Innovative Medicaid Payment Strategies for Upstream Prevention and Population Health: An Executive Summary

Executive Summary

This brief summarizes barriers to upstream prevention including making the business case for investment, and understanding what Medicaid can and can't pay for, among others. It concludes with nine lessons learned about how to accelerate state action in this area.

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Medicaid and other payers are increasingly aware that health outcomes and costs are driven by factors beyond clinical care and are exploring ways to move care upstream and collaborate with community partners in order to connect patients to health-related, non-clinical services. Work in Maryland, Oregon, and Washington highlights current Medicaid authorities to promote and/or provide prevention services in community settings, cover upstream prevention benefits, and deliver services using nontraditional community-based providers.

This executive summary outlines several practical lessons and approaches that state Medicaid agencies, health plans, providers, and other stakeholders can use to demonstrate the business case for making these investments as well as understand the nuts-and-bolts of implementing value-based payment strategies.

This brief summarizes tria series on Medicaid Payment Strategies for Financing Upstream Prevention resulting from an AcademyHealth Payment Reform for Population Health initiative collaboration with Nemours Children’s Health System. See the rest of the series here.

Tricia McGinnis
Committee Member

Tricia McGinnis, M.P.P., M.P.H.

Vice President of Programs - Center for Health Care Strategies

Tricia McGinnis, M.P.P., M.P.H., is Vice President of Programs at the Center for Health Care Strategies (CHCS)... Read Bio

Jennie Bonney, M.P.H.

Independent Consultant

Jennie Bonney, M.P.H., is an independent health policy consultant focusing on Medicaid and the State Children'... Read Bio

Debbie I. Chang, M.P.H.

Senior Vice President, Policy and Prevention - Nemours Children’s Health System

Debbie I. Chang, M.P.H, is Senior Vice President of Policy and Prevention and a Corporate Officer for Nemours ... Read Bio