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HMA Insights: Your source for healthcare news, ideas and analysis.

HMA Insights – including our new podcast – puts the vast depth of HMA’s expertise at your fingertips, helping you stay informed about the latest healthcare trends and topics. Below, you can easily search based on your topic of interest to find useful information from our podcast, blogs, webinars, case studies, reports and more.

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Blog

Advancing workforce through Collective Impact

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The National Council for Mental Wellbeing (NCMW) launched the Center for Workforce Solutions in 2023 in partnership with The College for Behavioral Health Leadership (CBHL) and Health Management Associates (HMA). The partnership is leveraging Collective Impact to address the workforce crisis, and using a cross-sector approach to address the long-standing challenges for expanding and solidifying the behavioral health workforce. The partners identified a gap in advancing workforce solutions with many national convenings creating various sets of recommendations without a coordinated or clear approach to moving recommendations to action.

Why use Collective Impact?

  • Workforce challenges and solutions require a cross-sector approach including changes in Federal and State regulations as well as at the provider level. Need a coordinated approach to truly reach change.
  • There are a lot of recommendations nationally with stalled action in many cases because the recommendations require other implementers to act.
  • No single accountable entity to ensure recommendations move forward
  • Need for cross-sector agreement on strategies and then cross-sector implementation
  • Scale of the challenge can create overwhelm and inertia to address big gaps
  • Leverage the work being done across partners while building a coordinated effort

Check out this webinar recording to learn more about the history of this effort.

Watch the webinar, “Partnership in Action: A Collective Impact Approach to Implementing Workforce Solutions”.

2023 Progress

The partnership was busy in 2023 with activities to build multiple avenues for change:

  • Building a robust partnership and backbone for the collective impact approach which is working seamlessly to support a national and cross-sector group of leaders to support implementation of recommendations that often require multiple levels of the system and cross-sector engagement.
  • Developing a draft framework for the complexity of the workforce challenges and solutions and thinking about the implementers (regulators, policy makers, providers, and others) that are needed to implement recommendations.
  • Cross-walking more than 400 recommendations from national sources including national and state approaches as well as provider lessons using the framework to understand consistent recommendations, identify themes and prioritize where to focus moving recommendations to action.
  • Launching a Behavioral Health Provider and Association ECHO on workforce building a network of providers to share case studies and learn from each other and discuss innovative solutions for addressing workforce challenges.
  • Continuing to identify funding support to move the collective impact approach forward.

What’s Coming in 2024?

  • National Workforce Conversation—a virtual meeting open to all interested nationally to communicate and share information broadly and to collectively track what’s working and lessons learned in workforce efforts.
  • Launch Steering Committee and Working Groups—which will include national key decision makers who will guide a coordinated approach to implementing recommendations and working cross-sector to be accountable to change.
  • Launch Second ECHO for Providers and Associations to continue to share what’s working and improve the immediate workforce crisis at the provider level. Stay Tuned https://www.thenationalcouncil.org/program/center-for-workforce-solutions/engage/echo/
  • NatCon’24: Register and join the Workforce Development and Talent Management Track (April 15 – 17, 2024)
Blog

Collaborating to improve children’s behavioral health

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Investments in children’s behavioral health represent a critical window of opportunity for fostering healthy child development and nurturing the resilience necessary for lifelong well-being. With over 40 percent of U.S. children and youth relying on the Medicaid system for healthcare coverage, it presents a platform to significantly enhance early intervention and prevention services, particularly for vulnerable children. Federal and state policymakers are increasingly active in formulating policies that prioritize investments in initiatives promoting mental and physical health at this pivotal developmental stage.

Health Management Associates (HMA) has partnered with the National Association of State Mental Health Program Directors (NASMHPD) Technical Assistance Coalition to produce a series of briefs that characterize the opportunities to improve coordination of services for children. Beyond the statistics lie the stories of countless vulnerable children and families facing immediate and critical needs. Addressing these issues requires comprehensive cross-system reforms, including policies that promote integrated financing, enhance care coordination, facilitate provider collaboration, and bolster upstream prevention efforts.

The importance of socio-emotional wellbeing as core to childhood development is underscored by evidence-based models and approaches, which consistently demonstrate the substantial value and long-term impact of investing in children’s mental and behavioral health. These investments not only benefit children and adolescents but also extend their positive effects to primary caregivers, creating a comprehensive and sustainable framework for fostering well-rounded, mentally resilient, and physically healthy lives.

The insights and recommendations presented in these briefs* underscore the urgency of coordinated action to improve the well-being of our nation’s youth and the opportunity for collaborative approaches to improve outcomes:

  1. Bolstering The Youth Behavioral Health System: Innovative State Policies To Address Access & Parity (previously published in 2022)
  2. System Integration Across Child Welfare, Behavioral Health, And Medicaid (previously published in 2022)
  3. State Policy and Practice Recommendations to Advance Improvements in Children’s Behavioral Health*
  4. Improving Outcomes for Children in Crisis with Evidence-Based Tools*
  5. The Role of Specialized Managed Care in Addressing the Intersection of Child Welfare Reform and Behavioral Health Transformation*
  6. Early Childhood Mental Health: the Importance of Caregiver Support in Promoting Healthy Child Development and Clinical Interventions for Children*
  7. Connecting Schools to the Larger Youth Behavioral Health System: Early Innovations from California*

*Briefs 3-7 were funded by SAMHSA’s TT1 grant award for FY 2023.

This is part of a larger effort supported by HMA and a number of partner organizations, including NASMHPD, The Annie E. Casey Foundation, Casey Family Programs, MITRE, National Association of Medicaid Directors (NAMD), Child Welfare League of America (CWLA), and the Federal Government agencies ACF and SAMHSA, to help create a dialogue among state agencies and stakeholders working to improve child welfare. The briefs HMA released are a starting point for much of the upcoming dialogue. A federal policy discussion is being held at SAMHSA in mid-November.

Recognizing the complexity of the challenges that lie ahead, it is evident that no single agency can tackle them in isolation. This approach requires adequate funding and robust partnerships at all levels, from local to state and federal. HMA and our partners are producing a unique convening of state agencies promoting a collective approach to improving child-centered care, one that emphasizes child and family-centered practices and fosters local collaborations across each community’s system of care. This invitation-only event in early February 2024 will convene eight state government child welfare agencies and experts to develop methods for improving their services.

The work HMA is doing with our partners highlights the gravity of the problems while providing inspiring examples of successful collaborations from across the country. By examining what works in these models, the way forward becomes evident —a path toward the development of more seamless systems of care for children and youth grappling with behavioral health needs. As states and communities navigate these critical issues, we put forward this body of work as a valuable resource, offering insights and strategies to transform our approach to children and youth well-being and behavioral health support.

HMA will be sharing more about this effort in the coming months, including a webinar with our partners on December 12; registrants will receive a summary of the findings following the February 2024 event. If you want to learn more about this and other initiatives in child behavioral health, please contact our featured children’s behavioral health experts.

Timeline of Key Events

Blog

Medicaid managed care final rule anticipated soon

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HMA has previously reviewed and discussed some of the implications of provisions put forward in the Medicaid and Children’s Health Insurance Program managed care access, finance, and quality proposed rule published by the Centers for Medicare & Medicaid Services (CMS) back in May 2023. It is now anticipated that the final rule will be published later this month in April 2024. Given that the final rule, if it codifies many of the proposed provisions as written, will have a significant impact across Medicaid stakeholders including states, managed care organizations (MCOs), and providers, and that its publication appears imminent, it is valuable to recall the major areas that the final rule will likely address.

The final rule is anticipated to include policy changes in several major areas. These include in lieu of services (ILOS), the Medicaid and CHIP Quality Rating System (MAC QRS), medical loss ratios (MLRs), network adequacy, and state directed payments. When taken together, the policymaking in each of these areas represents the start of a new era of accountability and transparency in the Medicaid program and will affect Medicaid coverage and reimbursement for years to come.

HMA is on the alert for the final rule and will provide analysis and expertise relevant to states, MCOs, and providers, both before and following its release. Whether it is understanding the opportunities to leverage ILOS to address health-related social needs, ensuring operational readiness for data collection and calculation obligations for the MAC QRS, or preparing to comply with MLR requirements related to provider incentive arrangements and quality improvement activity reporting, as well as a host of other topics, HMA will be able to provide insight.

For More Information

If you have questions about how HMA can support your efforts related to the final rule’s implications for states, MCOs, or providers, please contact our featured experts.

Blog

HMA experts to present on “Lifting Voices” project at NATCON24 in St. Louis, April 15-17

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At the upcoming NATCON24 convention, HMA principals Heidi Arthur and Ellen Breslin will conduct a motivating workshop called “Lifting Voices for Meaningful, Actionable Change: Insights from Navigating the Children’s System of Care.” During this workshop, Heidi and Ellen will discuss how their own journeys as mothers of children with significant behavioral health needs have informed their work as policy and practice advisors to state and local authorities. They will lift up the voices of their fellow parents and youth, whose insights they sought in order to inform improvements to behavioral health care and access at the state and local levels around the country. Heidi and Ellen seek to make this an engaging workshop for attendees and encourage all to join the call to action. 

Please join their workshop at NATCON24 on Monday, April 15, 2024 from 10:30– 11:30 AM CT in room 132, Level 1, ACCC.

As longtime leaders in health and human services, HMA’s behavioral health experts bring front line and leadership experience to their work supporting behavioral health authorities, child welfare programs and community and school-based providers of all kinds. We consult with public and private sector entities who serve children and families in order to improve access, streamline, and integrate care. We aim to advance equity and improve quality in state, county, and local program development. Contact us to learn more.

Learn more about the foundations of this project by accessing the Lifting Voices report from October 2023 below.

READ THE FULL REPORT
Blog

CMS releases Medicare Advantage and Part D payment policies for CY 2025

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This week, our In Focus section reviews the recently announced policy and payment updates from the Centers for Medicare & Medicaid Services (CMS) that will affect Medicare Advantage (MA) and Medicare Part D programs in calendar year (CY) 2025. We also take a look at the CY 2025 Part D Redesign Program Instructions. 

Both the rate announcement and program instructions include important technical updates and payment policy changes that will affect MA and Part D plans. CMS previously released a proposed rule in November 2023 that included proposed policy changes to MA and Part D. Health Management Associates, Inc., colleagues are closely monitoring how the final Rate Notice will shape the industry’s approach to the separately proposed policies for supplemental benefits, integrated dual eligible special needs plans (D-SNPs), and encounter data policies among others.  

The following are highlights from the CY 2025 Rate Announcement and significant changes CMS made from the Advance Notice released earlier this year. 

Payment Impact on MA 

CMS estimates that the final ate announcement will lead to a 3.70 percent increase in average payments to MA plans in CY 2025. This reflects the net payment impact of policy changes and updates to MA plan payments relative to 2024 and is the same amount as proposed in the CY 2025 Advance Notice released on January 31, 2024. As a result, MA plans will receive an estimated $16 billion increase in payments for CY 2025, and according to CMS, the federal government is expected to make $500−$600 billion in payments to MA plans in 2025. This reimbursement increase—which include all the various elements affecting MA plan payments, including the MA risk score trend—represents the average payment increase across all MA plans, although the actual impact on each plan will vary. 

Effective Growth Rate 

The effective growth rate finalized in the CY 2025 rate announcement is 2.33 percent, down slightly from 2.44 percent in the advance notice. The effective growth rate is driven largely by growth in Medicare fee-for-service expenditures, and the CY 2025 Rate Announcement was updated to include program payments during the fourth quarter of 2023. In addition, the technical medical education adjustment has declined from 67 percent in the Advance Notice to 52 percent in the Rate Announcement. 

Medicare Advantage Risk Adjustment and Coding 

The rate announcement continues to phase in the updated risk adjustment model by blending 67 percent of the risk score calculated using the updated 2024 MA risk adjustment model with 33 percent of the risk score calculated using the 2020 MA risk adjustment model.  These revisions to the MA risk adjustment model, which include important technical updates to improve the model’s predictive accuracy, were finalized last year under the CY 2024 Rate Announcement with a three-year phase-in. The Rate Announcement also finalizes that CMS will adopt a new methodology for normalizing risk scores to more accurately address the effects of the COVID-19 pandemic. 

Consistent with what the agency proposed in the Advance Notice, in CY 2025, CMS will apply the statutory minimum 5.90 percent MA coding pattern difference adjustment. 

Star Ratings 

CMS continues work toward implementing the “Universal Foundation” of quality measures—a subset of metrics aligned across public programs. CMS invites stakeholder feedback as it continues to explore adding measures to the Star Ratings, which are components of the Universal Foundation. 

For the CY 2025 rate announcement, Star Ratings changes include the types disasters that are included in the adjustment, updates to the non-substantive measure specification, and the list of metrics for inclusion in the MA and Part D improvement measures and Categorical Adjustment Index for 2025 Star Ratings. 

Part D Design and Part D Risk Adjustment Changes 

The Rate Announcement details several important changes to the standard Part D drug benefit for CY 2025 as required by the Inflation Reduction Act (IRA). These adjustments include eliminating the coverage gap phase from a three-phase benefit (deductible, initial coverage, and catastrophic) and setting the annual cap on patient out-of-pocket prescription drug costs at $2,000. The changes in Part D coverage design will have a significant impact on liability for Medicare beneficiaries, Part D plans, drug manufacturers, and CMS.  

CMS also finalized updates to the Part D risk-adjustment model to reflect Part D design changes included in the IRA and to ensure Part D plan sponsors can develop accurate bids for CY 2025. These changes include calibrating the Part D risk model using more recent data years and updating the normalization factor to reflect differences between MA-PD plan and standalone Part D plan risk score trends. 

Key Considerations 

Overall the final rate notice maintains stability and the opportunity for beneficiary choices in the MA program even as it continues to implement noteworthy changes in risk adjustment. The payment policies finalized in the CY 2025 Rate Announcement will have varying effects across MA plans, with some experiencing larger or smaller impacts in CY 2025. Plans should assess these effects as they prepare their bid submissions for 2025. 

In the CY 2025 rate announcement, CMS indicates that the 3.70 percent increase will provide continued stability in beneficiary access, choice, and benefits while ensuring accurate, appropriate payments to Medicare Advantage organizations. 

Looking ahead, CMS also has proposed policy and technical changes to the MA and Part D programs, which are expected to be finalized in the coming days. HMA’s summary analysis homes in on key issues that likely will be included in the final rule. CMS continues to solicit feedback from stakeholders on ways to reinforce and improve transparency in the MA program through the CMS Request for Information on MA data collection. Comments are due May 29, 2024. 

The HMA team will continue to analyze the important payment and technical changes finalized in the CY 2025 rate announcement. We have the depth, experience, and subject matter expertise to assist with tailored analysis and the modeling capabilities to assess the policy impacts across the multiple rules and guidance. 

If you have questions about the comments of the CY 2025 Rate Announcement and payment policies that impact MA plans, providers, and beneficiaries, contact our featured experts.

Blog

HMA experts in data integrity and governance to present at NATCON24 in St. Louis, April 15-17

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At the upcoming NATCON24 convention, HMA principals Robin Trush and Jodi Pekkala will present “Achieving Data Integrity and Staff Satisfaction through Technology Data Governance.” Health equity, alternative payments, and social determinants of health are all healthcare “North Stars” in healthcare grounded in data collection. To achieve standard metrics and address patient care coordination, EHRs, population-health platforms and other technology innovations must be used accurately, consistently and be configured properly. Cross-department database governance is grounded in standards to ensure data integrity. Too often, organizations have been unable to successfully stand-up technology and maintain consistent use over time, resulting in staff dissatisfaction and turnover.

This presentation will provide an overview of proven methods for bringing technology governance and leadership into clinical planning and operations, resulting in staff satisfaction, and putting your organization on the path toward those North Stars. Presenters will share lessons in how to bring technology management into clinical planning and operation. This enhanced organizational integration model will drive better outcomes and support the staff experience.     

Learning Objectives:

  • Describe current industry initiatives with technology infrastructure requirements.
  • Define and address common technology pain points for organizations and staff.
  • Define guidance for data governance, data integrity, and staff satisfaction.
  • Provide tools to take an organizational “pulse” and create a path to improvement.

Please join this workshop at NATCON24 on Monday, April 15, 2024 from 4:15 – 5:15 PM CT Location: 100/101, Level 1, ACCC

As longtime leaders in health and human services, HMA’s behavioral health, IT and data experts bring front line and leadership experience to their work supporting Health and Human Services IT projects. Combine this with the broad programmatic and operations expertise of the HMA team—which includes former clinicians, Medicaid directors, and leaders of provider and payer organizations—and we are able to deliver targeted, relevant, actionable advice to our clients. We aim to advance equity and improve quality in state, county, and local program development. Contact us to learn more.

Solutions

Achieving and Sustaining Success in the Health Insurance Marketplaces: Considerations for States and Managed Care Organizations

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The successful operation of the health insurance marketplaces created by the Affordable Care Act remains a key federal and state policy priority and an important business opportunity for managed care organizations (MCOs). At Health Management Associates (HMA), we are prepared to support both states and MCOs to achieve success in the operation of and participation in the marketplaces as these markets continue to evolve in the coming months and years.

Our team is made up of former state-based and federal marketplace leaders, insurance commissioners, state Medicaid directors, other senior government officials, payer executives, and provider leaders—meaning that we have the first-hand experience to navigate the complexities of marketplace establishment, operations, and participation toward successful outcomes. Our consultants have had expansive experience in this market since its inception. We have worked as and for federal and state regulators, enabling us to understand regulator goals. Additionally, we have worked for and with local, regional, and national MCOs on market entry strategy and/or profitability strategy. Our team has looked at the same problems from many angles and has the broadest historical perspective on the challenges and opportunities in this market.

CONSIDERATIONS FOR STATES

For states, operating a state-based marketplace (SBM) that flexibly meets the health coverage needs of the population in an efficient and responsive way is a common and critical goal. HMA understands the importance of establishing and continually operating a strong and lasting SBM capable of weathering and protecting against current and future threats to access and affordability. Key SBM policy outcomes include:

Local Control and Better Coordination

SBMs can increase enrollment and reduce gaps in coverage for families through closer alignment with the Medicaid program, customer-centric policies and procedures, and local, tailored engagement and outreach.

Lower Costs and Improved Consumer Protections

SBMs can establish plan design standards, coverage requirements, and consumer protections to improve choice and competition, lower out-of-pocket costs, and protect access to the affordable care individuals need and deserve.

Universal Coverage

Through innovative enrollment initiatives, federal waivers, and affordability programs, SBMs can be a catalyst for additional reforms to put the state on the pathway to universal coverage.

To be able to successfully accomplish the policy aims outlined above, states must excel across and within a range of strategic and operational areas including: organizational development and implementation, governance and project management, vendor procurement and oversight, strategic policy development, maximizing federal funding and financial management, federal compliance, stakeholder engagement, and communications and training. HMA can support states in all these areas with services that enable operations, regulatory compliance, strategy, and policy advancement.

CONSIDERATIONS FOR MCOS

For MCOs, the marketplace represents a key business opportunity where existing capabilities can be leveraged as part of a successful growth strategy. With our extensive regulatory expertise and expansive state market knowledge, HMA understands that customized support is necessary to allow MCOs to succeed in the marketplace as either a new market entrant or an existing participant. For MCOs, the marketplace has the following features:

A Highly Regulated Environment

At the federal and state levels, the marketplace environment has strict standards in terms of plan design, rating rules, network adequacy, marketing practices, producer (broker and agent) activities, and marketing practices.

Significant Public Funding

As a result of the marketplace premium tax credits, most marketplace consumers qualify and as a result, significant public funding is involved.

An Evolving Market

The end of the Medicaid continuous enrollment condition as of March 31, 2023, which has been in effect throughout the Coronavirus Disease 2019 Public Health Emergency, makes providing coverage in the marketplace even more critical—as millions of individuals transition to this market after losing Medicaid coverage.

How HMA can help

HMA can support clients every step of the way in the planning and execution of efforts to participate in and optimize performance for the marketplace. To achieve and maintain success in the marketplace, MCOs must excel across strategic, operational, and analytical areas including:

Market analysis and feasibility

Operational gap analysis

Product management scoping

Vendor procurement

Regulatory filings development and implementation

Actuarial analytics

Provider contract reimbursement analysis, and

Network development

HMA can bring to bear a comprehensive continuum of services to solve your most pressing marketplace challenges.

If you have questions about how HMA can support your state or MCO related to the marketplace, please contact Zach Sherman, managing director or Patrick Tigue, managing director.

Contact our experts:

Headshot of Zach Sherman

Zach Sherman

Managing Director

Zach Sherman is an Affordable Care Act (ACA) expert and Health Insurance Marketplace leader with extensive experience with start-ups and … Read more
Headshot of Patrick Tigue

Patrick Tigue

Senior Vice President, Practice Groups

Patrick Tigue is an accomplished executive with experience leading and managing critical efforts to achieve strategic health policy goals on … Read more
Blog

CMS Innovation Center announces ACO PC Flex model to enhance Medicare access

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This week, our In Focus section looks at the voluntary Accountable Care Organization Primary Care Flex (ACO PC Flex) Model, which the Centers for Medicare & Medicaid Services (CMS) Innovation Center announced on March 19, 2024. This model is designed to increase the number of low revenue ACOs in the Medicare Shared Savings Program (MSSP). Model participants will receive a one-time advanced shared savings payment and monthly prospective population-based payments. The ACO PC Flex Model is intended aims to support care delivery transformation, innovation, and team-based approaches to improve quality and reduce costs of care.

The ACO PC Flex Model is structured to increase the number of low revenue ACOs (i.e., ACOs composed of physicians, a small hospital, and/or serve rural areas). CMS published results in August 2022 indicating  that low revenue ACOs generated $113 more per capita savings than their high revenue counterparts.  CMS wrote in July of 2023 that the agency was seeking new opportunities for ACOs to serve Medicare beneficiaries. With this model, the Innovation Center is providing flexible payment to support innovative, team-based, person-centered, and proactive approaches to care for a subset of ACOs that have historically generated savings.

ACO PC Flex Model payments are structured to provide advanced shared savings to support administrative activities necessary for the model and ongoing payments specifically for primary care. The payment approach includes:

  • A monthly prospective primary care payment consisting of 1) a county base rate determined by average primary care spending, and 2) payment enhancements to support increased access to primary care, provision of care, and care coordination, which are exempt from CMS recoupment
  • An advanced shared savings payment as a one-time advance the changes needed to support needed operations and administration

With the approach, the Innovation Center anticipates CMS will be able to improve access to primary care services, particularly for underserved communities, and empower providers through flexible, stable payments to innovate care delivery to better meet their patients’ needs.

The demonstration will start January 1, 2025, and run for five years. The request for applicants (RFA) is expected in the second quarter of 2024, and ACOs must apply for participation in MSSP as a new or renewing organization to be eligible for ACO PC Flex. Applications for MSSP close June 17, 2024.

More details are expected to be included in the RFA. If you are interested learning more about the ACO PC Flex Model, please contact our featured experts.

Podcasts

Is food the missing link in healthcare’s cost crisis?

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R.J. Briscione is a principal with the HMA Strategy and Transformation Practice. R.J. shares insights gained from his experience in Medicaid managed care, CVS business development, and how he made the leap into healthcare from aeronautics. R.J. shares key insights on addressing food insecurity, nutrition education, and tailored food interventions that measurably drive better health outcomes. Join us as we highlight the vital role of food in healthcare and uncover actionable strategies for community organizations looking to impact patient outcomes by improving upstream determinants of health.