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HMA webinars offer insights into big changes expected after the 2024 election

Following the 2024 election, incoming federal officials have begun to lay the groundwork for significant changes in the federal policy landscape and agency operations. In 2025, Republicans will control the executive branch and both chambers of Congress, a trifecta of power that affords more opportunity for advancing their federal healthcare agenda over the next two years.  HMA consultants are available to help organizations understand, inform, and plan for future federal policy initiatives and the impact for publicly funded programs and the healthcare sector.

Experts from HMA and from Wakely and Leavitt Partners, both HMA companies, collaborated to host three webinars that examine key issues and considerations for different parts of the healthcare sector.

 2024 Political Checkpoint webinar

This webinar explored insights on the election results, discussed both confirmed outcomes and remaining uncertainties, along with the mandate for change that has emerged. Panelists from HMA and Leavitt Partners provided an overview of what to expect from Congress and the Administration, focusing on key legislative priorities and executive actions, and shared their prediction for what to watch over the first 100 days.

With a Republican majority in Congress and presidency, healthcare priorities are expected to include revisiting ACA tax subsidies, addressing Medicaid allotments, and reexamining Medicare’s system for reimbursing providers. Powerful tools like budget reconciliation could drive major changes in tax and healthcare entitlement programs, however, this tool can be limited by parameters of the Senate’s procedural rules, known as the Byrd Rule.

Panelists also addressed the regulatory policy landscape which could include reinstating Trump-era policies like the 1332 waivers, allowing non-ACA plans, and altering Medicare and Medicaid policies to emphasize transparency and fiscal responsibility.

The Future of Medicare Advantage: How the Election Results Impact the Program 

With Medicare Advantage (MA) a key area of focus for incoming federal agency leaders, experts from HMA, Leavitt Partners, and Wakely discussed how the election results will impact what policy changes could be considered in the coming year.

As the MA program expands, conversations about its future reveal a mix of partisan priorities and bipartisan opportunities. Partisan changes are likely to include moderation of regulatory oversight, and the possibility of easing the audit process and restrictions on payment models. Other strategies and policies may shift the emphasis away from health equity initiatives and revise the federal approach to competitive prescription drug pricing negotiations.

There are, however, certain reforms that are likely to garner bipartisan support, such as the expansion of telehealth services and increased access to behavioral healthcare. Ongoing discussions about health plans’ approaches to prior authorization and management of prescription drug will likely remain a bipartisan priority.

Electoral Consequences: Impact on the ACA Marketplace

The 2024 elections may lead to significant changes in the ACA Marketplace. Enhanced ACA subsidies available during the COVID-19 pandemic are set to expire in 2025, and the new CMS administrator will shape policy and regulatory components that affect marketplace and consumer dynamics.

Key insights highlight anticipated changes to the Meaningful Difference Rules for non-standard plans, an increase in Marketplace user fees, and a proposal to codify silver loading into regulation. Additionally, it’s important to monitor policy areas focused on improving compliance among agents and brokers in the Marketplace the unveiling of a new Risk Adjustment model and coefficients to reflect costs that are not related to active medical conditions.

Our consultants are ready to meet with you to discuss any projects or ideas to help you navigate the evolving landscape in 2025.

The release of 2025 Medicare Advantage Star ratings and improving future rating cycle performance

This week, our In Focus section reviews the release of the 2025 Medicare Advantage (MA) Star Ratings and pivots to the actions that Medicare Advantage Organizations (MAOs) could take to improve performance in future rating cycles. 

Background 

Newly released MA Star Ratings information is based on the 2025 Star Ratings published on the Medicare Plan Finder on October 10, 2024. Star Ratings are largely based on the quality of care, member satisfaction, and retention. 

The Centers for Medicare & Medicaid Services (CMS) increased many measure-level cut points from the 2024 Star Ratings, requiring MAOs to achieve higher performance on these measures to receive a four or higher Star Rating. An earlier In Focus reviewed a white paper published by Wakely, an HMA Company, which provides an in-depth analysis of CMS’s latest policy and methodology changes that affect an MAO’s overall quality performance and Star Rating. 

Topline Results 

Significant attention is being given to the notable overall industry decline in Star Ratings. Specifically, only seven Medicare Advantage (MA) plans received an overall 5-Star Rating in 2025, compared with 38 in 2024. Only 40 percent of MA prescription drug plans achieved a score of four or five Stars versus 43 percent in 2024. 

Key Considerations for Star Ratings, and What to Do About Them 

The ratings significantly influence the financial and operational effectiveness of each MAO, directly affecting plan reimbursement and ability to enhance benefits. The 2025 Star Ratings will impact 2026 MA quality bonus payments. Health plans that earn four or more Stars are eligible for quality bonus payments and greater rebate percentage the following year. Plans may reinvest payments to make plan products more attractive to beneficiaries and emphasize a higher rating in their marketing efforts. 

In the wake of CMS’s release of Star Ratings, an intense focus has shifted to each MAO’s specific overall Star Rating. Given the clear implications for population health and health plan sustainability, companies will need to quickly pivot to address opportunities for performance improvement. Key steps to optimize Star Ratings include: 

  • Grow Foundational Knowledge – MAOs need to build broad organizational understanding of the domains and measures, the weights, the levers that can affect individual measures and domains, and the rating cycle. 
  • Assess the Current Landscape – Organizations will benefit from having executive sponsorship, a governance structure, and overall leadership for each domain and measure. They should develop the ability to report on measures, and set interim goals. Assessments also need to ensure the network and bonus structure are aligned with Stars. 
  • Develop a Roadmap –A calendar of events is critical for supporting performance improvement. This should include a preoperational and operational strategy as well as a year-over-year workplan to track, assess, and identify systems, technology, processes and people with a process for evaluation. Formulate a hiring and investment plan, if needed. 
  • Prepare for Reporting and Oversight – Develop a reporting and oversight structure, including a cadence of reporting and structure for review, process, and timing of reports by measure/domain leads. Ensure dashboards are updated annually to include new measures and weights and that a process is in place for managing display measures. 

What to Watch 

The MA landscape is highly dynamic, with some companies leading in market share, while others are leaders on quality ratings. As companies adapt to regulatory changes and strive for higher quality ratings, we can anticipate further shifts in the coming years. This will be exacerbated by shifts we are forecasting based upon the Health Equity Index and upcoming changes in Star weights. Strategies and actions MAOs implement in 2024 and 2025 will affect their 2026 Star Ratings. 

Connect with Us 

HMA experts have conducted in-depth analysis on all contracts, domains, and measures that roll into the Star Ratings. For further analysis of the 2025 trends and plan-specific impacts, contact our featured experts below.

Explore The HMA Stars Accelerator Solution for additional insights into programmatic strategies, best practices for design of meaningful solutions to implement, and approaches to measure the effectiveness of these solutions. 

What to watch for in Medicare Advantage policy this fall

This week’s In Focus section previews key public policy issues affecting Medicare Advantage (MA) and Medicare Part D that could potentially be addressed under regulations issued by the Centers for Medicare & Medicaid Services (CMS) later this fall. CMS’s highly anticipated regulations—which include annual programmatic, policy, and technical updates to the MA and Part D programs for the coming plan year—are under review at the Office of Management and Budget and are expected to be released in the coming weeks ahead.

In addition to the proposed rule, healthcare organizations are closely tracking CMS regulations that are expected to be released later this year, which would impact MA plan payment rates as well as proposed regulations intended to streamline the prior authorization process for prescription drug coverage under Medicare. This annual regulatory policymaking process is getting under way as the Medicare Open Enrollment period begins October 15, 2024, during which Medicare beneficiaries will compare Medicare health plan and drug coverage options and select the coverage that best meets their health care needs. (See Table 1 for key 2024 MA dates.)

As the last major Medicare policy regulations from the Biden Administration, healthcare entities can expect a continued focus on regulatory policies and requirements that strengthen program oversight and enhance beneficiary protections, while also seeking to maintain stability in Medicare benefits offerings and plan choices.

Following are some of the key issues to watch for as CMS’s annual regulatory process begins this fall.

Health Equity

Ensuring health equity is a foundational element of CMS’s strategic plan and the agency seeks to advance health equity goals and improvements across all of its programs, including Medicare Advantage. Beginning next year, MA plans will be required to conduct an annual review and analysis of utilization management (UM) policies and procedures from a health equity perspective. By requiring public reporting and identifying any impacts on underserved populations, this requirement is designed to ensure MA plans’ UM policies and procedures ensure access to medically necessary care, especially for vulnerable, low-income populations, such as beneficiaries who receive the Part D low-income subsidy and those who are dually eligible for Medicare and Medicaid.

In addition, CMS has finalized rules to collect health equity data, including race and ethnicity data, and adopted changes to the MA quality measurement program that will provide incentives for MA plans to improve care for underserved and vulnerable populations, including beneficiaries with high social risk factors.

Stakeholders should expect CMS to continue building and strengthening policies to advance health equity goals while exploring new initiatives to reduce disparities and close gaps in care for vulnerable populations.

Consumer Protection and Oversight

Earlier this year, CMS launched a high-profile effort to increase transparency in Medicare Advantage, including the release of a request for information (RFI) to solicit public input on ways to improve data collection and enhance oversight over all aspects of the MA program. More details are available in the press release. In addition to seeking comments on improving overall MA data collection and public reporting, the CMS RFI on MA data collection solicited specific recommendations to improve data collection and accountability for MA plans’ provider networks and prior authorization process.

While the formal comment period closed in May 2024, responses to the CMS RFI on MA data collection can inform and shape future regulatory policy direction, as CMS continues to examine ways to improve transparency and oversight over MA plans.

Quality and Star Ratings

CMS will soon release the Medicare Advantage Star Ratings, which measure the quality of MA plans based on a range of quality and performance metrics. The Star Rating system provides beneficiaries with crucial information to compare plans and select the coverage option that best meets their needs. High-performing plans receive bonuses—which provides incentives for plans to continue to improve quality of care for beneficiaries and patient outcomes. Last year, MA plans received $11.8 billion in bonus payments, and 74 percent of MA beneficiaries were enrolled in plans that achieved a rating of four or more stars. For more information, read the issue brief.

On the regulatory front, CMS recently adopted significant changes to Star Ratings that continue to have far-reaching impacts on MA plans’ quality performance, which, in turn, will continue to shape and inform their quality improvement strategies. Among the notable regulatory changes CMS has adopted is the new Health Equity Index, which rewards MA plans that provide high quality care to beneficiaries with social risk factors, including low-income beneficiaries and those dually eligible for Medicare and Medicaid. Though this policy change takes effect in 2027, MA plans can take steps now to prepare and enhance their capabilities to improve quality of care for beneficiaries with social risk factors, including using targeted care coordination programs.

As policymakers and stakeholders continue to monitor the impact of recently finalized changes to MA Star Ratings, CMS will continue exploring improvements to the MA Star Ratings system that further raise the bar on quality and ensure the program aligns with CMS’s broader goals and objectives.

Prior Authorization

As MA plans have increased the use of prior authorization and drawn scrutiny among patient advocates and providers, CMS has taken important steps to streamline and improve the prior authorization process to ensure timely access to care for Medicare beneficiaries. These regulatory policy changes—which include continuity of care requirements beneficiaries, increased oversight over UM practices, and ensuing evidence-based clinical decisions within MA are consistent with traditional fee-for-service (FFS) Medicare—are intended to ensure prior authorization and other UM tools do not create barriers to medically necessary care for Medicare beneficiaries.

Policymakers continue to look for ways to further improve the prior authorization process, and CMS has signaled additional interest in further regulatory standards to strengthen oversight and improve beneficiary protections. Potential policy options CMS could pursue include requiring more detailed reporting by MA plans (including number of prior authorization requests, denials, and appeals by type of service), extending prior authorization standards and consumer protections to prescription drugs covered by Medicare, and improving the timeliness of prior authorization decisions to avoid delays in necessary care.

Risk Adjustment Payment Policy and Coding

CMS has adopted significant changes to the MA risk-adjustment model, which continue to be phased in over a three-year period (2024−2026). These changes include important technical changes to improve the model’s payment accuracy, including a focus on conditions that are subject to more coding variation. Because CMS risk-adjustment changes will be fully implemented by calendar year 2026, policymakers and stakeholders are closely monitoring whether CMS will pursue additional regulatory policies to improve the accuracy of the risk adjustment program and address coding issues.

Since 2018, CMS—as required by statute—has applied a coding intensity adjustment that reduces MA risk scores by 5.9 percent annually to ensure consistency with Medicare FFS coding. However, MedPAC and others have continued to raise concerns that MA risk scores are higher than those for similar Medicare FFS beneficiaries, even after accounting for the 5.9 reduction in MA risk scores, which results in increased payments to MA plans. As policymakers continue to evaluate changes to ensure the long-term sustainability of the Medicare program, CMS could consider further changes in this area to equalize payments between MA and FFS Medicare through risk adjustment or coding changes.

Table 1. Key 2024 Medicare Advantage Dates

DateEvent
September 2024CMS announces average premiums, benefits, and plan choices for MA and Medicare Part D for 2025.
Early-to-mid October 2024CMS releases MA and Part D plan Star Ratings 2025.
October 15, 2024Medicare Annual Election Period begins. Medicare beneficiaries can enroll in MA or Part D plans for CY 2025.
October or November 2024CMS CY 2026 Policy and Technical Changes to MA and Medicare Part D (CMS-4208).
November 2024CMS Interoperability Standards and Prior Authorization for Drugs (CMS-0062).
December 7, 2024End of Annual Election Period.

Next Steps

The imminent release of CMS regulations come at a critical time for the Medicare Advantage program, which continues to experience enrollment growth amid a challenging and ever-changing regulatory environment. MA plans and other stakeholders need to be prepared to engage in the formal notice and comment process as well as offer policy solutions and best practices to strengthen and enhance the program for the 33 million beneficiaries it serves.

The Health Management Associates, Inc. (HMA), team will continue to closely monitor the timing of the release of CMS regulations and will analyze the impact of the key provisions once these rules are released. We have the depth, experience, and subject matter expertise to assist organizations engaging in the rulemaking process and assessing their impact. HMA can also assist with tailored analysis and modeling capabilities to assess the policy impacts across the multiple rules and guidance.

If you have any questions about the forthcoming CMS regulations and potential impact on MA plans, providers, and beneficiaries, contact our featured experts below.

CMS’s CY 2025 Medicare proposed rules support primary care, care coordination, and increased access for beneficiaries

This week, our In Focus section provides an overview of the two key Medicare proposed payment rules that the Centers for Medicare & Medicaid Services (CMS) released last week—the Physician Fee Schedule (PFS) and the Hospital Outpatient Prospective Payment System (OPPS). These two rules include policies that will affect a variety of providers. Below we highlight some key provisions. Comments on these proposals are due to CMS in early September.

PFS Proposed Rule for 2025

Released on July 10 and with comments due by September 9, this wide-ranging regulation proposes policy changes for many different types of providers.

PFS Payment Update: The estimated 2025 PFS conversion factor is $32.36, a $0.93 or 2.80 percent decrease from the calendar year (CY) 2024 level of $33.29, which included a one-time update required by statute. In previous years with cuts like this one looming, Congress has stepped in and adjusted the payment update in the positive direction. Congress is now considering approaches to do so again for this year.

Caregiver training services (CTS): CMS is proposing a new code for caregiver training for direct care services and supports such as wound dressing changes, infection control, and medication administration. These services could be provided via telehealth.

Telehealth services: CMS is proposing to add several new codes to the telehealth list and to refine a variety of policies related to the type of technology that must be used and what supervision must be provided for telehealth services and other requirements such as removing frequency limitations. Nonetheless, several telehealth flexibilities will end December 31, 2024, because of the expiration of pandemic era expansions unless Congress extends or makes telehealth flexibilities permanent.

Advanced primary care management services (APCM): CMS proposes to create a new set of APCM codes that would incorporate parts of several existing care management and communication technology-based services into a monthly bundle of services. The billing codes are differentiated by three levels based on a person’s number of chronic conditions and enrollment as a qualified Medicare beneficiary to reflect patient medical and social complexity. These APCM services could be provided by advanced primary care teams and are tied to primary care quality measures.

CMS seeks feedback on whether the agency should consider additional payment policies to recognize the delivery of advanced primary care, including on potential changes to coding and payment policies within traditional Medicare such as for additional bundles of services.

Behavioral health servicesCMS is proposing new codes for behavioral health crisis services, including safety planning and interventions for patients at risk of suicide or overdose, follow-up contact after a crisis emergency department (ED) visit, for digital mental health treatment (DMHT) services, and for nonphysician practitioners to bill for interprofessional consultations.

Screening and risk assessment: The agency updates and expands coverage for screening and preventive services, including proposals to cover screening computed tomography colonography (CTC) for colorectal cancer, drugs covered as additional preventive services, the hepatitis B vaccine, and cardiovascular risk assessment and risk management.

Dental and oral health servicesCMS proposes to add services provided to Medicare beneficiaries with end-stage renal disease to the list of clinical scenarios in which Medicare payment may be made for dental services. CMS also seeks comments on other clinical conditions appropriate for coverage.

Improving ambulatory specialty care: CMS seeks stakeholder feedback about a potential Innovation Center model that would increase specialist participation in value-based care through Merit-based Incentive Payment System (MIPS) Value Pathways (MVPs) and expand incentives for primary and specialty care coordination.

Medicare Shared Savings Program (MSSP): CMS is proposing several refinements to the permanent accountable care program. These include a prepaid shared savings option that lets eligible accountable care organizations that have previously earned shared savings to receive advanced earned shared savings to make investments that support beneficiaries, the addition of a health equity benchmark adjustment (HEBA) that increases an ACO’s historical benchmark based on proportion of beneficiaries who are enrolled in the Medicare Part D low-income subsidy (LIS) or dually eligible for Medicare and Medicaid, changes to the MSSP quality measure set to align the measure with the universal foundation measure set and seeking comment on creating a risk track that is higher than what currently exists.

Rural health clinics and federally qualified health centers: CMS proposes several changes to update payment and coverage of services provided in these facilities including care coordination services, vaccines, and dental services.

Payment for major surgical procedures: CMS makes coding proposals to address scenarios in which follow-up care for beneficiaries who have undergone major surgical procedures is provided by different clinicians in different group practices.

Opioid treatment programs: CMS makes several proposals related to opioid treatment programs, including allowing assessments conducted via audio-only telecommunications, and increasing payments for social determinants of health (SDOH) risk assessments. CMS also proposes to pay for new FDA-approved opioid agonist and antagonist medications.

2025 Medicare Hospital OPPS Proposed Rule

CMS released the Medicare Hospital OPPS proposed rule on July 10, 2024, with comments due by September 9, 2024. This regulation proposes policy changes that largely impact hospital outpatient departments and ambulatory surgery centers (ASCs).

OPPS and ASC Updates: CMS proposes to update OPPS rates for hospitals that meet applicable quality reporting requirements as well as ASCs by 2.6 percent.

Access to non-opioid pain relief: The Consolidated Appropriations Act (CAA) of 2023, provides temporary additional payments for certain non-opioid treatments for pain relief in hospital outpatient department (HOPD) and ASC settings from January 1, 2025, through December 31, 2027. CMS proposes to implement this law with proposals on the evidence requirements for medical devices and the Food and Drug Administration (FDA)-approved indications that would meet the criteria for the temporary additional payments. CMS has identified seven drugs and one device that would qualify as non-opioid treatments for pain relief and proposes that they receive separate payment in 2025. CMS also is soliciting comments on other products that may qualify for these payments.

Justice-involved individuals: To support individuals returning to the community from incarceration, CMS proposes to narrow the definition of “custody” in Medicare’s payment exclusion rule and to revise the Medicare special enrollment period (SEP) for formerly incarcerated individuals. These modifications would remove real or perceived barriers to Medicare access for individuals who have recently been released from incarceration or are on parole, probation, or home detention.

Maternal health: CMS is proposing several new maternal health related requirements for hospitals and critical access hospitals (CAHs). The proposed changes to conditions of participation, include new requirements for maternal quality assessment and performance improvement; baseline standards for the organization, staffing, and delivery of care within obstetrical units; and annual staff training on evidence-based maternal health practices. CMS further proposes changes to the emergency services requirements related to emergency readiness for hospitals and CAHs that provide emergency services.

Connect with Us

HMA’s Medicare policy experts collaborate to monitor legislative and regulatory developments in the physician, outpatient, and ASC policy arenas and to assess the impact of changes in these reimbursement systems. HMA’s Medicare experts interpret and model policy proposals and use these analyses to assist clients in developing their strategic plans and comment on proposed regulations.

For more information or questions about the policies described below, please contact our experts below.

Announcing HMA’s new VBP readiness assessment tool for behavioral health providers

Dollars and Sense: Is Your Organization Positioned to Thrive in the World of Value-Based Payments?

As the healthcare system in the U.S. moves away from the costly and inefficient framework of fee-for-service to patient-centered structures focused on value and quality, every Behavioral Health organization finds itself with challenges ahead. Whether your organization stands at the forefront, poised for a full dive into value-based payment implementation, or is tentatively exploring initial steps, understanding your organization’s readiness on the VBP spectrum is paramount to success. Health Management Associates (HMA) is helping provider organizations in every phase of readiness move forward. We understand the detailed steps to help you focus on value, change payment structures, adapt clinical and operation workflows, and prepare and train your workforce to improve quality. Our tool is not just a promise but a practical solution to assess your current organizational readiness, providing valuable insights to focus your attention toward the next level of value.

VBP Readiness Assessment Tool

HMA’s VBP Readiness Assessment is a free, online survey tool that can help you gauge your organization’s preparedness across six pivotal domains of core functions necessary for successful participation in payment reform models. Completing the survey will provide a snapshot about a single provider or an entire organization and determine where you stand on the value-based payment spectrum.  The six domains encompass measuring outcomes, evaluating board and leadership readiness, assessing technological capabilities for capturing and sharing data, gauging partnerships, payer engagement strategies, and financial alignment.

Readiness Assessment Results

VBP graphic 1
VBP graphic 2

Example plot of a readiness assessment showing an organization’s scores on the VBP spectrum.
This organization has an overall Intermediate level of readiness with the highest levels demonstrated in
Board & Leadership Readiness and Partnership and lowest levels in Financial Readiness.

The journey toward successfully navigating the realm of value-based payments demands a strategic and informed approach. The crucial first step is a comprehensive assessment of organizational readiness, and the HMA VBP Readiness Assessment Tool stands as a valuable resource for this purpose. The ever-changing landscape of healthcare payments requires organizations to be adaptive and forward-thinking. With HMA’s team of experts offering guidance at every stage, providers, associations, health plans, and states can gain a profound understanding of the necessary organizational efforts required to engage in VBP successfully. The current landscape increasingly emphasizes value, therefore, the importance of transitioning from fee-for-service to value-based models cannot be overstated. As the demand for value continues to grow, organizations that proactively position themselves to meet these evolving expectations will not only thrive but contribute significantly to shaping the future of healthcare delivery. The HMA VBP Readiness Assessment Tool is not just a survey; it’s a compass guiding you through the dynamic terrain of value-based payments, serving as a way to identify meaningful progressive steps you can take to strengthen your organizational position within the VBP space.

Taking the survey and receiving one analyzed response is free, but you may find value in contracting with HMA for a more in-depth analysis of your organization. Click below for more details and to access the survey.

learn more about the Assessment Tool

For more information, please contact our featured experts.

HMA Fall Conference: Highlights and Takeaways

HMA Fall Conference October 2023

As we look back at our 2023 Fall Conference on publicly sponsored healthcare held in October, we wanted to highlight a few key takeaways from the event:

  • Behavioral Health Pre-Conference workshop: An impactful pre-conference session convened influential leaders in behavioral health to deliberate on the urgent need for a purposeful disruption of mental health accessibility across multiple sectors. Participants were actively challenged to reimagine strategies that could effectively disrupt the prevailing status quo in behavioral health, focusing on three key components essential for constructing a comprehensive system of care: population health and prevention, quality, and network.

The discourse highlighted pervasive issues such as silos that contribute to a lack of accountability within the system. There was a unanimous recognition of the imperative to eliminate barriers to access, accompanied by a resounding call for a pivotal transformation in payer models. Throughout the session, a prevailing theme underscored the critical need for fostering collaborative efforts across different sectors, emphasizing the creation of opportunities for cross-sector groups to work together.

Participants echoed a shared sentiment regarding the urgency of dismantling the current lacking system and replacing it with a more inclusive, patient-centered approach. The session served as a platform for thought-provoking discussions, inspiring innovative solutions to address the challenges in behavioral health, paving the way for a more effective and accessible system.

The three main conference themes – Equitable Access, Digital Innovation, and Value-based Care – were touched upon in many of the panels and plenary sessions.

  • Equitable Access: Several panels and speakers talked about health equity as a moral imperative as well as an organizational priority. Payers and providers understand that the Centers for Medicare and Medicaid Services (CMS) is developing metrics and measures to incorporate equity into accreditation and reimbursement and are anxious to get down to the details of the specific items that will be included. There was also robust discussion about how to incorporate community-based organizations and social services into Medicaid managed care plans to ensure that health-related social needs are being addressed in a more holistic way. There are opportunities to ensure contracting parameters and quality metrics work as intended to enable payers and providers to improve outcomes and reduce inequities of all types.
  • Digital Innovation: In addition to a “shark tank” style presentation of innovative technology vendors, the HMA conference featured a panel of experts in data liquidity and interoperability. They discussed the opportunity to embrace application programming interfaces (APIs) and digital health as a strategic imperative instead of a compliance issue. The new electronic prior authorization requirements are already starting to produce big results by expediting approvals, which is good for patients, but also reducing workload to allow staff to be redeployed to other areas of need. The panel also discussed the real need to improve digital access for rural health clinics (RHCs) and federally qualified health centers (FQHCs) that serve rural communities, where fee-for-service payment creates barriers to greater data coordination. And finally, the panel discussed the need to improve Medicaid procurement, so it does not impose barriers to digital innovation for vulnerable populations.
  • Lessons of Value-Based Care: This session featured a lively conversation about how value-based care is more important than ever, and frankly, that it is the right thing to do for mission-driven organizations to improve the health of patients. The organizations represented discussed how it has not been easy to learn new approaches to care coordination and managing financial risk, but they can do what is best for the patient by investing in the right things up front. Value-based care approaches are proliferating, including FQHCs where the providers’ motivation to serve vulnerable families is now supported by the right financial incentives.

HMA is committed to bringing together experts from across the healthcare spectrum, and advancing the conversation about ways to improve access, equity, and innovation in healthcare. In early March 2024, we will be offering an HMA Spring Workshop on value-based care in Chicago. Registration will open soon; to receive the invitation, please be sure you are subscribed to the HMA News and Events list.

Proposed changes to opioid treatment: implications for providers, payers, and regulators

After more than two decades, SAMHSA and its Center for Substance Abuse Treatment (CSAT) is revisiting regulations governing opioid treatment programs (OTPs), as required by the 2023 Consolidated Appropriations Act passed by Congress. These new federal rules around treatment will change how medications are delivered to persons with opioid use disorder (OUD), offering opioid treatment centers a unique opportunity to advance person-centered care, and can build on the lessons learned from the flexibilities offered during the public health emergency.

This is a real opportunity to change how care is delivered. It will increase access to lifesaving medications, including:

  • A change in take-home schedules, which will allow for additional take-home medications sooner in the treatment process to reduce the burden of coming to the program daily, alleviating transportation challenges and the disruption of work and family routines.
  • Emphasizing and codifying the importance of harm reduction.
  • Clarifying diagnoses required for admission to be active moderate-to-severe OUD, OUD in remission, or at high risk for recurrence or overdose.
  • Removing access barriers for persons under 18; expanding use of telehealth; and finally, expanding interim maintenance dosing up to 180 days in a 12-month period. 

These new changes will help alleviate admission barriers caused by workforce shortages and allow patients better access to medication and treatment. The increase in use of telehealth combined with medications for opioid use disorder (MOUD) will remove time and travel barriers for treatment, allowing persons treated with methadone and buprenorphine, including new persons, to be treated remotely.

What does this mean for the field?

OTPs have historically been reimbursed based on volume, with daily attendance as a steady source of revenue and a “captive” audience for counseling services. For persons with OUD to feel the full benefits of the new rule, changes will need to be made at all levels:

  • OTPs will need to rethink their clinical models to develop a service mix driven by a person’s need as opposed to regulations. Engagement will drive attendance, outcomes and thus revenue. Additionally, there will be a need to:
    • Retrain staff.
    • Work with medical team to develop new clinical protocols.
    • Structure revenue cycle management processes and business models of service delivery.
  • Regulators will need to adapt state licensing rules and re-train licensing staff.
  • Payers have an opportunity to move Value-Based Payment (VBP) more steadily into the OUD treatment space and will need to realign payment structures to incentivize providers to provide care according to a person’s need.

If you want to learn more about the changes ahead, HMA hosted a 3-part webinar series on the effect of proposed regulations on delivery of opioid treatment services. The series New Rules in Treatment of Opioid Addiction was aimed at helping stakeholders prepare for and adapt to these changes to ensure a successful transition for the people they serve. Our series focuses on three areas where changes can help those managing OUD:

  1. How do OTPs deliver services to better support persons with OUD?
  2. How do payers create the right financial incentives to help providers deliver better behavioral health solutions for OUD?
  3. How do state regulators make changes to rules and laws to promote a treatment system that prioritizes a person’s health and recovery?

Watch here:

Part 1 Opioid Treatment Providers

Part 2 Opioid State Payers – Aligning Incentives for Treatment

Part 3 Opportunities for State Regulators to Shape Policy and Regulation of Treatment

If you are ready to explore these changes in your organization, HMA can help. We have experience in:

  • Developing clinical workflows
  • Aligning revenue cycle and clinical operations
  • Developing and implementing state OUD code
  • Supporting health plans and providers in moving into VBP
  • Supporting health plans in adapting to new clinical models

HMA recognizes unseen populations on International Overdose Awareness Day 2023 

In honor of International Overdose Awareness Day (IOAD), August 31, 2023, we take time to pause and reflect on this year’s theme of “recognizing those people who go unseen.” HMA stands with those affected by overdose and promotes an ecological approach to addressing substance use, one that acknowledges the many facets of the crisis that leads to approximately 300 overdose deaths every day in the United States.  

We recognize that many Americans experience the repercussions of overdose in ways that are often unseen: friends and family members who act as first responders by reversing an overdose with naloxone; seniors and older adults experiencing addiction; pregnant and parenting people who use drugs and/or medications for opioid use disorder; those who are often unable to access resources due to structural barriers such as homelessness or those living in rural and frontier communities; and, the justice-involved population, who serve as a salient example and often go unseen. Research has confirmed that overdose is the leading cause of death among people leaving carceral settings, as well as the third leading cause of deaths in custody in U.S. jails.  

We also recognize that many of the racial disparities in U.S. overdose deaths are unseen and underrepresented in national dialogue about the crisis. At a time when people of color are dying at a higher rate than non-Hispanic White people, the International Overdose Awareness Day theme of recognizing those unseen is timely, and apt. Non-Hispanic American Indian or Alaskan Native people had the highest drug overdose death rates in both 2020 and 2021. Rates of overdose among Black or African American men outpace other groups. Racial disparities extend beyond overdose fatality rates and into the broader substance use disorder continuum of care. People of color are offered medications for opioid use disorder at a rate almost 50% lower than non-Hispanic White people, and the duration of their treatment tends to be shorter; ultimately leading to increased risk of returning to use. These statistics only reinforce the need for an expanded, comprehensive, and equity-centered approach to care

Finally, we recognize that the overdose landscape is developing unseen changes, as overdose deaths involving psychostimulants such as methamphetamine are increasing with and without synthetic opioid involvement. Polysubstance use is the norm, not the exception. The healthcare sector must broaden and expand services to meet the current needs, including incorporating harm reduction strategies for stimulants, especially in states with high concentrations of deaths such as Nevada, West Virginia, Maine, and among non-Hispanic American Indians or Alaskan Natives.  

HMA honors the often-unseen work and expertise of those leading advances in the field including peers, public health professionals, people who use drugs, and friends and family who become first responders. In remembrance of those impacted by overdose, our call to action is to honor unseen populations affected by this crisis, to elevate existing work by and for these communities, and to continuously seek innovative approaches that ensure we carry everyone forward into a responsive system of care.  

Someone you know or may have seen may be struggling with addiction. Help is always available. The Substance Abuse and Mental Health Services Administration (SAMHSA) offers free, confidential, and 24/7 support in both English and Spanish at 1-800-662-HELP (4357). 

For more information on HMA overdose prevention services, visit HMA’s Behavioral Health page or contact our experts below.