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 Annual Conference on Innovations in Publicly Sponsored Healthcare
HMA is pleased to welcome new experts to our family of companies in April 2023. This diverse team brings significant expertise in Medicare, Medicaid, regulatory strategies, and managed care, strengthening HMA’s capabilities in healthcare consulting across areas like actuarial support, regulatory compliance, and strategic leadership in Medicare Advantage and Medicaid programs.
This is part of an ongoing series highlighting efforts in Human Services and Family Wellbeing.
During the month of May, National Foster Care Month provides an opportunity to raise awareness on issues related to foster care and to celebrate those who are dedicated to serving our children, youth, and families. Yet it is important to note that unfortunately issues surrounding children and youth experiencing foster care are not limited to one month a year. As noted in our recent child well-being blog, Child welfare services face challenges every day to prevent, treat, and reduce risk of maltreatment, neglect, trauma, housing instability, and violence in communities. All these issues contribute to the significant number of children and youth who enter or remain in the foster care system. These issues are year-round and decades in the making. They need to be seen as a priority for public health and community wellbeing and not just the jurisdiction and responsibility of child welfare agencies.
To positively impact the number of children and youth experiencing foster care, there are some strategies that can be implemented now to promote change:
HMA can help public sector and community partners align themselves to improve and develop new delivery systems that will work to address inequalities and disparities as communities strive to meet the needs of children, youth and families impacted by issues like mental health and substance use disorder, domestic violence, child abuse and neglect, food insecurity, housing instability, incarceration and other traumas that impact them greatly.
HMA can help support foster care prevention or reunification program efforts in the following ways:
Read other parts of this blog series:
If you have questions on how HMA can support your efforts in Child and Family Wellbeing, please contact our experts below.
[1] Data: National Foster Care Month Outreach Toolkit | Child Welfare Information Gateway
The Current Public Health Environment
The public health workforce is in the midst of a crisis, dealing with staff shortages, accelerated retirements and unfilled positions.
The current climate was exacerbated by Covid-19, but many challenges began long before 2020’s pandemic. The public health system underwent a significant contraction following the Great Recession in 2008-2009, losing more than 40,000 positions in state and local governments across the country. While some of those positions were regained with Covid-19 funds during the pandemic, recruitment, diversity and retention remain as challenges, especially for hard to fill positions in nursing and epidemiology. Public health staff report high rates of burnout due to the Covid-19 response and the political climate that resulted, including suffering symptoms of post-traumatic stress disorder. It is likely that there will be staff shortages for the foreseeable future, increased retirements, and departures to other parts of the healthcare industry competing for skills with higher compensation.
New Funding Streams Available
State and local health departments have been receiving significant amounts of one-time money, including the Centers for Disease Control and Prevention (CDC) recent allocation of $3.5 billion specifically for governmental public health efforts.
Health Resources and Services Administration (HRSA) has created a new workforce research center for public health. The AmeriCorps program has developed a specific public health component. These new initiatives were designed to build and support the workforce in governmental public health. As state and local health departments receive or apply for these various sources of workforce development funding, HMA can provide existing technical assistance and training to minimize inefficiencies and duplication of efforts that might be created by a fragmented approach across state and local units of government developing independent approaches to the utilization of WFD funds.
HMA Workforce Expertise
The public health group at Health Management Associates (HMA) is made up of more than 100 colleagues with expertise in public or population health improvement, experienced working with national, state or local organizations seeking to improve public health outcomes. If your organization is looking to improve your public health workforce efforts, it is important to utilize expertise and consolidate efforts across the country so each unit of government is not “reinventing the wheel.” HMA can help multiple organizations in developing plans and coordinating processes for recruiting, training and development of the public health workforce.
HMA understands the skills that are needed to achieve high-performing public health and accountable care. Our expertise developing workforce within safety net delivery systems and accountable care organizations involve transferrable skills for the current challenges in building and developing the public health workforce. We have expertise in recruiting and are creating new training and retraining methods to meet the needs of public health teams, accountable care organizations, graduate medical education, nursing education, learning collaboratives, online training and team simulation training. We understand the care coordination, care management and IT support systems needed to backstop the workforce and meet quality and equity goals.
This week our In Focus section reviews the Illinois Healthcare Transformation 1115 Waiver Extension request, posted for review on May 12, 2023.
In pursuing this waiver extension, Illinois joins a growing list of states taking advantage of new Centers for Medicare & Medicaid Services (CMS) policy flexibilities to address health-related social needs (HRSNs) through Medicaid and test community-driven initiatives that are focused on improving health equity, improving access to care, and promoting whole-person care.
The Illinois waiver incorporates two of the most significant new opportunities in the CMS demonstration waiver flexibilities by proposing to incorporate housing supports for people who are experiencing or at risk of homelessness. The waiver also would extend community reintegration services for justice-involved adults and youths for up to 90 days before their release from incarceration. For a full list of proposed benefits and demonstrations, see Table 1.
Table 1. Summary of Illinois Medicaid 1115 Waiver Extension
The Illinois waiver represents an unprecedented opportunity to demonstrate the long-term, positive impact of providing HRSN services to achieve health equity and create a sustainable, community-driven system for delivering those services. The demonstration proposes to offer a range of HRSN services that are focused on the unmet needs of people who are homeless and housing insecure, are justice-involved, have behavioral health conditions, are pregnant, are unemployed, are food insecure, and/or have been exposed to violence or are at risk of violence with the goal of eliminating health disparities.
The waiver projects a five-year total of $4.4 billion in HRSN services expenditures and another $800 million in HRSN-related infrastructure, indicating Illinois’ long-term commitment to healthcare transformation and to building an equitable, accessible, and high-quality delivery system.
For additional information, please email [email protected].
Illinois Requests Section 1115 Waiver Extension to Respond to HRSNs and Eliminate Inequities
Healthcare executives gathered with HMA leaders in March to learn and share about new initiatives in quality improvement. Panels and discussions were led by esteemed experts, who provided important insight into the multitude of opportunities to improve quality and equity:
From the Experts: CMS has doubled down on its commitment to improve healthcare quality, equity, and access.
The HMA Point of View: Current leadership in Washington has set very clear goals to improve health equity, aligning federal policy as a lever to improve healthcare outcomes. Federal dollars passed along to states are including new rules and objectives to improve quality in an equitable manner. Therefore, those applying for federal contracts and grants must include a strategy to improve quality, equity, affordability, and access.
From the Experts: Interventions need to be robustly evaluated to address equity and social determinants of health (SDOH).
The HMA Point of View: Governments, care providers, and payers have been experimenting with approaches to SDOH, but the bar is now higher and results have to be measurable. New investments that address SDOH and aim to improve equity must include a strategy to measure and analyze results of interventions, including evaluation of critical subpopulations to address disparities. Although experiments will continue, we have reached the point where a robust analysis of outcomes is an expectation.
From the Experts: Quality is playing a central role in operationalizing equity.
The HMA Point of View: While there are many reasons for disparities in health, quality metrics and programs must be designed to improve quality for all patients. Identifying inequities is only the first step; successful programs will advance equity by reducing barriers to care. Measurable quality programs should be designed for population health, but personalized for individuals with clear provider incentives to not only identify disparities but also minimize them. Quality is the tool by which we achieve health equity.
From the Experts: We are on the precipice of doing great things in quality.
The HMA Point of View: Our ability to integrate data from multiple sources is finally getting to a place where patients can get the quality care they need, and providers can give the right care at the right time to improve outcomes. Policymakers have broken down barriers to data sharing, enabling a new economy of information sharing that promises to empower patients and reduce costs. It is no longer enough to have a separate IT or data strategy; anyone working to improve healthcare quality needs to have data strategies within and across every operational function across their organization.
From the Experts: Being rewarded for doing what’s right for the patient is central to continuous quality improvement.
The HMA Point of View: Quality care for the patient means creating the right incentives for payment and care delivery that focus on outcomes and experience. Every point of care in the patient’s health journey needs to be evaluated and designed from the point of view of providing a quality experience. Not every patient has the same journey, and our healthcare system must meet them where they are, delivering for their unique needs. Convenience, personalization, accuracy, simplification, and affordability are nearly as important as clinical outcomes in the mind of most patients and addressing barriers to health can have clinical benefits.
HMA has a long history of working with clients to achieve their quality improvement goals including securing accreditation for both payer and provider organizations, driving clinical practice transformation, and improving the overall value of care. We strongly believe that there is no quality without equity, access, and measurement, and are investing in people and resources to support these needs. Together we are working with clients to advance value-based care, develop programs demonstrating quality, value, and equity in behavioral health, and implement new quality and accreditation programs to better serve their communities.
Learn more about HMA’s continuing work in quality and accreditation and join the conversation on LinkedIn and Twitter using #HMAtalksQuality.
This week’s In Focus is the second in a two-part look at the Centers for Medicare & Medicaid Services’ (CMS’s) recently proposed changes to the Medicaid program. Last week we covered CMS’s proposed changes to the federal Medicaid managed care regulations (CMS-2439-P). This week we review the Medicaid Access to Care proposed rule (CMS-2442-P).
As we discussed last week, the managed care and access to care rules include significant changes to core structural and financing aspects of the Medicaid program. Though state agencies, providers, health plans, consumer groups, and other stakeholders will want to understand the distinct requirements and expectations in each rule that apply to them, the proposed changes cannot be viewed in isolation.
The Access to Care rule addresses a range of challenges that shape the experience of Medicaid enrollees, regardless of whether they are in managed care programs or traditional fee-for-service (FFS). The proposed policy changes also are designed to create an updated federal framework for Medicaid’s home and community-based services (HCBS) programs. These proposals come at a pivotal time, as states are facing workforce shortages, particularly among HCBS direct care workers (DCWs).
The remainder of this In Focus delves into notable components of the proposed changes and includes analysis of the implications of these policies for stakeholders. CMS will benefit from stakeholder input; the deadline for submitting comments is July 3, 2023.
Table 1. Access to Care Regulations: Overview of Proposed Changes
Key Themes and Considerations
Ensuring Payment Adequacy for Key HCBS Services Experiencing Workforce Shortages. One of the most notable proposed changes that would directly impact DCWs is a requirement that at least 80 percent of Medicaid payments be spent on compensation. The proposed rule would apply to homemaker, home health aide, and personal care services, as they represent a large portion of HCBS services that DCWs provide. The proposal is based on feedback from states that have implemented similar provisions, which have ranged from 75 to 90 percent compensation requirements.
CMS specifically seeks stakeholder feedback on the percentage that should be adopted. This policy provision also is important from an equity perspective, given that 90 percent of DCWs are women and 60 percent are members of racial or ethnic minority populations. However, increased or mandated DCW rates may make it difficult for HCBS providers to sustain their businesses as they manage the increased administrative pressures of electronic visit verification, the complexity of filing claims for managed long-term services and supports (MLTSS), and the additional work that HCBS quality measurement may create. Smaller HCBS providers, some of which may have deep cultural expertise, may struggle to sustain themselves and meet these requirements.
Table 2. Access to Care Regulations: Snapshot of Proposed Rate, Access, and Payment Changes
Payment Alignment. CMS is seeking to align access to care strategies and payment rate transparency more closely across the FFS and managed care delivery systems. The proposed rule includes several changes that CMS has developed achieve this goal. For example:
Strengthening the Focus on Quality in State HCBS Programs. Over the last several decades, states and Medicaid stakeholders have made significant progress toward increasing participation in HCBS programs and community integration initiatives to counter Medicaid’s institutional bias. CMS is proposing more consistency in the expectations and reporting for HCBS quality measures to further the impact and create a consistent foundation for the recently mandated HCBS quality initiatives starting to take root.
In the short-term, the proposed changes will require states, and likely downstream providers and Medicaid agencies, to immediately change their quality reporting policies and systems. States and their stakeholders will want to map out processes for cyclical updates to HCBS quality measures, including cross-walking the future measures with existing ones, making systems changes, and updating dashboards. Targeted attention and focus will be needed to identify realistic HCBS performance targets that yield successful improvement strategies in the midst of a workforce crisis. Longer term, it will be necessary to map out when updates and reporting will be required to strengthen the rigor and accountability for state performance in the HCBS quality measure set, as well as reinforce the information available to make policy, clinical, and operational improvements to Medicaid programs.
HCBS Access Measurement. CMS is proposing new FFS HCBS payment and access transparency requirements to ensure compliance with Medicaid provider payment rules that require payments to be adequate to enlist at least the same number of providers that the overall geographic population can access. Because the targeted HCBS services do not have a comparable Medicare rate, CMS proposes implementation of a payment rate disclosure approach that would standardize data and monitoring across service delivery systems, with the goal of improving access. In addition to proposed payment transparency changes, CMS proposed new reporting on HCBS waiver waiting lists and timelines for the start of related services once authorized.
These new reporting requirements will provide stakeholders with more information to benchmark their state’s experience with other providers across the nation. This information could be influential to policymakers and legislators and help uncover some of the core contributors to our nation’s HCBS workforce shortage.
Improving Health Equity with Medicaid Beneficiary Input. CMS proposes overhauling the scope and membership of the state Medical Care Advisory Committee. The new Medicaid Advisory Committee (MAC) would continue to advise the state on health and medical matters and play an expanded advisory role on matters of policy development and effective administration of the program. CMS also plans to require that states establish a Beneficiary Advisory Group (BAG) composed of current or past Medicaid beneficiaries. A subset of BAG members would serve on the MAC to ensure their perspectives are integrated into the committee’s recommendations to states.
Under the new federal requirements, MAC representatives could have greater relative input and influence on policies and actions each state Medicaid agency advances. Medicaid stakeholders will want to ensure the MAC’s minimum federal requirements support effective structures and processes in states.
What’s Next
CMS plans to reframe Medicaid access as one of three parts of the continuum of care, along with enrollment and maintenance of coverage. The proposals in the Access to Care rule would have a meaningful impact on the volume and type of data available to evaluate the relationship between Medicaid payment rates and access across all delivery systems.
States, managed care organizations, providers, Medicaid enrollee advocacy organizations, and other interested stakeholders should analyze the proposals and consider submitting comments to CMS on the feasibility, potential impact, and, where applicable, alternatives to the proposed changes. They also can use this time to begin planning and determine which resources and tools they may need to prepare for implementation of changes across delivery systems in the Medicaid program.
HMA’s experts are taking a wholistic approach to reviewing the Access to Care and Managed Care proposed rules in tandem and identifying key points of intersection.
For more information on the access to care proposed rule, contact our experts below.
How Will CMS’s Proposed Rule Shift Standards for Medicaid Enrollee Access to Services?
This is part of a three-part series on significant implications of the end of the Public Health Emergency (PHE).
The end of the Public Health Emergency on May 11, 2023 is likely to mark a transitional point in the rapidly evolving arena of virtual care services and not a dramatic end of coverage. Coverage of virtual care services will continue to evolve significantly over the next five years given the exponential growth in the public’s awareness of, and comfort with, these services — all hastened by the COVID-19 Federal Public Health Emergency.
The U.S. Congress and the Centers for Medicare and Medicaid Services (CMS) used its authority during the PHE to significantly expand Medicare coverage for virtual care services, covering telehealth visits in urban areas and from patient’s homes. In addition, Medicare began covering a wide range of clinical services virtually such as behavioral health and physical therapy; it also expanded coverage for different service delivery modalities to include audio-only visits. As a result of the changes, Medicare became a leading payer for virtual care nationally between 2020 and 2022. Over this same period, private insurers and state Medicaid programs largely followed Medicare’s lead by expanding their own virtual care coverage.
One of the consequences of the PHE is that most payers have embraced Medicare’s basic definitional structure for types of virtual care services. As a part of this typology, virtual care services are divided into two general buckets of services: telehealth visits (physician office visits conducted via audio and video technology), which are typically prohibited by statute in urban areas or a patient’s home; and Communication Technology-Based Services (CTBS) which can be conducted anywhere. CTBSs include: remote patient monitoring (RPM); virtual check-ins (brief patient-to-clinician exchanges); e-visits (online portal or email visits); and e-consults (clinician to clinician interaction).
With the end of the PHE on May 11, Medicare coverage of virtual care services and coverage offered by other payers will change. The details and scope of this change have many stakeholders concerned and confused. HMA has a keen sense for which virtual care services may get a new lease on life in the coming months and which are likely to be hotly debated in the years ahead. The one certainty is that the last 3 years have altered the landscape for virtual care services for years to come.
As a result of the statutory geographic limitations and restrictions placed on traditional fee-for-service (FFS) Medicare coverage, use of telehealth services was minimal most of the last decade, with only one-quarter of 1 percent (0.25%) of beneficiaries in FFS Medicare using virtual care services.[1] Even among Medicare Advantage plans and Medicare Accountable Care Organizations (ACOs), neither of which which face the same restrictions, virtual care was utilized very rarely before 2019.
This sluggish use of telehealth was radically altered when HHS used its PHE authority to relax constraints on the use of use virtual care services by Medicare beneficiaries and providers.[2],[3] Among the most consequential changes made by policymakers at the outset of the PHE were:
Due to these policy changes, rates of virtual care skyrocketed during the PHE (Figure 1). In April of 2020 the number of Medicare claims for any type of virtual care service exceeded 9 million, while 2019 the number of these services provided monthly never exceeded 100,000 (Figure 1). On an annual basis, from 2019 to 2021 the number of virtual care visits jumped from roughly 1 million to 39 million and the number of unique beneficiaries receiving these services increased from 300,000 to nearly 12 million.
Figure 1: Number of Virtual Care Service Visits, Number of Unique Medicare Fee-For-Service Beneficiaries, and Number of visits per Utilizer by Month, December 2019 to December 2021.
The growth of virtual care services has largely been driven by an increase in telehealth visits, but we observe important trends in the use of CTBSs, as well. In late 2021, more than 90 percent of visits were associated with telehealth, while 10 percent were associated with CTBSs. Early in the PHE, all of these service types experienced an initial, abrupt increase in use (Figure 2). By contrast, the growth in the use of remote patient monitoring (RPM) has been continuous since 2020. The growth in use of RPM reflects the general movement of services into patients’ homes and has been accelerated by specialist such as cardiologists and endocrinologists beginning to leverage the power of RPM. We expect greater diffusion and use of RPM and other CTBSs in the next five years.
Figure 2: Number of Virtual Care Service Visits for Remote Patient Monitoring, Virtual Check-ins, E-visits, and E-Consultations by Month, December 2019 to December 2021.
During the PHE, Congress made critical long-term changes to Medicare’s coverage of virtual care services that continued to spur the use of these services and offer access to care for beneficiaries. In 2021, Congress changed the law to permanently allow Medicare beneficiaries to receive behavioral/mental telehealth services regardless of location (urban or rural) and for this care to be available to patients in their own homes.
In 2022, Congress severed the link between the PHE declaration and Medicare coverage policies for virtual care services, extending those benefits through the end of calendar year 2024. We expect that coverage for all telehealth services will receive considerable attention from federal policymakers and stakeholders towards the end of 2024.
Certain aspects of Medicare’s virtual care policies will, however, terminate May 11, 2023, when the PHE declaration comes to an end. Several of the expiring policies have a broader impact beyond the Medicare program, affecting patients insured by private payers and State Medicaid programs.
Specifically, when the PHE ends, policymakers will need to address the following anticipated changes:
Potential policy changes occurring before 2025 As explained earlier, Medicare coverage for many virtual care services will remain in place for the next 19 months. Before the end of 2024, Congress will need to address several policy questions, and among the most widely debated are whether to:
Lawmakers will look to payers, patients, and providers for feedback before making these policy decisions. Among the most critical pieces of information they will also consider will be the results of the study Congress has required of HHS regarding trends in the use of virtual care. This study’s final report is due in 2026, which has led some to speculate that Congress will delay action on virtual care coverage policy until then. In the meanwhile, we expect HHS will be assessing the overall volume of virtual care use, who is using which types of services, and the levels of related fraud and abuse.
In the United States, our experience during the acute phase of the pandemic demonstrated that patients and providers are more receptive than previously thought to utilizing digital technologies for the delivery of care. This experience may also influence policymakers’ decisions about reimbursement and coverage of wearable devices, as well as other cutting-edge tools that rely on artificial intelligence or machine learning.
HMA believes payers and providers alike can take steps now to strategically prepare for the still evolving and growing landscape of digital health care.
Based on the various changes that have occurred in the virtual care environment over the last 3 years, we are intently watching several areas of potential change in the practice of medicine and the ways payers set coverage policy. Below are some of the trends we anticipate in the years ahead:
Virtual care services are primed for additional growth and HMA is working with a wide variety of payers, providers, and foundations to develop strategies for adapting to state and federal rules and regulations related to virtual care. Changes in this landscape will hinge on research CMS will complete by the end of 2026, and coverage decisions made by states and commercial payers. HMA is well positioned to assist stakeholders with work in this area and can leverage access to Medicare and Medicaid claims data to conduct health services research to illustrate geographic variations in the use of virtual care.
If you have questions on how HMA can support your agency before or after the end of the PHE, please contact our experts below.
Read other parts of this blog series:
[1] (2016) https://www.cms.gov/About-CMS/Agency-Information/OMH/Downloads/Information-on-Medicare-Telehealth-Report.pdf
[2] Centers for Medicare & Medicaid Services. Medicare telemedicine health care provider fact sheet. March 17, 2020. https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet
[3] HHS Administration for Strategic Preparedness & Response (ASPR). https://aspr.hhs.gov/legal/PHE/Pages/default.aspx
This webinar was held on May 23, 2023.
HMA’s 3-part New Rules in Treatment of Opioid Addiction webinar series is aimed at helping stakeholders prepare for new federal rules that will change how medications are delivered to persons with opioid use disorders. Reducing daily visits will allow persons served to engage in work, family and community activities that sustain recovery, but programs have historically relied on daily visits for revenue. With the new rules, opioid treatment centers (OTPs) have a unique opportunity to advance person-centered care. In part 1 of this series, we addressed changes in clinical and business practices, as well as payment structures that will enable OTPs to implement new treatment programs and other flexibilities to improve patient outcomes. Other parts of the webinar series examine policy and incentives in the new system.
Learning Objectives
OTP Regulatory Changes – Understand expected changes from the point of view of clinicians and providers.
Critical Action Steps – Identify what OTPs will need to do next to comply.
State Variation – Consider how to navigate new rules across states with different approaches to treatment.
Featured Speaker
Nick Stavros, CEO, Community Medical Services
Mark your calendars for other webinars in this series:
Opportunities for State Payers to Improve and Align Incentives – June 6, 2023 at 3 p.m. ET
Opportunities for State Regulators to Shape Policy and Regulation – June 20, 2023 at 3 p.m. ET
