New Federal Commission’s Top Task May Be Setting a Truly Bipartisan Evidence Agenda

Efforts to broaden the use of data and research in federal policymaking may receive a substantial boost from a commission created by Congress last month.  The new Evidence-based Policymaking Commission, established by legislation signed by President Obama on March 30, is charged with identifying ways to increase the use of such information. Its most important task, however, may not be coming up with new ideas, but providing a bipartisan imprimatur for ideas that already exist.

Continue reading SIRC’s column at Government Executive.

Posted in Evidence

Medicare and Medicaid Continue Transition to Value-based Payments

Earlier this month, the Department of Health and Human Services (HHS) announced that 30 percent of Medicare payments are now tied to quality or value, nearly a year ahead of goals that it set for itself in early 2015.

According to HHS, over 10 million Medicare recipients are receiving care under alternatives to traditional fee-for-service arrangements. HHS credited most of its progress to the growth of Accountable Care Organizations (ACOs).  According to the department, there are now a total of 477 ACOs participating in its Shared Savings Program and the Pioneer ACO program.

The administration says that the transition to ACOs and value-based care will reduce costs and improve health-related outcomes for patients. It hopes to tie 50 percent of Medicare payments to these models by the end of 2018.

The ACO model is also increasingly being adopted within the Medicaid program. According to a recent report from the Center for Healthcare Strategies, eight states ─ Colorado, Illinois, Maine, Minnesota, New Jersey, Oregon, Utah, and Vermont ─ have launched Medicaid ACO or ACO-like programs, serving a total of more than 2.5 million beneficiaries.

“Value-based purchasing is quickly becoming the new paradigm in Medicaid,” said Tom Betlach,  president of the National Association of Medicaid Directors (NAMD), which released a study of alternative payment models in Medicaid in late March.

These developments suggest rapid advancement in the use of value-based payment systems, but there is enormous variation among them, including the size of their financial incentives and the performance measures that are being used, according to a recent analysis for Health Affairs.

Organizations like the National Quality Forum have been working to support improvements in performance measures. Progress will also depend heavily on advancements in electronic health record (EHR) systems, which are still being rolled out in many health systems and have experienced a number of usability, interoperability, and security problems.

Some provider groups remain skeptical. According to a study released by American Academy of Family Physicians in late 2015, 69 percent of its members said that value-based payments would not improve patient care. They cited a number of barriers, including lack of evidence that using performance measures improved such care, lack of standardized measures, and increased costs in terms of staff time and training.

HHS is working to address these problems through a number of initiatives, including technical assistance and a pilot program for testing new financial incentives, quality standards, and increases in coordinated care.

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Posted in Health, Social Impact Bonds / Pay for Success

Congress Passes Evidence-based Policymaking Commission Bill

The House today approved legislation (H.R. 1831) that would create an Evidence-Based Policymaking Commission charged with making recommendations to Congress and the administration on the use of evaluations and administrative data for assessing federal programs and tax expenditures.

The bill, an amended version of which was passed by the Senate on March 16, now goes to President Obama who is expected to sign it into law.

The bill (text) creates a 15-member commission that is charged with developing recommendations. Appointments to the commission must be made within 45 days of the bill’s enactment. The commission is directed to issue a report within 15 months.

“We won’t be able to expand opportunity in this country until we figure out which policies actually work. That’s why we need to make use of all the data we already collect, and that’s exactly what the Evidence-Based Policymaking Commission would help us do,” said House Speaker Paul Ryan in a statement.

“I am proud that Speaker Ryan and I were once again able to break through the gridlock and work together to take this step toward improving federal programs and our tax code,” said Sen. Patty Murray in a statement after the bill passed in the Senate.

Among other responsibilities, the commission is directed to develop recommendations for creating a federal clearinghouse for program and survey data for researchers, officials, and institutions while simultaneously protecting individual privacy and confidentiality.

It is also directed to make recommendations on how best to incorporate outcomes measurement, randomized controlled trials, and rigorous impact analysis into federal program design.

Update: President Obama signed the legislation on March 30, 2016.

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Posted in Evidence

Hidden In the Partisan Budget Divide: An Agreement on Evidence-based Policy

Presidential budgets are often greeted with little enthusiasm when Congress is controlled by the opposite party. This year’s Obama budget is no exception. But buried within the president’s $4.15 trillion budget are recommendations on evidence-based policymaking that may prove more influential than some expect.

Continue reading SIRC’s column at Government Executive.

Posted in Evidence

Senate Committee Passes Health IT Improvement Bill

The Senate Health, Education, Labor and Pensions (HELP) Committee passed legislation (S.2511) on February 9 that would address a number of shortcomings in federal law governing electronic health records (EHRs). The committee passed the bill unanimously by a vote of 22-0. It is awaiting action on the Senate floor.

Electronic health records are computer records that contain a patient’s medical history, including information on past physician visits, diagnoses, and medications. They can create a more comprehensive view of a patient’s health and reduce costs by avoiding unnecessary duplication of tests. A recent study funded by Agency for Healthcare Research and Quality suggests that EHRs have helped reduce adverse events such as hospital-acquired infections. Under optimal conditions, they can also be shared between health providers and improve care coordination.

The federal government has provided substantial financial subsidies to encourage the use of EHRs and they are being increasingly adopted by hospitals and other health providers.

Despite their potential benefits, however, their adoption has not been completely smooth. Some doctors complain that EHRs force them to spend too much time looking over and updating electronic health records and less time with their patients.

Their potential for coordinating care across multiple providers has been hampered by poor interoperability among competing systems. EHRs have also come under increasing attack from cyber criminals. Such records often include substantial personal and financial information, well beyond what might be found financial or credit card records. In some cases, such information has been used for insurance fraud. In other cases, hospitals have been threatened with data destruction and subjected to ransom demands.

The new Senate bill (summary) would address a number of these barriers, including promoting interoperability among EHR systems and allowing other health professionals to update records so that doctors can focus more on patients.

In late February, the Obama administration also announced an agreement among major hospital systems, leading vendors representing 90 percent of the EHR market, and health care systems in 46 states that would reduce barriers to information sharing and make it easier for patients to access their records.

Update: The House Oversight and Government Reform Subcommittee held a hearing on health IT issues on March 22.

Posted in Health

Building Performance Systems in Child Welfare

The Social Innovation Research Center has today released a new report:

Building Performance Systems in Child Welfare
Lessons from Performance-based Contracting, Performance Management, and the Emergence of Social Impact Bonds
(February 8, 2016)

The executive summary is below.


Executive Summary

Child welfare organizations work with one of the nation’s most vulnerable populations, children who have been abused or neglected and removed from their homes. While performance is important for all social services, the stakes are especially high for these children, where failure can mean futures marked by domestic violence, homelessness, teenage pregnancy, criminal involvement, and suicide.

Despite this hard reality, there are also reasons to be optimistic. Advances have been made in multiple performance-related systems, including evidence-based practices, performance management, data systems, performance-based contracting, and social impact bonds. Most of these have made individual contributions, but they are also substantially interconnected and mutually reinforcing.

These advances have not yet significantly changed all or even most child welfare systems, but there are glimmers of progress throughout the field. This paper reviews these overall national trends in the context of two promising cases studies – one of performance-based contracting in the state of Tennessee and the other of a high-performing national nonprofit provider based in the state, Youth Villages – before concluding with lessons learned from the recent emergence of social impact bonds.

Highlights are summarized below:


Performance-based Contracts:
  A central tenet of child welfare practice is that children fare better in stable, loving homes. Several policy changes have been instituted at the federal and state levels over the past two decades to divert more children from group homes to more permanent living arrangements with biological or adoptive families or legal guardians.

One policy change that has been instituted in several states is performance-based contracting. Such contracts establish financial incentives for providers to achieve faster placement of children in permanent homes and they appear to have produced results.  A 2011 study of performance-based contracting in three states found that they were associated with improved permanency-related outcomes for children. Tennessee’s system has followed this same pattern.

Unfortunately, because outcomes can be driven by many factors other than the work of providers, including the availability of foster homes or other policies adopted at the same time, it is difficult to be certain how much, if any, of the observed improvements are attributable to performance-based contracts. Indeed, the general history of performance-based contracting contains several examples of systems that appeared to be generating positive results only to see these results overturned when subjected to more rigorous impact studies.

A closer look at this overall history, however, also reveals a number of consistent design flaws. Reviewing Tennessee’s system in light of these flaws, which have largely been avoided, provides reason to be cautiously optimistic that it is actually contributing to improved permanency for the state’s foster children.


Service Provider Case Study:
  Federal and state policies can establish a supportive framework, but actual improvements must take place on the front lines. This paper explores how one nationally-recognized child welfare provider, Youth Villages, has implemented a best-in-class performance system within Tennessee’s broader system of performance-based contracting. It explores several major components, including the organization’s: (1) leadership and culture; (2) evidence-based program models; (3) performance management system; (4) use of follow-up evaluations; and (5) funding sources for its performance-related work


Social Impact Bonds:
While performance-based contracts have a longer track record, social impact bonds have also begun to draw interest in recent years, with several child welfare-related projects now underway both in the United States and abroad. This paper compares the strengths and weaknesses of these two approaches and concludes that while different, they are highly complementary. Although performance-based contracts are easier to scale, social impact bonds may help address some of the known shortcomings of performance-based contracts.

The paper concludes with recommendations to policymakers on how to further improve performance systems throughout the nation’s child welfare system.

Full Report


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Posted in Children and Families

The Emerging Flight Deck of Pay for Success

With authorizing legislation that would extend the concept now stalled in Congress, the Obama administration appears to be following an alternate path to supporting the small but growing model of performance-based government called pay for success.

Like performance-based contracting, pay-for-success projects tie payments to proven results. They differ primarily because they often use rigorous assessments to determine their impact and because they rely on third-party financing from foundations and other investors to cover costs until payments are made.

The idea has generated significant interest across a variety of fields, including social services, education and health. Fewer than a dozen projects, however, have actually been brought online in the United States, and progress has been bumpy so far.

The Obama administration and a bipartisan group of congressional supporters are working to change this. In 2015, legislation was introduced in both the House and Senate that would create a $300 million fund and a central interagency council to oversee federal efforts.

However, despite an influential cast of supporters that includes House Speaker Paul Ryan, the legislation has not yet moved. In part, this has been due to skepticism among some Republicans who view it as a possible path to big government, and among some Democrats who are suspicious of third-party financing by profit-motivated investors like Goldman Sachs. Public sector unions are also wary of its potential for privatizing public services.

More immediately, the legislation has been held up by disagreements over how it would be paid for and by the usual growth in partisanship that occurs at the beginning of an election year.

In spite of these disagreements, there have been bursts of sporadic progress. Over the past two years, Congress has made pay for success an allowable use of funds in education, labor and transportation legislation. A major unanswered question has been whether these funds will actually be tapped without the support of a central coordinating body, which the Government Accountability Office has suggested is needed.

Into this void has stepped a little-known initiative called the Social Innovation Fund. During the past year, the program has been quietly providing funding for feasibility studies and technical assistance for dozens of early-stage projects across the country. While only some of them may reach fruition, the program is already filling the coordinating role that GAO and pay-for-success supporters in Congress and the administration have been calling for.

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Posted in Social Impact Bonds / Pay for Success

Pending Child Welfare Legislation Would Boost Funding for Evidence-based Services

Child welfare services that are evidence-based may see a significant jump in financial support under legislation that is being drafted by the Senate Finance Committee.

A bipartisan bill that is now being assembled by Sens. Orrin Hatch (R-UT) and Ron Wyden (D-OR) would expand federal support for evidence-based prevention and family service programs, including mental health, substance abuse prevention, and in-home parent skill-based services.

Under the proposal, to be eligible for federal support the new services would need to qualify under an increasingly stringent set of evidence guidelines.  Starting on October 1, 2017, the services would need to be rated as promising practices to receive federal support.  By 2020 they would need to be rated as evidence-supported and by 2023 they would need to be rated as well-supported.  The legislation directs the Department of Health and Human Services to assemble a list of evidence-based services that qualify.

The proposal’s three tiers of evidence (described below) are loosely based on those of the California Evidence-based Clearinghouse for Child Welfare. They differ primarily because they do not require a randomized controlled trial to meet the highest definitions. As drafted, the proposed definitions appear less strict than those included in a major education bill that Congress enacted last year.

This may be due in part to the relatively nascent state of evidence in child welfare generally.  As of February, 2014, only 27 of 325 child welfare programs (just 8 percent) catalogued by the California Clearinghouse met its criteria for being well-supported by research.

Moreover, many evidence-based practices in the field are borrowed or adapted from those originally used in other settings or with other populations. Ratings for mental health and substance abuse programs more broadly, for example, can be found at SAMHSA’s National Registry of Evidence-based Programs and Practices.

Nevertheless, child welfare experts appear to be welcoming the bill’s evidence provisions, arguing that creating greater demand will probably create increased supply. A 2015 report by Results for America and Bridgespan, for instance, found that some private purveyors were withholding their programs from review until they could be sure that they would earn top ratings.  By creating financial incentives, the legislation may quicken the pace of evidence development.

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Posted in Children and Families

The Promise and Peril of an “Outcomes Mindset”

Late last year, the White House and a number of former Obama administration officials began rolling out an apparently coordinated campaign to promote an “outcomes mindset” for government and the social sector. Unfortunately, while this agenda includes many positive recommendations, its central message is worrisome.

The outcomes-focused paradigm proposes leveraging data and new technology to achieve “21st-century solutions” to the nation’s most pressing social needs. But in reality, outcomes-based policies and funding have been around for decades, and their history is far from universally positive.

Continue reading SIRC’s article at the Stanford Social Innovation Review.

Posted in Social Impact Bonds / Pay for Success