Government Regulation and Guidance

2024 Hospital Inpatient Prospective Payment System and
Long-Term Care Hospital Prospective Payment System Final Rule

Initiative Description: The final rule includes the required annual updates on Medicare payment policies for Inpatient Prospective Payment System (IPPS) hospitals and long-term care hospitals (LTCHs). The updates include changes to the payment structure of IPPS and LTCHs and updates to social determinants of health diagnoses codes, including requiring screening for social drivers of health and promoting health equity and patient safety. Mandatory reporting went into effect in October 2023.

Strategic and Tactical Uses: IPPS provides opportunities for alignment, primarily through investments in health equity. The rule includes healthy equity adjustments to the Hospital Value-Based Purchasing Program to reward delivery of excellent care in underserved populations. These adjustments include incentives to hospitals that provide care to populations with a high proportion of underserved individuals, as defined by dual eligibility status. The rule also changed the definition of three diagnosis codes describing homelessness to accurately reflect the use of hospital resources during treatment: the severity of a patient’s illness, the complexity of service, and the consumption of resources.

Multi-payer Alignment Foundational Element: Advancing Health Equity, Aligning Key Payment Model Components

Timeframe: Active

For additional information, please visit https://www.cms.gov/newsroom/fact-sheets/fy-2024-hospital-inpatient-prospective-payment-system-ipps-and-long-term-care-hospital-prospective-0

Who Might Use This: Health Plans | Providers 

Collaboratives and Innovative Partnerships

Vermont’s All-Payer Accountable Care Organization Model

Initiative Description: The Vermont All-Payer Accountable Care Organization (ACO) Model (VTAPM) began on January 1, 2017 and is scheduled to end on December 31, 2024. It is a culmination of Vermont’s commitment to health care transformation, building from Vermont’s Global Commitment to Health Section 1115 waiver, the Blueprint for Health, and a multi-payer ACO Shared Savings Program (SSP) pilot under Vermont’s State Innovation Models (SIM) Testing Grant. Medicare, Medicaid, BlueCross BlueShield of Vermont (BCBSVT), MVP Health Care, and the State Employees’ Health Care Plan — a self-insured plan administered by BCBSVT — participate in the model, representing the majority of covered lives in the state. The Model is administered by OneCare Vermont, which coordinates all funding from all VTAPM payment mechanisms — all-inclusive population-based payment, fixed prospective payment, and traditional fee-for-service (FFS). The Model aims to use this ACO structure to reduce statewide spending and improve population health outcomes.

Strategic and Tactical Uses: The VTAPM has been linked to reductions in Medicare spending, decreases in acute hospital and specialty visits, and efforts to improve care coordination and strengthen primary care. Despite these successes, the Model had mixed success related to payment reform, with FFS as the primary funding mechanism by participating commercial plans, and mixed quality measure alignment, with only 7 of the 18 OneCare measures in common among participating health plans.

Other states can look to the VTAPM model to understand how decades of work toward health care payment reform efforts can be used to develop a statewide model with successful cost and quality outcomes. Lessons learned from the evaluation report — including the need to align financial incentives and attribution, and the importance of goal setting for aligned payment mechanisms (see additional information below) — should also be reviewed for states looking to leverage findings from Vermont.

Multi-payer Alignment Foundational Element: Aligning Key Payment Model Components

Timeframe: Active

For additional information, please visit https://www.cms.gov/priorities/innovation/data-and-reports/2023/vtapm-3rd-eval-full-report

Who Might Use This: Health Plans

Collaboratives and Innovative Partnerships

Washington Multi-Payer Collaborative

Initiative Description: The Washington State Health Care Authority formed a Multi-Payer Collaborative (MPC) to increase access to high-quality comprehensive primary care to improve health care outcomes. The MPC aims to improve primary care by enhancing the patient experience, improving population health outcomes, reducing costs, and improving the work life of health care providers. Part of the work being done by the MPC is the introduction of the MPC Learning Cohort, which will be an avenue for providers to shape where payers align their efforts to create primary care provider supports.

Strategic and Tactical Uses: Practices that are good candidates and meet certain characteristics can join an MPC Learning Cohort and help guide health plan alignment. Those that are not involved in the Washington MPC can use the strategies and direction of the MPC to help shape their own guiding principles. Practices in Washington that are participating in the Centers for Medicare & Medicaid Services’ new Making Care Primary model can benefit from the lessons of MPC’s current Learning Cohort to enable greater success in the new model.

Multi-payer Alignment Foundational Element: Providing and Leveraging Technical Assistance

Timeframe: Active

For additional information, please visit https://www.hca.wa.gov/about-hca/programs-and-initiatives/value-based-purchasing/primary-care-transformation

Stakeholders can reach out to the Multi-payer Collaborative directly with questions wampc-cebpstaff@ohsu.edu

Who Might Use This: Health Plans

Alignment Resources and Helpful Documents

The Future of Sustainable Value-Based Payment:
Voluntary Best Pracrices to Advance Data Sharing

Initiative Description: The National Association of Accountable Care Organizations (NAACOs), American Medical Association (AMA), and AHIP created a playbook that presents voluntary guidelines and best practices to advance data sharing, which includes data privacy, data infrastructure, value-based care participant readiness, federal health information technology requirements, and financial investment. The playbook is based on findings from an advisory workgroup comprising members from each partner association, a managing committee of association leaders, a literature review, an environmental scan, and interviews with subject matter experts.

Strategic and Tactical Uses: Organizations can use the playbook to develop or refine their own value-based care strategy, especially with regard to data and infrastructure practices.

Multi-payer Alignment Foundational Element: Timely and Consistent Data Sharing

Timeframe: Active

For additional information, please visit https://www.aurrerahealth.com/wp-content/uploads/2023/07/Voluntary-Best-Practices-to-Advance-Data-Sharing.pdf

Who Might Use This:Health Plans | Purchasers | Providers | Policy Makers | Enabling Organizations | Community-Based Organizations

Collaboratives and Innovative Partnerships

The Gravity Project

Initiative Description: The Gravity Project advances equitable health and social care by developing consensus-driven standards on social determinants of health (SDOH). The Gravity Project focuses on: (1) creating universal definitions of different social needs to be used in the health care space, (2) improving standards for recording, documenting, and exchanging SDOH information, and (3) testing evolving terminology and data exchange standards through affinity groups.

Strategic and Tactical Uses: Individuals and organizations can join the Gravity Project to work toward the shared goal of health equity across cultural, institutional, and social contexts. Interested parties can implement the shared technical and terminology standards to streamline data sharing for SDOH screening questions. Doing so can reduce inefficiencies from using different standards across different health care and social service organizations.

Multi-payer Alignment Foundational Element: Timely and Consistent Data Sharing, Advancing Health Equity

Timeframe: Active

For additional information, please visit https://thegravityproject.net/overview/

Who Might Use This: Health Plans | Providers | Community-Based Organizations

Alignment Resources and Helpful Documents

Oregon Regional Multi-Payer Global Budget Model: Aligning 4 Health

Initiative Description: The Oregon Health Authority developed a report that provides recommendations for a global budget health care delivery pilot. The proposed model, Aligning 4 Health (A4H), is designed to change incentives for health plans and providers to improve health. The model establishes an annual, predetermined total budget for a defined population, which offers new flexibility for how health services are reimbursed, so that providers can focus their services on keeping people healthy. The model also includes shared expectations around promoting high-quality care, paying for outcomes, and addressing health inequities. Features of the model include centering health equity; shared accountability to quality and health equity; containing costs; building on and advancing health system transformation; seeking alignment and promoting broad participation and partnership; and flexibility, scalability, and resiliency in the model.

Strategic and Tactical Uses: As Oregon takes steps to develop and launch the pilot, health plans, providers, and other health care organizations can educate themselves on the model design and requirements and take preliminary steps in strategic planning. States interested in using a global budget model can leverage the key elements from this report as a roadmap for their own analysis and planning efforts.

Multi-payer Alignment Foundational Element: Aligning Key Payment Model Components

Timeframe: Active

For additional information, please visit https://www.oregon.gov/oha/hpa/hp/docs/HB-2010-Global-Budget.pdf

Who Might Use This: Health Plans | Providers

Collaboratives and Innovative Partnerships

NEW
Alignment Proposal for the North Carolina State Transformation Collaborative

Initiative Description: The North Carolina State Transformation Collaborative (NC STC), launched by the NC Department of Health and Human Services, HCPLAN, the Centers for Medicare & Medicaid Services, and the Duke-Margolis Institute for Health Policy, is a public-private initiative designed to promote high-value and whole-person health care. Since its launch, the NC STC has convened a broad coalition of health care industry groups, conducted landscape analysis, established working groups, and gathered feedback to identify areas to advance NC STC goals of improving population health, advancing health equity, enhancing patient experience, relieving provider burden, and reducing cost. The Alignment Proposal for the NC STC outlines strategies and action areas to advance health care transformation and address common challenges NC stakeholders were trying to address independently. The Alignment Proposal is intended to be a starting point for multi-stakeholder alignment in NC. Future efforts can expand areas for action and measure impact on key goals and strategies for the state.

Strategic and Tactical Uses: The Alignment Proposal for the NC STC outlines a set of actions to address shared challenges across key NC STC strategies — aligning quality measures, improving data infrastructure, and enhancing health equity data to enable advanced, coordinated care models, starting with primary care. The Alignment Proposal also describes the focused efforts, use cases, and partnerships needed to make progress on broader health care transformation and advance the goals of the NC STC.

Multi-payer Alignment Foundational Element: Timely and Consistent Data Sharing, Performance Measurement and Reporting, Advancing Health Equity

Timeframe: Active

For additional information, please visit https://healthpolicy.duke.edu/events/advancing-whole-person-health-care-through-north-carolinas-state-

Who Might Use This: Health Plans |  Providers  

Collaboratives and Innovative Partnerships

National Quality Forum Aligned Innovation

Initiative Description: Aligned Innovation is a multi-stakeholder initiative from the National Quality Forum (NQF) that advances quality measures for behavioral health and maternal health outcomes. The recent new measures prioritized by the Coalition include outcomes for mild to moderate behavioral health conditions and the reduction of severe maternal morbidity. The program is differentiated by a rapid-cycle measure development process, rather than the multi-year timeframe that’s typical of traditional measure development.

Strategic and Tactical Uses: These measures are outcome-oriented and patient-centered and can be used to support prospective measure alignment across the industry. Health plans not participating in Aligned Innovation can look to the initiative for lessons on measure development and achieving shared implementation.

Multi-payer Alignment Foundational Element: Performance Measurement and Reporting

Timeframe: Active

For additional information, please visit https://www.qualityforum.org/News_And_Resources/Press_Releases/2023/NQF_s_Aligned_Innovation_Initiative
_to_Advance_Next_Generation_Measures_of_Outcomes_for_Behavioral_Health_and_Maternity_Care.aspx

Who Might Use This: Health Plans

Collaboratives and Innovative Partnerships

National Committee for Quality Assurance Bulk FHIR Coalition

Initiative Description: The Bulk FHIR Quality Coalition is a National Committee for Quality Assurance (NCQA) and public-private sector collaboration focused on leveraging regulated Fast Healthcare Interoperability Resources (FHIR) data for NCQA’s Healthcare Effectiveness Data and Information Set (HEDIS) measures. Phase 1 of the Coalition involves health plans, providers, and accountable care organization cohorts that create pipelines from clinical data and claims data, which are tested and validated against specific HEDIS FHIR Implementation Guides from NCQA.

Strategic and Tactical Uses: By participating in NCQA’s Bulk FHIR Coalition, organizations can be at the forefront of health care technology and data management, as well as support the broader goals of enhancing health care quality, efficiency, and patient outcomes. Organizations not yet ready to participate can follow the results of the Coalition for future implementation.

Multi-payer Alignment Foundational Element: Timely and Consistent Data Sharing

Timeframe: Active

For additional information, please visit https://www.ncqa.org/bulk-fhir-api-quality-coalition/

Who Might Use This: Health Plans | Providers | Policy Makers

Collaboratives and Innovative Partnerships

Massachusetts Quality Measure Alignment Taskforce

Initiative Description: Massachusetts began convening the Taskforce in 2017 in order to: (1) build consensus on an aligned measure set for voluntary adoption by health plans in global budget-based risk contracts, (2) identify strategic priority areas for measure development, and (3) advise on the measurement and reporting of health inequities. Since 2017, the Taskforce has released annually updated measure sets for shared implementation. The Taskforce also maintains “Developmental Set measure topics,” which lists topics and measures that may be implemented in the future.

Strategic and Tactical Uses: The state releases a yearly Massachusetts Aligned Measure Set for health plan uptake and alignment. The Taskforce publicly tracks uptake of the measure set and reports findings. Adherence to the Aligned Measure Set among insurers that report to the Task Force has steadily increased from 65% in 2019 to 93% in 2023. Other states can look to the Taskforce to pursue and track measure alignment or expand the work to create a cross-state approach to quality measure alignment.

Multi-payer Alignment Foundational Element: Performance Measurement and Reporting

Timeframe: Active

For additional information, please visit https://www.mass.gov/info-details/eohhs-quality-measure-alignment-taskforce#upcoming-meeting-schedule-

Who Might Use This: Health Plans 

Alignment Resources and Helpful Documents

HCPLAN’s Guidance on Social Risk Adjustment

Initiative Description: The HCPLAN’s Health Equity Advisory Team (HEAT) meets regularly to identify and prioritize opportunities to advance health equity through alternative payment models (APMs). The HEAT’s Advancing Health Equity Through APMs Guidance on Social Risk Adjustment provides health care entities with a starting point for action by offering guidance on three core components of social risk adjustment: data collection (e.g., tools to social risk factors such as housing, food security, and transportation needs), payment incentives and mechanisms, and care transformation.

Strategic and Tactical Uses: For organizations collecting data on social risk factors, the HEAT guidance offers recommendations and considerations on how to incorporate those factors in social risk adjustments. By doing so, organizations can explore how to allocate health care resources more equitably and facilitate increased APM participation by safety net providers. The recommendations also include suggested actions so that the data collection, quality measurement, payment, and care transformation strategies that support social risk adjustment are aligned between groups.

Multi-payer Alignment Foundational Element: Aligning Key Payment Model Components, Advancing Health Equity

Timeframe: Active

For additional information, please visit http://hcp-lan.org/workproducts/APM-Guidance/Advancing-Health-Equity-Through-APMs-Social-Risk-Adjustment.pdf

Who Might Use This: Health Plans | Purchasers | Policy Makers |  Community-Based Organizations

Alignment Resources and Helpful Documents

HCPLAN’s Guidance for Health Care Entities
Partnering with Community-Based Organizations

Initiative Description: The HCPLAN’s Health Equity Advisory Team (HEAT) meets regularly to identify and prioritize opportunities to advance health equity through alternative payment models (APMs). The HEAT’s Guidance for Health Care Entities Partnering with Community-Based Organizations (CBOs) provides interested parties with recommendations and examples of health policy and payment mechanisms utilized to address health-related social needs (HRSNs), with a focus on collaboration between CBOs and health care entities involved in APM design and delivery.

Strategic and Tactical Uses: Advancing health equity is becoming a key priority in APMs and should be directly integrated into the design, implementation, and evaluation of innovative payment and delivery models. This guidance explains how involving CBOs as participants in payment models and including them in design and implementation helps health care partners move closer to achieving value-based care by addressing HRSNs. Partnerships with CBOs and health plans must be grounded in mutual respect, shared decision-making, and opportunities to build CBO capacity and financing.

Multi-payer Alignment Foundational Element: Aligning Key Payment Model Components, Advancing Health Equity

Timeframe: Active

For additional information, please visit https://hcp-lan.org/workproducts/APM-Guidance/HEAT-CBO-Partnership-Guidance.pdf

Who Might Use This: Health Plans |  Community-Based Organizations 

Collaboratives and Innovative Partnerships

Delaware Primary Care Reform Collaborative

Initiative Description: The Delaware Health Care Commission created the Delaware Primary Care Reform Collaborative as part of a statewide effort to expand value-based care delivery models. The Collaborative develops recommendations to strengthen the primary care system in Delaware and includes health plans, providers, and Delaware state health leaders. The Collaborative also creates annual reports that provide insight into the primary care workforce and other relevant trends.

Strategic and Tactical Uses: The Delaware Primary Care Reform Collaborative hosts open meetings and posts the schedule, along with meeting minutes and materials, to their website for the public to review. The Collaborative also publishes trends and guidelines that result from their meetings. Other state agencies and collaboratives can learn from and collaborate with the Delaware Primary Care Reform Collaborative to draw larger, nationwide alignment on value-based care solutions.

Multi-payer Alignment Foundational Element: Aligning Key Payment Model Components, Performance Measurement and Reporting

Timeframe: Active

For additional information, please visit https://dhss.delaware.gov/dhss/dhcc/collab.html

Who Might Use This: Health Plans | Purchasers | Providers | Policy Makers | Enabling Organizations | Community-Based Organizations 

Government Regulation and Guidance

Cures Act Final Rule for Data Sharing

Initiative Description: The Office of the National Coordinator for Health Information Technology’s (ONC) Cures Act Final Rule aims to promote secure access, exchange, and use of electronic health information. The Act accelerates the uptake of standardized application programming interfaces (APIs), requires IT developers to provide API capabilities for population health management, and increases patient access to electronic health information.

Strategic and Tactical Uses: This rule helps to standardize the measure reporting process by promoting interoperability and enabling access to patient-level data from health plans, providers, and patients. Organizations should continue to track ongoing updates to the data sharing infrastructure.

Multi-payer Alignment Foundational Element: Timely and Consistent Data Sharing

Timeframe: Active

For additional information, please visit https://www.healthit.gov/buzz-blog/category/21st-century-cures-act

Who Might Use This: Health Plans | Purchasers | Providers | Policy Makers | Enabling Organizations | Community-Based Organizations

Collaboratives and Innovative Partnerships

Core Quality Measures Collaborative Measure Sets

Initiative Description: The Core Quality Measures Collaborative (CQMC) develops and releases core sets of quality measures for 10 clinical focus areas (primary care, behavioral health, cardiology, gastroenterology, Human Immunodeficiency Virus/Hepatitis C, medical oncology, neurology, obstetrics and gynecology, orthopedics, and pediatrics). CQMC Workgroups convene on an annual basis to update the existing core sets, conduct yearly maintenance, and hear from a broad-based coalition of health care leaders to gain different perspectives on the measures and consider new ones.

Strategic and Tactical Uses: Organizations can compare the CQMC measure sets with other aligned sets to identify overlap and prioritize measures for multi-payer implementation initiatives. Organizations should also look to CQMC’s non-primary care measure sets with partners to increase industry alignment in specialty care.

Multi-payer Alignment Foundational Element: Performance Measurement and Reporting

Timeframe: Active

For additional information, please visit https://www.qualityforum.org/CQMC_Core_Sets.aspx

Who Might Use This: Health Plans | Providers | Purchasers

Collaboratives and Innovative Partnerships

Colorado Social Health Information Exchange (SHIE)

Initiative Description: The Colorado State Health Information Exchange (SHIE) will be a network of social health data, insights, and resources that helps people understand and access the best path to positive health outcomes. The state is actively building a unifying architecture that provides a secure overarching network for the sharing of health information between providers. Regional hubs are also part of the SHIE program and will ensure that SHIE development is driven by the needs and priorities of people in Colorado.

Strategic and Tactical Uses: Colorado providers will be able to use SHIE to meet their patients’ holistic needs more effectively, reduce administrative burden, and improve care utilization. The Office of eHealth Innovation (OeHI) is developing their regional health approach and will be soliciting applications from community care organizations seeking to share data through the architecture. Organizations across the health care industry can stay informed on OeHI’s progress by attending webinars and reviewing the Office’s helpful resources.

Multi-payer Alignment Foundational Element: Timely and Consistent Data Sharing, Advancing Health Equity

Timeframe: Upcoming

For additional information, please visit https://oehi.colorado.gov/SHIE

Who Might Use This: Health Plans | Providers | Policy Makers | Enabling Organizations

Collaboratives and Innovative Partnerships

Colorado Regulation 4-2-96 Concerning Primary Care Alternative Payment Model Parameters

Initiative Description: Colorado’s recent Regulation 4-2-96 directs the Division of Insurance (DOI) to establish aligned parameters for primary care alternative payment models (APMs). Regulation 4-2-96 aims to improve health care quality and outcomes in a manner that reduces health disparities, actively advances health equity, and increases the number of Coloradans who receive the right care at the right time and place at an affordable cost. The DOI engaged a broad array of organizations in order to gather feedback and insight prior to developing and promulgating a rule on quality measures, patient attribution, risk adjustment, and core competencies.

Strategic and Tactical Uses: Health insurance carriers must annually report on their use of the aligned APM parameters for primary care services. For plans issued or renewed on or after January 1, 2025, the APM Implementation Plan must conform to the alignment parameters in the new regulation. DOI will continue to engage organizations as the alignment parameters are reviewed and updated on an annual basis. Other state agencies can monitor Colorado’s experience with using regulation to drive alignment and consider adopting a similar strategy.

Multi-payer Alignment Foundational Element: Aligning Key Payment Model Components, Performance Measurement and Reporting

Timeframe: Upcoming

For additional information, please visit https://doi.colorado.gov/hb22-1325-primary-care-alternative-payment-models/

Who Might Use This: Health Plans

Collaboratives and Innovative Partnerships

Colorado Primary Care Payment Reform Collaborative

Initiative Description: Created through HB 19-1233 and convened by the Division of Insurance (DOI), the Colorado Primary Care Payment Reform Collaborative (PCPRC) has been meeting since July of 2019. The PCPRC focuses on developing strategies for increased investments in primary care and advises on the development of affordability standards and targets for carrier investments in primary care. The PCPRC is also working on strategies to reduce health care costs, implement evidence- and value-based incentives, direct resources to the patients and practices that need increased capacity, and sustain advanced primary care delivery models.

Strategic and Tactical Uses: The Collaborative has open meetings for members of the health care community to join and advocate for primary care strategies. Active members of the Colorado health care community are encouraged to join the Collective and influence the future of primary care payment reform in Colorado. Health plans, providers, and other organizations from other states can build a group like Colorado’s to align on primary care payment goals in their state.

Multi-payer Alignment Foundational Element: Aligning Key Payment Model Components, Performance Measurement and Reporting, Advancing Health Equity, Providing and Leveraging Technical Assistance

Timeframe: Active

For additional information, please visit https://doi.colorado.gov/insurance-products/health-insurance/health-insurance-initiatives/primary-care-payment-reform

Who Might Use This: Health Plans | Purchasers | Providers | Policy Makers | Enabling Organizations | Community-Based Organizations 

Government Regulation and Guidance

Centers for Medicare & Medicaid Services Medicaid Child Core Sets

Initiative Description: The Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) included provisions to strengthen the quality of care provided to and health outcomes of children in Medicaid and the Children’s Health Insurance Program (CHIP). It required the Department of Health and Human Services (HHS) to identify and publish a core measure set of children’s health care quality measures for voluntary use by state Medicaid and CHIP programs and to review and update the list annually. Beginning in 2024, all states are required to report on the Child Core Set, which will continue to be updated annually.

Strategic and Tactical Uses: Organizations can compare the Medicaid Child Core Set with other aligned measure sets in use, to identify overlap and prioritize measures for multi-stakeholder implementation initiatives.

Multi-payer Alignment Foundational Element: Performance Measurement and Reporting

Timeframe: Active

For additional information, please visit https://www.medicaid.gov/medicaid/quality-of-care/performance-measurement/adult-and-child-health-care-quality-measures/childrens-health-care-quality-measures/index.html

Who Might Use This: Health Plans |  Providers | Enabling Organizations | Policy Makers 

Government Regulation and Guidance

Centers for Medicare & Medicaid Services Medicaid Adult Core Sets

Initiative Description: The Social Security Act (Section 1139B) requires the Department of Health and Human Services (HHS) to identify and publish a core set of health care quality measures for adult Medicaid enrollees and to review and update the list annually. The Adult Core Set includes a range of quality measures encompassing both physical and behavioral health. Beginning in 2024, all states are required to report on the behavioral health measures of the Adult Core Set, which will continue to be updated annually.

Strategic and Tactical Uses: Organizations can compare the Medicaid Adult Core Sets with other aligned measure sets in use, to identify commonalities and prioritize measures for multi-stakeholder implementation initiatives.

Multi-payer Alignment Foundational Element: Performance Measurement and Reporting

Timeframe: Active

For additional information, please visit https://www.medicaid.gov/medicaid/quality-of-care/performance-measurement/adult-and-child-health-care-quality-measures/adult-health-care-quality-measures/index.html

Who Might Use This: Health Plans | Providers | Policy Makers | Enabling Organizations

Government Regulation and Guidance

California Medi-Cal Managed Care Plan Requirements

Initiative Description: Beginning in 2024, the Department of Health Care Services (DHCS) is requiring plans to identify health disparities and inequities in access, utilization, and outcomes by race, ethnicity, language (including limited English proficiency), sexual orientation, and gender identity. Based on these disparities, managed care plans are required to have focused efforts to improve health outcomes within the most impacted groups and communities.

Strategic and Tactical Uses: California managed care plans have to implement new rules and policies in order to meet the requirements of DHCS. Medicaid agencies in other states may consider including similar requirements in their managed care plan requirements to advance health equity. Non-Medicaid plans may also consider adopting similar requirements to improve health equity among their own members. Interested organizations can also draw lessons from their approach to data collection and measure stratification.

Multi-payer Alignment Foundational Element: Advancing Health Equity

Timeframe: Active

For additional information, please visit https://www.dhcs.ca.gov/CalAIM/Pages/MCP-RFP.aspx

Who Might Use This: Health Plans | Policy Makers

Collaboratives and Innovative Partnerships

California Advanced Primary Care Initiative

Initiative Description: The California Quality Collaborative (led by the Purchaser Business Group on Health) and the Integrated Healthcare Association convene purchasers, health plans, and providers in California to strengthen the primary care delivery system. As part of this effort, health plans signed a Memorandum of Understanding (MOU) that commits them to shared primary care measures and a roadmap to advancing primary care in California. The Initiative culminates with the Payment Model Demonstration Project (July 2024-December 2025) to test a common value-based payment model with approximately 30 independent practices.

Strategic and Tactical Uses: The Initiative represents a multifaceted pilot that requires coordinated measure implementation, data sharing, and trust. In order to further statewide alignment, additional organizations in California are encouraged to sign the MOU and join the Initiative. Non-California health plans can use the MOU as a blueprint to build similar collaboratives in their state. The Advanced Primary Care Measure Set and Roadmap to Advanced Primary Care are also available for organizations looking to better align their primary care services.

Multi-payer Alignment Foundational Element: Aligning Key Payment Model Components, Performance Measurement and Reporting, Technical Assistance, Timely and Consistent Data Sharing

Timeframe: Active

For additional information, please visit https://www.pbgh.org/initiative/ca-advanced-primary-care-initiative/

Who Might Use This: Health Plans | Purchasers | Providers

Collaboratives and Innovative Partnerships<em

Arkansas’s Multi-State, Multi-Payer Collaborative

Initiative Description: Since 2011, Arkansas Blue Cross and Blue Shield, Blue Cross and Blue Shield of Kansas City, and Blue Cross and Blue Shield of Oklahoma (BCBS health plans) have engaged in a regional, multi-payer learning and technical assistance effort. The effort started as an initiative to stay connected, share lessons learned, and demonstrate best practices related to the Comprehensive Primary Care Initiative, but now the Collaborative has spanned two additional Innovation Center models (Comprehensive Primary Care Plus and Primary Care First). The multi-state effort has continued to grow organically beyond the models and BCBS health plans.

Strategic and Tactical Uses: Regional health plans in Arkansas, Oklahoma, and the Kansas City area participate in the multi-state, multi-payer Collaborative and are involved in alignment efforts for quality measures, technical assistance, and information exchange. Health plans outside of the area can use the collaborative as an example of regional plans coming together to align and can explore forming a Collaborative in their own region.

Multi-payer Alignment Foundational Element: Performance Measurement and Reporting, Advancing Health Equity, Timely and Consistent Data Sharing, Providing and Leveraging Technical Assistance

Timeframe: Active

For additional information, please email Alicia Berkemeyer (amberkemeyer@arkbluecross.com) or Adam Whitlock (mawhitlock@arkbluecross.com).

Who Might Use This: Health Plans

Government Regulation and Guidance

2024 Physician Fee Schedule: Medicare
Shared Savings Program Final Rule

Initiative Description: The Centers for Medicare & Medicaid Services (CMS) issued the calendar year 2024 Medicare Physician Fee Schedule (PFS) final rule that includes changes to the Medicare Shared Savings Program (MSSP). The final rule establishes a new Medicare Clinical Quality Measure (CQM) collection type for accountable care organizations (ACOs) and aligns standards for data completeness, benchmarking, and scoring ACOs with the Merit-based Incentive Payment System (MIPS). The rule applies a health equity adjustment to an ACO’s MIPS Quality performance category score when calculating shared savings payments. It also reduces barriers in the adoption of digital measurement to allow the Shared Savings Program to align with the Universal Foundation for adults in 2025.

Strategic and Tactical Uses: The 2024 Physician Fee Schedule final rule advances CMS’s overall value-based care strategy of growth, alignment, and equity. Organizations can apply model design components to other alternative payment model arrangements. Data and infrastructure changes that support the move to digital quality measures will benefit value-based care programs across the health plan landscape and reduce provider burden. The health equity adjustment in shared savings payment calculations will support and encourage ACOs to deliver high-quality care while also serving a high proportion of underserved individuals.

Multi-payer Alignment Foundational Element(s): Performance Measurement and Reporting, Aligning Key Payment Model Components, Advancing Health Equity

Timeframe: Active

For additional information, please visit https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2024-medicare-physician-fee-schedule-final-rule-medicare-shared-savings-program

Who Might Use This: Health Plans | Providers

Government Regulation and Guidance

NEW
Medicaid and Children’s Health Insurance Program
Managed Care Access, Finance and Quality Final Rule

Initiative Description: On April 22, 2024, Medicaid and Children’s Health Insurance Program (CHIP) finalized two key regulations: “Ensuring Access to Medicaid Services” (Access Rule) and “Medicaid, CHIP Managed Care Access, Finance, and Quality” (Managed Care Rule), aimed at improving access to care in Medicaid across delivery systems (fee-for-service and managed care) and authorities (state plan and waiver services). The Managed Care Rule addresses five primary areas: (1) access in managed care, including network adequacy, (2) state directed payments, (3) medical loss ratio standards, (4) in lieu of services and settings (ILOSs), and (5) quality and performance assessment.

Strategic and Tactical Uses: The new rule will improve how managed care plans serve their members. Plans will need to collaborate closely with providers to implement the requirements of the rule.

Multi-payer Alignment Foundational Element: Aligning Key Payment Model Components, Timely and Consistent Data Sharing

Timeframe: Active

For additional information, please visit https://www.medicaid.gov/medicaid/managed-care/guidance/medicaid-and-chip-managed-care-final-rules/index.html

Who Might Use This: Health Plans | Providers | Policy Makers

Government Regulation and Guidance

NEW
2025 Hospital Inpatient Prospective Payment System and Long-Term
Care Hospital Prospective Payment System Proposed Rule

Initiative Description: On April 10, 2024, the Centers for Medicare & Medicaid Services (CMS) issued the fiscal year (FY) 2025 Medicare hospital inpatient prospective payment system (IPPS) and long-term care hospital prospective payment system (LTCH PPS) proposed rule.

Strategic and Tactical Use: The proposed rule would update Medicare fee-for-service payment rates and policies for inpatient hospitals and LTCHs for FY 2025. CMS is publishing this proposed rule to meet the legal requirements to update Medicare payment policies for IPPS hospitals and LTCHs on an annual basis.

Multi-payer Alignment Foundational Element: Aligning Key Payment Model Components

Timeframe: Upcoming

For additional information, please visit https://www.cms.gov/newsroom/fact-sheets/fy-2025-hospital-inpatient-prospective-payment-system-ipps-and-long-term-care-hospital-prospective

Who Might Use This: Health Plans |  Providers

Government Regulation and Guidance

NEW
Updates to the Office of Management and Budget’s
Race and Ethnicity Statistical Standards

Initiative Description: The Office of Management and Budget (OMB) is charged with developing and overseeing the implementation of Government-wide principles, policies, standards, and guidelines concerning the development, presentation, and dissemination of statistical information. Since 1977, race and ethnicity data questions and categories have been revised one time, resulting in the 1997 Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity. In 2023, OMB announced updates to the categories and requested that the public review and submit comments on revisions. OMB released its updated set of questions and categories in March 2024.

Strategic and Tactical Uses: The updated questions and categories are more comprehensive and will better reflect various patient identities. Implementing OMB standards for race and ethnicity data collection helps promote consistent and accurate data collection within and across organizations, which is critical to advancing health equity initiatives that measure disparities.

Multi-payer Alignment Foundational Element: Timely and Consistent Data Sharing, Advancing Health Equity

Timeframe: Active

For additional information, please visit https://www.federalregister.gov/documents/2024/03/29/2024-06469/revisions-to-ombs-statistical-policy-directive-no-15-standards-for-maintaining-collecting-and

Who Might Use This: Health Plans | Purchasers |  Providers | Policy Makers

Government Regulation and Guidance

NEW
Contract Year 2025 Medicare
Advantage and Part D Final Rule

Initiative Description: In April 2024, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that revises the Medicare Advantage Program, Medicare Prescription Drug Benefit Program (Medicare Part D), Medicare Cost Plan Program, Programs of All-Inclusive Care for the Elderly (PACE), and Health Information Technology Standards and Implementation Specifications. The changes strengthen protections and guardrails for prospective enrollees, encourage healthy competition, ensure Medicare Advantage and Part D plans best meet the needs of enrollees, and promote access to behavioral health care providers, equity in coverage, and improved supplemental benefits.

Strategic and Tactical Uses: The final rule is designed to provide a more flexible, transparent, and equitable framework for beneficiaries to receive high-quality, affordable health care. For other organizations, these changes represent important areas to monitor for compliance, strategic adjustments, and opportunities to deliver improved patient care through innovative plan offerings.

Multi-payer Alignment Foundational Elements: Aligning Key Payment Model Components

Timeframe: Active

For additional information, please visit https://www.cms.gov/newsroom/fact-sheets/contract-year-2025-medicare-advantage-and-part-d-final-rule-cms-4205-f

Who Might Use This:  Health Plans | Providers

Collaboratives and Innovative Partnerships

Partnership to Align Social Care

Initiative Description: The Partnership to Align Social Care convenes health stakeholders to develop strategies that enable partnerships between health care organizations and networks of community-based organizations (CBOs) delivering social care services. The Partnership provides thought leadership on ways to address health-related social needs with CBOs, contracting and billing guidance between health care and community care networks, and how to integrate health equity into clinical care.

Strategic and Tactical Uses: Value-based care provides an opportunity for organizations to develop payment arrangements that include services related to health equity. Organizations should look to the Partnership to determine how to work with CBOs and better integrate health and social care in their contracts.

Multi-payer Alignment Foundational Element: Aligning Key Payment Model Components, Advancing Health Equity

Timeframe: Active

For additional information, please visit https://www.partnership2asc.org/

Who Might Use This: Health Plans |  Providers | Community-Based Organizations 

Collaboratives and Innovative Partnerships

The Center for Medicare & Medicaid Innovation Models

Initiative Description: The Center for Medicare and Medicaid Innovation develops new payment and service delivery models in accordance with the requirements of section 1115A of the Social Security Act. In 2021, the Innovation Center set a strategic goal for its next ten years: to transform the health system into one that achieves equitable outcomes through high-quality, affordable, person-centered care. As part of this, the Innovation Center aims to design models that are inclusive of a variety of providers to increase beneficiaries’ access to high-quality care. Model categories include accountable care models, disease-specific and episode-based models, health plan models, prescription drug models, state and community-based models, and statutory models.

Strategic and Tactical Uses: Innovation Center models have implications for multi-payer alignment efforts across several priority areas, including increased integration of specialists and safety-net providers in value-based care, integration of behavioral health services, alignment of quality measures, and health equity initiatives.

Multi-payer Alignment Foundational Element: Aligning Key Payment Model Components, Performance Measurement and Reporting, Advancing Health Equity, Timely and Consistent Data Sharing, Providing and Leveraging Technical Assistance

Timeframe: Active

For additional information, please visit https://www.cms.gov/priorities/innovation/models#views=models

Who Might Use This: Health Plans | Purchasers | Providers | Policy Makers | Enabling Organizations | Community-Based Organizations 

Government Regulation and Guidance

NEW
2025 Physician Fee Schedule: Medicare
Shared Savings Program Proposed Rule

Initiative Description: On July 10, 2024, the Centers for Medicare & Medicaid Services (CMS) issued the calendar year (CY) 2025 Medicare Physician Fee Schedule (PFS) proposed rule that includes changes to the Shared Savings Program to further advance Medicare’s value-based care strategy of growth, alignment, and equity.

Strategic and Tactical Uses: The proposed rule establishes a new “prepaid shared savings” option to assist eligible Accountable Care Organizations (ACOs) with a history of earning shared savings to encourage investments that would aid beneficiaries, such as investments in direct beneficiary services and investments to improve care coordination through staffing or health care infrastructure. The rule also proposes modifications to the Shared Savings Program’s financial methodology to encourage ACO participation in the Shared Savings Program by removing barriers for ACOs serving underserved communities and increasing incentives to enter and remain in the program through the application of a proposed health equity benchmark adjustment. New policies also better align quality measure reporting with the Universal Foundation.

Multi-payer Alignment Foundational Element: Performance Measurement and Reporting, Aligning Key Payment Model Components, Advancing Health Equity

Timeframe: Upcoming

For additional information, please visit https://www.cms.gov/newsroom/fact-sheets/fact-sheet-calendar-year-cy-2025-medicare-physician-fee-schedule-proposed-rule-cms-1807-p-medicare

Who Might Use This: Health Plans | Providers

Collaboratives and Innovative Partnerships

NCCARE360

Initiative Description: NCCARE360 is a statewide network that unites health care and human services organizations with a shared technology. The NCCARE360 implementation team includes United Way of North Carolina/NC 211, Unite Us, and Expound Decision Systems. These organizations link people and families to free and local health and human services resources, offer a platform for secure and timely care coordination and outcomes, and create a data repository model to manage social determinants of health resources in North Carolina.

Strategic and Tactical Uses: North Carolina community-based organizations, health plans, and health systems can join the NCCARE360 network and gain access to the resources that they provide. Outside of North Carolina, organizations can look to form a public-private partnership like NCCARE360 and create a similar cross-sectoral referral technology platform or expand their current platforms to a statewide scale.

Multi-payer Alignment Foundational Element: Timely and Consistent Data Sharing, Advancing Health Equity

Timeframe: Active

For additional information, please visit https://nccare360.org/

Who Might Use This: Health Plans | Providers |  Enabling Organizations | Community-Based Organizations

Collaboratives and Innovative Partnerships

National Committee for Quality Assurance Health Equity Accreditation Programs

Initiative Description: National Committee for Quality Assurance’s (NCQA) Health Equity Accreditation and Health Equity Accreditation Plus are a guide to help health systems, health plans and other care organizations advance health equity. The programs assist organizations in meeting their health equity related goals by building an internal culture that supports the organization’s external health equity work, identifying opportunities to reduce health inequities and improve care, collecting data on community social risk factors and patients’ social needs, and establishing partnerships that support community-based organizations.

Strategic and Tactical Uses: Many organizations are pursuing NCQA’s Accreditation to realize their health equity goals, and Accreditations are increasingly required by state Medicaid agencies for participating plans. Widespread adoption of NCQA’s Accreditation will help accelerate the shift toward more equitable, effective, and sustainable health care practices. The collective effort also supports a cultural shift within the health care industry, prioritizing and normalizing equity as a fundamental aspect of quality care.

Multi-payer Alignment Foundational Element: Advancing Health Equity

Timeframe: Active

For additional information, please visit https://www.ncqa.org/programs/health-equity-accreditation/

Who Might Use This: Health Plans | Providers | Policy Makers

Collaboratives and Innovative Partnerships

Minnesota Community Measurement

Initiative Description: Minnesota Community Measurement (MCM) is using data to improve health care in the region. They work with doctors, hospitals, clinics, insurance companies, purchasers, and state agencies to design measures, and then collect, analyze, and share actionable data on health care quality and cost. MCM releases a variety of annual public reports, including cost and utilization, health care quality, disparities by plan and demographics, and spotlight reports. These reports help consumers compare and choose clinics based on quality and cost ratings, understand the care they should receive, and learn how to save money on their care.

Strategic and Tactical Uses: MCM hosts public meetings and forums in order to gather community feedback on upcoming measures, guiding principles, specifications, and priorities. Entities in Minnesota are also encouraged to become members of MCM and help further their mission of using data to improve the health care industry.

Multi-payer Alignment Foundational Element: Performance Measurement and Reporting, Timely and Consistent Data Sharing

Timeframe: Active

For additional information, please visit https://mncm.org/

Who Might Use This: Health Plans | Providers | Purchasers 

Collaboratives and Innovative Partnerships

Michigan Multipayer Initiatives

Initiative Description: Michigan Multipayer Initiatives (MMI) serves as a convening and policy alignment hub that brings together stakeholders to develop, implement, evaluate, and spread effective models that sustain high-quality, comprehensive, accountable primary care. MMI has a history of convening large statewide multi-payer demonstrations, including several Innovation Center demonstrations and voluntary multi-payer efforts. MMI’s 2023-2025 Priority Focus Areas include advancing alternative payment models, improving health equity, reducing provider burden, and advancing performance measure alignment.

Strategic and Tactical Uses: MMMI publishes resources that organizations can use to understand how Michigan stakeholders are aligning, including evaluations of multi-payer advanced primary care demonstrations. Michigan stakeholders interested in learning more or sharing their ideas can reach out to the MMI team.

Multi-payer Alignment Foundational Element: Providing and Leveraging Technical Assistance

Timeframe: Active

For additional information, please visit https://mimultipayerinitiatives.org/about/

Who Might Use This: Health Plans 

Alignment Resources and Helpful Documents

The Health Care Transformation Task Force’s Resources and Perspectives

Initiative Description: The Health Care Transformation Task Force is a nonprofit, private-sector consortium comprising patient advocacy organizations, providers, payers, and health care purchasers dedicated to creating a health care delivery system that achieves equitable outcomes through high-quality, affordable, and person-centered care. The Task Force has developed best practices and toolkits for implementing value-based payment models and identified actionable policy recommendations.

Strategic and Tactical Uses: The Task Force’s compendium of resources on value-based care topics — including accountable care, bundled payments, maternal health, and health equity — is a great way to learn about emerging topics, particularly for organizations new to value-based care.

Multi-payer Alignment Foundational Element: Providing and Leveraging Technical Assistance

Timeframe: Active

For additional information, please visit https://hcttf.org/resources-perspectives/

Who Might Use This: Health Plans | Purchasers | Providers | Policy Makers | Enabling Organizations | Community-Based Organizations

Alignment Resources and Helpful Documents

The Maternal Health Hub’s Maternal Health Quality Report

Initiative Description: The Maternal Health Hub was a forum to share learnings and best practices, payment reform evidence, and resources to accelerate the identification and dissemination of effective value-based care delivery and payment strategies for maternity care. The Hub produced guidance on the development and implementation of maternity patient reported experience measures (PREMs) and patient reported outcome measures (PROMs) by identifying innovative patient-focused measures to fill existing measure gaps.

Strategic and Tactical Uses: While the hub no longer meets regularly, this framework was one of the first to focus specifically on a priority area like maternal health/birth outcomes and can serve as a model for other prioritized public health domains with implications for quality measure alignment and health equity.

Multi-payer Alignment Foundational Element: Advancing Health Equity, Performance Measurement and Reporting

Timeframe: Archived

For additional information, please visit https://maternalhealthhub.org/wp-content/uploads/2023/04/Evolving-the-Quality-Measurement-Enterprise_Final-Brief.pdf

Who Might Use This: Health Plans

Collaboratives and Innovative Partnerships

Kentuckiana Health Collaborative

Initiative Description: The Kentuckiana Healthcare Collaborative (KHC) is a coalition of businesses and health care stakeholders focused on improving health care quality, making health care more affordable, and promoting equitable health care. KHC leads efforts for consolidated measurement and reporting by working with health plans to collect claims data that informs a quality measure list and reporting.

Strategic and Tactical Uses: KHC releases the Kentucky Core Healthcare Measures Set (KCHMS) bi-yearly. The measure set includes 42 primary care quality measures that serve as the foundation for KHC’s consolidated reporting. The set aims to reduce provider reporting complexity and align Kentucky’s health care organizations around a common set of quality measures. Other states can look to KHC for how to publicly report on quality measures.

Multi-payer Alignment Foundational Element: Performance Measurement and Reporting

Timeframe: Active

For additional information, please visit https://khcollaborative.org

Who Might Use This: Health Plans | Purchasers 

Alignment Resources and Helpful Documents

Integrated Healthcare Association’s Align. Measure. Perform. Program

Initiative Description: The Integrated Healthcare Association’s (IHA) Align. Measure. Perform. (AMP) program is an initiative designed to improve health care quality and reduce costs through a coordinated approach in California. The program seeks to align incentives, measure performance, and reward high-quality, cost-effective care. AMP has four program components: an aligned measure set and benchmarking, incentive design, public reporting, and public recognition. Today, 16 health plans and more than 200 physician organizations participate in AMP.

Strategic and Tactical Uses: Plans, providers, and patients in California can participate in AMP programs by implementing measures, identifying improvement opportunities, and reviewing publicly reported results to make decisions about their health care providers. Other states or convening organizations can look to the AMP program for guidance on collective action toward value-based payment and quality measure improvement.

Multi-payer Alignment Foundational Element: Aligning Key Payment Model Components, Timely and Consistent Data Sharing, Performance Measurement and Reporting

Timeframe: Active

For additional information, please visit https://iha.org/performance-measurement/amp-program/

Who Might Use This: Health Plans | Providers

Government Regulation and Guidance

Updated Centers for Medicare & Medicaid Services Health Equity Framework

Initiative Description: The Centers for Medicare & Medicaid Services (CMS) has updated the agency’s Framework for Health Equity, expanding upon its initial 2022-2032 priorities. The five priorities for reducing disparities in health include: expanding the collection, reporting, and analysis of standardized data; assessing causes of disparities within CMS programs, and addressing inequities in policies and operations to close gaps; building capacity of health care organizations and the workforce to reduce disparities in health and health care; advancing language access, health literacy, and the provision of culturally tailored services; and increasing all forms of accessibility to health care services and coverage.

Strategic and Tactical Uses: The Framework offers insight on alignment priorities for health equity data collection, sharing, and use to reduce observed health disparities.

Multi-payer Alignment Foundational Element: Advancing Health Equity

Timeframe: Active

For additional information, please visit https://www.cms.gov/About-CMS/Agency-Information/OMH/health-equity-programs/cms-framework-for-health-equity

Who Might Use This: Health Plans | Purchasers | Providers | Policy Makers | Enabling Organizations | Community-Based Organizations

Government Regulation and Guidance

Final Rule to Expand Access to Health Information and Improve the Prior Authorization Process

Initiative Description: The final rule requires Medicare Advantage (MA) organizations, Medicaid and the Children’s Health Insurance Program (CHIP) fee-for-service (FFS) programs, Medicaid managed care plans, CHIP managed care entities, and issuers of Qualified Health Plans (QHPs) offered on the Federally-Facilitated Exchanges (FFEs) to improve the electronic exchange of health information and prior authorization processes for medical items and services. It also requires the same entities to implement a Health Level 7 (HL7) Fast Healthcare Interoperability Resources (FHIR) prior authorization application programming interface (API), which can be used to facilitate a more efficient electronic prior authorization process between providers and health plans by automating the end-to-end prior authorization process. Compliance requirements will begin in January 2027.

Strategic and Tactical Uses: Medicare FFS has already implemented an electronic prior authorization API, demonstrating the efficiencies other health plans could realize by implementing such an API. By implementing the requirements, the prior authorization process will reduce administrative burden on the healthcare workforce, empower clinicians to spend more time with patients, and prevent avoidable delays in care for patients. Health plans can prepare for compliance ahead of the start date January 1, 2027.

Multi-payer Alignment Foundational Element: Timely and Consistent Data Sharing

Timeframe: Upcoming

For additional information, please visit https://www.cms.gov/newsroom/press-releases/cms-finalizes-rule-expand-access-health-information-and-improve-prior-authorization-process

Who Might Use This: Health Plans |  Providers |  Enabling Organizations

Collaboratives and Innovative Partnerships

Covered California’s Quality Transformation Initiative

Initiative Description: Covered California’s Quality Transformation Initiative (QTI) is focused on improving care for a small number of clinically important conditions for which there are major opportunities for improvement and established measures in current use. The four clinical areas of focus for improvement that are subject to Quality Transformation Fund payments are Controlling High Blood Pressure, Comprehensive Diabetes Care: Hemoglobin A1c Control, Colorectal Cancer Screening, and Childhood Immunization Status. Qualified Health Plan (QHP) issuers that fail to meet specified measure benchmarks will be required to make payments to the Quality Transformation Fund. For Measurement Year 2023, QHP final scores will be confirmed in September 2024, and issuer performance will be finalized and published by Spring 2025.

Strategic and Tactical Uses: QHP issuers in California can join the QTI to benefit from the financial incentives and quality measure improvements. For QHP issuers outside of California or other state agencies, this initiative can be used to set a baseline for financial incentives and quality measure alignment.

Multi-payer Alignment Foundational Element: Aligning Key Payment Model Components, Performance Measurement and Reporting

Timeframe: Active

For additional information, please visit https://hbex.coveredca.com/stakeholders/plan-management/qti/

Who Might Use This: Health Plans | Providers 

Government Regulation and Guidance

Civitas Networks for Health

Initiative Description: Civitas Networks for Health (Civitas) brings together organizations that focus on improving health in communities throughout the country through data-led multi-stakeholder collaboration. Civitas focuses on increasing collaboration and shared learning, providing thought leadership and technical expertise, and educating public and private entities about the benefits, functions, and roles of Civitas’ community. Members and topics include all-payer claims databases, health information exchanges, regional health improvement collaboratives, quality improvement organizations, and the emerging Health Data Utility model.

Strategic and Tactical Uses: Organizations can become members of Civitas to participate in multi-site workgroups and projects alongside organizations in pursuit of advancing interoperability and data-sharing alignment. Organizations can also learn about relevant reports, resources, and policy briefings.

Multi-payer Alignment Foundational Element: Timely and Consistent Data Sharing

Timeframe: Active

For additional information, please visit https://www.civitasforhealth.org/

Who Might Use This: Health Plans | Purchasers | Enabling Organizations | Policy Makers 

Government Regulation and Guidance

Centers for Medicare & Medicaid Services Meaningful Measures Initiative

Initiative Description: The Meaningful Measures Initiative addresses measurement gaps, reduces burden, and increases efficiency by: (1) Using only high-value quality measures impacting key quality domains; (2) Aligning measures across value-based programs and across partners, including the Centers for Medicare & Medicaid (CMS), federal, and private entities; (3) Prioritizing outcome and patient-reported measures; (4) Transforming measures to be fully digital and incorporating all-payer data; (5) Developing and implementing measures reflecting social drivers/determinants of health (SDOH).

Strategic and Tactical Uses: Organizations can look toward the Meaningful Measures Initiative when developing their measure strategy. Industry movement toward similar goals (e.g., digital quality measurement) helps reduce fragmentation.

Multi-payer Alignment Foundational Element: Performance Measurement and Reporting

Timeframe: Active

For additional information, please visit https://www.cms.gov/medicare/quality/meaningful-measures-initiative

Who Might Use This: Health Plans

Collaboratives and Innovative Partnerships

California Health and Human Services
Data Exchange Framework

Initiative Description: The Data Exchange Framework (DxF) is an agreement across health and human services systems and providers to share information safely and effectively. The Framework aims to make data available to drive decisions and outcomes, promote individual data access, reinforce data privacy and security, and establish clear and transparent terms and conditions for data collection, exchange, and use. Starting January 2024, health care entities are required to exchange real-time information with each other and with public health and social services for treatment, payment, and health care operations.

Strategic and Tactical Uses: California organizations are required to use the Framework to communicate with each other regarding the sharing of patient data. States outside of California can apply a similar data exchange framework to improve data sharing for their own populations.

Multi-payer Alignment Foundational Element: Timely and Consistent Data Sharing

Timeframe: Active

For additional information, please visit https://www.cdii.ca.gov/committees-and-advisory-groups/data-exchange-framework/

Who Might Use This: Health Plans | Purchasers | Providers | Policy Makers | Community-Based Organizations | Enabling Organizations

Government Regulation and Guidance

Alternative Payment Model Performance Pathway

Initiative Description: The Alternative Payment Model (APM) Performance Pathway (APP) is an optional Merit-based Incentive Payment System (MIPS) reporting and scoring pathway for MIPS-eligible clinicians who are also participants in MIPS APMs. Performance is measured across three areas: quality, improvement activities, and promoting interoperability. The idea behind the measure set is to reduce burden, create new scoring opportunities for participants in MIPS APMs, and encourage participation in APMs through alignment.

Strategic and Tactical Uses: APM entities in a MIPS APM may report the APP on behalf of their MIPS-eligible clinicians. Accountable Care Organizations (ACOs) participating in the Medicare Shared Savings Program are required to report the APP for the purpose of assessing their quality performance for that program. Groups and individuals may also report the APP on behalf of their MIPS-eligible clinicians.

Multi-payer Alignment Foundational Element: Aligning Key Payment Model Components, Performance Measurement and Reporting

Timeframe: Active

For additional information, please visit https://qpp.cms.gov/mips/apm-performance-pathway

Who Might Use This:  Providers

Government Regulation and Guidance

Trusted Exchange Framework Common Agreement Standards

Initiative Description: The Trusted Exchange Framework Common Agreement (TEFCA) was published by the Office of the National Coordinator for Health Information Technology (ONC) to establish the infrastructure model and governing approach for users in different networks to securely share basic clinical information with each other, all under commonly agreed-to expectations and rules. TEFCA describes a common set of non-binding, foundational principles for trust policies and practices that can help facilitate an exchange among organizations. These principles include standardization, transparency, cooperation and non-discrimination, privacy, security, patient safety, access, and data-driven accountability.

Strategic and Tactical Uses: Currently, providers may have disparate access to patient data across multiple networks, adding to their administrative burden. Patients may also struggle to access their own data easily. As TEFCA becomes operational, organizations and patients will benefit from improved access to data as TEFCA aims to create seamless nationwide exchange.

Multi-payer Alignment Foundational Element: Timely and Consistent Data Sharing

Timeframe: Active

For additional information, please visit https://www.healthit.gov/topic/interoperability/policy/trusted-exchange-framework-and-common-agreement-tefca

Who Might Use This: Health Plans |  Providers | Policy Makers

Government Regulation and Guidance

The Universal Foundation Measure Set

Initiative Description: In an effort to align measures that drive quality improvement and care transformation, the Centers for Medicare & Medicaid Services (CMS) selected adult and pediatric measures that promote the best, safest, and most equitable care for individuals across critical quality areas: wellness and prevention, chronic conditions, behavioral health, person-centered care, and seamless care coordination. The measures will be used across CMS quality programs and prioritized for stratification and digitization.

Strategic and Tactical Uses: Organizations can compare the Universal Foundation with other aligned measure sets to identify overlap and prioritize measures for multi-payer implementation initiatives. The Universal Foundation will continue to evolve over time with population-specific “add-on” measure sets.

Multi-payer Alignment Foundational Element: Performance Measurement and Reporting

Timeframe: Active

For additional information, please visit https://www.cms.gov/aligning-quality-measures-across-cms-universal-foundation

Who Might Use This: Health Plans |  Providers | Purchasers |  Policy Makers

Collaboratives and Innovative Partnerships

North Carolina Healthy Opportunities Pilots

Initiative Description: The North Carolina Health Opportunities Pilots (HOP), part of NC’s Section 1115 waiver, is a comprehensive program dedicated to solving non-medical needs for Medicaid enrollees. HOP covers the cost of 29 interventions defined and priced in the Department of Health and Human Services’ Pilot Fee Schedule, including housing navigation and move-in fees, food and nutrition access care, transportation reimbursement, and violence intervention services. The North Carolina Department of Health and Human Services intends to expand HOP services to new populations beginning with those eligible for Tailored Care Management.

Strategic and Tactical Uses: HOP is the country’s first comprehensive program to reimburse for such a broad set of services and, unlike traditional Medicaid services, supports the enrollee and their family (e.g., an enrollee who is food insecure will receive a food box covering the entire family). Other states can use North Carolina’s HOP program to evaluate the benefits of non-medical interventions. Based on the reports from the Department of Health and Human Services, similar programs can be implemented across other states, helping to reduce health care costs and improve population health.

Multi-payer Alignment Foundational Element: Advancing Health Equity

Timeframe: Active

For additional information, please visit https://www.ncdhhs.gov/about/department-initiatives/healthy-opportunities/healthy-opportunities-pilots and https://ncmedicaljournal.com/article/94844-reflecting-on-nearly-two-years-of-north-carolina-s-healthy-opportunities-pilots

Who Might Use This: Health Plans | Providers |  Community-based Organizations

Innovative Initiatives and Partnerships

Core Quality Measures Collaborative Measure Sets

Initiative Description: The Core Quality Measures Collaborative (CQMC) develops and releases core sets of quality measures for 10 focus areas. The CQMC Workgroups convene on an annual basis to update the existing core sets, conduct yearly maintenance, and dialogue with members from a variety of stakeholder groups to gain different perspectives on the measures and consider new ones.

Strategic and Tactical Uses: Organizations can compare the CQMC Measures Collaborative Core Measure Sets with other aligned measure sets in use to identify overlap and prioritize measures for multi-payer implementation initiatives.

Multi-payer Alignment Foundational Element: Performance Measurement

Timeframe: Active

For additional information, please visit https://www.qualityforum.org/CQMC_Core_Sets.aspx

Who Might Use This: Payers | Providers | Purchasers