysis, and financial sources.

Contracting Methodologies Subcomponent

Supports the progression of advancing patient-centric financial arrangements to achieve accountable care.

Measurement Track: Payment Reform

Learning stage supports baseline performance and commitment to develop an understanding of alternative payment models and movement toward accountable care.

Measurement Track: Payment Reform

Capability: Implement pay-for-reporting

Definition: Gaining experience in alternative payment models through payments for reporting data or penalties for not reporting data.

Resources:

Certified Community Behavioral Health Clinics Receive a Prospective Payment – National Council for Mental Wellbeing

Measurement Track: Health Equity Advancements

Capability: Utilize member, patient, and family portal data appropriate to the population

Definition:
Includes capturing member/patient feedback data which connects back to Data and Infrastructure Measurement Track to assess the success of the interventions to change the behavior, health, and medical costs of the member/patient.

Resources:

Applying Value-Based Payment to Health Equity – Health Care Transformation Task Force

Measurement Track: Health Equity Advancements

Capability: Coordinate cross-organization approach to address gaps in equitable access to services

Definition:
Collaborative approach to coordinate reporting and promising practice sharing to have greatest impact/change. Cross-functional efforts to define processes, roles, and responsibilities within the organization and community resources to help close gaps in access for specific members/patients.

Resources:

Flexible Services Program – Community Care Cooperative

Measurement Track: Health Equity Advancements

Capability: Develop population health approach utilized across the health care ecosystem

Definition:
Comprehensive analysis of equity gaps impacting all including low, moderate, and rising risk populations while defining the extent of an issue by barrier (e.g., housing, food, transportation).

Resources:

Measurement Track: Health Equity Advancements

Capability: Develop community engagement and partnerships

Definition:
Includes active collaboration and alignment of community needs assessments between hospitals, Federally Qualified Health Centers (FQHCs), Certified Community Behavioral Health Clinics (CCBHCs), community action agencies, etc., to define initiatives at a community level to address population needs. Engagement and partnerships may be informally or formally organized under a charter, mission statement, or other governance structure.

Resources:

Measurement Track: Health Equity Advancements

Capability: Develop community resource directory for local community

Definition:
Consolidated collection of local resources available to internal organizational stakeholders to facilitate referrals and better support individuals’ social needs (e.g., meal delivery, housing, transportation).

Resources:

Access for Everyone: A Toolkit for Addressing Health Equity and Racial Justice within Integrated Care Settings – National Council for Mental Wellbeing

Measurement Track: Health Equity Advancements

Capability: Develop assessment approach for care access barriers

Definition:
Partner with community advisory boards and other governance structures to identify and mitigate barriers to care (e.g., transportation, childcare, etc., medication adherence) to improve community-enabled resource priorities and efforts.

Resources:

Measurement Track: Health Equity Advancements

Capability: Develop population-focused complex case management and transition management

Definition:
Inclusion of patients with multiple chronic co-morbidities with modifiable risks to promote supportive, trusting relationships between providers and patients, and empower patients to better manage their condition. Interventions include focused attention on adherence to medical treatments, condition education, navigating the health care ecosystem, and provider care coordination.

Resources:

Improve Healthcare Through Value-Based Payment – American Heart Association

Measurement Track: Health Equity Advancements

Capability: Care management identification and stratification based on encounter data

Definition:
Proactive identification of patients for care management services based on provider-collected clinical conditions diagnosed, as well as the proactive delivery of services and items to treat these conditions in advance of a deterioration in health status.

Resources:

Measurement Track: Multi-stakeholder Alignment & Design

Capability: Develop integrated approach and referral management to address underserved populations on shared partnership and resources

Definition:
Utilize a digital referral management platform to enable timely referrals and promote coordination between community resources/partnerships focused on resolving health inequities and disparities. Monitor referral patterns and dedicate resources to provide education to clinicians on when referrals are appropriate. Utilize quality and cost data to drive referral decisions based on specialty or patient condition.

Resources:

Addressing Variations in Care Delivery – Healthcare Leadership Council

Measurement Track: Multi-stakeholder Alignment & Design

Capability: Create appropriate partnerships and initiatives to address the needs of historically underserved populations with complex needs

Definition:
Identify and establish partnerships which supplement existing service, capability or other known gaps to more comprehensively address the needs of historically underserved populations with complex needs. Partnerships could be evaluated based on findings from the community health needs assessment, applicability to the disease states most prevalent in the community, and/or ability to provide non-traditional health care services such as transportation to address known health care disparities more holistically.

Resources:

Value in Healthcare Initiative – American Heart Association

Measurement Track: Multi-stakeholder Alignment & Design

Capability: Organize/join network of local and diverse stakeholders to identify and design community health goals

Definition:
Assemble local stakeholders to start aligning on common goals and share individual organizational promising practices.

Resources:

Measurement Track: Multi-stakeholder Alignment and Design

Capability: Analysis of community organizations and partnerships for underserved populations

Definition:
Identify community-based organizations, or similar entities, which promote improvements in the health and well-being of individuals in local communities. Analyze these organizations to understand the shared populations served and identify where partnership opportunities may exist to promote patient education, provide additional support for underserved populations, and share data.

Resources:

Value-Based Care Change Package – National Council for Mental Wellbeing

Measurement Track: Multi-stakeholder Alignment and Design

Capability: Ability to assess current ecosystem (alignment framework inclusion in strategic planning)

Definition:
Gain an understanding of the various stakeholders that exist across the health care ecosystem which play a role in promoting and maintaining wellness beyond the traditional health care delivery assets. Utilize patient journey maps or other tools to educate clinicians, staff, and administrators on the role they play in the broader ecosystem.

Resources:

Measurement Track: Multi-stakeholder Alignment and Design

Capability: Develop multi-disciplinary education and coaching on value of accountable care

Definition:
All stakeholders understand the importance of accountable care and understand their role in achieving outcome targets.

Resources:

Measurement Track: Multi-stakeholder Alignment and Design

Capability: Implement provider performance reporting

Definition:
Create provider scorecards, dashboards, or other tools to track and monitor provider performance. Measures utilized should address quality, cost, access, and other relevant domains that are included in, or related to, current and planned alternative payment models. Providers should receive periodic feedback on their performance, including direction on how to improve. Consider publishing performance data within the organization to encourage sharing of promising practices.

Resources:

Accelerating and Aligning Population-Based Payment Models: Performance Measurement – Health Care Payment Learning and Action Network

Measurement Track: Multi-stakeholder Alignment and Design

Capability: Develop strategy for market supply and analysis

Definition:
Determine market supply gaps within network of employed and independent primary and specialty provider groups.

Resources:

Measurement Track: Multi-stakeholder Alignment and Design

Capability: Develop strategy for provider network adequacy analysis

Definition:
Establish criteria and metrics for evaluating network adequacy on an ongoing basis, including capacity, timely access, specialties, and geographic coverage. Perform a preliminary analysis to identify gaps and establish a strategy for addressing those gaps over time.

Resources:

Interactive Physician Assessment Tool – American Medical Association

Measurement Track: Data and Infrastructure

Capability: Population risk stratification and registries

Definition:
Utilize multiple data sources (e.g., clinical, claims, SDOH, consumer behavior patterns) combined with public health registries to perform predictive analytics to identify/stratify individuals and populations with the highest addressable risk. Utilize various inputs and weights, which are periodically refined, to develop a composite risk score to compare relative risk of members/patients across the panel.

Resources:

Measurement Track: Data and Infrastructure

Capability: Comparative and benchmarked performance reporting across all alternative payment model contracts

Definition:
Utilization of multiple data sources (e.g., clinical, claims, SDOH) to report and analyze contracts individually, compared to others, and compared to benchmarks.

Resources:

Value-Based Payment Planning Guide – National Council for Mental Wellbeing

Measurement Track: Data and Infrastructure

Capability: Implement hierarchical condition category/risk stratification

Definition:
Ability to utilize claims and clinical data to analyze conditions as well as apply risk and rating for basic identification of high and rising-risk members/patients.

Resources:

Measurement Track: Quality

Capability: Transformed utilization management with AI-assisted clinical reviews with provider/payer interoperability

Definition:
Using the latest AI capabilities to pre-populate authorization submissions with the mandated data elements. Includes implementation of FHIR API standards.

Resources:

Developing Interoperability Contract Language – Healthcare Leadership Council

Measurement Track: Quality

Capability: Develop utilization management approach

Definition:
Framework to evaluate medical necessity, appropriateness and efficiency of health care services, procedures, and facilities.

Resources:

Payment Reform Readiness Assessment Tool – National Association of Community Health Centers

Measurement Track: Quality

Capability: Promote evidence-based decisions and support

Definition:
Understanding the value and purpose of effective decision-making by leveraging data analysis and information. Putting support systems in place to support compliance and inter-rater reliability.

Resources:

Measurement Track: Quality

Capability: Reporting of patient-reported outcomes (PROs)

Definition:
Effective collection and analysis of patient-reported outcomes by the provider or health plan, including measurement of health disparities; timely collection and use of alternative collection methods (e.g., mobile devices).

Resources:

Quality Measurement in Crisis Services – National Council for Mental Wellbeing

Measurement Track: Payment Reform

Capability: Implement shared savings payment model

Definition:
Participate in payment models which set a benchmark target for cost within a defined population, and evaluate performance based on whether the provider achieves the benchmark (subject to quality, minimum savings rates, or other factors). In this model, providers are not subject to any losses for failing to achieve the target, which allows for a lower-financial risk environment to gain experience in these types of arrangements.

Resources:

Measurement Track: Payment Reform

Capability: Implement pay-for-performance payment model

Definition:
Participate in alternative payment models that provide incentives based on performance in quality, cost, access and other measures. To the extent possible, work across health plans to standardize the measures used in these alternative payment models, and work with operational stakeholders to establish processes for tracking and monitoring performance on these measures. Include these measures in administrator and clinician goals.

Resources:

Understanding Value-Based Payment: A Primer for Staff – National Council for Mental Wellbeing

Measurement Track: Payment Reform

Capability: Integrated financial and clinical team actively engaged to incorporate clinical perspectives with data outputs to identify insights and target performance improvement opportunities

Definition:
Clinical and financial data are reviewed together to capture understanding of cost, utilization, quality, and outcomes relative to metric targets.

Resources:

Building Stronger Business Practices for Value-Based Payment Readiness: Examples from the Field – National Council for Mental Wellbeing

Measurement Track: Payment Reform

Capability: Implement bundled payments

Definition:
Begin participation in episodic payment arrangements that set payment for managing the care for a defined diagnosis or procedure across a preset time period. Develop processes to analyze claims data to evaluate opportunities to reduce clinical variation within episodes. Develop clinical programs that are aligned to alternative payment models.

Resources:

Measurement Track: Multi-stakeholder Alignment and Design

Capability: Coordinated patient-centric partnerships that serve as foundation for multiple commercial and governmental payer products

Definition:
Applying promising practices identified from coordinated care delivery and incorporating into a standardized approach with payer products.

Measurement Track: Data and Infrastructure

Capability: Leverage interoperable data exchange

Definition:
May include the usage of a regional Health Information Exchange (HIE) or other tools that facilitate the exchange of multiple types and formats of data between organizations.

Resources:

Developing Interoperability Contract Language – Healthcare Leadership Council

Measurement Track: Data and Infrastructure

Capability: Leverage clinical natural language processing (cNLP) to optimize medical record data capture

Definition:
Utilization of cNLP to assist with comprehensive clinical data capture and categorization to inform population health risk stratification, input to chronic disease registries, and identify care gaps.

Measurement Track: Data and Infrastructure

Capability: Leverage claims system that accommodates alternative payment models (APMs)

Definition:
Implementation and utilization of a claims system which can process payments beyond fee-for-service, without manual workarounds.

Measurement Track: Data and Infrastructure

Capability: Implement electronic health records (EHR)

Definition:
Implementation and usage of an EHR to capture medical records and other clinical data for usage in reporting.

Measurement Track: Data and Infrastructure

Capability: Leverage employer and administrative services only (ASO) reporting

Definition:
Develop reporting specifically for self-insured entities, such as employer groups, where the health plan serves in an ASO capacity. Reporting should provide insights on utilization trends and patterns, areas of high expenditures, common health conditions, and cost containment strategies. Additional insights may be provided in areas such as employee engagement (e.g., utilization of preventative services), benchmarking, and pharmacy (e.g., use of generics vs. branded drugs).

Measurement Track: Data and Infrastructure

Aligning stage supports participation in broader data-sharing activities and patient/consumer engagement in their own care.

Measurement Track: Quality

Capability: Develop inclusive and equitable medical policies

Definition:
All policies include rationale for the mandate based on industry standards and evidence-based promising practices.

Measurement Track: Quality

Capability: Coordinate clinical quality and performance metrics across governmental and commercial health plans enabling synergistic improvements in health outcomes

Definition:
Develop comparisons of quality results from different organizations and/or populations to look for promising practices that can be applied to other organizations/populations.

Measurement Track: Health Equity Advancements

Capability: Identify care management activities and stratification based on clinical, claims, social drivers, urgency of needs

Sub-capability: Develop provider/payer coordinated plan of care

Definition:
Initial collaboration in development of patient plans of care that span the continuum of care, prioritize efforts, and support ongoing cross-functional communication on updates to support alignment.

Measurement Track: Health Equity Advancements

Capability: Enable online appointment and resource scheduling

Definition:
Giving patients the option to self-schedule appointments from a computer or mobile device to improve convenience, experience, and satisfaction.

Measurement Track: Health Equity Advancements

Capability: Omni-channel communication including mobile and digital designed with cultural diversity

Definition:
Focuses on offering and delivering a personalized and culturally sensitive communication experience using multiple communication tools including phone, email, mobile apps, and online platforms.

Measurement Track: Health Equity Advancements

Capability: Administer wellness and preventative screenings

Definition:
Used to screen for potential illnesses and maintenance of health. Screenings are inclusive of mammograms, colonoscopies, blood pressure, diabetes, cholesterol, weight loss, depression/anxiety, alcohol use, etc.

Measurement Track: Health Equity Advancements

Capability: Development of a health equity plan

Definition:
Includes engagement with community organizations to develop a list of priority activities, timelines, and responsibilities that addresses gaps voiced by community representatives with multiple community and state stakeholders.

Measurement Track: Health Equity Advancements

Capability: Investment in digital community resource directories

Definition:
Shared, electronic list of community organizations with which care team members/patients may partner to serve patients/individuals. Having shared digital community resource directories provide accurate and consistent information across all members/patients of the care teams. Ideally, organizations create or leverage regional and national platforms that allow for referral monitoring and are continually updated with the latest information on available services and resources.

Measurement Track: Health Equity Advancements

Capability: Interdisciplinary coordination and site of care

Definition:
Deliberate collaboration between multiple health specialties to provide holistic approach to care. Focused attention on most appropriate level and site of care based on performance and cost containment strategies. Integrated care leads to less confusion for the patient and better adherence and outcomes.

Peter T. Walsh, M.D, M.P.H

Dr. Peter Walsh joined the Colorado Department of Health Care Policy and Financing as the Chief Medical Officer on December 1, 2020. Prior to joining HCPF, Dr. Walsh served as a Hospital Field Representative/Surveyor at the Joint Commission, headquartered in Oakbrook Terrace, Illinois.

Dr. Walsh is an Aerospace Medicine Specialist, who provided primary care to aircrew and special operational personnel and their families during much of his 21-year active duty career in the U.S. Air Force. Upon retirement in 2006 he served as an Urgent Care Physician at the previous Memorial Health System in Colorado Springs between 2006 and 2008 and practiced at the Centura Center for Occupational Medicine in Colorado Springs, CO and Pueblo, CO between 2006 and 2009.

His prior positions include serving as the Chief Medical Officer, South State Operating Group of Centura Health, Corporate Chief Medical Executive for Centura Health in Denver, Colorado, and the VP of Medical Affairs at St. Francis Medical Center in Colorado Springs, Colorado.

Dr. Walsh received his B.A. at the University of Southern California, his M.D. from the Medical College of Ohio in Toledo, Ohio, and a M.P.H. from Harvard School of Public Health. He completed his residency in Aerospace Medicine at the USAF School of Aerospace Medicine at Brooks AFB, Texas.

Dr. Ryan Schwarz

Ryan Schwarz is chief of the Office of Payment and Care Delivery Innovation at MassHealth, Massachusetts’s Medicaid and CHIP program, and an internal medicine and pediatrics physician. Ryan oversees the Massachusetts 1115 demonstration with the Center for Medicare & Medicaid Services, including MassHealth’s Accountable Care Organization and Managed Care Organization programs providing care for ~1.5 million members, MassHealth’s primary care reform efforts, health equity incentives programs, and health-related social needs initiatives. Ryan previously served as the clinical lead for the Massachusetts COVID-19 Response Command Center. Prior to his time with Massachusetts state government, Ryan worked with multiple governments and health care systems globally, including as a technical adviser to the World Bank.

Ryan received his MD and MBA from Yale University, completed his internal medicine and pediatrics training at Harvard Medical School, and is a practicing internal medicine and pediatrics physician at Massachusetts General Hospital’s Chelsea Healthcare Center.

Elisa Wrede

Elisa Wrede is the project manager for primary care in the Office of the Secretary at the New Mexico Human Services Department. She oversees the New Mexico Primary Care Council (PCC), which is working toward revolutionizing primary care in New Mexico. Her role includes creating primary care payment reforms in New Mexico Medicaid that move toward paying for quality and population health. Elisa’s work on PCC initiatives has gained national attention. The Center for Health Care Strategies selected New Mexico as one of five states to participate in a national learning collaborative to support approaches to advance health

equity in primary care payment models. In addition, the Center for Medicare & Medicaid Innovation sought out a partnership with New Mexico on aligning primary care payment models. Elisa previously worked in community engagement and corporate social responsibility helping to connect communities with volunteers and resources through grants and sponsorship. She enjoys thrifting, playing her mandolin, and creating art. Elisa lives in Santa Fe with her family and two cats.

Measurement Track: Health Equity Advancements

Learning stage, the organization can assess and evaluate health disparities impacting the population against a baseline.

Measurement Track: Health Equity Advancements

Investing stage, the organization can expand into baseline health disparities identification and provides and supports patients with access to community resources initiatives while successfully measuring outcomes.

Measurement Track: Health Equity Advancements

Aligning stage, the organization supports alignment of multiple internal and community resources, supports patients in accessing resources, and continues monitoring ongoing health equity initiatives and disparities.

Measurement Track: Health Equity Advancements

Transforming stage, the organization supports improved equity across all its components, supports community initiatives to improve access to clinical care and reduce the impediments to care, and demonstrates improved outcomes and access to care across all populations.

Care Management Subcomponent

Supports an inclusive, equitable, and integrated care management framework that identifies opportunities to improve health outcomes for underserved populations. Please note that the Health Equity Measurement Track, and specifically the Care Management subcomponent, has significant integration and dependencies with the Data and Infrastructure Measurement Track, as access to timely and accurate data is paramount to driving equitable care management and equity overall.

Community Commitment Subcomponent

Supports capturing and addressing social determinants of health concerns, and partnering with the community in shaping equity investments, interventions, and measurement outcomes to optimize equitable, high-value access to care.

Member/Patient Engagement Subcomponent

Supports the activation and empowerment of members and patients to improve their own care using a range of communication mediums (e.g., text, chat, secure email, and phone).

Measurement Track: Multi-stakeholder Alignment & Design

Capability: Develop regional collaboration approach to drive alternative payment model movement

Definition:
Establish forums for organizations across the health care ecosystem, including providers, health plans, community-based organizations (CBOs), state/local governments, and employers, to come together to collectively address health care challenges.

Measurement Track: Multi-stakeholder Alignment & Design

Capability: Build qualitative indicators for multi-stakeholder network success

Definition:
Identify success indicators and set short-and long-term goals.

Measurement Track: Multi-stakeholder Alignment & Design

Capability: Conduct community health needs assessment focused on historically underserved populations with complex needs

Definition:
Targeted assessment focused on historically underserved populations with complex needs in the community to identify potential gaps and required interventions.

Convener Subcomponent

Supports the organization of stakeholders to partner, collaborate, and integrate on accountable care approaches to drive alternative payment model movement.

Measurement Track: Multi-stakeholder Alignment and Design

Capability: Develop network development strategy to improve adequacy gaps

Definition:
Create a strategy and actionable interventions to improve network adequacy using identified gaps from provider network adequacy analysis.

Provider Network Subcomponent

Supports the development of provider networks into accountable care partnerships.

Measurement Track: Multi-stakeholder Alignment and Design

Transforming stage supports transparent multi-stakeholder alignment and forward-thinking infrastructure that advances accountable care models and arrangements.

Measurement Track: Multi-stakeholder Alignment and Design

Aligning stage supports multi-stakeholder participation in advancing accountable care models and arrangements with measurable progress.

Measurement Track: Multi-stakeholder Alignment and Design

Learning stage supports identifying opportunities available to educate multiple stakeholders on the existing accountable care landscape.

Measurement Track: Data and Infrastructure

Capability: Enhanced usage of enterprise software

Definition:
Utilization of enterprise software such as data warehouses to capture, store, and analyze multiple types of data at once (e.g., clinical, claims, quality, financial data).

Measurement Track: Data and Infrastructure

Capability: EHR incorporates digital integration with community and social services

Definition:
Ability of EHR to capture and communicate with community or social services tools and systems for sharing of data and referrals.

Measurement Track: Data and Infrastructure

Capability: Enhanced member/patient portals

Definition:
Usage of the portal to further capture and communicate enhances/additional services and activities such as online scheduling or provider bidirectional messaging.

Measurement Track: Data and Infrastructure

Capability: Implement enterprise software approach

Definition:
Implementation and usage of several enterprise-wide software/tools such as data warehouse, clinical decision support, security, and privacy to enable the collection, analysis, and reporting needs in other Measurement Tracks.

Measurement Track: Data and Infrastructure

Capability: Leverage employer and administrative services only (ASO) reporting

Sub-capability: Insights identified in employer and ASO reports utilized for improved quality, outcomes, and utilization

Measurement Track: Data and Infrastructure

Capability: Analytics rules engine with multidimensional identification and stratification modeling

Definition:
Building on the initial Analytics Rules Engine to utilize multiple data sources (e.g., claims, clinical, social determinants of health (SDOH)) in the performance of advanced reporting and identification of members/patients from historically underserved populations with complex needs for care management and interventions.

Measurement Track: Data and Infrastructure

Capability: Leverage analytics rules engine

Definition:
Consumes raw data to apply and execute a defined logical rule set to create meaningful output that can be further analyzed to develop actionable next steps.

Measurement Track: Data and Infrastructure

Capability: Implement singular source of data capture

Definition:
Relevant source systems used to capture important data elements have been identified and are under the purview of the data management structure. Instances where the same data is being captured in multiple locations (e.g., different fields within the EHR) are being identified and a process exists to standardize the inputs received for use in reporting.

Measurement Track: Quality

Capability: Ongoing monitoring of low-value care

Definition:
Incorporating low-value care monitoring and analysis into ongoing quality performance reviews and comparisons of volumes of low-value services by provider/practice.

Measurement Track: Quality

Capability: Leverage quality standards and benchmarks for top performance

Definition:
Using top performance benchmarks and quality standards to show gaps in performance and to align quality improvement plan targets.

Measurement Track: Quality

Capability: Utilizes insights from reporting to support provider specific and system improvements

Definition:
Application of blinded quality performance results comparisons between individual providers to drive provider-specific process improvements.

Measurement Track: Quality

Capability: Leverage gold carding in utilization management

Definition:
Develop artificial intelligence (AI)-assisted utilization management programs and gold carding standards of performance and allow top performing practices a reprieve from authorization submission to increase clinical review efficiency and accuracy, as well as reduce administrative burden.

Measurement Track: Quality

Capability: Clinician leadership receives quality outcomes and participates in results’ interpretation and improvement efforts

Definition:
Ensuring clinical stakeholders participate in outcomes discussions to determine interventions and next steps.

Measurement Track: Quality

Capability: Develop approach to address low-value care

Definition:
Approach may include focus on appropriateness of care that is anchored in improving outcomes (evidence-based promising practices).

Measurement Track: Quality

Capability: Enhancements to utilization management to reduce barriers to care

Definition:
Includes continual re-evaluation of prior authorization list to eliminate low-value/non-standard sub-categories and electronic submissions.

Measurement Track: Quality

Capability: Develop medical policy review approach

Definition:
Collection and clinical review of medical records and related information for specific conditions/procedures against predefined guidelines and requirements.

Measurement Track: Quality

Capability: Develop organizational quality management program

Sub-capability: Measurement framework

Definition:
Awareness of the organizational approach/framework on quality measurement that will be used for consistent monitoring and comparison year over year.

Measurement Track: Quality

Capability: Develop key performance indicator management and alignment

Definition:
Aligning on what key performance indicators the organization will focus on as well as tools to monitor results with actionable interventions.

Tech Infrastructure Subcomponent

Supports advancing health IT ecosystem with progressive data exchange and communication across multiple stakeholders.

Measurement Track: Quality

Capability: Encourage provider-specific reporting incorporating quality, utilization, financial outcomes, and benchmark comparisons

Definition:
Ensuring that quality reporting includes multiple sources of measurement and comprehensive assessment within a defined provider network/group with comparisons across providers to identify promising practices and successful intervention methods.

Measurement Track: Quality

Capability: Engage and collaborate with provider leadership in reconciling perceived conflicts between clinical quality and governmental and health plan performance quality metrics

Definition:
Ensuring that provider/clinical stakeholders are included in quality measure definition/specification development, analysis, reporting, and resolving potential conflicts early in the performance review period in order to positively impact outcomes (e.g., different definitions and targets for diabetes management across HEDIS, provider, and health plan).

Measurement Track: Data and Infrastructure

Transforming stage supports advanced data collection, sharing infrastructure, and activities to measure progress on payment reform, quality, affordability, and equity.

Measurement Track: Data and Infrastructure

Investing stage supports investment in improved data collection, analytics, and measurement outcomes.

Measurement Track: Data and Infrastructure

Learning stage supports development of data management and governance necessary for infrastructure to support analytics and insights development.

Quality Reporting Subcomponent

Supports capturing and benchmarking quality reporting metrics across populations to monitor the progress and success of quality improvement initiatives or the need for additional quality intervention efforts.

Measurement Track: Quality

Transforming stage supports using standardized system-wide processes and tools to predict populations with gaps in care needs to drive interventions and improve patient experience as well as drive high-quality care and improved outcomes for all.

Measurement Track: Quality

Learning stage supports recognition of standard quality metrics and current state of quality performance.

Measurement Track: Payment Reform

Capability: Manage financial reconciliation

Definition:
Process of making financial payments consistent with payment methodology, typically at the end of a defined period, e.g., annually.

Measurement Track: Payment Reform

Capability: Development of contract management platform

Definition:
System to organize, track, and monitor contracting terms, performance metrics, and payment methodology across contracts with payers and providers.

Measurement Track: Payment Reform

Capability: Reporting of monitor targets and performance

Definition:
Includes stratified and risk adjusted performance measures.

Measurement Track: Payment Reform

Capability: Enhanced physician education and coaching (including provider network collaboration)

Definition:
Intersects with Multi-Stakeholder Alignment and Design Measurement Track. An important component of contract performance is first understanding the value proposition of accountable care, and educating physicians in the tenets of accountable care (e.g., emphasis on team-based care, strong physician/patient relationships, primacy of prevention, focus on outcomes, understanding and addressing social determinants of health).

Measurement Track: Payment Reform

Capability: Develop provider dashboards and portals

Definition:
Reporting tools displaying defined provider specific metrics and key performance indicators often accessed through a secure website.

Measurement Track: Payment Reform

Capability: Provide administrative and financial support

Definition:
Support resources available to capture and track alternative payment methodologies across commercial and governmental businesses.

Performance to Contracts Subcomponent

Emphasize transparent monitoring of payment contract performance.

Measurement Track: Payment Reform

Capability: Enhance product and price transparency (episode-level pricing)

Definition:
Share pricing for episode level products and services per governmental standards and in a manner that enables informed decision-making between patient and provider.

Measurement Track: Payment Reform

Capability: Develop shared savings/losses payment model

Definition:
Participate in alternative payment models which set a benchmark target for cost within a defined population, and provide shared savings or losses based on whether the provider achieves the benchmark (subject to quality, minimum savings/losses rates, or other factors).

Measurement Track: Payment Reform

Transforming stage supports understanding of the impact population-based payment methodologies have on organizational financial performance and health.

Measurement Track: Payment Reform

Aligning stage supports increasingly advanced payment models which better align incentives of providers to address cost and quality outcomes to improve affordability.

Measurement Track: Payment Reform

Investing stage supports alternative payment model framework for outcome reimbursement.

Daniel Tsai

Daniel Tsai, M.B.A., is the deputy administrator and director of the Center for Medicaid and CHIP services (CMCS) at the Centers for Medicare & Medicaid Services (CMS). He leads CMCS in addressing disparities in health equity and serving the needs of individuals and families who rely on these essential programs.

Before joining CMS, Daniel served in Massachusetts as the assistant secretary for MassHealth and as the state’s longest-serving Medicaid director in nearly two decades. His six-year tenure focused on building a robust and sustainable Medicaid program to ensure equitable coverage and improve health care delivery for two million individuals and families in the state.

Daniel also helped lead Massachusetts Medicaid through its most significant restructuring since the 1990s through its landmark 2016 Medicaid 1115 waiver. Under these reforms, MassHealth implemented one of the most at-scale shifts to value-based care in the nation. Through the waiver, MassHealth also launched a unique program committing significant investments for nutritional and housing supports to address the social determinants of health for high-cost, at-risk individuals. In addition, during his tenure, the agency made critical investments in strengthening community health centers, behavioral health, and home- and community-based services.

Having worked closely with organizations across almost every aspect of health care, including a diverse range of Medicaid programs and provider organizations, Daniel brings extensive experience across Medicaid, Medicare, and health care stakeholders. He has worked with stakeholders to design and implement innovative models for health care coverage, delivery, and payment. Daniel earned a Bachelor of Arts in applied mathematics and economics from Harvard University, summa cum laude.

Measurement Track: Data and Infrastructure

Capability: Population risk stratification and registries

Sub-capability: Analytics reporting includes insights generated from the addition of clinical, financial, and business considerations

Measurement Track: Data and Infrastructure

Capability: Population risk stratification and registries

Sub-capability: Value based contract insights identified across sub-populations utilized to improve quality, outcomes, utilization, and performance

Dr. Mark McClellan

Mark McClellan, M.D., Ph.D., is Director and Robert J. Margolis, M.D., Professor of Business, Medicine, and Health Policy at the Margolis Center for Health Policy at Duke University. He is a physician-economist who focuses on quality and value in healthcare, including payment reform, real-world evidence, and more effective drug and device innovation.

He is former administrator of the Centers for Medicare & Medicaid Services and former commissioner of the U.S. Food and Drug Administration, where he developed and implemented major reforms in health policy.

He is an independent director on the boards of Johnson & Johnson, Cigna, and Alignment Healthcare and is co-chair of the Health Care Payment Learning and Action Network Executive Forum.

Chiquita Brooks-LaSure

Chiquita Brooks-LaSure is the Administrator for the Centers for Medicare and Medicaid Services (CMS), where she oversees programs including Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), and the HealthCare.gov health insurance marketplace.

A former policy official who played a key role in guiding the Affordable Care Act (ACA) through passage and implementation, Brooks-LaSure has decades of experience in the federal government, on Capitol Hill, and in the private sector.

As deputy director for policy at the Center for Consumer Information and Insurance Oversight within the Centers for Medicare & Medicaid Services, and earlier at the Department of Health & Human Services as director of coverage policy, Brooks-LaSure led the agency’s implementation of ACA coverage and insurance reform policy provisions.

Earlier in her career, Brooks-LaSure assisted House leaders in passing several healthcare laws, including the Medicare Improvements for Patients and Providers Act of 2008 and the ACA, as part of the Democratic staff for the U.S. House of Representatives’ Ways and Means Committee.

Brooks-LaSure began her career as a program examiner and lead Medicaid analyst for the Office of Management and Budget, coordinating Medicaid policy development for the health financing branch. Her role included evaluating policy options and briefing White House and federal agency officials on policy recommendations regarding the uninsured, Medicaid, and the Children’s Health Insurance Program.

Elizabeth Fowler

Elizabeth Fowler, Ph.D., J.D., is the deputy administrator and director of the Center for Medicare and Medicaid Innovation (CMS Innovation Center). Fowler previously served as executive vice president of programs at The Commonwealth Fund and vice president for Global Health Policy at Johnson & Johnson. Liz was special assistant to President Obama on healthcare and economic policy at the National Economic Council. In 2008-2010, she was chief health counsel to Senate Finance Committee Chair, Senator Max Baucus (D-MT), where she played a critical role developing the Senate version of the Affordable Care Act. She also played a key role drafting the 2003 Medicare Prescription Drug, Improvement and Modernization Act (MMA). Liz has over 25 years of experience in health policy and health services research. She earned her bachelor’s degree from the University of Pennsylvania, a Ph.D. from the Johns Hopkins Bloomberg School of Public Health, where her research focused on risk adjustment, and a law degree (J.D.) from the University of Minnesota. She is admitted to the bar in Maryland, the District of Columbia, and the U.S. Supreme Court. Liz is a Fellow of the inaugural class of the Aspen Health Innovators Fellowship and a member of the Aspen Global Leadership Network.

Jeff Micklos

Jeff Micklos, J.D., is the executive director of the Health Care Transformation Task Force. An attorney by training, Jeff is the former executive vice president of Management, Compliance & General Counsel for the Federation of American Hospitals, a national trade association representing investor-owned hospitals. He is also a former partner in the Health Law department of the international law firm Foley & Lardner LLP. Jeff began his career as a litigator and regulatory counsel for the Health Care Financing Administration of the U.S. Department of Health and Human Services. Additionally, Jeff served in the Office of General Counsel of the Social Security Administration.
Jeff is a graduate of the Catholic University of America’s Columbus School of Law. He received a Bachelor of Arts from Villanova University. He resides in Washington, D.C., with his wife, Monica, and their four children.

Measurement Track: Multi-stakeholder Alignment & Design

Capability: Cohesive digital referral and management platform

Dr. Judy Zerzan-Thul

Dr. Judy Zerzan-Thul is the Chief Medical Officer at Washington State Health Care Authority, Co-Chair of the LAN Executive Forum, and a general internal medicine physician. She leads the state of Washington’s Medicaid Transformation Project, where she collaborates with stakeholders to advance health equity and the innovative use of data. As Chief Medical Officer of the Washington State Health Care Authority, she administers the state’s Medicaid program. She also works to advance the LAN’s strategic objectives to drive equitable health outcomes and lower the total cost of care.

Dr. Zerzan-Thul specializes in value-based payment models and healthcare financing. Prior to her role as the Chief Medical Officer for Washington State, Dr. Zerzan-Thul was the Chief Medical Officer at the Colorado Department of Health Care Policy and Financing. She led the implementation of the Affordable Care Act (ACA) in Colorado. She has extensive experience designing and implementing health plans and benefits for Medicaid programs. Dr. Zerzan-Thul’s background also includes leadership positions in the Medicaid Medical Director’s Network. She has also served as a committee member and advisor for national organizations, including the Agency for Healthcare Research and Quality, the National Quality Forum, the National Committee for Quality Assurance, the National Academy for State Health Policy, the Patient-Centered Outcomes Research Institute, and the Centers for Medicare & Medicaid Services.

Dr. Zerzan-Thul holds a Doctor of Medicine from Oregon Health and Science University and received a Master of Public Health in Health Policy and Administration from the University of North Carolina. She completed the Robert Wood Johnson Clinical Scholars Program at the University of Washington/VA Puget Sound Health Care System in 2007. From 2008 to 2010, she was a non-residential Health and Aging Policy Fellow for the office of Senator John D. Rockefeller IV of West Virginia, where she supported public policy for the Affordable Care Act.

Dr. Judy Zerzan-Thul

Dr. Judy Zerzan-Thul is the Chief Medical Officer at Washington State Health Care Authority, Co-Chair of the LAN Executive Forum, and a general internal medicine physician. She leads the state of Washington’s Medicaid Transformation Project, where she collaborates with stakeholders to advance health equity and the innovative use of data. As Chief Medical Officer of the Washington State Health Care Authority, she administers the state’s Medicaid program. She also works to advance the LAN’s strategic objectives to drive equitable health outcomes and lower the total cost of care.

Dr. Zerzan-Thul specializes in value-based payment models and healthcare financing. Prior to her role as the Chief Medical Officer for Washington State, Dr. Zerzan-Thul was the Chief Medical Officer at the Colorado Department of Health Care Policy and Financing. She led the implementation of the Affordable Care Act (ACA) in Colorado. She has extensive experience designing and implementing health plans and benefits for Medicaid programs. Dr. Zerzan-Thul’s background also includes leadership positions in the Medicaid Medical Director’s Network. She has also served as a committee member and advisor for national organizations, including the Agency for Healthcare Research and Quality, the National Quality Forum, the National Committee for Quality Assurance, the National Academy for State Health Policy, the Patient-Centered Outcomes Research Institute, and the Centers for Medicare & Medicaid Services.

Dr. Zerzan-Thul holds a Doctor of Medicine from Oregon Health and Science University and received a Master of Public Health in Health Policy and Administration from the University of North Carolina. She completed the Robert Wood Johnson Clinical Scholars Program at the University of Washington/VA Puget Sound Health Care System in 2007. From 2008 to 2010, she was a non-residential Health and Aging Policy Fellow for the office of Senator John D. Rockefeller IV of West Virginia, where she supported public policy for the Affordable Care Act.

Judy Zerzan-Thul

Dr. Judy Zerzan-Thul is the Chief Medical Officer at Washington State Health Care Authority, Co-Chair of the LAN Executive Forum, and a general internal medicine physician. She leads the state of Washington’s Medicaid Transformation Project, where she collaborates with stakeholders to advance health equity and the innovative use of data. As Chief Medical Officer of the Washington State Health Care Authority, she administers the state’s Medicaid program. She also works to advance the LAN’s strategic objectives to drive equitable health outcomes and lower the total cost of care.

Dr. Zerzan-Thul specializes in value-based payment models and healthcare financing. Prior to her role as the Chief Medical Officer for Washington State, Dr. Zerzan-Thul was the Chief Medical Officer at the Colorado Department of Health Care Policy and Financing. She led the implementation of the Affordable Care Act (ACA) in Colorado. She has extensive experience designing and implementing health plans and benefits for Medicaid programs. Dr. Zerzan-Thul’s background also includes leadership positions in the Medicaid Medical Director’s Network. She has also served as a committee member and advisor for national organizations, including the Agency for Healthcare Research and Quality, the National Quality Forum, the National Committee for Quality Assurance, the National Academy for State Health Policy, the Patient-Centered Outcomes Research Institute, and the Centers for Medicare & Medicaid Services.

Dr. Zerzan-Thul holds a Doctor of Medicine from Oregon Health and Science University and received a Master of Public Health in Health Policy and Administration from the University of North Carolina. She completed the Robert Wood Johnson Clinical Scholars Program at the University of Washington/VA Puget Sound Health Care System in 2007. From 2008 to 2010, she was a non-residential Health and Aging Policy Fellow for the office of Senator John D. Rockefeller IV of West Virginia, where she supported public policy for the Affordable Care Act.

Mark McClellan, MD, PhD

Mark McClellan, MD, PhD, is Director and Robert J. Margolis, M.D., Professor of Business, Medicine and Policy at the Margolis Center for Health Policy at Duke University. He is a physician-economist who focuses on quality and value in health care, including payment reform, real-world evidence and more effective drug and device innovation. Dr. McClellan is at the center of the nation’s efforts to combat the pandemic, the author of COVID-19 response roadmap, and co-author of a comprehensive set of papers and commentaries that address health policy strategies for COVID vaccines, testing, and treatments, nationally and globally. He is former administrator of the Centers for Medicare & Medicaid Services and former commissioner of the U.S. Food and Drug Administration, where he developed and implemented major reforms in health policy. Dr. McClellan is an independent board member on the boards of Johnson & Johnson, Cigna, Alignment Healthcare, and PrognomIQ; co-chair of the Executive Forum for the Health Care Payment Learning and Action Network; and serves as an advisor for Arsenal Capital Group, Blackstone Life Sciences, and MITRE.

Aza Nedhari, CPM, LGPC

Ms. Nedhari brings more than 18 years of experience in community organizing, reproductive justice, and program development. She is a mother, licensed Certified Professional Midwife, Family Counselor, and the Co-founding Executive Director of Mamatoto Village. Aza is a fiercely dedicated woman who believes that by promoting a framework of justice, the reduction of barriers in maternal and child health begins to dissipate; giving rise to healthy individuals, healthy families, and healthy communities. Aza is pursuing her Doctorate in Human Services with a concentration in Organizational Leadership and Management with an eye towards the sustainability of Black led organizations and cultivating innovative models of perinatal care delivery and workforce development.

Timothy P. McNeill, RN, MPH

Timothy P. McNeill is the founder of Freedmen’s Health, a Washington, DC healthcare consulting firm specializing in implementation of innovative models of care. Mr. McNeill also serves as the co-chair of the Partnership to Align Social Care. The Partnership to Align Social Care is a multi-sectoral group of health plans, health systems, community-based organizations and Government liaisons that work together to identify and address priority issues that are essential to a fully aligned health and social care system that incorporates the vital voice of the community.

Mr. McNeill has started or expanded multiple sustainable health programs including two Medicare Shared Savings Program (MSSP) ACOs, an IPA made up of FQHCs and independent physicians, a network of community-based free clinics, managed the operations of a network of Federally Qualified Health Centers, and established multiple regional networks to deliver Long-Term Services and Supports, contracting with MCOs, in support of State Medicaid Waiver implementation.

Mr. McNeill is a Registered Nurse with a bachelor’s degree from Howard University and a Master of Public Health from Eastern Virginia Medical School. Mr. McNeill is also a retired U.S. Navy Nurse Corps Officer.

Sam Hoeffler

Sam oversees food programs and systems change work at Reinvestment Partners, an anti-poverty non-profit based in Durham NC. She manages a $10m produce prescription program portfolio; guides program evaluation with a focus on strategic impact; and contributes to advocacy that seeks to integrate non-medical health services into healthcare delivery.

Before joining Reinvestment Partners, Sam was the program evaluator and food systems lead for a SNAP-Education program at NC State University. She received an MS in Food Policy and Applied Nutrition from the Friedman School of Nutrition Science and Policy, and she brings a critical perspective to food work.

Joseph D. Strickland, Jr., MS

Mr. Joseph Strickland resides in southeast Alabama having lived in the Wiregrass region for most of his life. He holds a Master of Science degree from Troy University.  Mr. Strickland serves as the Director of Home and Community Services at SARCOA Area Agency on Aging, where he has been employed for the past 22+ years.  He is passionate about developing and implementing quality LTSS: Long Term Services and Supports, for the Aging population. He was instrumental in developing a model of delivery for LTSS case management that led to successful contracting with a managed care organization.

In addition, Mr. Strickland served as lead developer for a case management software system used by all AAAs in support of their Medicaid Waiver case management activities. The case management system now serves as the data warehouse, “system of record”, and centralized case management system for all Alabama AAA case management activities. The development and implementation of the case management system was pivotal in the Alabama AAA effort to demonstrate proficiency in case management activities as well as provide a platform to manage programs, staff, and enrollees.

In addition to his work in developing and managing the case management system used by the Alabama AAA network, Mr. Strickland also serves as the lead for organization efforts focused on National Committee for Quality Assurance (NCQA) Accreditation standards for CM-LTSS.

SARCOA was the first AAA in Alabama to become Accredited by the National Committee for Quality Assurance for CM-LTSS and was instrumental in leading all Alabama AAAs in their efforts to become accredited.

Alice Chen, M.D., M.P.H.

Alice Hm Chen, MD, MPH, serves as Chief Health Officer (CHO) for Centene Corporation. Dr. Chen is responsible for Centene’s strategies, policies, and programs in support of improving population health for Centene’s more than 26 million members.

Prior to joining Centene, Dr. Chen was Chief Medical Officer at Covered California, the state’s health insurance marketplace, where she was responsible for healthcare strategy focused on quality, equity and delivery system transformation. She previously served as Deputy Secretary for Policy and Planning and Chief of Clinical Affairs for the California Health and Human Services Agency, where she led signature health policy initiatives on affordability and access, and played a leadership role in the state’s response to the COVID-19 pandemic. Dr. Chen was also a professor of medicine at the University of California San Francisco School of Medicine, based at the Zuckerberg San Francisco General Hospital, where she served as its Chief Integration Officer and founding director of the eConsult program.

Dr. Chen received a Bachelor of Science in Environmental Biology from Yale University and has a Doctor of Medicine from the Stanford University School of Medicine. She also has a Master of Public Health in Health Care Management and Policy from Harvard School of Public Health. A primary care internist by training, she provides clinical care at Zuckerberg San Francisco General Hospital.

Leah Binder

Since 2008, Leah Binder, M.A., M.G.A., has served as president and CEO of The Leapfrog Group, an award-winning national nonprofit based in Washington, D.C. Leapfrog represents employers and other purchasers of health care calling for improved safety and quality in hospitals. She is a regular contributor to Forbes.com, Harvard Business Review, and other publications and is consistently cited among the most influential people and top women in health care.

Through annual surveys, The Leapfrog Group collects data from hospitals and ambulatory surgery centers on the quality of care. Leapfrog also grades hospitals on how safe they are, a bold initiative that experts estimate has saved over 40,000 lives a year since 2017. Before joining Leapfrog, Leah was vice president for a nationally noted rural health system in Farmington, Maine. Prior to that, she served as a senior policy advisor in the New York City Office of the Mayor. She started her career at the National League for Nursing. Leah has a bachelor’s degree from Brandeis University and two master’s degrees from the University of Pennsylvania. She lives in the Washington, D.C., area with her husband and two sons.

Jeff Micklos

Jeff Micklos, J.D., is the executive director of the Health Care Transformation Task Force. An attorney by training, Jeff is the former executive vice president of Management, Compliance & General Counsel for the Federation of American Hospitals, a national trade association representing investor-owned hospitals. He is also a former partner in the Health Law department of the international law firm Foley & Lardner LLP. Jeff began his career as a litigator and regulatory counsel for the Health Care Financing Administration of the U.S. Department of Health and Human Services. Additionally, Jeff served in the Office of General Counsel of the Social Security Administration.

Jeff is a graduate of the Catholic University of America’s Columbus School of Law. He received a Bachelor of Arts from Villanova University. He resides in Washington, D.C., with his wife, Monica, and their four children.

Dr. Rhonda Medows

Rhonda M. Medows, M.D., is president of Population Health Management at Providence, one of the largest nonprofit health systems in the United States, and chief executive officer of Ayin Health Solutions, a population health management company launched by Providence.

She leads Providence’s Medicaid, Medicare, commercial, and employer population health strategies, as well as the organization’s value-based care, health plans, population health informatics, government programs, care management, contracting, and community health partnerships. Providence Population Health leads the mental health improvement strategy across Providence’s seven-state footprint.

Dr. Medows has extensive health care industry experience in both the private sector and government health programs including Medicare and Medicaid. She formally served on the U.S. Department of Health and Human Services Physician-Focused Payment Model Technical Advisory Council focused on developing new alternative payment models.

Prior to joining Providence, she served as an executive vice president and chief medical officer of UnitedHealth Group. While there, she led quality management and improvement initiatives and provided leadership and oversight of efforts to improve clinical quality and operational excellence. Until March 2010, Dr. Medows served as commissioner for the Georgia Department of Community Health and as Georgia’s state health officer, where she oversaw the state’s Medicaid and State Children’s Health Insurance (SCHIP) programs and ran the state employee benefit plan, public health department, public health emergency preparedness, rural health, and information technology.

Dr. Medows also served as secretary of the Florida Agency for Health Care Administrative, the state agency responsible for the Medicaid and SCHIP programs, health facility regulation, managed care quality, health information exchange, and public policy development. She also served as the chief medical officer for the Centers for Medicare & Medicaid Services southeast region.

Dr. Medows holds a bachelor’s degree from Cornell University and earned her medical degree from Morehouse School of Medicine in Atlanta, Georgia. She practiced medicine at Mayo Clinic and is board certified in family medicine. She is also a fellow of the American Academy of Family Physicians.

Sinsi Hernández-Cancio

Sinsi Hernández-Cancio, JD, is a vice president at the National Partnership for Women & Families, where she leads the Health Justice team. She is a national health and health care equity policy and advocacy thought leader with 25 years of experience advancing equal opportunity for women and families of color, and almost 20 years advocating for increased health care access and improved quality of care for underserved communities. Sinsi is deeply committed to transforming our health care system to meet the needs of our rapidly evolving nation so we can all thrive together. She believes that our future prosperity depends on ensuring our health care system routinely provides excellent, comprehensive, culturally centered and affordable care for every single person, family and community, and that this requires the dismantling of structural inequities including racism, sexism, ableism, homophobia, transphobia, xenophobia and religious bigotry.

Sinsi is a recognized leader in the national health equity movement, a sought-after strategic advisor and a dynamic, inspiring speaker. She has presented at national events across the country and served on numerous advisory committees for organizations including the National Academy of Medicine, the National Committee for Quality Assurance, the Patient Centered Outcomes Research Institute, the Robert Wood Johnson Foundation, the National Center for Complex Health and Social Needs and the American Association of Pediatrics. She has published extensively and has appeared in national and state level English and Spanish television, radio and print media.

Sinsi’s extensive experience in health and health equity policy and advocacy spans the state government, labor and non-profit arenas. Prior to joining the National Partnership’s staff, she was the founding director of Families USA’s Center on Health Equity Action for System Transformation, where she led efforts to advance health equity and reduce disparities in health outcomes and health care access and quality by leveraging health care and delivery system transformation to reduce persistent racial, ethnic and geographic health inequities with an intersectional lens. Prior to that, she advised and represented two governors of Puerto Rico on federal health and human services policies, and she worked for the Service Employees International Union (SEIU) as a senior health policy analyst and national campaign coordinator for their Healthcare Equality Project campaign to enact the Affordable Care Act.

Born in San Juan, Puerto Rico, Sinsi is bilingual and bicultural. She earned an A.B. from Princeton University’s Woodrow Wilson School of Public and International Affairs and a J.D. from New York University School of Law, where she was an Arthur Garfield Hays Civil Liberties Fellow, and won the Georgetown Women’s Law and Public Policy Fellowship. She lives in Fairfax with her husband, teenage son and two rescue dogs. She loves sci-fi, board games and expressing her love for family and friends by feeding them.

Purva Rawal, Ph.D.

Purva Rawal, Ph.D., is the chief strategy officer at the CMS Innovation Center at the Centers for Medicare and Medicaid Services. As part of the Senior Leadership team, she provides guidance and leadership on the execution of the Innovation Center’s strategy.

Previously, she was a principal at CapView Strategies, where she developed evidence-based public policy and business strategies for providers, health systems, life sciences companies, and coalitions. She also conducted policy research on health system transformation and sustainability issues. She is also an adjunct assistant professor at Georgetown University. In 2016, she published a book, The Affordable Care Act: Examining the Facts. Previously, Dr. Rawal served as professional staff on the Senate Budget Committee during the passage of the Affordable Care Act and as the health and social policy advisor to Sen. Joseph Lieberman (I-CT). She was also a director in the Health Insurance and Reform Practice at Avalere Health. She began her health policy career as a Christine Mirzayan Science and Technology Fellow at the National Academy of Sciences and as a Congressional Fellow for the Society for Research on Child Development and the American Association for the Advancement of Science. Dr. Rawal received her B.A. and Ph.D. from Northwestern University.

Dora Hughes, M.D., M.P.H.

Dora Hughes, M.D., M.P.H., is the Chief Medical Officer at the CMS Innovation Center at the Centers for Medicare & Medicaid Services. She leads the Center’s work on health equity, provides clinical leadership and input on models, serves as the Innovation Center’s primary liaison with medical and clinical stakeholders, and provides leadership to CMMI’s clinician community. In addition, Dr. Hughes is part of the Innovation Center’s Senior Leadership Team, helping to provide enterprise-level leadership and strategic direction to the Center.

Previously, Dr. Hughes served as an Associate Research Professor of Health Policy & Management at the Milken Institute School of Public Health at The George Washington University, where her work focused on the intersection of clinical and community health, health equity, social determinants of health, healthcare quality and workforce. Prior to this role, Dr. Hughes was a Senior Policy Advisor at Sidley Austin, where she advised on regulatory and legislative matters in the life science industry. Additionally, Dr. Hughes served as the Counselor for Science & Public Health to Secretary Kathleen Sebelius at the U.S. Department of Health & Human Services. In this role, she helped implement the Affordable Care Act and provided oversight and guidance to the Public Health Service Act authorized agencies and Food and Drug Administration.

Dr. Hughes began her career in health policy as Senior Program Officer at the Commonwealth Fund, and subsequently was Deputy Director for the Health, Education, Labor, and Pensions Committee under Senator Edward M. Kennedy. She then served as the Health Policy Advisor to former Senator Barack Obama.

Dr. Hughes received a B.S. from Washington University, M.D. from Vanderbilt and M.P.H. from Harvard. She completed internal medicine residency at Brigham & Women’s Hospital.

Emily Brower

Emily DuHamel Brower, M.B.A., is senior vice president of clinical integration and physician services for Trinity Health. Emphasizing clinical integration and payment model transformation, Ms. Brower provides strategic direction related to the evolving accountable healthcare environment with strong results. Her team is currently accountable for $10.4B of medical expense for 1.6M lives in Medicare Accountable Care Organizations (ACOs), Medicare Advantage, and Medicaid and Commercial Alternative Payment Models.

Ms. Brower joined Trinity Health from Atrius Health in Massachusetts, where she last served as vice president of Population Health. There, she built and executed the essential capabilities required to achieve strong financial and clinical outcomes within integrated care models under value-based reimbursement, particularly for publicly insured populations.

Prior to her career at Atrius Health, Ms. Brower spent 15 years in leadership roles at Urban Medical Group, a Massachusetts nonprofit healthcare organization specializing in the care of medically complex, chronically ill populations across a community-based, long-term care continuum. During that time, Ms. Brower launched a Program of All-inclusive Care for the Elderly (PACE) program and other innovative, capitated contracts for medically complex populations and served as Principal Investigator for a multi-year research project analyzing cost and quality outcomes to support payment reform.

Ms. Brower received her B.A. from Smith College and her M.B.A. from the New York University Stern School of Business.

James Sinkoff

Mr. James Sinkoff is the Deputy Executive Officer and Chief Financial Officer for Sun River Health (formerly known as Hudson River HealthCare), and the Chief Executive Officer of Solutions 4 Community Health (S4CH); an MSO serving FQHCs and private physician practices.

Sun River Health cares for over 240,000 general medicine, dental, behavioral health, mental health, agricultural, public housing, homeless, developmentally disabled, HIV and substance abuse patients and families generating nearly 780,000 patient encounters in over 43 clinical sites in both rural and urban settings in 10 counties of the Hudson Valley, 2 counties on Long Island and all of NYC. Sun River Health provides a full range of primary care, behavioral and mental healthcare services including but not limited to pediatrics, internal medicine, family medicine, OB/GYN, dentistry, urgent care, MAT and specific specialty care such as cardiology, endocrinology, and ophthalmology. Over 95,000 patients are managed under a variety of risk-based contacts as well as 11,000 MSSP ACO patients.

Mr. Sinkoff has worked in all sectors of the healthcare industry starting his career with Ernst & Young as an auditor and then as a senior management consultant to hospitals, physician practices, long term care facilities, and home health agencies. In the late ‘90s, he became the director of managed care financing for Berkshire Health Systems. Subsequently, he became the Chief Financial Officer for Fidelis Care New York (now Centene). Mr. Sinkoff was the Chief Executive Officer of Whitney M. Young Jr. Health Center in Albany, New York, before joining Sun River Health and Solutions 4 Community Health in late 2009.

As the DEO, Mr. Sinkoff oversees all aspects of Sun River Health’s service delivery system; clinical, financial and operational. He has been invited to share his thoughts on many topics including value-based systems of care, health equity, IT, interoperability, LEAN and Emotionally Intelligent management. Mr. Sinkoff is a coach to a number of clients seeking to grow and achieve their professional aspirations.

Mr. Sinkoff was an appointed member of the NYSDOH Transparency, Evaluation and HIT Workgroup. He is a member of the board and an executive committee member of the Health Care Transformation Task Force, formerly a part of the Levitt Group. He is a member serving the Robert Wood Johnson Foundation to Improve Health Equity led by the University of Chicago, the Institute for Medicaid Innovation, and the Center for Health Care Strategies. He is a member of the legislative, public policy and sub-committee on health center financing of the National Association of Community Health Centers. He is a member of the board of Amida Care, an HIV and Special needs plan. Mr. Sinkoff is the former chair of the board of the Community Healthcare Association of New York.

Dr. Victor Yung-Tao Wu

Victor is the Chief Medical Officer for TennCare, Tennessee’s Medicaid Agency. At TennCare, Victor leads the medical office to ensure quality and effective delivery of medical, pharmacy, and dental services to its members. He also leads TennCare’s opioid epidemic strategy, social determinants of health, and practice transformation initiatives across the agency. Prior to joining TennCare, Victor worked at Evolent Health supporting value-based population health care delivery. In 2013, Victor served as a White House Fellow to the Secretary of Health and Human Services. Victor completed his Internal Medicine Residency at Emory University still practices clinically as an internist in the Veteran’s Affairs Health System.

Dr. Brandon G. Wilson

Dr. Brandon G. Wilson, DrPH, MHA (he, him, his) joined Community Catalyst as the Director of the Center for Consumer Engagement in Health Innovation, where he leads the Center in bringing the community’s experience to the forefront of health systems transformation and health reform efforts, in order to deliver better care, better value and better health for every community, particularly vulnerable and historically underserved populations. The Center works directly with community advocates around the country to increase the skills and power they have to establish an effective voice at all levels of the health care system. The Center collaborates with innovative health plans, hospitals and providers to incorporate communities and their lived experience into the design of systems of care. The Center also works with state and federal policymakers to spur change that makes the health system more responsive to communities. And it provides consulting services to health plans, provider groups and other health care organizations to help them create meaningful structures for engagement with their communities.

Dr. Wilson joined the Center, following his tenure in federal service as a Senior Public Health Advisor with the Centers for Medicare and Medicaid Services (CMS) Office of Minority Health, where he led strategic initiatives to implement the Biden/Harris Administration’s priorities on health equity for underserved communities, and developed a health equity business case portfolio. He most recently received the CMS Impact Award from CMS Administrator Chiquita Brooks-LaSure for advancing health equity and accessibility in COVID-19 for persons living with disabilities. Prior to joining CMS OMH, Dr. Wilson led a $250 million portfolio in the CMS Innovation Center’s Accountable Health Communities Model and the Health Care Innovation Awards. At CMMI, he spearheaded the Health Equity Working Group, which laid the foundation for CMMI’s health equity focus in its 10-year strategy refresh. He later directed culture of patient safety quality improvement projects for the NIH Clinical Center Office of the Director, by reducing medication errors in the inpatient oncology pharmacy department. He also headed recruitment and retention approaches for increasing minority screening, enrollment, and retention in preventative and therapeutic vaccine clinical trials and participation in the Community Advisory Board at NIH. For his exceptional commitment and dedication in identifying a solution for a global infectious disease threat by advancing a malaria vaccine through a clinical trial, Dr. Wilson received awards from NIH’s Director, Dr. Francis Collins and NIAID’s Director, Dr. Anthony Fauci.

Dr. Wilson brings a wealth of knowledge, skills, and abilities in advocacy, health policy, and research from national policy organizations as the National Association of People with AIDS. Dr. Wilson completed his Master’s in Health Systems Management at George Mason University and his Doctor of Public Health at Morgan State University. He also holds Public Health faculty appointments at Purdue University and the UNC Gillings School of Global Public Health, where he teaches courses in health economics and policy, cultural competence and communications for health professionals, community health assessments, and healthcare marketing. His research interests include using patient centered and indigenous models of care, health economics outcomes research, policy analysis, and community-based participatory and action research to eliminate health disparities and advance health equity in underserved and disinvested communities.

Tamara Ward

Tamara Ward is the SVP of Insurance Business Operations at Oscar Health, where she leads the National Network Contracting Strategy and Market Expansion & Readiness. Prior to Oscar she served as VP of Managed Care & Network Operations at TriHealth in Southwest Ohio. With over 15 years of progressive health care experience, she has been instrumental driving collaborative payer provider strategies, improving insurance operations, and building high value networks through her various roles with UHC and other large provider health systems. Her breadth and depth of experience and interest-based approach has allowed her to have success solving some of the most complex issues our industry faces today. Tam is passionate about driving change for marginalized communities, developing Oscar’s Culturally Competent Care Program- reducing healthcare disparities and improving access for the underserved population. Tamara holds a B.A. from the University of Cincinnati’s and M.B.A from Miami University.