Insights

HMA Insights: Your source for healthcare news, ideas and analysis.

HMA Insights – including our new podcast – puts the vast depth of HMA’s expertise at your fingertips, helping you stay informed about the latest healthcare trends and topics. Below, you can easily search based on your topic of interest to find useful information from our podcast, blogs, webinars, case studies, reports and more.

Show All | Podcast | Blogs | Webinars | Weekly Roundup | Videos | Case Studies | Reports | News | Solutions

Filter by topic:

Receive timely expert insights on topics you care about.

Select Topics

1840 Results found.

Solutions

HMA knows rural.

Read Solution

Some 47 to 60 million people live in rural areas in the U.S. Many rural residents must navigate healthcare system challenges people living in urban and suburban areas generally do not face. Developing and supporting rural health programs requires understanding the unique characteristics of rural settings and how these dynamics influence healthcare policy, providers, payers, consumers, and health equity.

HMA understands the multilevel challenges for delivery of quality healthcare and social services to rural populations. From workforce concerns to access issues such as lack of services, transportation difficulties, and socio-economic barriers, we know the difficulties that often keep rural providers and organizations from achieving their full potential to serve and support their communities’ needs.

Changing dynamics in many rural areas also create the need for building awareness and understanding of issues of equity and reducing disparities and how to effectively address them in rural communities. HMA has the hands-on knowledge for practical solutions.

HMA brings together industry-leading policy, program, financial, community, and clinical experts to provide comprehensive solutions that make healthcare and human services work better for people living in rural and frontier areas across the country. With deep experience and through skilled analysis, guidance and technical know-how, our consultants help a wide range of clients successfully navigate the healthcare space. Our team is more than 900 members strong and growing, with expertise that spans the healthcare industry and stretches across the nation.

We offer a full suite of professional health and human services consulting services to clients serving rural and frontier communities, such as:

Critical Access and PPS Hospitals

Federally Qualified Health Centers, Rural Health Clinics, & Provider Practice Groups

Health Plans

National, Regional and Statewide Associations

Federal, State, & Local Governments

Tribal nations & Tribal Health Organizations

Community Based Organizations

Foundations

Our national, multisector, multisystem experience in healthcare and human services enhances our ability to support rural clients in making sustainable, positive impacts in their local communities. Whether your project has run into a snag in the final stages or hasn’t even gotten off the ground, we can provide the expertise and guidance to help you make it a success.

Our areas of expertise include:

Analytics

Behavioral Health

Care Integration

Clinical Services

Community Strategies

Crisis Systems & 988

Government Programs & the Uninsured

Healthcare Actuarial Services

Healthcare Delivery Development & Redesign

Healthcare IT Advisory Services

Investment Services

Justice-Involved Healthcare

Long-Term Services & Supports

Managed Care

Opioid Crisis Response

Public Health

Quality and Accreditation Services

Value-Based Care

Workforce development

PROJECT SPOTLIGHT

Health Equity & Access for Rural Dually Eligible Individuals (HEARD) Toolkit

With funding from Arnold Ventures, HMA created the HEARD Toolkit, a robust discussion of the access challenges facing dually eligible individuals in rural areas and a portfolio of actionable solutions to address these challenges. Dually eligible individuals in rural areas reside at the intersection of a major public health crisis and a fragmented Medicaid and Medicare delivery system. They experience poor access to services and to integrated care programs (ICPs) to address their whole person needs.

HMA designed this Toolkit to help policymakers address access issue dually eligible individuals in rural areas have to navigate every day. For example, addressing access must encompass getting to a comprehensive Medicaid and Medicare services continuum that includes home- and community-based services (HBCS), as well as ICPs. A primary focus on equity can help states, local communities, payers, and providers begin to address issues of access for these very vulnerable individuals in rural communities. The Toolkit provides examples and ideas for rural providers and communities to address equity and improve services and supports for dually eligible individuals.

Learn More

For example, HMA can assist rural communities and the organizations that support their needs with:

Rural-specific workforce solutions

Programs addressing Social Determinants of Health/Health-related Social Needs

Payment system reforms

Development of integrated care programs for Dual Eligibles

Substance Use Disorder/Opioid Use Disorder prevention, treatment, and recovery services

Behavioral health services and supports

Justice-involved carceral healthcare and transitions

Long-term services and supports and home and community-based services

HMA understands the multilevel challenges for delivery of quality health care and social services to rural populations. From workforce and care access issues to transportation difficulties and technology barriers, to socio-economic differences, we can help rural providers and organizations overcome challenges and achieve their goals to serve and support their communities’ needs.

Other Rural Health Project Examples:

HMA is supporting review and reform of the primary care payment environment in New Mexico working under a contract with Mercer. New Mexico’s Medicaid program had identified multiple challenges the primary care providers faced across the state, including rural sustainability and fiscal soundness. HMA’s approach includes coupling data analysis with stakeholder engagement. Our work to date includes designing, testing, and evaluating new primary care alternative payment models (APMs); fiscal, policy, and/or programmatic implementation recommendations related to the multi-payor roll-out of a primary care APM; and supporting primary care practitioners related to NM Medicaid APM implementation. Additional project work will include more provider specific analysis, recruitment for pilot testing and provide education, analysis and training for providers, health plans and state regulators.

HMA is working with the Colorado Department of Health Care Policy and Financing (HCPF) to perform a dynamic heat mapping as the first phase of a three-phase project that includes an environmental scan of home and community-based services (HCBS)/Medicaid. HMA is creating a tool that HCPF can leverage to update and track progress to close provider gaps. In subsequent work HMA will identify potential geographic regions which would benefit from reimbursement structure changes, including geographic adjustment factors to apply to preexisting fee-for-service rates or other mechanisms to effectively address identified care gaps. Based on these results, HMA will recommend strategies and best practices to expand the provider network in rural areas to avoid care deserts and assure access to services for all Medicaid members.

Over the past six years, HMA has supported tribal communities in Montana with an array of data and evaluation expertise specific to behavioral health system assessments and evaluation activities. To date, we have conducted feasibility assessments for tribes considering options to 638 their behavioral health services, evaluated high-fidelity wraparound services in tribal communities through the Montana Systems of Care program, supported efforts to discern a concept design for a joint tribally operated Substance Use Disorder (SUD) Continuum of Care, and assisted tribally operated clinics in best practices in opioid prescribing and addiction treatment.

The Georgia Health Policy Center provides technical assistance for grantees of HRSA’s Rural Health Programs. HMA created a primer and additional tools, including a webinar, designed to inform and support rural provider leadership on Value-Based Care. The primer serves as a self-paced guide helping organizations consider national trends and experiences, assess their current state and readiness, understand benefits and barriers of Value-Based Care. The primer and tools are used by the technical assistance team and rural health grantees.

HMA has worked with HSHS for over 10 years, providing a wide range of services including:

Grant surveillance related to strategic plans, project management, grant program development, and narrative writing for multiple state and federal grants including USDA, HRSA, and SAMHSA. 

Expanding access to medication assisted treatment (MAT) in emergency departments by activating a team of HMA experts to implement a global assessment of readiness to adopt MAT, create a comprehensive training curriculum, assist with development of policies, workflows and standardized orders; and provide technical assistance required to address stigma and implement change. HMA also aided in writing the successful proposal for state funding for this project.

Stakeholder engagement for a hub-and-spoke model of telehealth network, assessed strategic priorities across multiple diverse stakeholders, and developed a strategic plan for HSHS’ Wisconsin rural healthcare provider telehealth network.

Development of the Illinois Telehealth network composed of 21 rural healthcare providers across Illinois. HMA provided technical expertise on the adoption of telehealth services and the development of clinical protocols and led strategic planning efforts. The network now functions to support the members in disseminating best practices, implementing telehealth service lines, sharing clinical protocols, removing barriers, and promoting evaluation.

HMA is currently assisting HSHS’ rural behavioral health team in devising new models of community-based withdrawal management processes consistent with recent changes in Wisconsin’s regulations. HMA experts on residential substance use disorder and integrated care provide technical assistance, training, and evidence-based policy development.

HMA supported the Texas Department of Agriculture, State Office of Rural Health (SORH) by leading SORH’s three-year strategic plan and design future programs. For the needs assessment, HMA conducted a systematic assessment that included an environmental scan of rural health key issues and trends, online survey of rural Critical Access Hospitals (CAHs) and prospective payment systems (PPS) hospitals in Texas identify needs and gaps, and an analysis of publicly available data to identify health needs and differences between rural and urban residents. Informed by this assessment and close collaboration with SORH staff, HMA developed a strategic plan to guide the next three years of SORH’s programming, as well as created work and evaluation plans for the SORH and Flex grant programs. Other tasks included assessment of Texas rural hospital telemedicine readiness, recommendations for value-based payment models for rural hospitals, and opportunities to support rural hospitals in reducing health disparities.

Our depth and breadth of experience has helped a diverse range of healthcare industry leaders focused on rural and frontier areas. What can we do for you?

Contact our experts:

Kathleen Cahill

Kathleen Cahill

Associate Principal

Kathleen Cahill is a solutions-driven C-Suite executive with more than 40 years of experience in healthcare operations, working for entities … Read more

Kenneth Cochran

Managing Director, Delivery Systems

Kenneth Cochran is a healthcare executive with more than 20 years leveraging his clinical, business and academic background to deliver … Read more
Dan Castillo

Dan Castillo

Managing Principal

Dan Castillo is a seasoned healthcare executive with over 20 years of experience in health administration. He specializes in health … Read more
Stephanie Denning

Stephanie Denning

Principal

Stephanie Denning has worked in healthcare and human services for more than 25 years. Her experience spans the public, non-profit, … Read more
Shannon Joseph

Shannon Brown Joseph

Senior Consultant

Shannon Brown Joseph is a dynamic and accomplished workforce development liaison with experience in federal and state funded programs, diversity … Read more
Rebecca Kellenberger

Rebecca Kellenberg

Principal

Rebecca Kellenberg specializes in assisting public and private health care organizations with Medicaid and CHIP policy analysis and implementation. With … Read more
Jill Kemper

Jill Kemper

Senior Consultant

Jill Kemper has extensive experience improving access to care and care delivery, especially for vulnerable or complex patient populations and … Read more
Margaret Kirkegaard

Margaret Kirkegaard

Principal

Dr. Margaret Kirkegaard has extensive front line experience and an impressive breadth of knowledge about health care and its delivery. … Read more
Sarah Oachs

Sarah Oachs

Associate Principal

A collaborative health and human services professional, Sarah Oachs has vast experience in organizational leadership and assessments, operations management, and … Read more
Bill Snyder

Bill Snyder

Principal, Leavitt Partners, an HMA Company

Blog

The Health Equity & Access for Rural Dually Eligible Individuals Toolkit: Raising Rural Voices

Read Blog
Download the Toolkit

A public health crisis is growing more acute in rural America, disproportionately impacting individuals with both Medicaid and Medicare (the “dually eligible”). Dually eligible individuals residing in rural areas represent about 5 percent of all rural residents. They reside at the intersection of a public health crisis and a fragmented Medicaid and Medicare care delivery system. As HMA wrote in Health Affairs, this small population is at risk of falling through the cracks of this crisis and suffering a steep rural mortality penalty.

With support from Arnold Ventures, HMA prepared “The Health Equity & Access for Rural Dually Eligible Individuals (HEARD) Toolkit: Raising Rural Voices from New Mexico, North Dakota, and Tennessee to Create Action. The toolkit contains eight actionable solutions for federal and state policymakers to use and tailor to states’ needs. Ellen Breslin, Samantha Di Paola, and Susan McGeehan authored the toolkit, with research contributions from Rebecca Kellenberg and Andrea Maresca. The toolkit is available here.

Blog

An HMA toolkit and webinar to advance health equity & access for rural dually eligible individuals

Read Blog

In 2022, HMA convened stakeholder roundtables in three states – including New Mexico, North Dakota, and Tennessee to identify the challenges facing dually eligible individuals living in rural areas and to propose solutions to these challenges. Informed by this process, HMA developed the Health Equity & Access for Rural Dually Eligible Individuals (HEARD) Toolkit.

The toolkit is structured around three domains used to organize eight solutions. For each solution, HMA provides a description of the rural access challenge, the proposed solution, and the proposed tool. Each tool is powered by some type of lever available to the federal and state government. We anticipate that policymakers will build upon this toolkit through continued dialogue with rural communities. The toolkit’s framework, goals, and actionable solutions are summarized in the figure below.

HEARD Toolkit framework domains

HMA Principal Ellen Breslin, Consultant Samantha Di Paola, and Senior Consultant Susan McGeehan authored the toolkit, with research contributions from HMA Principals Rebecca Kellenberg and Andrea Maresca.

The toolkit is available here.

On February 2, 2023, 1pm ET, HMA will host a webinar on the HEARD toolkit. During this webinar, HMA experts and panelists including Dr. Kevin Bennett (USC-SOM Columbia, SC CRPH), Dennis Heaphy (DPC), Pam Parker (SNP Alliance), and Tallie Tolen (New Mexico Medicaid) will summarize and discuss the toolkit’s actionable solutions for improving rural dually eligible individuals’ health and social outcomes.

Click here to register.

Blog

Advancing health equity and integrated care for rural dual eligibles

Read Blog

This week, our In Focus section highlights the Health Affairs article, Advancing Health Equity and Integrated Care for Rural Dual Eligibles, authored by  Ellen Breslin, Samantha Di Paola, Susan McGeehan, Rebecca Kellenberg, and Andrea Maresca, Health Management Associates.

A public health crisis is growing more acute in rural America, disproportionately impacting individuals with both Medicaid and Medicare (the “dually eligible”). The rural health crisis is a health equity concern that affects all rural residents, including dually eligible individuals. There are 47 to 60 million people residing in rural areas. Twenty-one percent of dually eligible individuals live in rural areas—that’s about 2.6 million people. Based on these numbers, the authors calculate that the dual eligible population residing in rural communities accounts for about 5 percent of the total rural population. Dually eligible individuals living in rural areas are at risk of falling through the cracks.

Dually eligible individuals lack access to adequate medical, behavioral health, home-and community-based services (HCBS) and other social services; those living in rural areas face even steeper challenges. Since dually eligible individuals are among the poorest of all individuals covered under Medicare, they are at significant risk of paying a steep rural mortality penalty.

With these challenges there are opportunities for innovation for the dually eligible population living in rural communities. The US can reverse the mortality-disparity rate trajectory. Public and private entities are interested in revitalizing rural America, confronting the rural health crisis, and harnessing the power of rural communities. Investment in the rural health care sector is essential given it is a major economic driver of rural communities.

HMA is creating a toolkit with actionable solutions to improve access to services and integrated care and health equity for individuals dually eligible for Medicare and Medicaid who live in rural areas across the country. ​This project is a follow-on project to a previous HMA project supported by Arnold Ventures. ​In 2021, HMA prepared a brief, Medicare-Medicaid Integration: Essential Elements for Integrated Care Programs for Dually Eligible Individuals, to increase and promote enrollment in integrated care programs (ICPs) meeting dually eligible individuals’ needs and preferences. Interviewees including dually eligible individuals helped HMA to identify “access to needed services in rural areas” as an essential element of ICPs. In response, HMA started a new project to create a toolkit with actionable strategies to improve access to needed services and improve integrated care opportunities, specific to dually eligible rural residents’ needs.

HMA designed the toolkit around four values: 1) rural health equity is an imperative for dually eligible individuals, 2) actionable solutions and innovations must come from the community, 3) there is no single pathway to integration, and 4) Medicare and Medicaid flexibilities are critical to inspiring innovations to advance health equity, access, and integration. The toolkit will provide actionable solutions for states with and without integrated care programs for dually eligible individuals to increase access to needed supports and services, care coordination, and integrated care programs. We expect that states and rural communities will use the toolkit as a foundation for mapping a holistic plan to advance access to care coordination and integrated programs for dually eligible individuals residing in rural communities. Other states may employ contractual tools listed in the toolkit to expand access to providers and new services; strengthen partnerships among entities serving the community such as community-based organizations, providers, and health plans; and increase community-wide accountability for meeting dually eligible individuals’ whole person-centered needs. The toolkit is scheduled for an early 2023 release.

Link to Health Affairs article.

Webinar

Webinar replay: rural health equity for dually eligible individuals: improving access to services and integrated care programs

Watch Now

This webinar was held on February 2, 2023. 

Dually eligible individuals covered under Medicare and Medicaid living in rural areas struggle to access the services, care coordination, and integrated care programs they need. To address these needs, HMA conducted multi-state roundtable discussions with diverse stakeholders to create The Health Equity & Access for Rural Dually Eligible Individuals (HEARD) Toolkit. During this webinar, our experts summarized and discussed the toolkit’s actionable solutions for improving health and social outcomes for rural dually eligible individuals.

Learning Objectives:

  • Understand why the voices of rural dually eligible individuals must drive planning efforts to generate innovations and prioritize investments to advance independent living and recovery goals.
  • Learn how experiences shared from New Mexico, North Dakota, and Tennessee can offer lessons.
  • Explore eight actionable solutions for improving health and social outcomes among rural dually eligible individuals as outlined in the HEARD toolkit.
  • Understand why community engagement and investment in rural capacity are essential to improving access to services and integrated care programs for rural dually eligible individuals.

Speakers

Arielle Mir, Vice President, Health Care, Arnold Ventures

HMA Team

Ellen Breslin, Principal
Samantha Di Paola, Consultant
Susan McGeehan, Senior Consultant

Expert Panelists

Dr. Kevin Bennett, Professor of Family Medicine, University of South Carolina School of Medicine, Director of the Research Center for Transforming Health, and Director of the South Carolina Center for Rural and Primary Care
Dennis Heaphy, Health Justice Advocate and Researcher, Massachusetts Disability Policy Consortium, Co-Chair, One Care Implementation Council, a One Care member, and MACPAC Commissioner
Pamela J. Parker, Medicare-Medicaid Integration Consultant, SNP Alliance
Tallie Tolen, Long-Term Services and Supports Bureau Chief, Medicaid, New Mexico Human Services Department

Blog

Medicare Hospital Outpatient Rule Proposes Details for New Rural Emergency Hospitals, Creates New Questions for Other Payment Policies

Read Blog

Today’s blog is the next in our series highlighting significant developments in the Medicare program. In our first article we covered the Centers for Medicare and Medicaid Services’ (CMS) calendar year 2023 Medicare Physician Fee Schedule (MPFS) proposed rule. This week we are highlighting a few key policy developments in the proposed rule that governs payment levels and policy updates for hospital outpatient departments and ambulatory surgical centers (ASCs).

As we discussed last week, this is a pivotal moment for the Biden Administration’s Medicare policy agenda. Because the rulemaking cycle takes about 18 months, CMS needs to begin the process of collecting input on new proposals this year if it intends to finalize proposals before the end of the President’s first term. Additionally, the CY2023 rule represents an important transition year for CMS as it navigates the COVID-19 related anomalies in the data used to calculate payment levels.

Health care plans, providers, and facilities are continuing to transition to value based payment strategies, making it increasingly important to assess the entire environment of Medicare payment rules as these payment systems are the basis of financial benchmarks, quality incentives, and other key components of value-based payments. In addition, these payment rules provide insight into the cost pressures, incentives, and areas of misalignment throughout the health care system.

HMA experts are analyzing and closely tracking several issues in the CY 2023 hospital outpatient prospective payment system (OPPS) proposed rule. A brief summary of some of the most important proposed policy changes for the outpatient hospital setting are included below and highlight many of the Administration’s top health care priorities.

  1. Policies to sustain access and address health disparities in rural communities.
  2. Enhancing Medicare’s behavioral health payment and access policies beyond the COVID-19 public health emergency.
  3. Uncertainty in the hospital outpatient prospective payment system (OPPS) rate increase due to future implementation of changes in 340B payment.
  4. Increasing transparency of consolidation and mergers in the marketplace to help advance quality and affordability.

The remainder of our post delves into these issues and other notable proposals. Our post also includes analysis of the implications of these policies for stakeholders deserving.

Key Action Items for Stakeholders

The CY 2023 OPPS Proposed Rule was published on July 15, 2022, and all comments from stakeholders are due to CMS by September 13, 2022. We anticipate CMS will release their Final Rule in late fall 2022, before the new rules are implemented January 1, 2023.

The public comment period is also an important window of opportunity during which stakeholders can analyze the impact of CMS’s proposed policies, assess the proposals against other applicable pending federal and state payment policies, and consider how the proposals may impact business decisions. Further, the public comment period is essential for CMS to deepen its understanding of the impact of its policies on stakeholders. The agency benefits from hearing stakeholder’s perspectives, viewing their quantitative and legal analyses, and understanding the general stakeholder environment.

Rural Emergency Hospitals: Definition and Payment

The Consolidated Appropriations Act of 2021 (CAA) established a new provider type called Rural Emergency Hospitals (REHs) beginning in 2023. REHs are facilities that convert from either a critical access hospital (CAH) or a rural hospital with less than 50 beds, by choosing to close their inpatient capacity. Instead, these facilities provide emergency department services, outpatient services, post-hospital extended care services, and other defined services.

While the statute specifies many foundational aspects of REHs, CMS was given the authority to further define REH eligibility status and to specify the unique reimbursement mechanisms for REHs. All of these components will be vital to a provider or entity’s decision to pursue REH status.

On June 30, CMS released the first component: Conditions of Participation (CoPs) for REHs, which defined REH status within the Medicare program. Within the CY 2023 OPPS Proposed Rule CMS proposed to define reimbursement and several other key components of REHs. Below we detail the key elements of REH reimbursement. In HMA’s blog next week we will offer greater detail on the COP and reimbursement policies.

REH policies proposed in the CY 2023 OPPS Proposed Rule:

  • REHs will receive a monthly facility payment of approximately $268,000 (or more than $3 million per year) beginning in CY 2023. 
  • REHs will receive a 5 percent payment increase for all services covered under the Medicare OPPS.  
  • REHs may provide outpatient services that are not otherwise paid under the OPPS (e.g., the Clinical Lab Fee Schedule) as well as post-hospital extended care services furnished in a unit of the facility that is a distinct part of the facility licensed as a skilled nursing facility (SNF).
  • Beneficiaries served at REHs will not be charged a copayment on the additional 5 percent OPPS payments, but standard OPPS cost-sharing requirements would still apply.
  • REHs must comply with all applicable provider enrollment provisions in order to enroll in Medicare.
  • REHs will have a unique quality reporting program distinct to REHs, in order to reduce reporting burden on these smaller facilities. CMS seeks feedback from stakeholders on the measures used for the REH quality reporting program.
  • REHs will be provided an exception from the Physician Self-Referral Law (commonly known as the “Stark Law”).

Takeaway: The creation of REHs is both a significant change for the Medicare program and potentially a unique opportunity for small rural hospitals and health systems which own/operate rural hospitals. The Congress and CMS believe this model will address access to care concerns and health disparities present in rural communities. Many assert that under the REH approach, hospitals and health system providers serving rural communities may have greater flexibility to support the rural communities they serve.

Look for our additional analysis of the set of proposed REH policies next week.

Mental Health Services Furnished Remotely by Hospital Staff

For CY 2023, CMS proposes several updates to its remote services policy to plan for a transition from temporary policies enacted during the PHE to when the PHE is declared over. CMS proposes to:

  • Allow clinical staff of a hospital to conduct remote mental health and substance abuse services and to designate these services as hospital outpatient department services for purposes of reimbursement. Patients will be permitted to be in the homes and hospital clinical staff must conduct the service from inside the hospital facility. Further, CMS proposes new hospital outpatient codes for these services, and CMS will not permit these outpatient services to be conducted (and billed) in tandem with physician fee schedule services.
  • The agency will require an in-person service within 6 months prior to the initiation of the remote service and then every 12 months thereafter. CMS will allow exceptions to the in-person visit requirement based on beneficiary circumstances.
  • The agency is also proposing that audio-only interactive telecommunications systems may be used to furnish these services when the beneficiary is not capable of, or does not consent to, the use of two-way, audio/video technology.

Takeaway: As CMS wrote in the proposed rule, many beneficiaries may be receiving mental health services in their homes from hospital or critical access hospital staff during the COVID-19 PHE. The policy update could help minimize disruptions in continuity of care that might otherwise occur following the end of the PHE. The proposals also reflect CMS’ desire to adapt to changing beneficiary preferences and new methods of providing services that have evolved during the COVID-19 PHE.

Hospitals and health systems may benefit from these proposals because it will maintain and expand patient-provider access points and care coordination after the patient has left the hospital. Stakeholders will need to continue to assess beneficiary utilization of services furnished remotely, potential staffing changes to support these services, and community-specific access needs for remote mental health services. Stakeholders may have important perspectives to offer CMS through the regulatory comment proceed as the agency determines whether to finalize a requirement that hospital clinical staff be physically located in the hospital when furnishing services remotely using communications technology.

Payment Policies  

CMS is proposing to update OPPS payment rates for hospitals and ASCs that meet their respective applicable quality reporting requirements by 2.7 percent. This update reflects the following factors:

  • Projected hospital market basket percentage increase of 3.1 percent; and  
  • A 0.4 percentage point reduction for projected multifactor productivity.

In the context of the OPPS, CMS proposes to increase the OPPS conversation factor by 2.7 percent from CY 2022 to CY 2023, from $84.18 to $86.79. CMS estimates this will increase OPPS payments to providers from CY 2022 to CY 2023 by $1.8 billion.

In the context of ASCs, CMS estimates a proposed increase to the ASC conversation factor by 2.7 percent from CY 2022 to CY 2023, from $49.91 to $51.31. CMS estimates this change will increase industry-wide payments from CY 2022 to CY 2023 by $130 million. In addition, CY 2023 is the final year in which CMS will apply the productivity-adjusted hospital market basket update to ASC payment system rates for an interim period of 5 years (CY 2019 through CY 2023).

Consistent with CMS’s methods for updating other Medicare prospective payment systems during the 2023 regulatory cycle, the agency proposes to use claims data from CY 2021 and hospital cost report data from the June 2020 Healthcare Cost Report Information System (HCRIS) to update payment rates for CY 2023. Some stakeholders have expressed concern during this regulatory cycle that claims data continue to include anomalous trends influenced by covid cases and the cost data do not accurately reflect covid-related costs because the data primarily are associated with pre-COVID time period. 

340B Payment Policy

CMS’s proposed rule acknowledges the recent Supreme Court decision in American Hospital Association v. Becerra (No. 20-1114, 2022 WL 2135490), which will have a significant impact on the 340B program. However, given the recency of this decision the agency formally proposed to maintain the current payment rate of Average Sale Price (ASP) minus 22.5 percent for drugs and biologics acquired through the 340B program.

In response to the decision, CMS stated that the agency will adjust 340B payment rates within the CY 2023 final rule. In its recent ruling, the Supreme Court held that HHS may not vary payment rates for drugs and biologicals among groups of hospitals without having surveyed hospitals’ acquisition costs. The decision relates to payment rates for CYs 2018 and 2019 but has implications for the CY 2023 rates.

CMS also stated that it anticipates applying a 340B payment rate of ASP plus 6 percent for specified drugs and biologics in the CY 2023 final rule. This would likely result in a budget neutrality reduction approaching 5% in the OPPS conversion factor.

Takeaway: Hospitals and federally qualified health centers (FQHCs) receiving 340B reimbursements will view the court ruling and potential increase to 340B payment rates as positive. However, it remains unclear at what exact level 340B payments will be set. Therefore, stakeholders may want to comment on the CY2023 policy options CMS is considering. Additionally, stakeholders should plan for CMS to conduct a survey of acquisition costs as it considers newly proposing changes to the payment rates. It remains possible that CMS will continue to apply the 340B cut for 2023 in light of a 2020 survey of hospital acquisition cost that it conducted. Future budget neutrality adjustments may also be necessary for any payments that are returned to hospitals due to the overturning of the 340B cut for 2018 and 2019.

Additional Issues for Stakeholder Consideration

In addition to the financing and policy issues discussed above, the wide-ranging rule contains numerous other policy proposals with direct and indirect implications on Medicare providers, beneficiaries, and other stakeholders. Table 1 provides a snapshot of some of the issues that warrant further consideration.

 Table 1. Other Notable Proposed Changes Impacting Health Care Providers and Stakeholders

TopicSummary
Provider TransparencyCMS issues a request for information linked to the President’s July 2021 Executive Order (E.O.) on Promoting Competition in the American Economy. CMS currently manages a database of nursing homeowners and operators, and the agency has begun to leverage that data to support hospital and nursing home patients and their families. The agency solicits feedback on whether it should release additional data that is already being collected “to help identify the impact of provider mergers, acquisitions, consolidations, and changes in ownership on the affordability and availability of medical care.” CMS also invites comments on whether the agency should release similar data for other types of providers. The solicitation represents the next phase in CMS’ expansive portfolio of work to address the impact of market consolidation on health care prices, consumer costs, and quality in the healthcare industry writ large. Medicare providers and stakeholders should be tracking how federal health care regulators, including CMS, are working to respond to the E.O. There is a strong likelihood that CMS will begin to include data on other types of providers and stakeholders will need to understand this shifting landscape and how it could impact their current and potential future business decisions.
SaaSCMS discusses its desire to address the novel and evolving nature of Software as a medical Service (Saas) procedures. The agency is seeking comments on the specific payment approach we might use for these services under the OPPS as SaaS-type technology becomes more widespread. We are also concerned about the potential for bias in algorithms and predictive modeling, and are seeking comments on how we could encourage software developers to prevent or mitigate the possibility of bias in new applications of this technology.
Inpatient Only ListRemoves ten services from the Inpatient Only (IPO) list.While the IPO list has previously been targeted for major reforms, this year’s narrower set of proposed changes signal CMS’ is deprioritizing IPO list reform.  
Payment for surgical N95 RespiratorsCMS recognizes that hospitals may incur additional costs when purchasing domestic NIOSH-approved surgical N95 respirators. CMS is proposing payment adjustments under the IPPS and OPPS that would reflect, and offset, the additional marginal resource costs that hospitals face in procuring domestically made NIOSH-approved surgical N95 respirators. Under this proposal, these payments would be provided biweekly as interim lump-sum payments to the hospital and would be reconciled at cost report settlement. The rule outlines the information providers need to include on the cost report to determine payments for cost reporting periods beginning on or after January 1, 2023.
Ambulatory Surgery CentersCMS requests stakeholder feedback on methods that could be implemented to collect cost data from ASCs that minimize reporting burden.This could be the beginning of a process to implement cost reports for ASCs.

The HMA Medicare team will continue to analyze these proposed changes. We have the depth and breadth of expertise to assist with tailored analysis, to model policy impacts, and to support the drafting of comment letters to this rule.

Blog

CMS proposes regulation for Rural Emergency Hospitals

Read Blog

On June 30, 2022, the Centers for Medicare & Medicaid Services (CMS) released a proposed regulation establishing the Conditions of Participation (CoPs) for a new hospital provider type, Rural Emergency Hospitals (REHs). The REH concept was first developed by the Medicare Payment Advisory Commission (MedPAC) and subsequently mandated by Congress through the Consolidated Appropriations Act (CAA) of 2021 to address the growing concern over closures of rural hospitals.

REHs provide an opportunity for Critical Access Hospitals (CAHs) and rural hospitals to improve the way care is delivered in their communities, maintain access, and avert potential closure by choosing to focus on the service offerings that are most essential to their communities, such as emergency services, observation care, and additional medical, behavioral, and maternal outpatient services. Importantly, the REH concept enables facilities to maintain a hospital designation absent inpatient capacity thereby ensuring that rural communities retain access to services. This proposed regulation is a significant milestone in CMS’ work to implement the REH designation and their novel payment methodology by their mandated start date of January 1, 2023.

The REH concept is expected to help address the observed health inequities that arise when rural communities lack access to hospitals and other providers. Obtaining an REH designation could be an opportunity for many independent hospitals and delivery systems to strategically reshape themselves in line with their community’s needs while receiving payments from Medicare for doing so.

Within CMS’ proposed regulation, the agency proposes to establish a novel set of REH CoPs which will define the parameters of the REH designation. The REH CoPs closely align with the current CAH CoPs in most cases, while considering the uniqueness of REHs and the statutory requirements. In some instances, the proposed REH policies closely align to the current hospital and ambulatory surgical center standards, such as the polices for outpatient services’ requirements and life safety code, respectively.

As a part of this proposed regulation, CMS seeks input from the rural community on a few key aspects of the REH designation, including:

  • The specific proposed REH standards, including the ability of an REH to provide low-risk childbirth-related labor and delivery services and whether the agency should require REHs to provide outpatient surgical services in the event that surgical labor and delivery intervention is necessary.
  • Whether it is appropriate for an REH to allow a physician, physician assistant, nurse practitioner, or clinical nurse specialist, with training or experience in emergency medicine, to be on call and immediately available by telephone or radio contact and available on site within specified timeframes.

Updates to CoPs for Critical Access Hospitals

Also within this draft regulation CMS proposes to update the CoPs for CAHs by: (1) adding a definition of primary roads to the location and distance requirements; (2) establishing a patient’s rights CoP; and (3) allowing CAHs that are a part of a larger health system (containing other hospitals and/or CAHs) to unify and integrate their infection control and prevention and antibiotic stewardship programs, medical staff, and quality assessment and performance improvement programs (known as QAPI) to ensure consistent and safe care.

What’s Next

CMS is accepting comments on this rule until August 29, 2022. CMS intends to propose additional policies related to Medicare enrollment, payment, and quality reporting in the upcoming Calendar Year 2023 Outpatient Prospective Payment System/Ambulatory Surgery Center proposed rule. CMS will develop final policies for this program later this year.

For more information about this proposed regulation including how to submit comments and how the REH concept may impact the hospital industry and patients in rural communities please contact our Medicare team who have knowledge in Congressional, MedPAC and CMS policy and operations – Zach Gaumer (HMA Principal) ([email protected]), Amy Bassano (HMA Managing Director, lMedicare) ([email protected]), or Andrea Maresca (HMA Principal) ([email protected]). To access CMS’s proposed Rural Emergency Hospital and Critical Access Hospital Conditions of Participation, visit: https://www.federalregister.gov/public-inspection/current.

Case Study

Helping life science manufacturers navigate Medicare payment systems

Download

The HMA Medicare team was asked to apply our subject matter expertise—and access to Medicare
claims information—to provide a fully formed picture of the reimbursement process for this new
drug formulation. Our work involved researching other precedents and the implications of those
precedents for the reimbursement of this new formulation, as well as the existing product.

Download the results and approach below.

Case Study

Patient journey analysis for a new oncology drug

Download

Bundled payment can serve as a disincentive to provide high-cost drugs, so the client was interested
in pursuing reimbursement policy options that would ensure appropriate reimbursement to these
facilities, thus ensuring patient access to the drug during the treatment regimen.

Download the results and approach below.

Case Study

Ensuring appropriate payment for transformative therapies to secure patient access to CAR Ts

Download

CAR T therapies first entered the market in late 2018. These transformative treatments for certain
types of cancer involve modifying a patient’s own cells to fight the cancer—producing a long term,
potentially curative response. Initially, CAR T therapy was administered to patients in the inpatient
hospital, where Medicare payments are bundled so that the hospital gets a single payment for the
entire hospital stay. The cost of the CAR T therapy greatly exceeded the payment rate the hospital
would receive, leading to concerns that hospitals would be reluctant to provide CAR T.

Download and read the approach and results.

Brief & Report

HMA paper examines federal funding streams supporting crisis pregnancy centers

Download

Crisis pregnancy centers (CPCs) are organizations that represent themselves as reproductive healthcare clinics offering services for pregnant people and appear similar to clinics offering a full range of reproductive health services. Federal funding to CPCs may constitute non-allowable uses of such support based on the legislative intent and grant requirements of these programs. In this paper, HMA provides a comprehensive analysis of federal funding streams and state allocations of that funding to CPCs and CPC networks. HMA found that more than 650 CPCs in 49 states and Washington, DC, received federal funding between 2017 and 2023, totaling more than $400 million.

Brief & Report

HMA report evaluates needs of Nevada’s Medical Assistance for the Aged, Blind, and Disabled program

Download

The Nevada Division of Health Care Financing and Policy (DHCFP) engaged HMA to evaluate Nevada’s Medical Assistance for the Aged, Blind, and Disabled (MAABD) program and the needs of its participants. A targeted focus of the evaluation was on home and community-based services (HCBS) within the Nevada MAABD population, including Nevada’s Frail Elderly (FE) and Physically Disabled (PD) waiver.

The project included:

  • Data analyses of Nevada’s population and long term services and supports (LTSS) landscape, the state’s ongoing efforts to rebalance LTSS dollars from institutional to HCBS services and demographic and other information about the MAABD population
  • Stakeholder engagement, including three focus groups that engaged 55 stakeholders and individual interviews, to provide stakeholders a greater voice in the MAABD improvement process
  • Evaluation of the MAABD structure and administration
  • Program recommendations to help inform and guide DHCFP’s considerations for better serving the FE and PD MAABD populations throughout the state

The report made recommendations to enroll the MAABD population aged 65 and older into a combination MLTSS/FIDE-SNP (managed long-term services and supports/fully integrated dual eligible special needs plan) program, implement Program of All-Inclusive Care for the Elderly (PACE) as a targeted nursing home diversion strategy and strengthen Nevada’s Medicaid quality framework to better deliver and ensure improved quality of care for the MAABD population.