With a focus on improving health outcomes and controlling costs, state Medicaid agencies are using financing and contracting mechanisms to accelerate the adoption of evidence-based prevention strategies under the Centers for Disease Control and Prevention’s (CDC) 6|18 Initiative. The 6|18 Initiative provides a clear pathway to help state Medicaid and public health partners implement proven prevention interventions for targeted high-burden health conditions, both in managed care and fee-for-service delivery models. The 6|18 interventions can bolster Medicaid efforts around quality improvement and value-based payment (VBP) as well as advance cross-agency collaboration with public health partners.

What is the 6|18 Initiative?

CDC launched the 6|18 Initiative in 2015 to assist state Medicaid and public health agencies, as well as commercial plans, in working together with providers to align prevention practices with emerging VBP and delivery models. The goals of the Initiative are to: (1) improve health and control health care costs by enhancing coverage and utilization of evidence-based prevention and control interventions; and (2) promote sustainable cross-sector collaboration between public health and health care stakeholders.

The 6|18 Initiative features six common and costly health conditions — tobacco use, high blood pressure, inappropriate antibiotic use, asthma, unintended pregnancies, and type 2 diabetes — and associated interventions with evidence of improved health outcomes and cost reduction/neutrality. CDC used the following criteria to choose the conditions and interventions:

  1. Health conditions that affect large numbers of people and are associated with high costs;
  2. Interventions that are specific and underutilized;
  3. Interventions that prevent or control the condition and yield short-term savings; and
  4. Interventions that can be implemented in both clinical and community settings.

The interventions promote access to and utilization of discrete prevention and treatment benefits that can be covered by health plans and other payers.

How does the 6|18 Initiative help advance Medicaid’s strategic priorities?

For decades, the U.S. health care system has grown more costly without a commensurate improvement in health outcomes or quality. At the same time, preventive care, despite demonstrated evidence for improving outcomes and controlling costs, is historically largely underutilized. In response to this long-term trend, the system is now undergoing substantial change at the local, state, and national levels. Emerging cross-payer alignment across quality improvement efforts, health outcomes reporting, and payment strategies has placed a renewed focus on providing coverage and delivering care that will have the greatest health impact. To take advantage of this movement, the CDC 6|18 Initiative’s evidence-based interventions have the potential to improve health outcomes, reduce costs, and spur ongoing innovation in three core ways:

  • Supporting Medicaid’s quality improvement goals;
  • Accelerating the impact of VBP reform efforts; and
  • Promoting effective and results-driven cross-sector collaboration.

Supporting Medicaid’s quality improvement goals

Adopting one or more of the 6|18 interventions can support achievement of Medicaid’s quality goals. States operating a Medicaid managed care program are required to develop a state quality strategy, which includes measurable goals and targets for improvement. States use a variety of mechanisms to hold managed care plans accountable for improving health outcomes, including financial incentives and accreditation standards. For example, states increasingly use capitation withholds to incentivize plans to achieve specific quality benchmarks, including health outcomes. The National Committee for Quality Assurance 2018 Health Plan Accreditation standards include a new category, Population Health Management, to shift health plans’ focus toward prevention and wellness activities. 6|18 interventions are practical, evidence-based approaches that could help health plans meet these expectations. Adopting CDC’s 6|18 interventions may provide health plans with an opportunity to:

  • Focus on high-priority members (e.g., children with poor asthma control, as demonstrated by frequent emergency department visits for asthma attacks);
  • Provide evidence-based interventions (e.g., asthma self-management education and home visits);
  • Inform members about available interventions (e.g., appropriate parent education about asthma triggers and medication use to prevent asthma attacks); and
  • Improve measurable health outcomes. States such as Georgia have incorporated 6|18 interventions related to asthma self-management education into Medicaid health plans’ performance improvement projects.

Accelerating the impact of value-based payment efforts

The selection criteria used to identify 6|18 interventions align with the goals of VBP efforts: improve health outcomes and curb cost growth. As such, CDC’s 6|18 interventions can potentially support and strengthen Medicaid VBP strategies. The 6|18 Initiative promotes concrete coverage changes that payers can make to better align benefits with VBP efforts. Massachusetts, for example, aligned its 6|18 efforts to remove barriers to smoking cessation treatment with its Medicaid accountable care organization (ACO) program, which holds ACOs financially accountable for the total cost of care and performance on tobacco cessation quality measures. From a provider perspective, increased use of 6|18 interventions can potentially help it succeed in improving quality and lowering costs under a VBP contract.

Promoting effective and results-driven cross-sector collaboration

The 6|18 interventions create a clearly defined scope of work around which Medicaid and public health can collaborate, leveraging their unique areas of expertise. The 17 states and counties that have participated in the 6|18 Initiative to date have articulated many benefits associated with this enhanced collaboration, including: accelerated progress on implementing payment and coverage changes; and greater sharing of resources, tools, and knowledge across state agencies. In addition, states are now applying the cross-agency collaboration approaches developed under 6|18 to new priority issues. While participating in the 6|18 Initiative, Colorado developed two new staff positions to serve as inter-agency liaisons. These individuals work together to identify new opportunities for cross-agency policy and strategy alignment and serve as points of contact for Medicaid and public health colleagues who wish to connect.

How to Learn More and Get Help Implementing CDC’s 6|18 Interventions

With support from the Robert Wood Johnson Foundation, the Center for Health Care Strategies is working with CDC, the Centers for Medicare & Medicaid Services, the Association of State and Territorial Health Officials, the National Association of Medicaid Directors, and other key partners to accelerate the implementation of 6|18 strategies. This initiative offers a unique opportunity to help payers and public health collaborate on enhancing the coverage, access, utilization, and quality of cost-effective prevention practices. Register for a national webinar on June 18 (2-3:30 pm ET) to learn more about how Medicaid and public health agencies are adopting CDC’s 6|18 interventions to advance strategic priorities. Visit www.618resources.chcs.org to access planning and implementation tools.

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