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Brief & Report

Report Provides Indigent Healthcare Community Investment Analysis for Florida County

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In late 2017, the Marion County Hospital District commissioned a study to define the medically indigent, identify the current volume and costs of healthcare for the medically indigent population in Marion County, describe the providers that comprise the health care safety net, summarize the investments made in the health care safety net, outcomes of this level of investment, and identify ways the community might better invest in this system. In the context of a recent reduction in federally funding to Marion County hospitals, and a decrease in the local Department of Health (DOH) funding and hospital funding to support the multi-site Federally Qualified Health Center (FQHC) in the county (Heart of Florida), community investment in the FQHC was a particular area of interest. A series of questions generated by the Marion County Hospital District guided the study and framed the report. To answer these questions, HMA analyzed publicly available data and reports, obtained quantitative and qualitative data from over 40 key stakeholders.

In terms of a definition for medically indigent, HMA recommends that Marion County consider uninsured individuals with an income less than 200 percent of the Federal Poverty Level to be considered “medically indigent.” This equates to 30,988 individuals in Marion County.  This definition is used by the state of Florida for several major programs, has been approved by the federal government, and is routinely used by hospitals in defining indigent care.

HMA found that the hospitals – Munroe Regional Medical Center and Ocala Health – provide services to approximately the same proportion of Medicaid patients on an inpatient basis, and that Munroe serves a disproportionate number of Medicaid patients compared to the State-wide average in their Emergency Department and in Labor and Delivery. Both hospitals combined incur $3 million in unreimbursed charity care cost for the medically indigent in Marion county.

Heart of Florida (HOF) is the single largest primary care provider in the county and has limited behavioral health services.  Ocala Community Care (the county jail health service provider) is the next largest provider of indigent primary care and outpatient behavioral health, followed by Langley Health Center that has one primary care site in the county and offers some behavioral health services.  HOF’s proportion of paying patients is less (66%) than Langley (80%) and HOF provided approximately 24,000 in uninsured visits to Langley’s 5,000.

The Centers is the traditional safety net behavioral health provider in the community and is the only provider that receives state funding for serving residents who are indigent; accessibility is an issue for many given the location of the main site. The Vines delivers inpatient, residential, and partial hospitalization services; they receive no funds from the state or county and report having delivered $4 million in charity care last year. Meridian Behavioral Health in Alachua County is serving nearly 600 Marion County residents, many who report access issues in Marion County. This led Meridian to begin a telemedicine relationship with HOF to address the need for more local behavioral health services.

Marion County budgets over $9 million for indigent health care (excluding an estimated $7 million for the county jail). This is primarily for statutorily required payments for Medicaid and funding for The Centers and the Department of Health. The Marion County Hospital District funded $1.6 million in local projects in its 2017 grant cycle.

The entirety of Marion County is federally designated as a Health Professions Shortage Area; demand exceeds supply of primary care and community behavioral health. There is an average of about 2 months wait for new patients to be seen at Heart of Florida, and Munroe Medical Center has a particularly high rate of low acuity Emergency Department visits (27.4%), many of which are likely individuals who are unable to access care in the community.  The Centers reports that they have instituted a walk-in system for initial assessments, and that an appointment for outpatient therapy is typically scheduled within 2-3 weeks. The Medication Clinic is also walk-in but maximum capacity is reached about one-third of clinic days such that patients arriving after the maximum capacity is reached cannot be seen that day; these patients are given priority status for the next clinic day.

In the report, we present challenges and opportunities for the safety net provider organizations individually and collectively. A particular challenge has been HOF’s continued management of the three former Department of Health primary care sites given that these sites have particularly high rates of uninsured patients ranging from 43 – 61 percent.  We present an analysis that concludes that these sites fill a community need and should continue to operate unless other alternatives become available. By contract, HOF will receive $800,000 from the DOH to help support operations of these three sites, but funding is scheduled to be reduced by 20% each year over a five-year period ending on September 30, 2021. In addition, the two hospitals are planning to discontinue their contributions to the HOF. Given the funding reductions anticipated, HMA’s opinion is that the county should continue to fund HOF at the current level of $380k at least for Fiscal Year (FY) 2019. We recommend that HOF be required to develop an operational plan to present to the county in FY 2019 to detail strategies to address the loss of their other funding streams. If HOF requires continued funding from the county it should clearly articulate how that funding would be utilized and the benefit it would bring to the community.

Given the primary care and behavioral health provider shortages in the county, HMA also analyzed and highlighted where new primary care/behavioral health sites might best be located and presented justifications with supporting maps.

Finally, HMA conducted an environmental scan to identify indigent care funding models and delivery system best practices. We developed a set of recommendations for the community that identifies particular models and best practices that drive care to the outpatient setting and reduces preventable and costly hospital utilization. The recommendations also call for a process to bring key provider groups and other stakeholders together to collaboratively plan and implement strategies to strengthen the health care safety net.

Blog

Medicaid and Exchange Enrollment Update – 2017-18

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This week, our In Focus section reviews updated reports issued by the Department of Health & Human Services (HHS) Centers for Medicare & Medicaid Services (CMS) on Medicaid expansion enrollment from the “December 2017 Medicaid and CHIP Application, Eligibility Determination, and Enrollment Report,” published on April 30, 2018. Additionally, we review 2018 Exchange enrollment data from the “Health Insurance Marketplaces 2018 Open Enrollment Period: Final State-Level Public Use File,” published by CMS on April 3, 2018. Combined, these reports present a picture of Medicaid and Exchange enrollment at the beginning of 2018, representing more than 74 million Medicaid and CHIP enrollees and nearly 12 million Exchange enrollees.

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Blog

Electronic Visit Verification: Implications for States, Providers, and Medicaid Participants

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This week, our In Focus, written by HMA Principal Jen Burnett in collaboration with the National Association of States United for Aging and Disabilities (NASUAD), summarizes key considerations and policy decisions contained in Electronic Visit Verification: Implications for States, Providers, and Medicaid Participants for state consideration as they work to implement electronic visit verification (EVV) systems in accordance with the mandate included in the December 2016 21st Century Cures Act (the CURES Act).

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Blog

Medicaid Community Engagement Initiatives: A Comparison Of Three States

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This week, our In Focus is the second in a series written by HMA Medicaid Market Solutions (MMS), which has worked with a number of states to design and implement Section 1115 Demonstration Waivers that support individual state goals for member engagement and personal responsibility while complying with new Centers for Medicare and Medicaid Services (CMS) guidance.

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Blog

The Policy, Implementation and Operations of Medicaid Personal Responsibility Initiatives: An Introduction

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This week, our In Focus section highlights HMA Medicaid Market Solutions (MMS), formerly SVC, Inc., which is at the forefront in supporting state flexibility in designing and implementing initiatives including Section 1115 Demonstration Waivers promoting member engagement and personal responsibility. Over the coming weeks, HMA MMS will present a series of articles providing an in-depth look at the facets of these new Medicaid models. 

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Brief & Report

Governors’ Proposed Budgets for FY 2019: Focus on Medicaid and Other Health Priorities

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This issue brief provides Medicaid highlights from governors’ proposed budgets for state fiscal year (FY) 2019 (July 1, 2018 through June 30, 2019 in most states). Proposed budgets reflect the priorities of the governor and are often blueprints for the legislature to consider. In total, 39 proposed state budgets and text from 46 state of the state speeches were reviewed. This review revealed that while state revenue collections improved in 2017 compared to 2016, considerable economic and regional variation persists, many states are facing significant budget challenges unrelated to Medicaid such as unfunded pension liabilities or falling oil prices, and the outlook for 2018 remains uncertain due, in part, to the impacts of the 2017 Federal Tax Reform Act.

Contributors

Larisa Antonisse, Policy Analyst, Program on Medicaid and the Uninsured, Kaiser Family Foundation
Robin Rudowitz, Associate Director, Program on Medicaid and the Uninsured, Kaiser Family Foundation
Kathleen Gifford, Principal, Health Management Associates

Blog

Medicaid Managed Care Spending in 2017

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This week, our In Focus section reviews Medicaid spending data collected in the annual CMS-64 Medicaid expenditure report. After submitting a freedom of information act request to CMS, we have received a draft version of the CMS-64 report that is based on preliminary estimates of Medicaid spending by state for federal fiscal year (FFY) 2017.  The final version of the report will be completed by the end of 2018 and posted to the CMS website at that time.  Based on the preliminary estimates, Medicaid expenditures on medical services across all 50 states and 6 territories in FFY 2017 exceeded $571 billion, with over half of all spending now flowing through Medicaid managed care programs. In addition, total Medicaid spending on administrative services was $27.8 billion, bringing total program expenditures to just under $600 billion.

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Blog

Puerto Rico Releases Government Health Plan RFP

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This week’s In Focus section, written by HMA Principal Juan Montanez, reviews the request for proposals (RFP) issued by Puerto Rico earlier this month to deliver managed care services to the territory’s Government Health Plan (GHP) members. The government of Puerto Rico is seeking to contract with between three and six MCOs to provide services to the approximately 1.3 million members of the GHP, the territory’s medical assistance and insurance affordability program. Proposals in response to the recently issued RFP are due in early April.

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Blog

Washington Releases 2019/2020 Integrated Managed Care RFP

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This week’s In Focus section reviews Washington’s 2019/2020 Integrated Managed Care (IMC) request for proposals (RFP) issued by the Washington State Health Care Authority (HCA) on February 15, 2018 to provide 1.6 million Medicaid enrollees with both physical and behavioral health services. The procurement will expand Washington’s Apple Health – IMC program (formerly known as Fully Integrated Managed Care (FIMC)) to eight additional Regional Service Areas (RSAs) and add an additional managed care organization to the Southwest RSA. It will also add one county to the Southwest RSA and one county to the North Central RSA.

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Brief & Report

Preliminary Look at Key Healthcare Proposals in 32 States from Governors’ Proposed Budgets for SFY 2019

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The preliminary report presents key healthcare proposals from governors’ proposed state budget documents for state fiscal year (SFY) 2019, state-of-the-state speeches, news reports, and other budget-related documents, based on a review of these materials by the Kaiser Family Foundation and Health Management Associates. Proposed budgets reflect the priorities of the governor and are often blueprints for the legislature to consider, however, the level of detail presented in governors’ proposed budget documents varies significantly and in most cases does not capture all of the activity in a given state. As of the time of this publication, the table includes information from 32 governors’ proposed budgets and will be updated periodically as additional budgets are released and reviewed. The table captures proposals that fall into six categories:

  • Medicaid spending cuts
  • Medicaid enhancements
  • Medicaid work requirements
  • Other major Medicaid proposals
  • Opioid/behavioral health proposals (both within and outside of Medicaid)
  • Other major non-Medicaid healthcare proposals

Read more: http://kaiserf.am/2HkH8GK