Accelerating and Aligning Clinical Episode Payment Models Chapter 4: Maternity Care
- January 17, 2025
- Posted by: Health Care Payment Learning & Action Network
- Categories:
No Comments
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
Government Regulation and Guidance
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
2025 Hospital Inpatient Prospective Payment System and Long-Term
Care Hospital Prospective Payment System Final Rule
Initiative Description: On August 1, 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) final rule.
Strategic and Tactical Use: The new rule will update Medicare fee-for-service payment rates and policies for inpatient hospitals and LTCHs for FY 2025. CMS is publishing this final 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: Active
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
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
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
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
Government Regulation and Guidance
NEW
2025 Physician Fee Schedule: Medicare
Shared Savings Program Final Rule
Initiative Description:On November 1, 2024, the Centers for Medicare & Medicaid Services (CMS) finalized new policies in the calendar year (CY) 2025 Medicare Physician Fee Schedule (PFS) final 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 final 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 includes 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: Active
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
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: MMI 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
Collaboratives and Innovative Partnerships
Kentuckiana Health Collaborative
Initiative Description: The Kentuckiana Health 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
Collaboratives and Innovative Partnerships
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
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
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
Who Might Use This: Health Plans
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
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
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
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
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
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
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
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
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
The Alignment Landscape includes a search bar and three filters to help narrow down items that are relevant to your alignment goals.
Filters:
The Timeframe section
filters by upcoming, active and archived opportunities and resources:
The Resource or Opportunity Type section filters by initiatives and resources which are categorized into the following three groups:
The Multi-Payer Alignment Foundational Elements section filters by key features of multi-payer initiatives, defined by the Duke-Margolis Institute for Health Policy.
Each card includes background information on the alignment opportunity, including anticipated strategic and tactical uses and audience, associated foundational element(s), timeframe, and where to find additional information.
The Alignment Landscape includes a search bar and three filters to help narrow down items that are relevant to your alignment goals.
Filters:
The Timeframe section filters by new, upcoming and archived opportunities and resources:
The Resource or Opportunity Type section filters by initiatives and resources which are categorized into the three following groups:
The Multi-payer Alignment Foundational Elements section filters by the Accountable Care Curve Measurement.
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
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
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
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
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
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:
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:
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:
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:
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:
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:
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:
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:
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:
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:
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:
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:
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:
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:
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:
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:
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:
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:
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:
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:
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:
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:
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:
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:
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:
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:
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:
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:
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:
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:
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:
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:
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.
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:
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:
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:
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:
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:
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:
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:
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:
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:
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:
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:
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:
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:
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:
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: