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Brief & Report

Economic Analysis of Opioid Use Disorder in the Medicare Fee-for Service Program


This report quantifies the economic impact of opioid use disorder (OUD) specific to the Medicare fee-for-service (FFS) program, which covers approximately 51.6 percent of Medicare beneficiaries. We find that the cost to Medicare for managing these newly diagnosed patients was $29,669 more per patient than the propensity-matched control patients without OUD in 2022. We thus estimate that newly diagnosed OUD patients cost the Medicare program $4.3 billion in 2022. If these incident patient results were extrapolated into a 10-year budgetary impact analysis and if we assume constant rates of OUD incidence in the Medicare population, we estimate that the 10-year impact of OUD to the Medicare program would be $62.56 billion.

Our analysis demonstrates that OUD results in significant Medicare spending, including rising costs to beneficiaries through copayments and increased premiums. Additional work may be needed to determine whether the cost differential for incident patients with OUD generalizes to prevalent OUD patients as well. Though the 10-year budgetary impact figures require extrapolation and assumptions about future OUD use, they illustrate for policymakers the size of the fiscal challenge created by OUD in the Medicare population.

Brief & Report

HMA paper examines federal funding streams supporting crisis pregnancy centers


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


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.

Brief & Report

New HMA report using VRDC data analyzes hip fracture outcomes in Dual Eligible population


In this new report, “Answering Questions Using Virtual Research Data Center (VRDC): How using Home and Community-Based Services (HCBS) Impacts Hip Fracture Outcomes“, HMA is now using Centers for Medicare & Medicaid Services (CMS) Virtual Research Data Center (VRDC) to answer important healthcare questions. One contractual obligation for use of CMS data is the release of a publicly available research paper using the dataset, which contains all Medicare fee for service (FFS) and Medicaid FFS and managed care organization (MCO) claims. HMA used the VRDC data to examine the relationship between Long-Term Services and Supports (LTSS) and Home and Community-Based Services (HCBS) on hip fracture outcomes for people who are dually eligible for Medicare and Medicaid benefits. The analysis found that patients who receive HCBS were less likely to incur a future inpatient stay. The report and data analysis are detailed below.

VRDC Medicare and Medicaid claims data can be used to develop best practices for the healthcare system, looking at patient demographics, including eligibility/enrollment types (including dual-eligibles), race/ethnicity, age, and other critical subgroups to inform equity analyses. These data can be used longitudinally to measure the effect of interventions as well as to inform population health strategies. HMA’s nationally renowned subject matter experts can now incorporate VRDC data analysis and analytics into their recommendations to help your organization solve your toughest challenges.

Brief & Report

Medicare Physician Fee Schedule Reform: Structural Topics and Recommendations to Strengthen the System for the Future


Recent years have witnessed a growing bipartisan call to reform how Medicare reimburses for physician and other health professional services. Stakeholders assert that the current system—the Medicare Physician Fee Schedule (PFS)—is misaligned to today’s practice patterns and market dynamics. Many constituencies maintain that the current approach is insufficiently updated, embeds known pricing distortions, and does not appropriately effectuate value-based care principles, such as providing cost-conscious, high-quality care that prioritizes performance measurement and patient experience. Calls for reform are further prompted by increasing concern about the viability of independent physician practices, including the implications of consolidation and private equity acquisition of physician offices. Finding a workable comprehensive solution to updating physician payments is an uphill battle stymied by the significant cost of doing so, competing stakeholder positions, and the complexities of restructuring payment.

The original design of the Medicare PFS, still in use today, is based on the resources typically needed to provide services to patients. First implemented in 1992, the PFS is a fee-for-service (FFS) system of payment premised on the idea that services should be separately valued in relation to each other. This requires information on the effort and costs incurred to perform those services and how those variables change over time. The Centers for Medicare & Medicaid Services’ (CMS’s) efforts to update data used to set rates in the required budget neutral manner often result in system instability and may take years to fully implement due to concerns about redistribution. These innate vulnerabilities have been compounded by three decades of policy decisions, statutory changes, and advancements in care delivery.

While established metrics suggest that physicians’ participation in the Medicare program and beneficiary access is currently adequate, the Medicare Payment Advisory Commission (MedPAC) raises concerns that beneficiaries may experience more access to care barriers moving forward. For the past two years, MedPAC has recommended physician payment updates based on changing economic conditions, as well as additional “safety net” payments to physicians treating low-income beneficiaries. Reducing health disparities and improving the foundation of care is a top priority for many in this country, and payment reform within the PFS and more broadly that expands technology while also investing in person-centered, community-oriented care (especially for populations that are underserved and/or living with multiple chronic conditions) is central to that cause.

As robust policy discussions are taking place to explore these issues and identify solutions, Arnold Ventures engaged HMA to provide accessible background and context on the PFS for people who may be unfamiliar with the payment system, including a review of how the stakeholder community got to the point of needing to “fix” the fee schedule. Through a thorough assessment of the most pressing policy and payment concerns, we identified several key structural issues within the physician fee schedule that should be considered and balanced when making policy changes to the payment system.

Brief & Report

Compassionate Overdose Response: Summit Highlights and Key Takeaways


HMA’s Compassionate Overdose Response Summit suggests “high dose” naloxone isn’t necessary.

More than 100,000 people in the United States die every year from drug overdoses, driven by the availability of illicitly manufactured fentanyl. On March 19, 2024, HMA held the Compassionate Overdose Response Summit to discuss overdose response and reversal drugs like naloxone in the context of a fluctuating drug supply. Forty experts participated in consensus-building discussion on a standard of care opioid overdose response protocol. Throughout four panel presentations, a critical message emerged: those responding to an overdose should aim to restore breathing without causing withdrawal by supporting the person’s breathing, giving low or standard doses of naloxone (0.4 mg intramuscular injection and <4 mg intranasal spray) until spontaneous breathing is restored, and creating a calm environment. Despite fluctuations in the drug supply, standard dose naloxone is effective.

The standard dose of naloxone is considered 0.4 mg intramuscular injection and <4 mg intranasal spray. It is extremely effective and preferred by people who experience overdose. Reports at the Summit from four states (Missouri, Kentucky, Pennsylvania, and New York) made clear that an increase in naloxone dose is not a necessary response to the presence of fentanyl in the drug supply. Negative reactions following naloxone administration may be avoided, and anger can potentially be managed via low-dose naloxone titration and a calm, compassionate, and considerate communication style between the person who overdosed, the person who administered an opioid antagonist, and bystanders, including EMS.

Another key takeaway from the Summit, and shared in the report released today, was the acute and long-term adverse outcomes of withdrawal on people who experience overdose. The way a person is treated during an overdose, i.e., the communication style of the responder, likelihood of withdrawal, and the care they are offered after, affects their risk behavior such as using more opioids to feel better. In a study from New York State, those who received 8 mg nasal spray were more likely to experience withdrawal than those who received 4 mg nasal spray. People who experience withdrawal after an overdose may be discouraged from seeking help in the future.

“A compassionate overdose response is looking at the entire person. It’s not that moment of reviving them. It’s [also] what happens afterward.” – Joy Rucker, Summit Panelist

The findings shared at the Summit are timely given the availability of high-dose and long-acting overdose reversal products in the US. The FDA continues to ignore the life-threatening side-effects of high-dose products and recently approved a 10 mg nasal spray. This trend has drawn concern from addiction medicine providers, emergency medical services, toxicologists, harm reductionists and people who experience overdose alike. Standard dose products are available at the lowest cost for bulk purchase and decades of research show their use in the community reduces overdose mortality. A chart with currently available opioid overdose reversal products is available at

What’s Next

To learn more about compassionate overdose response and the significance of overdose reversal product selection, listen to the event proceedings and read the report below. A webinar replay with links to download PDFs of speakers’ presentations is linked here.

Contact Erin Russell to discuss the policy and program implications of the Summit’s findings.


The Compassionate Overdose Summit was presented with support from HMA, Harm Reduction Therapeutics, Vital Strategies, the Bloomberg American Health Initiative, and the University of Pittsburgh Graduate School of Public Health. Funds were used to secure event space and speaker stipends to cover their time and travel needs, hotels, meals, AV equipment, and event staffing.

Brief & Report

HMA white paper examines expanding home care value through innovative client and caregiving supports


As the U.S. population ages, non-medical personal care services are increasingly important for supporting Americans to remain in homes, as the vast majority of them prefer. But in-home personal care services will remain in short supply throughout the country unless home care agencies have greater success recruiting and retaining caregivers. In this HMA white paper, we describe the programs developed by Help at Home, the nation’s largest personal care services providers with 53,000 in 11 states, to use technological solutions to increase ease of caregiver recruitment and to provide its caregivers with a greater sense of purpose and meaning in their work.

The latter accomplishment has been achieved through Help at Home’s innovative care management program, “Care Coordination at Help at Home,” in which its caregivers receive a weekly text asking them to complete a brief survey about their personal care client’s physical and behavioral health symptoms and any health-related social needs. This information is transmitted to the agency’s Clinical Support Team, composed of nurses, social workers, and community health workers, who review the caregivers’ observations and, if needed, conduct further evaluations of the clients and/or alert the appropriate primary care or specialty providers about their escalating health and social needs. The program’s outcomes: Decreased client utilization of Emergency Department visits and hospitalizations since brewing health concerns are addressed earlier on. Increased caregiver retention because caregivers feel like they are making a significant difference in the health and well-being of their clients.

Brief & Report

Analyzing the Expanded Landscape of Value-Based Entities: Implications and Opportunities of Enablers for the CMS Innovation Center and the Broader Value Movement


New Report Analyzes the Expanding Landscape of Value-Based Entities    

Research from HMA and LP VBP experts segments and sizes the growing enabler market, considering benefits and risks, and proposing guiding principles and policy recommendations for the CMS Innovation Center

A new in-depth HMA report analyzes the landscape of emerging value-based entities and the implications for accelerating the adoption of accountable care.

In recent years, the value-based care market has expanded to include a variety of risk-bearing care delivery organizations and provider enablement entities with capabilities and business models aligned with the functions and aims of accountable care. Despite their prevalence, there has been little formal research into the role, growth, and impact of these entities to date and publicly available information is limited.

The report, “Analyzing the Expanded Landscape of Value-Based Entities: Implications and Opportunities of Enablers for the CMS Innovation Center and the Broader Value Movement,” represents a nine-month research effort leveraging the combined VBP policy and market expertise of HMA and Leavitt Partners, an HMA Company with support from Arnold Ventures.

The report offers a detailed overview of this evolving landscape by introducing a novel framework for classifying these entities and estimating the size of the market.

The authors interviewed 60 entity leaders, providers, and policymakers and conducted extensive secondary research into approximately 120 organizations, generating report insights that detail the common offerings, partnership models, and growth strategies of these entities. Authors examined providers’ experiences selecting and collaborating with enablement partners and the role of these entities within Medicare accountable care models and the broader value movement.

The report concludes by proposing a set of guiding principles to describe the optimal attributes of value-based enablement entities that would be in alignment with CMS, provider, and patient goals. Authors point to steps CMS can take to best engage with this expanded ecosystem in support of its efforts to scale accountable care while ensuring appropriate guardrails to protect patients and providers.

As this landscape evolves and expands, CMS and its Innovation Center should continue to carefully consider how these entities participate in its models while also leveraging these important partners for learning and advancing accountable care.

With its acquisition of Leavitt Partners and Wakely Consulting, along with its strong and growing Medicare policy practice, HMA is developing a diverse and robust set of solutions for entities engaging in value-based care and payment. In March, HMA will be devoting its spring event to the topic, with the report authors featuring prominently among discussion leaders and presenters. More information about the Spring Workshop, “Getting Real about Transforming Healthcare Quality and Value”, can be found here.

Report authors include Kate de Lisle, Amy Bassano, Jared Staheli, Spencer Morrison, and Melissa Mannon. Data collection and analysis was supported by Thomas Gubbay, Tom Williams, and Lucas Asher.

Brief & Report

Medicaid Business Transformation DC: Recommendations for Technical Assistance


HMA was engaged by the Washington, District of Columbia Department of Health Care Finance (DHCF) to lead their Medicaid Business Transformation D.C. Initiative, assessing the technical assistance needs of Medicaid providers and organizations in the areas of legal analysis, budgeting, and business development as they move toward value-based care arrangements. HMA partnered with the D.C. Behavioral Health Association (BHA), Medical Society of the District of Columbia (MSDC), D.C. Primary Care Association (DCPCA), and DHCF to engage, recruit, and collaborate with organizations and stakeholders across the District.

The HMA team implemented a mixed-methods assessment approach that included a literature review of national value-based payment (VBP) best practices, focus groups, interviews, and a technical assistance (TA) survey of District organizations, agencies, and stakeholders. This strategy identified the TA needs of   District healthcare providers that informed the design of an intensive 3-month technical assistance program that included a variety of tools, webinars, and trainings. All resources and tools are available on the Integrated Care DC webpage.  The report and other information about the program were published this week at

Experts from HMA as well as Wakely Consulting Group and Lovell Communications, both HMA subsidiaries, contributed to this report. We offer our clients a wide range of deep technical, analytical, policy, and communications support to providers, state agencies, and recommendations on ways to improve value-based payment models.

Report authors include Caitlin Thomas-Henkel, Suzanne Daub, Art Jones, Hunter Schouweiler, Amanda White Kanaley, and Vicki Loner. It was peer reviewed by Jean Glossa and Sam DiPaola.

Brief & Report

A Look at Swedish Maternity Care with Medicaid in Mind


Health Management Associates (HMA) collaborates with state and federal agencies, health service providers, and community-based organizations to enhance access to comprehensive reproductive healthcare and address disparities in birth outcomes, particularly in the context of Medicaid. This involves evaluating and supporting the implementation of perinatal care models, addressing health determinants affecting birth outcomes, and overcoming barriers to reproductive health services. In an effort to inform these initiatives, Diana Rodin, an associate principal at HMA interviewed Swedish experts to understand the country’s universal, publicly funded maternity and reproductive healthcare system. The Swedish model emphasizes universal healthcare, generous socioeconomic supports, and collaborative team-based perinatal care led by midwives. Lessons from Sweden, such as the utilization of “kulturdoulas” for culturally aligned support, a consensus-driven decision-making approach, and a centralized perinatal data system, provide valuable insights for improving birth outcomes for Medicaid recipients in the United States. 

Brief & Report

Opportunities to Enhance HCBS for Older Adults and Individuals Providing Care


Minnesota Department of Human Services partnered with HMA to study Minnesota’s home- and community-based services (HCBS) trends; changes in its demographics, including the experiences of diverse communities; and successful local and national HCBS models to inform future efforts to improve access to supports for older Minnesotans and their informal caregivers. The report outlines recommendations to help address several of the challenges outlined in the brief, and identified several areas for DHS to consider for future innovations.

HMA has extensive expertise in HCBS and long-term services and supports (LTSS). If you would like to learn more about what HMA can do for your organization, you can contact the report authors Susan McGeehan, Barry J. Jacobs, Chris Dickerson, Aaron Tripp, Erica Reaves, and Anya Yermishkin.

Brief & Report

23rd annual Kaiser Family Foundation state Medicaid budget survey released


The 23rd annual Medicaid Budget Survey conducted by The Kaiser Family Foundation (KFF) and Health Management Associates (HMA) was released on November 14, 2023 in the report: Amid Unwinding of Pandemic-Era Policies, Medicaid Programs Continue to Focus on Delivery Systems, Benefits, and Reimbursement Rates”.

Survey results show that states expect a sharp increase in Medicaid spending that is a direct result of lower federal spending as Covid relief and enhanced matching declines. This budget pressure is compounded by increasing provider rates, workforce recruitment and compensation challenges, increased spending on behavioral health and maternity care, and spending on programs that improve health related social needs. These budget pressures will create a very challenging environment for state policy makers in the coming years.

The report was prepared by Kathleen Gifford, Aimee Lashbrook, Caprice Knapp, Beth Kidder from HMA and Leavitt Partner’s Bill Snyder; and by Elizabeth HintonElizabeth WilliamsJada RaphaelAnna MudumalaRobin Rudowitz from the Kaiser Family Foundation. The survey was conducted in collaboration with the National Association of Medicaid Directors (NAMD).