Accreditation Services

Accreditation Services

Rural Health Transformation Program Represents a One-Time Opportunity to Reshape Rural Care

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The Centers for Medicare & Medicaid Services (CMS) has officially opened the application window for the Rural Health Transformation Program (RHTP)—a $50 billion federal initiative designed to stabilize and transform rural health systems across the country. This one-time opportunity allows states to submit a comprehensive plan that could redefine how rural communities access care, manage chronic conditions, and sustain their healthcare infrastructure.

As outlined in our earlier In Focus article, States Begin to Engage with the Rural Health Transformation Program, RHTP represents one of the most significant federal investments in rural health in decades.

Applications must be signed by governors and submitted by November 5, 2025, and awards are expected by December 31, 2025, providing states with a very narrow window to act.

The remainder of this article explains key aspects of the RHTP application, including the evaluation and scoring aspects. Notably, the structure of the scoring system will reward states that are already aligned with these federal priorities, as well as those willing to implement new initiatives or make state policy changes to achieve alignment.

Program Overview and Funding Structure

Created under HR.1, the 2025 Budget Reconciliation Act, the RHTP allocates $10 billion annually from federal fiscal year (FY) 2026 to FY 2030, totaling $50 billion over five years. Funding is split into two tranches:

  • Tranche 1 (Baseline funding): $25 billion distributed evenly across all states with approved applications.
  • Tranche 2 (Workload funding): $25 billion distributed based on CMS scoring criteria, which include:
    • The percentage of the state population in rural census tracts
    • The proportion of rural health facilities in the state
    • The financial and operational status of hospitals
    • Other factors explained in the RHTP application notice

States must submit a single, one-time application that covers the full five-year period. Stand-alone provider applications will be declined. Hence, states must coordinate across agencies, providers, and stakeholders to develop a unified transformation strategy.

Importantly, this award is not a grant; rather, it is a cooperative funding agreement, which means CMS will play an active role in oversight and collaboration. States must be prepared to meet higher standards of accountability, transparency, and performance monitoring. According to the RHTP application, continued funding requires states to demonstrate satisfactory progress toward implementing their plan.

Application Requirements and Strategic Priorities

To be eligible for funding, states must submit a Rural Transformation Plan that addresses eight core priorities as follows:

Within these core priorities, state plans must propose activities that address several specific issues.

Technical Factor Weighting for Workload Funding Reflects Federal Policy Priorities

CMS outlines the eligibility criteria for baseline funding and the scoring components for workload funding. Baseline funds will be distributed equally among states, while workload funding will be based on each state’s rural facility and population score as well as their technical score. Evaluators will score technical factors based on state policy actions and initiative-based plans for each state.

The technical factors, and the weighting of these factors, in the RHTP application are not just neutral scoring mechanisms; rather, they are closely linked to the Trump Administration’s health policy priorities.

  • Weighting Structure: The RHTP funding is split evenly between baseline funding (50%) and workload funding (50%). Although baseline funding ensures all states receive support, the workload funding is directly tied to technical scores that reflect how well a state’s plan aligns with federal objectives and demonstrates readiness to implement transformative change that furthers federal objectives.
  • Scoring Criteria: Technical factors, such as rural population share, facility density, hospital financial status, scope of proposed activities, administrative capacity, stakeholder engagement, evaluation framework, and especially alignment with federal priorities, all contribute to the overall score. States that have already adopted or are willing to adopt federal policy priorities are positioned to score higher and receive more funding.
  • Annual Recalculation: CMS will recalculate each state’s technical score and workload funding annually to incentivize ongoing alignment with federal priorities and measurable progress toward transformation goals.
  • Alignment with Federal Priorities: One of the explicit scoring factors is “Alignment with Federal Priorities,” which measures the degree to which a state’s plan supports CMS goals for rural health transformation and sustainability. Under the Trump Administration, these priorities may include promoting value-based payment models, encouraging technology adoption, advancing adoption of Supplemental Nutrition Assistance Program (SNAP) food restriction waivers that prohibit the purchase of non-nutritious items, availability of integrated care plans for the Medicare-Medicare dually eligible population, reporting of full Medicaid T-MSIS data, and align policies with federal guidance on short-term limited duration insurance plans.

Preparing for What Happens Next: Implications for States, Providers, and Health Plans

The RHTP offers a rare opportunity to reshape rural healthcare. But success will require strategic coordination and a commitment to long-term change. States in the short and long term should consider include:

  • Identifying stakeholders who will be involved: Hospitals, rural health clinics, federally qualified health centers (FQHCs), behavioral health providers, and community organizations must be part of the planning process.
  • Reexamining priorities: States will need to reconcile competing needs across regions and provider types, balancing infrastructure investments with service delivery redesign.
  • Understanding infrastructure needs to support their project: Technology, workforce, and models of care must be strengthened to support long-term transformation.
  • Designing evaluation frameworks: States must include robust performance monitoring and reporting mechanisms to meet CMS expectations and secure future funding.

Providers and other stakeholders should also prepare to align with state strategies. Examples include:

  • Participating in regional partnerships
  • Adopting new care models and payment arrangements
  • Investing in technology and workforce development
  • Contributing data and insights to support evaluation efforts

The scoring structure also incentivizes states that may not yet be fully aligned to implement new initiatives or make policy changes that would improve their technical scores and secure greater funding. States and their partners will need to be united on the goals and initiatives, disciplined about implementing and evaluating the plans based on data informed reports, nimble and willing to make strategic pivots based on feedback and experiences.

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States that are already aligned with Trump Administration priorities—such as those with established value-based payment models, short-term limited duration plan options, preferred technology infrastructure, or strong rural hospital support policies—are positioned to be rewarded in the scoring and funding process.

Health Management Associates (HMA), is actively supporting states in developing compliant and compelling RHTP applications. Our advisory services include:

  • Strategic assessments and stakeholder engagement
  • Program design and grant writing
  • Implementation support and technical assistance
  • Actuarial support
  • Evaluation and performance monitoring

We help clients navigate the complexities of federal funding, align transformation goals with community needs, and build sustainable models for rural care delivery. For details about the RHTP, including the HMAIS State Action Tracker, contact HMA experts below.

Federal Shifts and the Potential Impacts on Healthcare Quality Oversight

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This week, our In Focus section explores how recent federal shifts—particularly under the Trump Administration—are reshaping healthcare quality oversight. Health Management Associates (HMA) has published several analyses on the 2025 Budget Reconciliation Act (H.R. 1, formerly known as the One Big Beautiful Bill), Title IV of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA), and the 2025 Centers for Medicare & Medicaid Services (CMS) Quality Conference. Together, these federal changes and the policy priority shifts described at the Quality Conference, have implications for monitoring and oversight of healthcare quality for publicly insured, commercially insured, and uninsured individuals.

In this article, HMA experts highlight potential areas for state Medicaid programs, healthcare organizations, and other industry partners to watch for as the rollout of new policies and programs begins to affect programs that monitor quality and creates the imperative to develop new oversight mechanisms.

Overview of Key Federal Policy Shifts

2025 Budget Reconciliation Act/H.R. 1

In July 2025, President Trump signed H.R. 1, the sweeping budget reconciliation legislation that directly affects publicly financed health coverage. Notable policy changes with quality implications include:

  • Mandatory six-month redetermination and community engagement for select populations
  • Stricter rules on healthcare-related provider taxes and state-directed payment policies
  • Elimination of Affordable Care Act (ACA) subsidy eligibility for certain lawfully present immigrants
  • An end to conditional eligibility for ACA subsidies, as well as passive re-enrollment
  • Required compliance with community engagement and work policies

Personal Responsibility and Work Opportunity Reconciliation Act of 1996

On July 10, 2025, the US Department of Health and Human Services (HHS) and other agencies, redefined “federal public benefits” to exclude individuals with “unsatisfactory immigration status” from certain healthcare programs. Examples include Certified Community Behavioral Health Clinics (CCBHCs), Community Health Centers/Federally Qualified Health Centers (FQHCs), grant-funded programs administered by the Substance Abuse and Mental Health Services Administration (SAMHSA), and Title X Family Planning.

2025 CMS Quality Conference

During the 2025 CMS Quality Conference, Centers for Medicare & Medicaid Services (CMS) Administrator Dr. Mehmet Oz and senior CMS officials, emphasized CMS’s and HHS’s evolving priorities under the Trump Administration. Notable priorities include empowering patients with data, reducing waste and tackling fraud, focusing on prevention, and transitioning to digital quality measures.

Quality Oversight Impacts

Key impacts on quality monitoring programs resulting from these federal changes and evolving priorities include:

Budget constraints elevate monitoring and value-based care metrics. Reduced Medicaid funding and tighter payment rules heighten the need for real-time monitoring of value-based care metrics to ensure financial sustainability in the changing market, optimize reimbursement.

Enrollment changes challenge quality tracking. Tighter eligibility and enrollment policies are expected to decrease enrollment in Medicaid (particularly among the adult expansion population) and the Affordable Care Act Marketplace program. Frequent redeterminations may cause coverage gaps and churn, distorting quality measure denominators and complicating performance tracking – especially for preventive and chronic care metrics.

Specifically, as the population mix in publicly funded programs changes or as gaps in enrollment exceed the 30‒45-day continuous enrollment criteria for many quality measures, the eligible population/denominators of quality measures will likewise fluctuate. Populations that lose coverage or churn on and off eligibility rolls can result in differential impacts for various quality measures (e.g., healthier individuals losing coverage affects prevention measures more than measures of chronic disease care).

Although performance on value-based care quality measures will have increased importance, the ability to track and trend performance will be increasingly challenging. Healthcare organizations will benefit from forecasting potential changes to patient mix and volume and real-time monitoring and improvement opportunities.

Rise in uncompensated care requires new quality monitoring. H.R. 1 changes that reduce eligibility, paired with PRWORA changes that limit treatment for certain individuals who receive public benefits, are likely to lead to increases in the uninsured population and inhibit access to preventive care. These populations tend to use emergency departments more often for health issues that could have been treated earlier or more effectively in outpatient settings, yet quality oversight is limited for populations that receive care outside of publicly or commercially funded programs. New mechanisms for quality oversight—and funding of those mechanisms—will be needed to monitor the health of these populations.

New programs and priorities warrant updated monitoring. H.R. 1’s Rural Health Transformation Program and CMS’s dual-track quality measurement approach (“treating illness” versus “maintaining health”) necessitate a reevaluation of current metrics and monitoring systems.

Implementation of digital quality measures will support these efforts when fully implemented. The accelerated movement toward digital quality measurement and interoperability may create an imperative for healthcare organizations to make the shift. For example, the transition to digital quality measures will be necessary to ensure real-time oversight and improvement of quality measures, population health analytics, maximizing value-based care payments and efficiencies needed to effectively respond to federal changes. At the same time, healthcare organizations will need strategies to effectively deploy digital quality and interoperability within and across their organizations to not just comply, but to maximize their capabilities.

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HMA works with state agencies, payers, health systems, and providers to assess and implement quality systems, value-based care programs, performance improvement and digital health. To discuss how federal changes will affect your organization’s quality programs, contact our featured experts below.

What’s Next in Quality: CMS Conference Highlights and Stakeholder Imperatives

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This week, our In Focus section covers the 2025 CMS Quality Conference. The event convened healthcare leaders, clinicians, researchers, and patient advocates to explore strategies for improving outcomes and modernizing service delivery. Centers for Medicare & Medicaid Services (CMS) Administrator Dr. Mehmet Oz and senior CMS officials emphasized the agency’s evolving priorities under the Trump Administration, with a strong focus on digital transformation, patient empowerment, and fraud prevention.  

In this article, Health Management Associates (HMA) experts highlight key themes from the conference. We note where these themes align with the agency’s recent proposed rules and requests for information (RFIs), including several RFIs included in the 2026 Medicare Physician Fee Schedule (PFS) proposed rule, with comments due September 12, 2025. Finally, they advise healthcare organizations of the immediate need to evaluate their risks and opportunities in this digital health ecosystem.  

Key Themes of the Conference  

Empower Patients with Data 

CMS leaders shared a vision for enabling Medicare beneficiaries to experience healthcare technology in the same way that they use in banking and streaming services. Within a year, CMS committed to enabling real-time digital communication with beneficiaries, becoming the nation’s “best payer.” Notably, a patient safety advocate challenged CMS to think about bi-directional data exchange where patients should be able to share data with CMS.  

Subsequent to the conference, Administration officials announced elements of the Health Technology Ecosystem infrastructure, including conversational AI tools, diabetes and obesity management platforms, and efforts to “kill the clipboard” by simplifying data access for patients and providers.   

Reducing Waste and Tackling Fraud  

The conference coincided with the federal government’s multi-billion dollar healthcare fraud takedown, underscoring CMS’ commitment to curbing waste. CMS officials highlighted several aspects of CMS’ work, including application of predictive algorithms dubbed “the Netflix model” to identify suspicious billing patterns. They also talked about the new CMS Innovation Center model—the Wasteful and Inappropriate Service Reduction (WISeR) Model—to engage technology companies to improve prior authorization processes in traditional Medicare, particularly for high-risk items like skin and tissue substitutes.  

Focusing on Prevention  

CMS tied the Make American Healthy Again (MAHA) agenda to quality measurement reform. CMS officials encouraged moving to two distinct sets of quality measures: one for treating illness and another for maintaining health. These measures could focus on preventing or delaying onset of disease and on measuring outcomes.   

Moving to Digital Quality  

CMS also emphasized its commitments to digital quality measurement and interoperability through the adoption of Fast Healthcare Interoperability Resources (FHIR®) application programming interface (API) technology. For example, CMS’ Center for Clinical Quality and Standards is testing a FHIR-based assessment tool for inpatient psychiatric hospitals. Separately, the Centers for Disease Control and Prevention (CDC) is transitioning National Healthcare Safety Network’s measures to FHIR.  

Policy Connections: From Conference Themes to Federal Action 

The conference themes reflect and preview broader federal policy changes including:  

  • The 2026 Medicare Physician Fee Schedule (PFS) proposed rule includes multiple requests for input on streamlining quality measures, enhancing chronic disease management, and expanding digital infrastructure.  
  • On July 30, CMS announced an updated voluntary blueprint for modern health data exchange, which encourages healthcare organizations to become CMS-aligned networks. The agency’s Interoperability Framework describes the voluntary criteria for CMS-aligned in areas of Patient Access & Empowerment, Provider Access & Delegation, Data Availability & Standards Compliance, Network Connectivity & Transparency, and Identity, Security & Trust.  

The Road Ahead for Healthcare Organizations 

Healthcare organizations need to prepare for a future regulatory environment that is significantly more digital, interoperable, and chronic disease–focused. CMS is building the highway that will enable healthcare organizations to build and maintain the technology necessary for these new initiatives.  

This will require state and local government, healthcare organizations, and other partners to retool their infrastructure and workflows to optimize needed operational transformations. All entities should have a strategic roadmap for obtaining and using interoperable clinical data for care management, population health and quality, among other use cases. 

Payers will benefit from initiatives such as: 

  • Exploring strategic partnerships to help accelerate technology advancement, such as digital identity providers and specialists in digital quality measurement  
  • Exploring ways to increase focus on prevention, such as increasing uptake of the Medicare Annual Wellness Visit or considering new payment approaches for services like medically tailored meals 
  • Staying current on AI tools and predictive analytics that identify individuals at risk for preventable conditions and working with their provider networks to intervene early 

States can take steps to prepare, including:  

  • Exploring strategic partnerships to help accelerate technology advancement, such as digital identity providers and specialists in digital quality measurement  
  • Assessing the reach and impact of existing primary prevention programs to understand how they can use their levers to incentivize healthy lifestyles, encourage culturally responsive health education, and address root causes of preventable illness and disease  
  • Identifying opportunities for aligned efforts and referral pathways, including with community organizations, to address upstream health factors 

Health systems and providers will need to reimagine the care experience by:  

  • Exploring early adoption of AI tools for medical documentation to improve both patient experience of care interactions and coding accuracy to support digital quality measurement 
  • Developing age-tailored checklists to ensure face-to-face time with patients to identify and support top primary prevention goals 
  • Evaluating and working with their patients to use digital tools that support chronic disease prevention, such as diabetes and obesity management platforms 

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The CMS Quality Conference signaled a substantial shift toward streamlined regulatory approaches and expanded standard data exchange, digital quality reporting and measurement, and AI deployment in care settings and by payers. Stakeholders should anticipate additional federal guidance updates, including in the Medicare Physician Fee Schedule final rule in the fall.  

HMA works with state agencies, payers, health systems, and providers to assess and implement digital health, quality systems, and information technology. We can help stakeholders develop cross-sector alliances, and organizations plan for and implement changes needed to react to these new initiatives. To discuss the implications of the Administration’s efforts in prevention, healthcare quality, and interoperability, contact our featured experts below.

How National Mandates in Digital Health & dQM are Transforming Healthcare

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Digital quality measures (dQM) are quickly emerging as a cornerstone of healthcare operations, propelled by federal efforts to enhance efficiency, interoperability, transparency, and real-time data sharing. New bipartisan proposals like the Healthcare Efficiency Through Flexibility Act (H.R. 483) highlight just how quickly the legislative landscape can change.

Healthcare organizations face mounting pressure to do more with less. As legislation continues to evolve at both federal and state levels, digital innovation remains a critical, key strategy for driving efficiency and reducing administrative burden.

National mandates, emerging legislative proposals, and regulations continue to set the “rules of the road” for healthcare, including digital quality transformation.  New bills can significantly reshape reporting requirements, data standards, and reimbursement models, often on accelerated timelines.  Organizations that proactively adapt to these shifting mandates will be better positioned to improve patient outcomes, streamline operations, and remain leaders in this evolving market.

Foundational Legislation

  • 21st Century Cures Act (2016): Enacted by the U.S. Congress, this laid the groundwork for modernizing the healthcare data ecosystem using application programming interfaces (APIs). Healthcare related provisions focused on interoperability & usability of electronic health data by preventing information blocking (unreasonable interference with access/ exchange of electronic health information); required certified electronic health records (EHRs) to utilize Fast Healthcare Interoperability Resources (FHIR)-based APIs to promote patient access to their health data.
  • The Centers for Medicare & Medicaid Services (CMS) Interoperability & Patient Access Final Rule(CMS-9115-F) (2020): Required CMS-regulated payers (Medicare Advantage, Medicaid, Children’s Health Insurance Program (CHIP), Qualified Health Plan (QHP), and Federally-facilitated Exchanges (FFEs) beginning on or after January 1, 2022, to offer FHIR-based APIs for Patient Access and Provider Directories.
    • Mandated Payer to Payer Data Exchange for patients to take their data with them if they change payers.
    • Promoted data exchange by requiring hospital participation in sending patient event notifications through an ADT (Admissions, Discharge and Transfer) feed.
    • Publicly reporting providers who do not list their digital contact information in the National Plan and Provider Enumeration System (NPPES).
    • Further curtailed information blocking by publicly reporting eligible clinicians and hospitals who may be blocking information.                                                                                     

Subsequent federal communication in December 2021 formalized CMS’s decision not to enforce certain provisions of this rule to give payers additional time to comply.

  • Health Data, Technology, and Interoperability (HTI-1): Certification Program Updates, Algorithm Transparency, and Information Sharing-Final Rule (2024): This rule, which was issued by the Office of the National Coordinator (ASTP/ONC)[1] introduces significant changes to software supporting care. It implements the Cures Act’s EHR Reporting Program, requiring transparent reporting on certified health IT metrics. It also updated information blocking regulations to make data easier to share. In addition, it established a new standard data model for all “certified” Health IT products: the United States Core Data for Interoperability (USCDI) version 3, starting January 1, 2026. In addition, the voluntary certification program (which has been adopted by 96% of all EHRs) has updated its standards, criteria, and requirements, including standardized FHIR APIs, electronic case reporting using Health Level Seven International Clinical Document Architecture (HL7 CDA) and FHIR-based specifications, revised decision support intervention criteria, and new functionality for patient Electronic Health Information (EHI) restriction requests.
  • CMS Interoperability & Prior Authorization Final Rule (CMS-0057-F) (2024): Builds on previous CMS efforts and the 2020 CMS Interoperability & Patient Access Final Rule to improve access to and exchange of health records among patients, providers, and payers. It also focuses on simplifying and modernizing prior authorization processes while expanding data-sharing requirements to reduce administrative burdens. Impacted payers must begin implementing certain measures by January 1, 2026, while most API-related requirements are extended until January 1, 2027, based on stakeholder feedback provided to CMS.

Beyond federal legislation, other influential entities like CMS, National Committee for Quality Assurance (NCQA), and ASTP/ONC, are adopting new frameworks that accelerate the shift to digital quality measurement.

Rapidly Evolving National Healthcare Frameworks & Healthcare Quality Landscape Changes

  • CMS National Quality Strategy/Meaningful Measures 2.0 and CMS Digital Quality Measurement Strategic Roadmap (Published in 2022)

These frameworks map out a future in which interoperability and digital measures play a pivotal role in improving care quality and outcomes.

  • NCQA’s Shift to Digital Healthcare Effectiveness Data and Information Set (HEDIS)® Measures:
    NCQA has taken a significant step in its quality measurement strategy for health plans. Specifically, HEDIS measures are moving to fully digital by 2030, signaling an industry-wide move toward automated data capture and reporting (published in 2024). In addition, they have also launched their Digital Content Services (DCS) product which allows organizations to submit their quality measures digitally for the 2024 measure year.
  • Digital Quality Implementers Community:
    In 2024, a collaborative consensus-based effort was initiated to develop, advance, and standardize tools and platforms that make digital quality measurement possible using open standards instead of proprietary tools. This group is actively working to advance a quality enablement layer including tools, guidance, and standards changes. Leavitt Partners, an HMA company, facilitates this community.

Signals from the Trump Administration Related to Digital Quality

There is ongoing speculation about how the Trump Administration and Congress will approach digital healthcare transformation—particularly in areas like digital quality measurement. Yet multiple indicators suggest they will stay on this course, and perhaps even accelerate the adoption of digital quality measures.

One key signal is that Ryan Howells, a Principal with Leavitt Partners, an HMA Company, is reportedly one of two finalists under consideration for the position of Assistant Secretary for Technology Policy (ASTP). Known as a champion for digital healthcare data, Howells leads the CARIN Alliance, a national group focused on improving health data access. The ASTP/ONC has significant influence in shaping federal regulations for electronic health records and broader data, technology, and artificial intelligence strategies within the Department of Health and Human Services (HHS).

Additionally, recent bipartisan legislation introduced in January 2025 further underscores a commitment to pursuing digital quality transformation as a linchpin for success in a “digital-first” environment, one that prioritizes efficiency and enhanced patient outcomes. 

H.R. 483: Healthcare Efficiency Through Flexibility Act

Proposes delaying electronic clinical quality measures (eCQM) adoption until 2030, citing the need to reduce provider burden and pilot more advanced, interoperable reporting tools, including digital quality measurement.

Meanwhile, the national shift toward dQM continues to gain momentum. With eCQM mandates set to begin in reporting year 2025 for Medicare Shared Savings Program Accountable Care Organizations (MSSP ACOs), many organizations view these requirements as redundant and burdensome, given the industry’s rapid move toward fully digital quality. Unlike eCQMs, dQMs leverage more robust structure and standardization, especially through FHIR-based APIs, to enable broader, more timely, and more efficient data capture. The result is a faster path toward high-impact quality measurement and improvement in our increasingly digital healthcare environment.

Major Implications for Healthcare Organizations

  • Compliance Deadlines:
    Evolving Administration rules can quickly shift timelines, significantly impacting prior authorizations, data exchange, and quality measurement.
  • Financial & Legal Risks:
    Non-compliance may lead to financial penalties, legal actions, or even program exclusion.
  • Workforce Readiness & Capacity:
    Requires strategic communications, robust change management efforts, and advanced technology infrastructure.

Strategic Recommendations

  • Cross-Functional Collaboration:
    Engage compliance, IT, clinical, and legal teams to track and adapt to new rules.
  • Stay Flexible:
    Monitor Congress, CMS, ONC, and other federal notices regularly, as new bills and guidance can rapidly change targets.
  • Technology Assessment:
    Evaluate interoperability, API readiness, and EHR workflows to identify gaps.

Need a Tailored dQM Strategy?

Contact HMA for best practices, policy insights, and a customized roadmap for your organization.

Learn more about HMA’s approach to dQM.

[1] ONC was renamed to the “Assistant Secretary for Technology Policy/Office of the National Coordinator (ASTP/ONC) in 2024, but in the current administration, may be folded back into CMS.

HMA partners with Healthcare Association of New York State (HANYS) on webinar series to help organizations with Survey Readiness

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In today’s complex healthcare environment, navigating the scrutiny of regulatory and accreditation bodies like The Centers for Medicare & Medicaid Services (CMS), Department of Health (DOH), The Joint Commission, and Det Norske Veritas (DNV) Healthcare is critical for the success of every hospital and health system. Unexpected surveys, triggered by recertification, validations or even complaints, can occur at any time.

Early this year, HMA partnered with the Healthcare Association of New York State (HANYS) to develop the content for Survey Readiness: Prepare, Respond, Succeed, a 5-part virtual series. HMA’s expert faculty co-taught the sessions. Attendees dove deep into organizational strategies and tactics to prepare, manage and respond to surveyors effectively – and get the essential skills to excel in survey readiness.

Survey Readiness: Prepare, Respond, Succeed

Virtual Series | April 2 – 30

  • April 2:  Survey readiness 101: Overview and getting started
  • April 9:  Preparation: How to mitigate risk and prepare for upcoming surveys
  • April 16: They’re here: Establishing a survey response and management protocol
  • April 23: Responding to survey findings: How to develop a strong correction plan and knowing your options
  • April 30: What’s next: Leveraging survey findings and strengthening organizational quality and compliance

How satisfaction impacts Medicare Advantage plans Star ratings 

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Medicare Advantage (MA) Star ratings are more than a quality score—they shape the financial and operational success of MA plans. These ratings hinge on factors that every plan can impact by developing continuous improvement processes. The Consumer Assessment of Healthcare and Provider Systems (CAHPS) survey, Healthcare Effectiveness Data and Information Sets (HEDIS) ratings, and the Member Retention rate are all significant levers affecting Star ratings.  

The importance of member retention rate 

Member retention rate is a measure of member satisfaction but also impacts plan scale. One Medicare Advantage (MA) plan typically reports 0% voluntary disenrollment each year. Another plan is reporting 60% voluntary disenrollment. The voluntary disenrollment threshold is currently set at 18% for a 4-star rating and 10% for a 5-star rating on the measure.  The average MA plan is losing more than $60 million in Medicare premium annually due to voluntary disenrollments. The voluntary disenrollment measure excludes members moving out of the service area or sponsor-initiated contractions of the service area.

CAHPS survey impact on Star ratings 

CAHPS metrics are an important factor in the Centers for Medicaid and Medicare Services (CMS) Star rating system. MA plans need to develop strong companywide focused member experience processes to help them navigate the healthcare delivery system and community resources available. Evaluating the entire member experience from enrollment through access to care, messaging, outreach, customer service, to disenrollment, involves mapping out every member touchpoint, from a population health approach, to ensure the plan has a caring, approachable, supportive, and balanced experience with the member. Opportunities to eliminate frustrative process steps include identifying health related social needs and disparities that provide easier and time-sensitive access to care and services that are essential to increasing member satisfaction and engagement.

Health plans need a process to identify members who are most likely to be dissatisfied due to events and contact these members to understand the needs and resolve issues quickly. A dissatisfying process issue will repeat if not addressed. Understanding what data the health plan should be continually monitoring and the steps to effectively address any issues is essential to increasing trust with members. It is imperative that members get the opportunity to express their concerns to the health plan with the opportunity to resolve issues satisfactorily before they receive a CAHPS survey.

HEDIS and Star ratings 

MA plans need to develop focused processes to proactively monitor HEDIS metrics and drive improvement interventions to keep up with the competition. Having a holistic approach to monitoring, understanding the status and what gaps persist, and a year-round strategy for addressing these gaps is essential to being able to focus efforts on improvement.

As the National Committee for Quality Assurance (NCQA) is moving from a hybrid sampled process to an administrative whole population calculation system, it’s essential that MA plans are addressing each measure in its entirety throughout the year. Digital measurement and Electronic Clinical Data Sets (ECDS) measures are increasing with CMS having a goal of interoperability and implementation of digital quality measures by 2030. Changes with CMS Star metric weightings has increased the total percentage that HEDIS impacts the overall calculation.

Partnering with Pharmacy Benefit Manager to improve Stars 

Medicare Part D measures are among the most highly weighted measures in the CMS Stars performance program. Having a strong Pharmacy Benefit Manager (PBM) p artner is a necessity for success. Measures include medication adherence for high blood pressure, cholesterol, and diabetes. Successful plans ensure that members have sufficient prescription fills and re-fills to cover 80% of the days during the year. Measures are scored based on the percentage of members in the denominator who are compliant by the end of the measurement year. Member satisfaction with the plan’s pharmacy program is a key determinant in plan rating by the member and plan retention, impacting other parts of the CMS Stars program, whether Part D is measured alone or as part of an MA-PD plan.

Accelerating Star Rating Performance 

The HMA Stars Accelerator Solution offers a comprehensive, results-oriented approach to Star Rating performance improvement that addresses the multifaceted challenges faced by health plans. It examines your plans leadership structure, operational processes, technology, reporting, member-centric engagement, provider partnerships, and develops a strategy for your organization using a data-driven approach for continuous improvement. Multiple “what-if” scenarios are developed that identify top priorities. Measure thresholds that are too far to reach are replaced by measures that are within reach during the final months of the year.

The Accelerator approach includes “all-hands-on-deck” – care coordination, customer service, network development, marketing, analytics, and others. Accelerator plans introduce provider and member incentives and/or fee schedule adjustments to increase interest. These plans also provide information to providers on those attributed members who have measure gaps to facilitate provider outreach that is coordinated with plan outreach.

HMA Accelerator plans experience a reduction in members choosing to leave, attributed more to prevailing cultural changes over time than to enhanced benefits or member rewards. This program is a cultural transformation designed to strengthen star performance. Click here to learn more about the HMA Stars Accelerator Solution’s capabilities, where you can request a copy of the HMA Stars Accelerator Playbook. Let’s have a conversation about how your plan can improve member retention for increased star rating and increased enrollment scale.

Watch a replay of Mastering Star Performance: Strategies from the HMA Stars Accelerator Program.

Decoding your defense: a playbook to help your plan increase your Star rating

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Watch a replay of our webinar Mastering Star Performance: Strategies from the HMA Stars Accelerator Program.

WATCH NOW

HMA works with managed care plans to maximize Star ratings and improve program quality.

Star Ratings have been on a steady decline over the last two years resulting in large reductions in quality bonus and rebate payments, potentially impacting opportunities to improve member health outcomes.

How HMA can help improve a plan’s
Star rating:

We have developed a playbook that captures The HMA Stars Accelerator Solution with proven strategies for Stars improvement based on our diverse and extensive expertise in managed care plan (MCP) operations, MCP strategy, performance improvement, actuarial science, data analytics, risk adjustment, and federal and state policy.

Using our vast experience in the Medicare and Medicaid space, HMA can help you maximize ratings in programs like Medicare Stars and Medicaid quality performance. Together with our actuarial colleagues from Wakely Consulting Group and federal policy expert colleagues from Leavitt Partners, both HMA companies, we can provide the assistance you need to move your organization to a higher Star rating level. With guidance from HMA experts, the Accelerator is scalable for both functional and matrix organizations.

Want a copy of HMA’s
Stars Accelerator Playbook?

Fill out this form and one of our consultants will get back to you.

HMA can help your organization create momentum by combining HMA’s programmatic strategies with a robust actuarial and analytical basis, inclusive of integrated risk adjustment.

Meaningful data analysis ensures plans can prioritize the most important areas for strategic focus. Improving performance in Stars requires a multi-pronged, multifactorial approach. The HMA Stars Accelerator Solution is consumer-oriented and customizable to meet the unique needs of your members’ needs. It facilitates understanding of the organization’s current state, identifies opportunities for improvement, provides best practices for design of meaningful solutions to implement, and measures the effectiveness of improvements.

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Why is a high Star rating important for a health plan?

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The Centers for Medicare & Medicaid Services (CMS) publishes the Medicare Advantage (Medicare Part C) and Medicare Part D Star ratings each year to measure the quality of health and drug services received by consumers enrolled in Medicare Advantage (MA) and Prescription Drug Plans (PDPs or Part D plans). Star ratings impact a managed care plan’s financial performance, competitiveness, growth, and member retention. They are based on measures of multiple aspects of plan performance including:

Member experience and satisfaction

Administrative performance

Medication safety and/or adherence

Hospital readmissions

Healthcare Effectiveness Data and Information Set (HEDIS) and Health Outcomes Survey (HOS), both of which measure performance improvement.

Contracts are rated on a scale of one to five stars (rounded to nearest half star) based on approximately 45 measures related to preventive care, member experience (health plan customer service, physician point of service care, and perceived health), prescription drug monitoring, health plan operations, etc.

The industry has meaningfully improved traditional quality metrics (e.g. preventative care and medication adherence rates). As performance peaks in those measures, CMS is placing increasing emphasis on the member experience with their health plan and their providers during care.

Plans with 5 stars can market year-round.

The marketing advantage is a distinction for a high rated plan.

Poor performers (under 3 Star rating for 3 years) receive a Poor Performance Icon and may not be able to renew with CMS.

In 2024 there were 29 Part C (Medicare Parts A & B) and 11 Part D (Pharmacy) measures, and they can change every year. CMS recently released plan preview Star performance data for health plans to review. Final scores and Star ratings will be released by CMS in early October 2024 for Star Year 2025 based upon 2023 dates of service.

Star Rating High Level Timeline

CMS Star Ratings are a lagged pay-for-performance system. For 2026 Star Ratings, 2024 and early 2025 performance timeframes are critical to success, even though payments for this performance will not be received until 2027.

This image shows a high-level timeline for CMS Star Ratings from 2024 to 2027.

What plans do in 2024 and 2025 impacts your 2026 Star rating which will affect your plan’s revenues in 2027.

Is your plan building a strategy for next year based upon underperforming measures?  Are you looking for ways to lean in on any remaining Consumer Assessment of Healthcare Providers and Systems (CAHPS) and HOS opportunities? Do you know where to start?

See our HMA Solutions page, Star Rating: We Can Help You Navigate to a Higher Level, for more information.

Contact our experts below for more information about HMA’s Stars Accelerator Solution.

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Amy Bassano

Senior Advisor

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Tom Lutzow

Principal

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Daniela Simpson

Senior Consultant II

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Mary Walter

Principal

HMA 2024 Spring Workshop summary and key takeaways

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On March 6, HMA convened a spring workshop of 100 healthcare stakeholders interested in making value-based care delivery and payment work better. This event was designed for those engaging in value-based care and payment transformation, but who are looking to learn from peers to overcome challenges; participants included insurers, health systems, data and tech innovators, service providers, and trade associations.

The event’s name implored people to “Get Real” about the challenges we all face, while reminding ourselves of the imperative of making this transition to ensure the sustainability of our uniquely American healthcare system. In between plenary panels, participants were engaged in cohort discussions exploring the opportunities for progress in areas critical to making value-based care work.  While a summary cannot recreate the real-time discussions and simulations from the event, our discussions delivered insights on several critical themes that we believe are important to track. 

EMPLOYERS ARE LEANING IN: For all employers pay, they are getting less value over the past decade; the changes made to ERISA that hold the C-suite accountable for paying fair prices for healthcare benefits is a seismic shift in making healthcare purchasing a more strategic priority for employers.

  • Elizabeth Mitchell of the Purchaser Business Group on Health illustrated the shift in employers’ awareness – due to data transparency rules – that they aren’t getting the quality they thought they were getting for all that they pay. Transparency, plus a recent change to the Employee Retirement Income Security Act of 1974 (ERISA), is bringing employers back to the table with very specific requests for better outcomes, which they are increasingly pursuing through direct contracting and specific quality frameworks for primary care, maternal care, and behavioral health. Participants continued to reflect on this dynamic in all subsequent discussions, underscoring that this could be a really big deal.
  • Cheryl Larson of the Midwestern Business Group on Health talked about the cost pressure on her members leading them to partner in new and different ways, expressing optimism about all payer solutions and other innovative approaches to leverage the cost data that are now available. In her closing plenary session, she said “this issue of accountability on employers…I am excited and optimistic that there are things we can do to get there faster now.”

Data & Technology HAVE TO IMPACT DECISION MAKING: Patients are using the system the way it is designed today, so we can’t just blame them for poor outcomes…we have to actually stop doing things that don’t work and start measuring things the right way.

  • Dr. Katie Kaney opened with a dinner keynote discussing her efforts to create metrics that give purchasers a better measurement of whole person care, including clinical, genetic, behavioral, and social factors. Audience members remarked that this was a novel approach to quantify what has become accepted correlation in adverse health outcomes.
  • Ryan Howells, Dave Lee, and Stuart Venzke led discussions on Data & Technology, diving into updated federal regulations that present both opportunities and challenges for stakeholders, as well as ways to create corporate strategies that include data and technology, as these issues are no longer optional for anyone in this business. The breakout discussions talked about where we are today vs where we need to be – bridging the gap between data and decision making.

Payment & Risk TOOLS ARE ALIGNING INFORMATION TO ACTION:  Achieving meaningful risk-based contracts is possible but the details matter…mismatched data and information leads to unequal buying power, which cannot be the case in value-based care.

  • Kelsey Stevens, Scott Malan, Hunter Schouweiler, and Kate de Lisle led discussions on Payment & Risk, including an exciting hands-on simulation exercise that helped participants understand ways to increase premium scores by implementing risk-based payment approaches within the care delivery system; this session provided very concrete takeaways for those who attended by combining a simulation with a discussion on measures of success to improve risk-based contracting strategies.
  • Amy Bassano and Kate de Lisle discussed their recent publication on the expanded ecosystem of value-based care entities, looking at the “enablers” who are working with providers and payers to manage risk. This groundbreaking landscape of this market segment highlighted a set of Guiding Principles to ensure these entities are aligned with CMS, provider, and patient goals. Participants had lots of questions for the presenters and were anxious to read the HMA full report.

CARE DELIVERY MEASURES MUST BE TANGIBLE TO PROVIDERS AND PATIENTS: Value-based care requires aligning the right metrics with the right incentives, ensuring providers understand not only WHY but HOW they help improve patient outcomes.

  • Rachel Bembas, Dr. Jean Glossa, and Dr. Elizabeth Wolff led discussions on Care Delivery Measures, underscoring the importance of involving clinicians in the establishment of outcomes measures, as well as ensuring that the diversity of patient experiences are included. Participants remarked that we have a lot of “messy” data today, so we now have to ask the next set of questions on how we best use the messy data to make an impact?
  • Former Congresswoman Allyson Schwartz talked about the continuing promise of Medicare Advantage, and the opportunity to convene a new alliance around Medicare quality metrics as well as the increasing pressure to align these metrics across payers. In the closing plenary, she said “We need to define what we want healthcare in America to look like and then go out and get it…. We have to align the measurements and the standards we use so that providers understand what’s needed and it benefits government, taxpayers, and beneficiaries…we should require plans to have risk-based contracting with providers.”

Policy & Strategy HAVE TO STAY THE COURSE TO ALIGN INCENTIVES: Policymakers can help or hinder movement forward to ensure success…value-based care has to be more than a section in an RFP, but part of the entire scope of paying for outcomes-based care delivery.

  • Governor and former HHS Secretary Mike Leavitt reminded us of the political and policy journey that got value to where it is today, and the unique moment we are in right now that gives us hope as we enter this post-pandemic phase of healthcare spending and policy. He reflected, “We are beginning to see regulations and mechanisms to hold people accountable for healthcare costs…we have to integrate value and caregiving or we will never get to value.”
  • Theresa Eagelson, former Illinois Director of Healthcare and Family Services, talked about the opportunity for states to expand value-based care by setting strong expectations through contracting and by thinking differently about policy choices. She reflected on the role of state administrators, “When we sit here and talk about value-based care, do we know what our north star is? Have we mastered what we want to see in RFPs (for Medicaid)?  We’re working on a good FQHC model in Illinois, but should it be just for FQHCs? We need to spend more time together, across payers, across plans and providers and consumers to figure out what success looks like.”
  • Caprice Knapp and Teresa Garate led a discussion on state and local Policy & Strategy to support integrated care and services that are required to achieve better outcomes. There is a need for services to better coordinate and manage care across social and health services, bringing contracting and payment expertise to more efficiently serve patients. The highly anticipated Medicaid managed care rule can help guide states in updating their approach. Federal analysis of Medicaid data is needed to set benchmarks before we can get to total cost of care approaches.
  • Amy Bassano and Anne Marie Lauterbach led a discussion on federal policy alignment of Medicare FFS and Medicare Advantage, particularly looking at drug spending and the very real burden of medical debt as a driver of policy change. Participants reflected that half the country is indirectly covered through some public insurance. It’s just being done hyper-inefficiently.

HMA is leading the way on value-based care and is committed to continuing these dialogues to drive local, state, and national change. HMA’s value-based care expertise draws from our acquisition of Leavitt Partners and Wakely Consulting Group, two firms with deep ties and expertise on policy, strategy and risk-based pricing strategies, as well as recruitment of clinicians and operational experts who have led organizations through this transition. We will continue to advance the dialogue – and the work – to drive value as a critical way to ensure that our systems of health and healthcare are more affordable, equitable, and sustainable.

Let’s keep the conversation going! Learn more about how HMA can help you succeed with value-based payments and check out the newly released value-based payment readiness assessment tool for behavioral health providers.

Devising a framework for non-profit fundraising

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Money is always “top-of-mind” among non-profit leaders, from CEO’s at Federally Qualified Health Centers (FQHCs) to Executive Directors at Community-based Organizations. To supplement projects and retain the ability to further their missions, non-profit organizations (NPOs) need funding. When non-profits and funding sources are not well aligned, programs are cut, curtailed, or never launched. Assisting clients in pursuing alternative funding sources requires a creative yet methodical approach to promote success and boost organizational sustainability.

Devising a framework for non-profit funding presents challenges. Funding models/strategies cannot be too general nor too specific. There is not a single approach, a one size fits all model or sourcing strategy for non-profits to pursue. Instead, non-profit leaders must clearly articulate the funding model or strategy that best supports the growth of their organization and use that insight to examine the potential funding opportunities preeminently associated with organization-specific success. For example, a community health center serving patients covered by Medicaid and a non-profit organization doing development work in housing for the homeless are both funded by the federal government, yet the type of funding each receives and the decision makers controlling that funding are very different. Utilizing the same funding methodology for the two would not be productive. Fortunately, there are multiple methods and strategies to acquire funds. Non-profits should be strategic in seeking approaches suitable to their needs and capabilities and be creative in pursuing more than one model to acquire supplemental funds.

The core success of NPOs is based on a range of funding options, private grants and government grants, corporate sponsorships, private funding, endowments, and community fundraising. There is also a considerable amount of money available from the public sector, businesses, charitable trusts, foundations, in-kind donations, and local and state legislative bodies. The goal of any successful fundraising campaign is to convey fully what the money is or will be supporting and clearly articulate the projected positive outcomes that will be derived from the funding. Once the project is fully clarified, the next step is research. Many funding avenues exist. The NPO must decide which funding sources are best suited for each project and pursue those options.

When choosing potential funding sources, NPOs must consider the size of their organization, their mission, and various other defining characteristics. Once this internal due diligence is completed, revenue needs should be clarified, and a tactical fundraising strategy outlined. Creating a “ratio” with the end-result in mind allows for revenue diversification and avoids the too heavy reliance on one income source. For example, an NPO might project obtaining 50% of needed revenues from grants, 20% from a corporate sponsorship, and the remaining 30% from a foundation. Once the funding sources have been identified, the types of decision makers and the motivations of these decision makers must be evaluated. Then, a tactical roadmap designed to obtain the needed funding should be implemented. 

As society looks to the non-profit sector to solve important problems, a realistic understanding of funding models is increasingly important to realizing these aspirations. As consultants whose mission is to turn challenges into triumph for our clients, championing efficacious, high-yielding funding models ensures long-term viability for the organizations we serve.

Success relies on planning. It is much better to be proactive than reactive. Consider your organization’s funding needs, do your research, and lay the groundwork before diving into any fundraising pursuit. An assessment of your organization’s current funding strategies is essential. What is working; what is not? Is the current funding source reflective of the organization’s mission and values? Use the answers to these questions to make decisions and recommendations on which fundraising strategies to source. Get creative! Brainstorm unconventional ways your organization will stand out to potential funders, but be analytical. Balance creativity with data, keeping in mind which funding strategy reflects the best return. Focus time and energy on the funding model that will be most reliable, profitable, and feasible.

The non-profit world rarely engages in a succinct conversation about an organization’s appropriate long-term funding strategy. That is because the different types of funding that fuel non-profits have never been clearly defined. More than a poverty of language, this represents and results in a poverty of understanding and clear thinking. As consultants, HMA can provide an outside perspective and sort through the minutia presenting a clear, methodical, appropriate path to fundraising success.

Potential links to aid in your fundraising endeavors:

HMA works with a wide variety of healthcare clients, including FQHCs, community-based organizations, hospitals, provider practices, behavioral health, and managed care organizations, and can help with:

  • Grant Writing
  • Technical Assistance
  • Strategic Planning
  • Financial planning, Implementation and Optimization

For more information about how HMA can help your organization’s grant and funding strategies, contact our experts below.

Learning the invaluable lessons of value-based care at 2023 HMA conference

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If you search the term “value-based care” on the internet you will find over 2.5 million hits on that term alone. No one would disagree with the need to provide value to patients and purchasers, but how we define value differs based on where we sit. Value is paying for outcomes, not volume of services. Value is ensuring that patients get the right care at the right time. Value is ensuring that purchasers pay a reasonable cost for the highest possible quality. Value is ensuring that healthcare is provided equitably and sustainably. Implementing value is even trickier than defining it, given the complexity of who pays for care and the challenges of measuring the outcomes we seek to reward.  

From the top office of HHS to the back office of a health center and everywhere in between, HMA leaders have been part of our collective journey to value: advancing policy and regulatory change, calculating risk and setting prices, crafting alternative payment models, integrating social services and behavioral health, and coaching industry leaders to make important changes to their business models to adapt to a more sustainable approach to American healthcare. These experiences – both successes and challenges – provide a unique perspective from which to advise clients on transformation of healthcare.  

The HMA 2023 fall conference, scheduled for October 30-31, 2023, has thoughtfully curated several discussions to educate, enlighten and motivate attendees on industry standards and navigating the practicality of providing value in care, coverage, and patient experience in publicly funded healthcare:  

Leading the Charge on Value, Equity and Growth: The Future of Publicly Sponsored Healthcare: Discuss how these public programs came to be the industry standard bearers and what this shift means for outcomes, affordability, policy, and the overall direction of U.S. healthcare.  

Positive Change and the Growing Importance of Managed Care in Publicly Sponsored Healthcare: Discuss the future of publicly sponsored healthcare, outline promising initiatives aimed at improving coverage and care, and address key concerns over funding, policy, equity, and coordination between government, plans, providers, and members.  

The Future of Delivery Systems: Achieving Operational and Financial Sustainability: Discuss a wide range of practical approaches to prepare for the future, including managing cash flow, optimizing the workforce, developing long-term reimbursement plans, improving operational efficiency, and addressing changes in government policy.   

Real Talk from the Trenches of Value-based Payments: Learn about the advantages and pitfalls of value-based payments, with important insights from organizations that have made it work.  

Navigating Change in Medicare Advantage: A Roadmap for Success: Discuss what Medicare Advantage plans must do to meet the demanding, new requirements – all against a backdrop of continued efforts to improve equity, access, outcomes, and cost.   

In addition, a pre-conference workshop on behavioral health will be held the afternoon of October 29th, prior to the official start of the conference. This workshop will highlight the integral role of behavioral healthcare in improving patient outcomes across the continuum of publicly sponsored healthcare programs.  

We are excited to engage with industry experts throughout these discussions about value-based care and forge a better path forward toward a more sustainable and equitable system of care.  

Ready to talk?