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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.
This was part 1 of our 3-part webinar series, “Substance Use Disorder Ecosystem of Care: Pivoting to Save Lives.” In this session, we provided an overview of the series and took a look at the services and support that comprise a system of care for people who are not yet in treatment. These services are often community-based and involve outreach, engagement, and meeting people where they are. As people enter treatment, experience relapse, or choose to move through different treatment modalities, health promotion and harm reduction can serve as a safety net to keep people continuously engaged.
Learning Objectives:
Explain the differences between prevention, promotion, and harm reduction.
Illustrate the primary goal of health promotion.
Distinguish the continuum and role of health promotion related to stages of chronic disease: active, controlled, and relapse.
Identify role of harm reduction as a health promotion activity in the public sector v. the harm reduction often carried out in CBO/non-profit sector.
Whether you are a healthcare professional, caregiver, or someone personally affected by substance use, this webinar offered a roadmap for navigating the complexities of the Substance Use Care Continuum, fostering hope and resilience in the pursuit of sustained well-being.
This week, our In Focus section reviews the Centers for Medicare & Medicaid Services (CMS) Calendar Year (CY) 2025 Advance Notice for the Medicare Advantage (Part C) and Part D Prescription Drug Programs published on January 31, 2024. Alongside the advance notice, CMS published draft CY 2025 Part D Redesign Program Instructions. This guidance includes CY 2025 payment updates as well as additional proposed technical and methodological changes to Medicare Advantage (MA) and Part D. CMS previously released a proposed rule in November 2023 that included proposed policy changes to MA and Part D for CY 2025.
The proposed payment policies signal CMS is working to ensure the stability of MA and Part D programs, while also addressing concerns about the appropriateness of payments to plans. Furthermore, CMS remains highly focused on the impact methodological changes could have on payment to plans that enroll beneficiaries who are dually eligible for Medicare and Medicaid services. Proposals to align quality measures across programs and strengthen the measures used to assess the quality of beneficiary experiences and services provide directional information on CMS’s plans for the forthcoming annual payment rules for 2025.
Following are highlights from the 2025 Advance Notice and Part D Redesign Program Instructions. The deadline for submitting comments is Friday, March 1, 2024. CMS will announce the MA capitation rates and final payment policies for 2025 no later than April 1, 2024.
Payment Impact on MA: CMS is projecting that federal payments to MA plans will increase on average 3.7 percent from 2024 to 2025. The increase reflects multiple factors, including growth rates in underlying costs, change in Star ratings, continued implementation of the new risk adjustment model and fee for service (FFS) normalization, and risk score trends. Actual impacts of the proposed payment policies will vary from plan to plan.
Risk Adjustment: CMS is proposing to continue its three-year phase in of the updated Part C risk adjustment model, first published in the CY 2024 Rate Announcement. In CY 2025, risk scores will be calculated by blending 67 percent of the risk score using the 2024 CMS hierarchical condition categories (HCC) risk adjustment model and 33 percent using the 2020 CMS-HCC risk adjustment model. In addition, the MA risk score trend is being calculated separately under each model, then blended by the respective percentage to determine a CY 2025 risk score trend of 3.86 percent.
CMS is proposing a new methodology for calculating the FFS normalization factor to accurately address the effects of the COVID-19 pandemic without excluding any years of FFS risk scores.
CMS also proposes to apply the statutory minimum MA coding pattern difference adjustment factor of 5.90 percent for CY 2025.
Frailty Adjustment for FIDE SNPs and PACE Organizations. For CY 2025, CMS is proposing to blend the frailty score calculated for fully integrated dual eligible (FIDE) special needs plans (SNPs) consistent with the phase-in of the 2024 CMS-HCC model. The FIDE SNP frailty score is the sum of:
33 percent of the score calculated with the 2020 CMS-HCC model frailty factors
67 percent of the score calculated with the 2024 CMS-HCC model frailty factors
CMS also intends to use only the full Medicaid frailty factors to calculate frailty scores for FIDE SNP enrollees in order to align with the requirement that FIDE SNPs must have exclusively aligned enrollment, meaning that enrollment in FIDE SNPs will be limited to full-benefit dually eligible individuals, beginning in CY 2025. CMS will use the frailty factors associated with the 2017 CMS-HCC model to calculate frailty scores for Program of All-Inclusive Care for the Elderly (PACE) organizations in CY 2025.
Star Ratings: CMS reiterates its plan to further implement the “universal foundation” of quality measures. CMS first announced this subset of metrics in 2023, with the goal of aligning a core set of metrics across the agency’s programs while continuing to allow for program specific measures. CMS reminds plans that beginning with the 2024 measurement year (2026 Star Ratings), the weight of patients’ experience, complaints, and access measures will be reduced from a weight of four to a weight of two.
CMS proposes several updates and refinements to the Star Ratings program, including:
Retiring the Care for Older Adults – Pain Assessment (Part C) measure, starting as early as the 2025 measurement year
Making changes to the Plan Makes Timely Decisions About Appeals and Reviewing Appeals Decisions (Part C) measures for cases submitted electronically to the independent review entity
Adding Social Need Screening and Intervention (Part C) to the display page for the 2025 Star Ratings and giving notice that National Committee on Quality Assurance (NCQA) is evaluating the potential addition of a utilities insecurity screening and intervention rate for this measure in the future
Adding Depression Screening and Follow-Up for Adolescents and Adults (Part C) and Adult Immunization Status (Part C) to the display page for the 2026 Star Ratings
Updating the Members Choosing to Leave the Plan (Part C and D) measure for the 2026 Star Ratings
Possibly adding the Initiation and Engagement of Substance Use Disorder Treatment (Part C) and Initial Opioid Prescribing for Long Duration (IOP-LD) (Part D) measures
Revisions to the Care Coordination (Part C) measure, and other changes through future rulemaking
Part D Impact
The advance notice reviews the significant changes to the Part D benefit occurring in 2025 as required in the Inflation Reduction Act (IRA). The IRA’s Part D changes effective in CY 2025 include:
Eliminating the coverage gap phase. A newly defined standard Part D benefit will consist of three phases: annual deductible, initial coverage, and catastrophic coverage. There is no initial coverage limit, and the initial coverage phase will extend to the maximum annual out-of-pocket threshold, after which the catastrophic phase begins.
Setting the out-of-pocket threshold at $2,000.
Sunsetting the Coverage Gap Discount Program and implementing of the Manufacturer Discount Program (Discount Program).
Making changes to the liability of enrollees, plans, manufacturers, and CMS.
Updating the definition of incurred costs to include, among other categories of costs, supplemental coverage and other health insurance, which was previously excluded. Manufacturer discounts provided under the Discount Program also will be excluded.
Premium stabilization will continue to be in effect.
CMS is recalibrating the RxHCC risk adjustment model to account for IRA changes and is proposing to calculate separate normalization factors for risk scores used to pay MA-PD plans versus PDPs.
Key Considerations
The impact of the MA risk score trend on payment will vary across individual MA plans. Plans will want to analyze these effects to inform their comments to CMS.
In the advance notice, CMS emphasized the strong growth in the dual SNP market for 2024. This market continues to present growth opportunities. CMS has sought to ensure that changes to payment accuracy better reflect more recent cost and utilization patterns and the risk profile of the sickest and most complex enrollees. Plans will want to consider payment incentives in the context of major policy, reimbursement, and operational changes required to improve integrated care for dually eligible individuals. MA organizations considering becoming FIDE SNPs and wishing to obtain frailty payments in 2025 will need to understand the specific requirements to be eligible for such payments.
The HMA Medicare team will continue to analyze these proposed changes. We have the depth and breadth of expertise to assist with tailored analysis, to model policy impacts across the multiple rules, and to support the drafting of comment letters on this notice.
If you have questions about the contents of CMS’s MA Advance Notice and payment policies and how these would affect MA plans, including SNPs, providers, and Medicare beneficiaries, contact our experts below.
As the U.S. population ages, non-medical personal care services are increasingly important for supporting Americans to remain in homes, as the vast majority of them prefer. But in-home personal care services will remain in short supply throughout the country unless home care agencies have greater success recruiting and retaining caregivers. In this HMA white paper, we describe the programs developed by Help at Home, the nation’s largest personal care services providers with 53,000 in 11 states, to use technological solutions to increase ease of caregiver recruitment and to provide its caregivers with a greater sense of purpose and meaning in their work.
The latter accomplishment has been achieved through Help at Home’s innovative care management program, “Care Coordination at Help at Home,” in which its caregivers receive a weekly text asking them to complete a brief survey about their personal care client’s physical and behavioral health symptoms and any health-related social needs. This information is transmitted to the agency’s Clinical Support Team, composed of nurses, social workers, and community health workers, who review the caregivers’ observations and, if needed, conduct further evaluations of the clients and/or alert the appropriate primary care or specialty providers about their escalating health and social needs. The program’s outcomes: Decreased client utilization of Emergency Department visits and hospitalizations since brewing health concerns are addressed earlier on. Increased caregiver retention because caregivers feel like they are making a significant difference in the health and well-being of their clients.
This In Focus section reviews the request for applications (RFA) that the Commonwealth of Pennsylvania Department of Human Services (DHS) released January 30, for the Community HealthChoices (CHC) Program. CHC is the mandatory managed long-term services and supports (MLTSS) program, which serves five CHC zones that cover all 67 counties in the commonwealth.
Notably, this procurement, as compared to the original CHC procurement in 2018, has increased emphasis on innovative approaches to address health equity and the Social Determinates of Health (SDOH). The health equity focus goes beyond traditional health-related social needs such as access to housing, transportation, food, and employment, and addresses some SDOHs that have a particular impact on the CHC population, such as environmental conditions and addressing hazardous or unsafe living conditions.
Behavioral health remains carved-out to separate behavioral health managed care organizations (BH-MCOs). Instead, CHC applicants will need to articulate how they will coordinate with the BH-MCOs to ensure access to appropriate BH services, which continues to be an area of significant interest for state Medicaid officials.
Background
The CHC Program serves individuals who are dually eligible for Medicare and Medicaid and people with physical disabilities who receive home and community-based waiver services or nursing facility care.
Participants may receive LTSS in the community or in a nursing facility.
CHC is the sole program option for fully dual eligible beneficiaries and most nursing facility clinically eligible (NFCE) individuals who reside in the five zones. The regional CHC zones are as follows:
Medicaid managed care organizations (MCOs) may submit applications for one or more zones. Applications are due March 15, 2024. The department anticipates awarding agreements to three to five CHC-MCOs in each of the five CHC zones. Selected applicants must provide CHC services in all counties in the zone(s) for which they are selected to participate and improve the accessibility, continuity, and quality of services for participants in the CHC program. The contract will run for five years and will have three one-year renewal options.
DHS indicates that the awarded CHC-MCOs must have an aligned dual-eligible special needs plan (D-SNP) and a current Medicare Improvement for Patients and Providers Act (MIPPA) agreement with the department. The aligned D-SNP must be operational and the MIPPA agreement must be in place by the anticipated implementation date (January 1, 2025).
DHS indicates selected MCOs must be as flexible and adaptable as possible and demonstrate the ability to coordinate services for multiple populations and across multiple programs, including programs with a focus that is broader than the delivery of healthcare services and LTSS.
Other RFA highlights include the following:
Does not require a cost submittal.
Includes small diverse business (SDB) or veteran business enterprise (VBE) goals of 11 percent and 3 percent respectively. Applicants must include separate SDB and VBE submittals for each zone in its application.
Includes a contractor partnership program (CPP) which requires entities that are awarded a contract or agreement with DHS to establish a hiring target to support Temporary Assistance for Needy Families (TANF) beneficiaries in obtaining employment with the contractor, grantee, or their subcontractors.
Notably, DHS has provided itself flexibility within the RFA to implement a pay-for-performance incentive to MCOs. Under this policy, DHS could make incentives available to MCOs that help participants successfully complete the financial eligibility redetermination process with their local County Assistance Offices (CAOs). The department may implement additional pay-for-performance incentives in later years.
Timeline
Evaluation
For an applicant to be considered responsible for this RFA and eligible for selection of best and final offers (BAFOs) and negotiations:
The total score for the technical submittal of the application must be greater than or equal to 75 percent of the available raw technical points
The applicant’s financial information must demonstrate that the organization possesses the financial capacity to fulfill the good faith performance of the agreement
The evaluation committee will evaluate technical submittals for each zone separately. For each zone, DHS must select for negotiations the applicants with the highest overall score. The weight for the technical criterion is 100 percent of the total available points. Technical evaluation will be based on soundness of approach, applicant qualifications, personnel qualifications, and understanding the project.
The final technical scores will be determined by giving the maximum number of technical points available to the application with the highest raw technical score. The remaining applications will be rated by applying the formula located at RFP Scoring Formula.
Financial information will not be scored as part of the technical submittal. It will be reviewed only to determine an applicant’s financial responsibility.
SDB and VBE participation submittals will not be scored, however, if an applicant fails to satisfy the SDB or VBE requirements described, and DHS will reject the application.
DHS will not score the CPP submittal. Once an applicant has been selected for negotiations, DHS will review the CPP submittal.
Current Market
The CHC incumbents are AmeriHealth Caritas, Centene, and University of Pittsburgh Medical Center (UPMC), serving 411,034 CHC members as of October 2023.
Want to know more about how the next phase of Community Health Choices will impact your organization?
HMA’s Pennsylvania-based teams can assist organizations seeking to understand the implications of this important procurement, key program changes and what the outcome may mean for providers, community base organizations, and other stakeholders. Please contact Dianne Bisacky with questions or if you are seeking more detailed analysis of this procurement or the Community Health Choices program generally.
Nine States to Participate in Children’s Behavioral Health Policy Lab
LANSING, MICH. – Health Management Associates (HMA), in partnership with the Annie E. Casey Foundation, Casey Family Programs, National Association of State Mental Health Program Directors (NASMHPD), the Child Welfare League of America (CWLA), the American Public Human Services Association (APHSA), National Association of Medicaid Directors (NAMD) and the Centene Foundation, will convene a Children’s Behavioral Health (CBH) State Policy Lab, Feb. 7-9 in Baltimore. HMA today announced that Georgia, Kansas, Kentucky, Maryland, Missouri, Pennsylvania, Texas, Utah, and Wisconsin will participate in the policy lab. MITRE, which previously hosted a related federal convening, will also take part in this state convening.
This pioneering effort, made possible by the partner organizations, aims to convene state interagency teams – including child welfare, juvenile justice, behavioral health, Medicaid, and K-12 public education – to collectively strategize, learn from innovators in the sector and promote cross-system alignment to drive outcomes for children, youth, and families.
COVID-19 has exacerbated long-standing system collaboration challenges across state child welfare, behavioral health, and Medicaid that lead to unsatisfactory outcomes for the most vulnerable children in our communities. Most worrisome is the worsening of behavioral and physical health challenges and trauma because of uncoordinated or fragmented care. This lack of coordinated strategy and policy leads to higher costs of treatment and also increasingly exposes states and local jurisdictions to threats or filings of class action lawsuits, and related settlements or those arising from Department of Justice investigations. Fortunately, federal and state efforts and investments to address the youth systems of care – including schools, community, delivery systems, and community-based child placing agencies – are in motion.
In November, a call for applications was released to U.S. states and territories for potential participation in the State Policy Lab. Applicants were required to identify demonstrated need, existing state agency governance structures focused on children and youth, technical assistance needs, and outcomes for attending the policy lab. The applications required demonstrated participation from Medicaid, child welfare and behavioral health agencies; a commitment to creating sustainable interagency solutions for children, youth, and their families and had to certify formal support from the Governor/Cabinet level.
An external independent panel reviewed applications for state agency participation using a standardized rubric that covered four domains:
Gaps and opportunities analysis
Intent of collaborative partnerships
Approach to engagement of youth and adults with lived experience
Imminent risks to public agency operations as a result of poor outcomes for children, youth, and their families
This convening is aimed at assisting child welfare, juvenile justice, behavioral health, Medicaid, and K-12 public education where possible to build upon existing efforts to improve outcomes for children, youth, and families, strategically layering on missing components and promoting alignment between them and with other agency priorities. Examples of what could be co-designed with state partners:
Build a shared strategic vision for a comprehensive continuum of care that ensures access to the “right service, at the right time based on individual and family need.” This vision can strengthen prevention initiatives and ensure the full array of evidence-based community-based interventions including use of crisis response and stabilization models.
Develop policies and strategies for improving the engagement of children, youth, and families with lived experiences to the “right part of the system for the right level of care,” agnostic of the door through which they enter any coordinated child serving system, while ensuring that all aspects of this system are anchored in equity.
Following the event, learnings and findings will be disseminated to help states and counties adopt innovative solutions to improve outcomes for children, youth, and their families.
This week, our In Focus section highlights a new report released on January 25, 2024, Analyzing the Expanded Landscape of Value-Based Entities: Implications and Opportunities of Enablers for the CMS Innovation Center and the Broader Value Movement. The analysis explores the growing ecosystem of new entities designed to assume accountability for the total cost and quality of care in order to understand the growth of this market and consider the role these entities play in advancing accountable care in Medicare, Medicaid, and the broader healthcare sector. The report combines the value-based payment (VBP) policy and market expertise of Health Management Associates (HMA) and Leavitt Partners, an HMA company, with support from Arnold Ventures.
At the start of the movement, value-based arrangements primarily involved traditional providers and payers engaging in relatively straight-forward and limited contractual arrangements. In recent years, the value-based care market has expanded to include a variety of risk-bearing healthcare delivery organizations and provider enablement entities, with capabilities and business models aligned with the functions and aims of accountable care. Despite their prevalence, little formal research has been conducted to determine the role, growth, and impact of these entities to date, and publicly available information is limited.
The report introduces a framework for classifying these entities and estimates the size of this market for the first time. Using insights from 60 interviews with entity leaders, providers, and policymakers, and extensive secondary research into approximately 120 organizations, the report details the common offerings, partnership models, and growth strategies of these entities. The research investigated primary care-focused entities as well as risk-bearing delivery organizations and VBP enablers focused on select specialty areas that align with total cost of care models (i.e., kidney care, oncology, cardiology, behavioral health, and palliative care). Authors examined providers’ experiences selecting and collaborating with enablement partners and the role of these entities within Medicare accountable care models, as well as the broader value movement, to inform a set of guiding principles that help providers and policymakers evaluate the attributes of ideal partners.
Market Landscape
For the past decade, the Centers for Medicare & Medicaid Services (CMS), through its Innovation Center (CMMI), has been leading the movement toward value. Going forward, the agency is focused on scaling accountable care adoption to achieve its 2030 goal, but also seeks to ensure that transformation is equitable and sustainable. These entities are helping providers to engage in accountable care, but our guiding principles and policy recommendations aim to support CMS in ensuring that their growth aligns with provider and patient priorities.
In assessing the value-based care market, the report divided the organizations into three main categories by their core business model: VBP enablers (which are not involved in the direct provision of care, but in assisting others to adopt VBP models); risk-bearing delivery organizations (entities designed to deliver value-based care and assume payment risk for the cost of care); and organizations that are a hybrid of the two (companies that own assets that enable other organizations and those that deliver care).
From risk-bearing delivery organizations with business models that hinge on effective population health management and longitudinal patient relationships, to VBP enablers that provide the population health functions needed to succeed in accountable care while sharing responsibility for those outcomes, these entities are creating more opportunities for clinicians to deliver the type of coordinated, proactive, whole-person care that is unsupported in a fee-for-service system.
A Growing Market
Fueling the growth of value enablers are signals from federal and state policymakers that value-based payment (VBP) is here to stay. The certainty of this approach is already leading to increased focus on underserved populations and safety net providers as CMS places greater focus on expanding VBP contracts in Medicaid and other public insurance programs.
As the market matures and pressure to participate in accountable care mounts, organizations will have several paths forward to implementation of alternative payment models. The growth and availability of enablement entities that are designed with the explicit purpose of helping providers overcome barriers to participation – and whose own financial success hinges on the success of their provider partners – could represent a promising gateway toward achieving accountable care.
The research found several similarities across most entities in this space, demonstrating a highly competitive market, with organizations focused on similar priorities in target providers, geographies, and key populations. Entities often use hybrid, high-touch clinical models to support physicians with patient navigators and other clinical extenders and support staff. They heavily rely on health information technology, and often develop homegrown, proprietary tech assets to better address provider pain points. Finally, most entities depend on outside capital and investment to fuel growth, and investor interest in the space seems to be robust and growing, along with the evolution of value-based care models.
Guiding Principles and Policy Recommendations
The report concludes by proposing a set of guiding principles to describe the optimal attributes of value-based enablement entities aligned with CMS, provider, and patient goals. Authors point to steps CMS can take to best engage with this expanded ecosystem in support of its efforts to scale accountable care while ensuring appropriate guardrails are in place to protect patients and providers.
As CMS works to accelerate adoption of accountable care to achieve its 2030 goal and beyond, the agency must find ways to bring in new providers who have yet to engage meaningfully in these models, while retaining current participants and advancing model designs for the next phase of VBP and delivery reform. The report makes policy recommendations to 1) drive new and sustained provider participation and 2) ensure high-quality partnerships for CMS and providers.
With its acquisition of Leavitt Partners and Wakely Consulting, along with its strong and growing Medicare policy practice, HMA is developing a diverse and robust set of solutions for entities engaging in value-based care and payment. On March 5 and 6, HMA will be devoting its spring event to the topic. The report authors will be featured prominently and will lead a session on the report’s implications. More information about the Spring Workshop, Getting Real about Transforming Healthcare Quality and Value, can be found here.
For details about this research, please contact the report authors below.
State behavioral health and children’s welfare agency officials from Georgia, Kansas, Kentucky, Maryland, Missouri, Pennsylvania, Texas, Utah, and Wisconsin selected to participate.
Health Management Associates (HMA), in partnership with the Annie E. Casey Foundation, Casey Family Programs, National Association of State Mental Health Program Directors (NASMHPD), the Child Welfare League of America (CWLA), the American Public Human Services Association (APHSA), and the National Association of Medicaid Directors (NAMD), will convene a Children’s Behavioral Health (CBH) State Policy Lab, February 7-9 in Baltimore. HMA today announced the selection of nine states – Georgia, Kansas, Kentucky, Maryland, Missouri, Pennsylvania, Texas, Utah, and Wisconsin – that will participate in the policy lab. MITRE, which previously hosted a related federal convening, will also take part in this state convening.
This pioneering effort, made possible by the partner organizations, aims to convene state interagency teams – including child welfare, juvenile justice, behavioral health, Medicaid, and K-12 public education – to collectively strategize, learn from innovators in the sector and promote cross-system alignment to drive outcomes for children, youth, and families.
COVID-19 has exacerbated long-standing system collaboration challenges across state child welfare, behavioral health, and Medicaid that lead to unsatisfactory outcomes for the most vulnerable children in our communities. Most worrisome is the worsening of behavioral and physical health challenges and trauma because of uncoordinated or fragmented care. This lack of coordinated strategy and policy leads to higher costs of treatment and also increasingly exposes states and local jurisdictions to threats or filings of class action lawsuits, and related settlements or those arising from Department of Justice investigations. Fortunately, federal and state efforts and investments to address the youth systems of care – including schools, community, delivery systems, and community-based child placing agencies – are in motion.
In November, a call for applications was released to U.S. states and territories for potential participation in the State Policy Lab. Applicants were required to identify demonstrated need, existing state agency governance structures focused on children and youth, technical assistance needs, and outcomes for attending the policy lab. The applications required demonstrated participation from Medicaid, child welfare and behavioral health agencies; a commitment to creating sustainable interagency solutions for children, youth, and their families and had to certify formal support of Governor/Cabinet level.
An external independent panel reviewed applications for state agency participation using a standardized rubric that covered four domains:
Gaps and opportunities analysis
Intent of collaborative partnerships
Approach to engagement of youth and adults with lived experience
Imminent risks to public agency operations as a result of poor outcomes for children, youth, and their families
This convening is aimed at assisting child welfare, juvenile justice, behavioral health, Medicaid, and K-12 public education where possible to build upon existing efforts to improve outcomes for children, youth, and families, strategically layering on missing components and promoting alignment between them and with other agency priorities. Examples of what could be co-designed with state partners:
Build a shared strategic vision for a comprehensive continuum of care that ensures access to the “right service, at the right time based on individual and family need.” This vision can strengthen prevention initiatives and ensure the full array of evidence-based community-based interventions including use of crisis response and stabilization models.
Develop policies and strategies for improving the engagement of children, youth, and families with lived experiences to the “right part of the system for the right level of care,” agnostic of the door through which they enter any coordinated child serving system, while ensuring that all aspects of this system are anchored in equity.
Following the event, learnings and findings will be disseminated to help states and counties adopt innovative solutions to improve outcomes for children, youth, and their families.
In the constantly changing healthcare environment, data analytics and technology are key tools to assist in controlling the burden of increased costs and identifying gaps in quality. As digital health tools and technology advance to include wearable devices, mobile health apps, telemedicine platforms, and other innovations, this enables the integration of digital solutions and real-time patient data. Artificial intelligence, still largely untapped, may have a significant impact as well.
Ideally better data will result in higher quality, better health outcomes, and an increase in provided value. To achieve this, effective health information technology platforms need to be interoperable and truly facilitate the exchange of patient information among providers and care coordinators. Data analytics tools and technology also must be consumer focused and focus on collecting and sharing data that is analyzable. These tools are a vital component of establishing new payment structures, allowing plans and providers to share some of the risk and the cost savings from producing better health outcomes. Identifying a core set of metrics that are patient-focused, measurable, and actionable along with optimizing data analytics tools can provide more efficient pathways to providing healthcare. Any company working in healthcare must elevate data and technology as a fundamental part of corporate strategy across all objectives.
You can explore best practices and emerging opportunities for data and technology at HMA’s 2024 Spring workshop on value-based care (VBC) March 5-6, in Chicago. Breakout discussions offer a unique forum for payers, government officials, community organizations, vendors, and providers to have an unvarnished conversation about the challenges, lessons, and opportunities in implementing value-based care. You will engage with HMA experts and peers in an intimate setting and come away with new ideas and new allies.
The Data and Technology cohort will include two small group discussions facilitated by HMA leaders Ryan Howells, Stuart Venzke, and David Lee, as well as former US Chief Technology Officer Aneesh Chopra. The sessions are designed to arrive at specific recommendations as to how stakeholders can advance their own data and technology capabilities and jointly address systemic barriers to better meet the needs of those taking risk for outcomes:
Making Data More Patient Centric: Opportunities in Trusted Exchange Framework and Common Agreement (TEFCA) implementation in producing and supporting FHIR APIs to create a more patient-centered data ecosystem that achieves a tangible return on investment.
Making Data Central to Strategy: Developing a strategic organizational technology roadmap that will support both current and future data and technology priorities
Other cohort discussions will delve into approaches to develop and manage risk-based contracting across sectors, establish effective partnerships with safety net providers and community-based organizations, and navigating changes in local market and policy conditions that are shaping value-based care adoption and innovation.
New Report Analyzes the Expanding Landscape of Value-Based Entities
Research from HMA and LP VBP experts segments and sizes the growing enabler market, considering benefits and risks, and proposing guiding principles and policy recommendations for the CMS Innovation Center
A new in-depth HMA report analyzes the landscape of emerging value-based entities and the implications for accelerating the adoption of accountable care.
In recent years, the value-based care market has expanded to include a variety of risk-bearing care delivery organizations and provider enablement entities with capabilities and business models aligned with the functions and aims of accountable care. Despite their prevalence, there has been little formal research into the role, growth, and impact of these entities to date and publicly available information is limited.
The report, “Analyzing the Expanded Landscape of Value-Based Entities: Implications and Opportunities of Enablers for the CMS Innovation Center and the Broader Value Movement,” represents a nine-month research effort leveraging the combined VBP policy and market expertise of HMA and Leavitt Partners, an HMA Company with support from Arnold Ventures.
The report offers a detailed overview of this evolving landscape by introducing a novel framework for classifying these entities and estimating the size of the market.
The authors interviewed 60 entity leaders, providers, and policymakers and conducted extensive secondary research into approximately 120 organizations, generating report insights that detail the common offerings, partnership models, and growth strategies of these entities. Authors examined providers’ experiences selecting and collaborating with enablement partners and the role of these entities within Medicare accountable care models and the broader value movement.
The report concludes by proposing a set of guiding principles to describe the optimal attributes of value-based enablement entities that would be in alignment with CMS, provider, and patient goals. Authors point to steps CMS can take to best engage with this expanded ecosystem in support of its efforts to scale accountable care while ensuring appropriate guardrails to protect patients and providers.
As this landscape evolves and expands, CMS and its Innovation Center should continue to carefully consider how these entities participate in its models while also leveraging these important partners for learning and advancing accountable care.
With its acquisition of Leavitt Partners and Wakely Consulting, along with its strong and growing Medicare policy practice, HMA is developing a diverse and robust set of solutions for entities engaging in value-based care and payment. In March, HMA will be devoting its spring event to the topic, with the report authors featuring prominently among discussion leaders and presenters. More information about the Spring Workshop, “Getting Real about Transforming Healthcare Quality and Value”, can be found here.
Report authors include Kate de Lisle, Amy Bassano, Jared Staheli, Spencer Morrison, and Melissa Mannon. Data collection and analysis was supported by Thomas Gubbay, Tom Williams, and Lucas Asher.
This week, our In Focus section highlights the Innovation in Behavioral Health (IBH) model, which the Centers for Medicare & Medicaid Services (CMS) announced January 18, 2023. It is the third state-based alternative payment model that the CMS Center for Medicare and Medicaid Innovation (Innovation Center) has released in recent months. HMA wrote about the Transforming Maternal Health (TMaH) Model here and States Advancing All-Payer Health Equity Approaches and Development (AHEAD) Model here.
IBH Model Overview
This model is designed to improve the quality of care and health outcomes for people with moderate to severe behavioral health conditions through person-centered care that integrates physical health, behavioral health, and health-related social needs (HRSN). Its objective is to improve care through healthcare integration, care management, health equity, and health information technology.
CMS will select up to eight state Medicaid agencies for participation in this eight-year model that will begin in fall 2024. Participating states must partner with the agencies that are responsible for mental health and/or substance use disorder treatment to ensure coordination and alignment of policies. Model participants will develop and implement the IBH model in partnership with at least one Medicaid managed care organization or another intermediary as applicable.
Community-based behavioral health organizations and providers in selected states can choose to engage as practice participants in the model. Community-based providers can include safety net providers, community mental health centers, public or private practices, and opioid treatment programs. Practice participants will be responsible for coordinating with other members of the care team to comprehensively address behavioral and physical health needs and HRSN, such as housing, food, and transportation for patients. Practice participants will conduct HRSN screenings, refer patients to specialists and community-based resources, and more. They will be compensated based on the quality of care provided and improved patient outcomes.
Opportunities and Considerations
The model will include three pre-implementation years during which states and practice participants will receive Medicaid and Medicare funding for development and capacity building. Medicare will provide practice participants with a per-beneficiary-per-month payment in pre-implementation years to support health IT, electronic health records (EHR), practice transformation, new workflows, and staffing investment necessary to implement the model. Starting in year four, the Medicaid alternative payment model must be implemented, and Medicare will begin making performance-based payments.
Notably, the announcement materials do not indicate the maximum funding amount selected state Medicaid agencies are eligible to receive in IBH. The cooperative agreement funding for selected states will support implementation preparations, such as statewide health IT infrastructure, supporting practice participants, stakeholder convening, and developing the Medicaid alternative payment model.
What’s Next
The Innovation Center expects to release a Notice of Funding Opportunity (NOFO) in spring 2024. More details on the requirements, including payment methodologies and funding, are expected to be included in the NOFO.
The HMA Behavioral Health and federal policy teams will continue to monitor developments in IBH and analyze the opportunities for states and providers in this model. HMA experts are also assessing the relative opportunities of the IBH model alongside other Innovation Center opportunities and initiatives already underway in states.
