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Reflecting on One Year of IAP

A year ago CMS launched a collaborative initiative between the Center for Medicaid and CHIP Services and the Center for Medicare-Medicaid Innovation called the Medicaid Innovation Accelerator Program (IAP). The goal of IAP is to improve care and improve health for Medicaid beneficiaries and reduce costs by supporting states’ ongoing payment and service delivery reforms. IAP is a unique commitment to ensure Medicaid’s presence in CMS’s wide ranging efforts to support system-wide payment and delivery system reform innovation. IAP activities assist states to address common challenges in order to advance innovation by developing resources (e.g., financial modeling algorithms, enhanced Medicaid quality metrics, rapid cycle learning expertise) and offering program support related to states’ ongoing Medicaid-focused innovations. Our intent is to focus on the greatest opportunities to improve health, improve care and, through these improvements, decrease costs in this critical program.

In looking back over the past 12 months, IAP may have appeared to be slow to start. In fact, if you had asked me back then, I would have been the first to say that I didn’t fully understand why we needed to spend so much time getting so much stakeholder feedback before we picked the program areas. The reality is that we needed to identify program areas that truly resonated with states. If we did end up spending a lot of the initial months of IAP gathering input through a series of in-person meetings with states and stakeholders across the country, we did it for very good reasons. After meeting with states and cogitating internally, we selected these four program areas for IAP:

  1. Substance Use Disorders
  2. Beneficiaries with Complex Needs and High Costs (“super-utilizers”)
  3. Community Integration - Long Term Services and Supports
  4. Physical/Mental Health Integration

The hard work and time invested in gathering feedback paid off -- we have heard from states that these program areas reflect priorities in their own states and where there are ongoing efforts to improve care. With priorities chosen, our next challenge was to design the first program support opportunity in a way that aligned with states’ needs, did not duplicate existing efforts, and did not contribute to the technical assistance fatigue that states were feeling. Such a simple thing to do, right?

In October 2014, we began working on Substance Use Disorders (SUD) as the first IAP program priority area. We are now seven months into a 12-month learning collaborative with seven states that want to work intensively on improving the ways they deliver, pay, and measure the health care provided to Medicaid beneficiaries with substance use disorders. We convene these seven states—Kentucky, Louisiana, Michigan, Minnesota, Pennsylvania, Texas, and Washington, — on a monthly basis to discuss and learn about key elements of SUD care delivery reform such as data analytics, benefit design, provider capacity, transitions across levels of care, and payment strategies. In May 2015, we had a productive in-person meeting with over 20 representatives from these states joining us to learn from content experts and each other about quality measurement, data analytics, medication-assisted treatment, driver diagrams and strategic planning, and “hot topics” within SUD service coverage.

The beginning of our work with these states had a more traditional learning collaborative approach, but we quickly decided that we needed to change how we were working with them. We began offering the seven states 1:1 support with subject matter experts tailored to their individual needs and aims. Examples of this type of program support include state-level benchmarking data, information about medication-assisted treatment, and cost analysis of adding an SUD service. These states are also collecting two common measures that will aid them (and us) in better understanding how the improvements they are making to their SUD systems result in improved care for their Medicaid beneficiaries, and will they report progress with performance on these measures over the next three years to CMS. A participating state recently shared with us that IAP has created the opportunity for the state to focus more on substance use disorders then it has in the past 10 years.

Understanding that designing and implementing delivery system reform takes time, we will offer each of the seven states ongoing, individualized program support after the end of the 12-month learning collaborative to address additional needs related to implementing SUD-related service delivery reforms as part of their Medicaid State Plan or waivers. To further support states’ SUD delivery system reform efforts, we recently issued this State Medicaid Director Letter (PDF, 205.64 KB). For other states that are interested in SUD, we continue to offer a web-based learning series of monthly webinars throughout the year called Targeted Learning Opportunities. The types of topics that we have and plan to cover as part of the monthly webinars series include:

  • Strategies for sharing information consistent with 42 CFR Part 2
  • Integrating SUD services into primary care settings
  • Enhancing program integrity
  • Incorporating SUD services into managed care
  • Linking and leveraging data sources
  • Benefit design
  • Pay-for-performance

With SUD up and running, last month we announced two additional ways states could access program support from IAP: Improving Care for Medicaid Beneficiaries with Complex Care Need and High Costs; and Medicare-Medicaid Data Integration. We received a very positive response to both of these opportunities and will be announcing the states with whom we will work in the weeks to come.

Throughout the development of all of IAP program and functional areas, we have been lucky enough to collaborate with the Commonwealth Fund on expert panels convened related to IAP’s work on Improving Care for Medicaid Beneficiaries with Complex Care Need and High Costs and Physical/Mental Health Integration, and a Milbank Memorial Fund IAP State Implementation Panel (comprised of senior state Medicaid officials). At the first Milbank Fund meeting, we did a lot of level setting and debunking of myths that states had about IAP. And, to answer the most common question we get, “no, we will not always do structured learning collaboratives.” Seriously, we did take the panel’s feedback to heart and have made changes such as adding regular commentaries such as these, along with additional and more frequent ways to share information with you about IAP (e.g. fact sheets and email updates). Additionally, we are redesigning how we offer program support to states in each of the program areas and how we connect that program support to data analytics, quality measurement, rapid cycle learning, and payment modeling.

So what does the second year of IAP hold for states and us? We will continue to build on the progress made, the feedback we have heard, and the lessons learned. In addition to launching the second IAP program area, Improving Care for Medicaid Beneficiaries with Complex Care Need and High Costs, we will launch program support opportunities for states in the last two program areas: Community Integration - Long Term Services and Supports and Physical/Mental Health Integration. We know that states already struggle with technical assistance fatigue and that choosing which IAP opportunity to devote time and resources to will become increasingly difficult. However, we have a great IAP team that is committed to tailoring these opportunities to meet states where they are and to designing program support in a way that addresses states’ individual needs rather than put additional burden on state staff that is already stretched thin.

The bottom line is that we’ve made a lot of progress over the past year in standing up this program. And, let’s be honest, we’ve made a lot of progress in taking an abstract concept of what IAP is and turning it into a true functioning program that is staffed up and is working with states. Those of you that were on the kick off webinar for Substance Use Disorder IAP last winter heard me say that the first year of IAP is going to be one of learning and building—we may not get it right the first time, but we will look to our state partners to tell us how we can continually improve and support your work.

IAP Commentary
Tim Hill, Deputy Director, CMCS
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Collections: IAP Commentary