Overview of Health Care Delivery System

The Title V program works across many state agencies and has strong partnerships with key players in the healthcare delivery system across Louisiana. Agencies within the Louisiana Department of Health (LDH) include: 

1. Bureau of Health Services Financing, comprised of state Medicaid (Medicaid and CHIP) and the Health Standards section
2. The Office for Citizens with Developmental Disabilities (OCDD) which includes the state’s Individuals with Disabilities Education Act (IDEA) Part C early intervention program
3. The Office of Behavioral Health (OBH), whose staff act as monitors and subject matter consultants for the children's Coordinated System of Care program and the Medicaid Healthy Louisiana managed care plans, which manage behavioral health services
4. Other sections of LDH including the newly established Office of Community Partnerships and Health Equity and the 11 Human Services Districts and the Bureau of Minority Health Access.
5. Other bureaus and sections within Office of Public Health (OPH), including the nine regional public health offices and local clinics, WIC, Bureau of Infectious Diseases, Vital Records and Statistics, Health Informatics, Sanitation, Bureau of Primary Care and Rural Health, chronic disease prevention, water safety and many other public health programs.

By having several offices organized under one administrative entity, LDH facilitates Title V’s work in carrying out the public health assessment, policy, and assurance functions in the state’s healthcare delivery and financing system. Over the past several years, strategic investments in policy roles and infrastructure to support patient safety and quality improvement initiatives at the facility and provider levels have deepened Title V’s work to improve systems of care for all women, children, and families in the state. 

Within LDH, Title V’s work has centered around strengthening the partnership with Medicaid and other LDH sections. Consultation with nationally recognized Medicaid and early childhood policy experts to identify potential payment and incentive changes, structured learning collaboratives around mental health and reproductive health, and ongoing interagency workgroups has resulted in a shared targeted policy and system change efforts. For maternal health, the collective national focus on preventable deaths, harm and inequities has been another catalyst for shared action, elevating Louisiana’ s Title V data, policy, and care improvement initiatives.  

Outside of LDH, Title V works with many of the core elements of the state’s healthcare delivery system in the course of carrying out public health functions and focused system improvement campaigns. System partners include all birthing facilities, pediatric hospitals, clinical providers, training programs, licensing boards, professional associations, payors, health system policy advocates and interest groups, and, increasingly, patient and community advocates working to achieve fundamental system change. 

Overall, Title V employs the Bureau’s foundational strategies to connect data to action to system change, at various levels of the healthcare delivery system.

Medicaid as a Key System for MCH Populations and Title V Efforts

In Louisiana, Medicaid is a major force in the state’s healthcare system. Over 29% of adults, 55% of children, and 52.2% of children with special health care needs are insured under Medicaid.1,2  With the expansion of Medicaid in July 2016, the program’s reach grew even further, covering an estimated 1.5 million individuals in Louisiana overall.3 The expansion of Medicaid along with the availability of coverage through the Federal Marketplace has resulted in the proportion of uninsured individuals declining from 17% (2012) to 8% (2018).2

Like many states, Louisiana Medicaid has experienced many changes in recent years including significant changes in eligibility, benefits and payment structures. With the pressures to shift payments and priorities away from volume to value, Louisiana changed from a fee-for-service (FFS) system to managed care in 2012, and has sought to improve the contracts with each rebidding cycle. In addition, Louisiana Medicaid has tested innovations in care and payment models. Although Title V does not have any direct jurisdiction over Medicaid finances (including FFS, Managed Care Organization [MCO] capitation rates, waivers and State Plan Amendments [SPAs]), collaboration between Title V and Medicaid has evolved in recent years with the intention to maximize resources, reduce duplication, support a statewide system of care, and improve health outcomes for Louisianans.

Title V/Title XIX Memorandum of Understanding: In FFY 2015, Louisiana’s Title V program established the BFH Health Systems Strategy Manager role, a dedicated position to coordinate and advance the program’s engagement with Medicaid and healthcare delivery and financing policy. Drawing upon the National Maternal and Child Health (MCH) Workforce Development Center (WDC) and the National Academy for State Health Policy (NASHP) memorandum of understanding (MOU) resources; examples from other states; the 2015 Title V Needs Assessment; and input from BFH and Medicaid staff, the agreement ultimately was framed around the following areas: 1) health policy; 2) sharing data findings in order to evaluate and inform programs and policies; 3) supporting and participating in one another’s state and national public health and payer committees and workgroups; 4) strengthening outreach, access and referral pathways within one another’s health programs and systems of care; and, 5) developing strategies to improve adequacy of insurance coverage. The process for revising this agreement allowed Louisiana Title V an important opportunity to begin to define a more strategic partnership with Medicaid and has resulted in a useful document to guide and strengthen the relationship between Title V and Title XIX programs.

When the new MOU was signed in FFY 2017, a small Title V / Title XIX Coordination Workgroup comprised of the Title V Director, a Medicaid Medical Director, and the BFH Health Systems Strategy Manager began meeting biweekly to ensure mutual awareness of priority issues and activities. The group collaborated on focused issues related to the domains outlined in the MOU and consulted additional BFH subject matter experts and Medicaid staff as needed. This partnership resulted in significant advancements in health policy development and implementation:

• Title V contributed to the Medicaid quality strategy and the content of the model contract for the state’s competitive solicitation for Medicaid MCOs.
• Various boards and commissions under BFH’s purview provided formal and informal feedback on the Medicaid quality strategy and the proposed elements for the 2020 MCO contract Request for Proposals (RFP).
• Specific coverage proposals advanced to deliberation and implementation including Long-Acting Reversible Contraception (LARC) for federally qualified health centers (FQHCs) and rural health centers, coverage of breast pumps, and coverage of parent-child dyadic therapy. Developmental screening and depression screening policy changes are under consideration and were included as incentivized measures for new contracts; and medical homes as a value based payment model option and tiered case management as elements of the MCO contract RFP.

In FFY 2019, significant staffing, leadership, and structural changes within both BFH and Medicaid prompted interagency coordination efforts to take place in other standing meetings rather than the Title V/Title XIX Workgroup. With a focus on sustaining momentum on the policy priorities developed over the course of the 2016-2020 State Action Plan, Title V staff continued to participate in OPH interagency leadership meetings with Medicaid, quality subcommittees and ad hoc meetings.

During FFY 2020, BFH and Medicaid leadership have reinitiated standing partnership meetings, though in a different form. The Health System Strategy Manager meets monthly with the Medicaid Quality and Innovations team to coordinate efforts around interagency programmatic collaboration. Every other week, the Title V Director and the Health System Strategy meet with the Medicaid Medical Director and newly-established pediatric Assistant Medical Director to review work around shared priorities. And lastly, the Title V Director anticipates that the Title V State Action Plan will help shape some shared priorities with Medicaid for an anticipated LDH business plan. The Title V Director aims to meet with the Medicaid Director quarterly. 

Additional proposals and activities related to Title V-Title XIX MOU are discussed in detail throughout the domain narratives.