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.
HMA created a comprehensive series of webinars discussing the potential for using 1115 demonstrations to expand and improve healthcare services for the justice-involved population. Replays of the webinars and other justice-involved healthcare resources are now available.
Part 1: Medicaid Authority and Opportunity to Build New Programs for Justice-Involved Individuals
Part 2: 1115 Justice Waivers to Improve Carceral Healthcare Delivery Information
Part 3: 1115 Justice Waivers: Connecting Community Partners to Improve Transitions of Care
Part 4: 1115 Justice Waivers: Medication Assisted Treatment for Substance Use Disorder in Carceral Settings
Part 5: Medicaid 1115 Justice Waivers and Special Populations: Meeting the Needs of Justice-Involved Youth
What’s next for 1115 Waivers in your organization?
If your organization or state agency is ready to create new initiatives to improve carceral healthcare delivery and facilitate smoother transitions back into communities, HMA can help. Our consultants bring unparalleled expertise in Medicaid policy and correctional health as well as a deep understanding of the unique needs of this population. We have the operational knowledge and experience with technology and digital health solutions – and the ability to collect and analyze the right data to drive meaningful improvements in equity and access to care.
If you have questions or want to discuss options, please contact any of the speakers from the series:
Linda Follenweider, Managing Director, Justice Involved Services
Tonya Moore, Senior Consultant
Margaret Tatar, Managing Principal
John Volpe, Principal
Julie White, Principal
Michael DuBose, Principal
Rich VandenHeuvel, Principal
Bren Manaugh, Principal
Caitlin Thomas-Henkel, Principal
Jon Rubin, Principal
Register today for HMA’s 6th annual conference on Trends in Publicly Sponsored Healthcare, Oct. 30-31 in Chicago. The event will feature the session, Medicaid and Individuals in Carceral Settings: Improving Coordination, Managing Transitions. Register now: https://conference.healthmanagement.com/
This week, our In Focus section reviews the new States Advancing All-Payer Health Equity Approaches and Development (AHEAD) Model, which the Centers for Medicare & Medicaid Services (CMS) Center for Medicaid and Medicare Innovation (the Innovation Center) announced on September 5, 2023. AHEAD is the third major model that the Innovation Center has introduced to its payment portfolio since July, clearly signaling that CMS has transitioned from conducting its internal review to laying the groundwork for action on approaches that will be tested over the next decade.
CMS views this model as the next iteration of earlier total cost of care (TCOC) models that were designed and tested in three states—Maryland, Vermont, and Pennsylvania. The AHEAD model includes several important updates based on its experience with these earlier models. For example, the AHEAD model is designed to be scalable in multiple states. Although it most certainly will be adapted to state-specific markets, landscapes, and provider needs, CMS intends to apply a consistent framework across participating states.
Additionally, though Medicare has been involved in formulating some state-level total cost of care initiatives, the AHEAD model promises specific investments in primary care and enhanced member engagement to support all-payer movement toward patient-centered care.
AHEAD Model Parameters
The goal of the AHEAD Model is to improve population health and health equity in states that apply and that CMS selects for participation. CMS plans to select up to eight pilot states, each eligible to receive up to $12 million to support statewide implementation over a six-year period. States will be accountable for constraining overall growth in healthcare expenditures. Requirements centered on health equity mirror other CMS policies and are integrated throughout the model.
The model focuses heavily on strengthening primary care. The primary care AHEAD component includes Medicare reimbursement for care management, a commitment to align with ongoing Medicaid transformation efforts, and expectations for primary care practices to achieve certain goals on quality measures.
The investments in primary care are paired with global budgets for hospitals. Participating hospitals will receive a fixed payment that will include both Medicare fee-for-service and Medicaid. States will need to ensure participation among other payers, including at least the state employee health plan, Marketplace Qualified Health Plans, or other commercial payers in the state or sub-state region. Other payers will have the option to pay participating hospitals based on a global budget.
All-Payer Health Equity Approaches and Developments (AHEAD)
The model will be in operation 2024−2034, and three cohorts will be to accommodate variation in readiness among participating states and providers. The first cohort pre-implementation period is scheduled to begin in summer 2024, and the performance period is scheduled to begin as soon as January 2026. CMS expects to release additional details in fall 2023.
AHEAD Opportunities and Considerations
The AHEAD Model will need significant gubernatorial leadership and possibly from state legislators, depending upon the particular state’s related healthcare laws, and the model does provide flexibility for interested states and relevant stakeholders to develop programs that are adaptable to their needs.
Health Management Associates (HMA) experts have identified the following list of policies and considerations that states; hospitals, health systems, and provider organizations; other payers, including employers; and other stakeholders will need to bear in mind when determining whether to participate in the program.
States will need to describe their partners and provide an assessment of their readiness to implement the AHEAD model. CMS will expect states to address whether they have legislation in place related to primary care investment and/or cost growth. Potential participating states should be able to describe their vision for population health improvement and primary care transformation, a proposed strategy for hospital and primary care provider recruitment, a plan for Medicaid and multi-payer alignment, and their current population health and health equity activities. Interested states will need early input from hospitals and health systems, providers, and other payers to define, develop, and implement a model that accommodates their healthcare landscape.
States will develop a Medicaid hospital global budget methodology that must have CMS approval. Medicaid hospital global budgets must be implemented in the first performance year. CMS will develop a standardized Medicare fee-for-service (FFS) hospital global budget methodology, that also accommodates critical access hospitals (CAHs).
CMS will set the parameters for quality measurement, but states will have significant flexibility to establish the metrics that will be applied for accountability and bonus purposes. CMS will use the current CMS hospital quality programs as the basis for determining eligibility for a health equity improvement bonus. CAHs will have a similar opportunity. States will work with CMS to set quality measures for participating primary care practices.
The model requires a statewide health equity plan. Additionally, participating hospitals will need to create their own health equity plans in alignment with statewide priorities and activities.
Participating states will need to generate savings. CMS will identify state-specific factors to determine the level of expected savings. All-payer cost growth targets include Medicare FFS, Medicare Advantage, Medicaid, commercial, state employee health plans, and marketplace-qualified health plans. States will also be responsible for performance on all-payer and Medicare FFS primary care investment targets.
The HMA team will continue to evaluate the AHEAD model as more information becomes available. We also can answer questions about the Innovation Center’s other recently announced models and the linkages with new Medicare and Medicaid regulations. For more information, contact our experts below.
Health Management Associates (HMA) is proud to offer a 3-part series of webinars looking at the effect of proposed regulations on delivery of opioid treatment services to the population facing addiction issues. In this second webinar, HMA consultants highlighted opportunities for state payers to improve & align incentives so that providers can expand access to treatment enabled by new federal regulations that encourage patient-centered care.
Patients seeking SUD treatment stand to truly benefit from the changes presented in the forthcoming SAMHSA regulations. However, payers need to restructure the reimbursement model to incentivize person-centered care and allow opioid treatment providers to remain fiscally viable without putting undue burden on patients. The change in regulations present a unique opportunity to advance value-based payment models in the SUD treatment system and expand access to treatment that meets patients where they are.
Learning Objectives:
How Payers Can Benefit – Understanding the opportunity for payers to close important gaps in current approaches to SUD treatment.
Innovation Inspiration – Learning from other programs to better deliver whole person care.
Tackling Challenges – Identifying the likely obstacles and how they can be overcome.
Speaker:
Chris Regal, Director, Clinical Innovation, America’s Health Insurance Plans
Stayed tuned for information on part 3 of our Opioid Treatment Providers series: Opportunities for State Regulators to Shape Policy and Regulation of Treatment for Substance Use Disorder
Correctional facilities can decrease the number of individuals with prediabetes who progress to type 2 diabetes by offering the National Diabetes Prevention Program (National DPP) lifestyle change program. HMA has published a white paper describing (1) the financial and individual impact of type 2 diabetes, (2) the prevalence of type 2 diabetes risk factors in correctional settings, and (3) how the National DPP lifestyle change program, which was created by the Centers for Disease Control and Prevention (CDC), can be used to achieve cost savings and better health for people at risk of developing type 2 diabetes in correctional settings.
This white paper also features a program spotlight from the Wisconsin Department of Corrections (DOC), where the National DPP lifestyle change program has successfully been implemented in three state correctional facilities. Wisconsin’s DOC is currently the only correctional system in the United States providing this program that has been awarded full-recognition status as a supplier of the National DPP lifestyle change program by CDC. A total of 131 individuals have participated in the program, and people who completed the program in 2018-2019 lost an average of 8.3 percent of their body weight.
Administrators of correctional settings, where the length of stay is a year or longer, might consider implementing the National DPP lifestyle change program in their facilities. A cogent argument can be made that type 2 diabetes prevention provides a good return on investment in downstream costs. Offering the program would also be an important step in promoting health equity within correctional settings.
For help starting the National DPP lifestyle change program in a correctional facility, contact the white paper’s authors below.
Managed Care Organizations (MCOs) are key partners in ensuring members have access to integrated physical and behavioral health care, which includes a robust, coordinated crisis care continuum. MCOs can also manage early intervention and help prevent crises and high-cost utilization through care coordination.
CRISIS SYSTEM AND SERVICES
Mental health and substance use distress has increased nationally and has been exacerbated by COVID-19. The Federal government in partnership with States and localities around the country are working to expand access to effective crisis interventions. The creation of the national 988 suicide and crisis hotline combined with new funding and guidance on mobile crisis services are critical to preventing and responding to behavioral health crises.
Health Management Associates (HMA) consultants have deep experience and expertise designing, operating, and overseeing crisis services. This includes a broad portfolio of current projects, working with a range of state and local policymakers, payers, providers, first responders, and communities to implement robust crisis continuums.
Opportunities for MCOs
MCOs can play an important role in informing how crisis services meet the needs of their members, and reduce high cost utilization of emergency departments and inpatient care. HMA can help you identify innovative ways to collaborate with States and community-based organizations to drive real access to crisis prevention and intervention services for individuals and families. This work includes building robust crisis continuum networks that include the full array of options, and best practices in crisis response including diversion from and alternatives to expensive emergency department and hospital visits.
This presents an opportunity for MCOs to play a pivotal role in driving better population health outcomes, expanded health equity, improved member experience, and to ultimately reduce the total cost of care.
Our Expertise and Capabilities:
Evidence-based and leading edge clinical and operational practices
Cross-sector partnerships with law enforcement, emergency service providers and community partners
System change by connecting policy to practice
Defining and measuring key performance indicators and outcomes
Identifying effective workforce strategies including training and maximizing of multi-disciplinary teams (e.g., peers, behavioral health providers, nurses, licensed health care providers)
Maximizing virtual and technology interventions
988 state planning and implementation support
Designing and implementing crisis receiving and stabilization facilities
Conducting certified community behavioral health clinic (CCBHC) readiness and implementation support
Cross-sector crisis collaboration and partnerships, including emergency management services (EMS) and law enforcement
Crisis call hotline and 911 centers collaboration
Individuals with Medicaid and justice system involvement (e.g., 1115 waivers, reentry, and care coordination during transition from jail/prison into the community)
Approaches, programs, and strategies for individuals with complex care needs and high utilizers
Identifying cross-sector technology and information sharing solutions and best practices
Crisis transportation services and financing models, including least restrictive alternatives to law enforcement transport
How HMA can assist MCOs:
Strategic Planning
Understanding emerging trends and federal and state policies that impact managed care plans, including maximizing funding streams at state and county levels, 1115 justice waivers and school-based mental health, and including key stakeholders in the planning process.
Design and Implementation
Adopting state Medicaid criminal justice reforms (e.g., in reach, care coordination, Medicaid eligibility); engaging local and county stakeholders in building partnerships with health plans; designing and developing requests for proposals (RFPs), procurement support and readiness reviews; and developing utilization management programs and care coordination strategies.
Training and Support
Assessing benefit design, and developing standards for network development, management, and adequacy; identifying quality, key performance indicators, monitoring and compliance strategies; identification and implementation of evidence-based practices across the age continuum; and developing training standards and oversight.
HMA has valued recent opportunities to support public health departments to collaborate with communities working to identify and address root causes and ultimately reduce maternal and infant mortality and racial disparities in birth outcomes in Delaware and Maryland.
In partnership with the Delaware Department of Health and Social Services’ Division of Public Health, HMA is in its fourth year of administering a mini-grant program and providing backbone services to community-based organizations. These entities provide wraparound services and a variety of other supports to pregnant and parenting people and their families, with the goal of improving maternal and infant health and reducing racial disparities. We also lead a collective impact evaluation of the programs, working closely with the participating organizations to help them build their capacity to collect and analyze data, developing interim and annual reports, and providing frequent updates to the Division of Public Health and other stakeholders in the state that are collaborating to improve health and wellbeing. HMA provides fiscal and administrative oversight, coaching and evaluation, and convenes the participating organizations for quarterly learning collaboratives, which have contributed to stronger relationships and collaboration among the mini-grantees. In addition, we are implementing and evaluating a guaranteed basic income program as part of the Social Determinants of Health committee of the Delaware Healthy Maternal Infant Consortium (DHMIC). This project is a long-term commitment to collaborating with community-based organizations to build their capacity to address racial disparities and support their work, which is driven by the needs of the people they serve and know best. Grantees are selected through a streamlined process with low administrative burden, prioritizing community input on needed services. Through a collective impact evaluation, the participating organizations are finding positive effects on the self-reported health and wellbeing of program participants.
Launch of the first cohort of Healthy Women Healthy Babies Zones Mini-grantees in 2019. Photo Credit: Division of Public Health – Delaware Health and Social Services
With the Frederick County, Maryland Health Department, HMA conducted a study in 2022 using a community-based participatory research (CBPR) approach to understand and articulate drivers of maternal and infant health disparities experienced by Black women in Frederick County. In collaboration with the health department and newly formed Community Advisory Board (CAB), we facilitated a series of in-person retreats to: collect, analyze, and share quantitative and qualitative data regarding disparities and the drivers of those disparities with stakeholders; understand the data and the story behind the health disparity numbers; and develop and deploy additional research methods, such as surveys, key informant interviews, and focus groups, to further explore the lived experience of Black Frederick County mothers. This iterative approach to conducting mixed-methods research uses the CBPR framework to ensure sustained and meaningful community engagement from project start to end. HMA also developed a driver diagram to illustrate how the root cause, systemic racism, directly influences other drivers of Black maternal health disparities such as historic disinvestment in Black maternal health, historical trauma navigating healthcare, low social capital, health insurance availability, and a perceived lack of emotional and physical safety in clinical settings. The diagram will be shared with relevant stakeholders and inform next steps.
In our reproductive health-related work, HMA has guided groups through decision-making processes, with transparency and without bias, and we understand the importance of group dynamics. Bringing decades of real-world public policy and community and key stakeholder facilitation experience, HMA collaborates with a variety of stakeholders and community members to develop and implement public policy at the local and state levels, as well as to evaluate these efforts. Our experience ranges from national, state, and county agencies, to private sector and community-based organizations that partner with governments to implement policy. Our team has extensive experience working with and within organizations to facilitate discussions, listen to and build consensus across sectors, develop strategic plans, and bring diverse perspectives together to promote health and wellness for communities.
See below for the HMA colleagues participating in these projects.
As part of recognizing Women’s History Month, HMA colleagues reflected on recent work to support maternal and infant health and reduce racial disparities in birth outcomes in collaboration with health departments and communities in Delaware and Maryland. More information on our recent projects supporting reproductive health can be found here.
Utilization of value-based payment (VBP) strategies continues to expand, with states and health plans recognizing the benefits of rewarding outcomes over volume. This includes population based VBP initiatives intended to address disparities. Health Management Associates (HMA) is at the center of these initiatives, supporting payers with development and implementation, as well as supporting providers through the transition from a traditional FFS model to maximizing reimbursement through effective care delivery, supported by the necessary administrative infrastructure and resources. As our clients in health care communities move forward with alternative payment models, we have developed tools and strategies to achieve the essential milestones to successful implementation.
Milestone 1: Provider Readiness Assessment
Successful planning for the transition to VBP begins with an understanding of where your organization is starting from, informing the targeted milestones associated with each providers’ unique strengths and challenges.
Understanding that success under VBP models requires adjustment of both clinical and administrative practices, HMA has created an assessment tool that considers the programmatic, financial, and technology resources necessary for VBP implementation. In addition to the ability to leverage these resources, organizations must have the capacity for VBP components such as cost reporting, revenue cycle management, and real time risk monitoring through the collection and analysis of data.
“With VBP on the horizon for our organization, HMA helped us to determine our readiness and to devise a strategy to remediate gaps in operations in order to be successful with the new payment model.”
– Tamara Player, CEO; Polara Health, AZ
Milestone 2: Strategy Development and Change Management
A change in reimbursement methodology requires organizational realignment of administrative and programmatic approaches. Assessing and supporting staff through these changes is a key milestone for success. Activities in which HMA have supported our clients include:
Creating leadership and governance buy-in
Preparing the Board and Staff for VBP
Aligning mission and vision with payment models and accountability metrics
Project Management, including development and monitoring of implementation plans
Cross functional team support
Milestone 3: Data Collection and Reporting Capabilities
The ability to collect and report meaningful outcomes is at the core of successful engagement in VBP. Following an assessment of current capabilities, HMA has supported provider organizations in maximizing electronic health record and other data system capabilities to capture data essential for reimbursement, as well as increasing analytic capabilities that are essential for monitoring outcomes to ensure programs can pivot when data indicates outcome achievement may be at risk. Activities include:
Technology and Data Enterprise configuration to support analytics and reporting
Creating real-time access to data
Benchmarking current outcomes against proposed VBP metrics
Alignment of current framework to payer metrics
Creation of internal clinical leadership infrastructure to support proactive monitoring and action in response to data
Milestone 4: Business Office and Finance
All aspects of an organization’s financing can be impacted by transitions in payment methodology, including cash flow, impacting cash on hand for capital and other expenses. Anticipating these changes and adjusting accordingly are key to readiness for VBP and importantly, mitigating risk during the transition. HMA can assist with:
Assessing organizational ability to accept risk
Developing a risk corridor based on organizational readiness
Negotiating alternative payment arrangements with payers
Milestone 5: Clinical Programmatic Approaches under VBP
VBP arrangements provide opportunities for organizations to move closer to the goal of achieving outcomes for their clients, rather than productivity targets and units of service. This includes incorporating approaches that could not receive reimbursement under an FFS model. With this flexibility comes the opportunity to review and adapt clinical approaches and programming, including population specific strategies. HMA is ready to support these efforts through:
Workforce analysis
Re/design of clinical workflows
Implementation of measurement-based care
Optimization of clinical templates within the EHR to support data collection and reporting
Understanding the opportunities of value-based payment across the continuum of payment models
While these activities may seem overwhelming, HMA is ready to support your organization to receive reimbursement based on meaningful improvement for your clients through technical assistance and training on each of the core elements outlined above.
