With the recent announcements of two new innovation models, the Centers for Medicare & Medicaid Services (CMS) is recognizing the role of digitally enabled care in improving access and outcomes.
The Transforming Maternal Health (TMaH) model will issue cooperative agreements to up to 15 state Medicaid agencies to participate in a ten-year payment and care delivery model to develop and implement a whole-person approach to pregnancy, childbirth, and postpartum care for individuals covered by Medicaid and the Children’s Health Insurance Program (CHIP). To support development and implementation, participating state Medicaid agencies will be eligible for up to $17 million in funding and technical assistance. CMS intends to release a Notice of Funding Opportunity (NOFO) in Spring 2024 with additional information ahead of the January 2025 model go-live date. Manatt analyzed the TMaH model’s key initiatives and outlined considerations for state Medicaid agencies in a recent Manatt Health Highlights newsletter.
The Innovation in Behavioral Health (IBH) model will select up to eight state Medicaid agencies to develop and implement state-administered approaches which integrate behavioral, physical, and social supports to coordinate and manage care for Medicare and Medicaid beneficiaries with moderate-to-severe mental health conditions or substance-use disorders (SUD). The model centers on four key pillars: care integration, care management, health equity, and health information technology. To support development and implementation, participating state Medicaid agencies will be eligible for up to $7.5 million in cooperative agreement funding. CMS intends to release a NOFO in Spring 2024 with additional information ahead of the Summer 2024 application deadline.
Through the new models, CMS is encouraging states and providers to invest in technology and supporting infrastructure.
The TMaH model proposes to enhance data collection, exchange, and linkage by making investments in electronic health records (EHR) and health information exchange technologies. It also aims to integrate home monitoring and telehealth technology for individuals with medical conditions complicating pregnancies, such as gestational diabetes and hypertension. Additionally, CMS will support states with implementing data infrastructure to enable collection of Health-Related Social Needs (HRSN) data and referral to support resources.
Similarly, the IBH model proposes to expand health care information technology (HIT) capacity through targeted investments in interoperability and clinical decision support tools, including EHRs. Critically, many behavioral health providers were ineligible to receive EHR adoption incentives as part of the HITECH Act and IBH funding will enable the basic digitization of health records, which is commonplace across the rest of the healthcare system. These investments will also enable participants to enhance quality metrics reporting and data sharing. Furthermore, funding will support behavioral health clinical practices in improving interoperability, encouraging secure and efficient transmission and exchange of patient health information at the point of care.
CMS is acknowledging the benefits of digitally enabled care experienced by patients during the COVID-19 public health emergency and is investing in continued digital innovation.
The TMaH model promotes remote monitoring programs particularly for conditions like hypertension and diabetes, which require additional monitoring during pregnancy to avoid complications, as part of comprehensive pregnancy care. As seen during the pandemic, digitally enabled care models can reduce the burden of frequent doctor visits, especially for patients with complex needs and those facing significant transportation barriers.
Similarly, the IBH model encourages behavioral health clinical practices to invest in HIT infrastructure, which became essential during the pandemic as use of telemedicine for behavioral health swelled. In fact, behavioral health has sustained higher than pre-pandemic telemedicine utilization levels, even as many other specialties have reverted to nearly pre-pandemic levels. The IBH model also advocates for improved data sharing to support integrated care models that combine behavioral and physical healthcare services. These models, like the Collaborative Care Model (CoCM), have shown benefits, but require ample upfront investment in technical assistance and infrastructure to be most successful.
The TMaH and IBH models offer providers an opportunity to enhance workforce and HIT capabilities—by promoting efficiency through proactive patient-centered care.
The TMaH model may create new opportunities for providers to leverage digital health solutions by increasing coverage for remote patient monitoring tools like continuous glucose monitors (CGM) for diabetic mothers or pregnant individuals. As of May 2023, 45 states offered some Medicaid coverage for CGM, albeit with varying authorization and eligibility criteria. This model could also broaden coverage for other remote patient monitoring programs, such as hypertension management through blood pressure monitoring tools.
The IBH model provides behavioral health providers with a chance to bridge the technology gap resulting from their exclusion from the 2009 HITECH Act. It is estimated that only 6% of behavioral health facilities and 29% of substance use disorder treatment centers in the U.S. utilize EHRs, whereas nearly 4 in 5 office-based physicians (78%) leverage an EHR platform today. The funding available through the IBH model aims to expand HIT capacity, enabling behavioral health providers to modernize their practices and participate in integrated care models, which rely on system interoperability and data exchange among all care team partners to function as designed.
In addition to the IBH model supports, the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Office of the National Coordinator for Health Information Technology (ONC) have announced a $20 million investment over the next three years to advance HIT in behavioral healthcare practices, aligning with the HHS Roadmap for Behavioral Health Integration that includes testing models that leverage behavioral health integration to support the delivery of whole-person care as a long-term strategic focus area.
The TMaH and IBH models also offer an opportunity for health tech companies to enter new markets and form strategic partnerships with state Medicaid agencies.
Both models present health tech companies with opportunities to target new markets for at-home monitoring, telehealth and HIT technologies that can support care delivery, care coordination, and referrals to healthcare providers and community-based services. With the new funding opportunities, providers and state agencies whose budgets prevented them from making technology investments in EHR systems, interoperability, or digitally enabled care may soon have award money to invest in this critical infrastructure. Furthermore, health tech companies aiming for strategic partnerships should see state Medicaid agencies' emphasis on finding cost-effective solutions that enhance health outcomes for underserved populations as a chance to collaborate with like-minded partners dedicated to advancing digital health innovations.
Embracing digitally enabled care for maternal health and behavioral health may offer new solutions to long-standing problems, benefiting those in greatest need.
The potential impact of digitally enabled care for maternal and behavioral health could be profound. Uncontrolled diabetes and hypertension during pregnancy can lead to serious risks, including preterm birth and preeclampsia, with hypertensive disorders being a leading cause of pregnancy-related deaths in the United States.
The opportunity to impact behavioral health is just as substantial as nearly 40% of Medicaid adults suffer from mental illness or SUD while a lack of providers, high out-of-pocket costs, and a fragmented delivery system continue to hinder access to needed care—particularly for historically marginalized, low-income, and remote communities.
Telemedicine utilization patterns observed during the pandemic demonstrated that digitally enabled care can improve appointment attendance especially among underserved and higher-risk populations, including for certain racial and ethnic groups and those with chronic conditions. These populations, as well as people living in rural communities, face transportation and other logistical access barriers that digital health solutions aim to lower.
By prioritizing investments in new models of digitally enabled care and HIT infrastructure, state Medicaid agencies, providers, and health tech companies can reimagine their approach to reducing health disparities, minimizing preventable complications, and improving access to high-quality care for vulnerable populations.