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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.
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
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
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.
Policies to sustain access and address health disparities in rural communities.
Enhancing Medicare’s behavioral health payment and access policies beyond the COVID-19 public health emergency.
Uncertainty in the hospital outpatient prospective payment system (OPPS) rate increase due to future implementation of changes in 340B payment.
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
Topic
Summary
Provider Transparency
CMS 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.
SaaS
CMS 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 List
Removes 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 Respirators
CMS 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 Centers
CMS 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.
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 associate, 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 featured below.
The New Mexico Office of the Superintendent of Insurance (OSI) was directed by its state legislature to explore hospital global revenue budgets and other innovative hospital payment models over several years, and to explore key elements of affordability and accessibility of coverage and care, including hospital global budgeting.
Background
OSI contracted with HMA to build on previous hospital global budgeting research and provide technical assistance in resolving the complex issues surrounding global budgeting, including development of a potential global budget payment model framework. The contract also called for HMA to prepare an implementation framework that involves stakeholder engagement, including a plan for engagement with the Centers for Medicare and Medicaid Services (CMS) Innovation Center and to identify key administrative and data challenges.
Approach
HMA divided the project’s scope into two phases:
Phase 1
Develop preliminary policy and model options, including submission of two deliverables:
Global Budgeting Principles and Experience in Other States Report
Hospital Global Budget Options Paper
Phase 2
Refine the hospital global budgeting model based on OSI’s input on the Hospital Global Budget Options Paper and develop and submit three additional reports:
Recommendations for a Proposal to the CMS Innovation Center, which supports the development and testing of state-based innovative healthcare payment models
Implementation and Stakeholder Engagement Plan
Administrative and Data Challenges Report on implementing the payment model
Results
HMA developed an overview of principles and global budgeting models developed by other states, policy options, recommendations for how to work with CMS, a blueprint for stakeholder engagement, and an assessment of data needs and challenges. The proposed hospital global budget payment model was informed by the HMA team’s expertise and research on three states’ experience with CMS Innovation Center payment models (Maryland, Pennsylvania, and Vermont). The five public reports can be found at Healthcare Affordability and Accessibility Research Projects. These reports detail a plan for budgeting and governance that will enable the creation of a value-based payment system that supports a delivery system in which hospitals provide services that their communities need, rather than focus on the services most likely to merely enhance revenue. Through leadership and innovation, the state can help ensure a sustainable provider network is available to deliver high-quality and efficient care to all New Mexicans.
A new report by Leavitt Partners, an HMA Company, outlines the concept of site-neutral payment reforms being considered as a potential program improvement, and proposes a compromise approach to implementing site-neutral payments that benefits beneficiaries, hospitals, and the Medicare program. Site-neutral payments, which would equalize payment for the same services across all settings of care, are most commonly considered in connection with outpatient or ambulatory settings. Because out-of-pocket costs for Medicare beneficiaries are based on a percentage of the total reimbursement costs, any policy that reduces reimbursement for some services would result in savings to Medicare beneficiaries.
The approach proposed in the report lowers out-of-pocket costs to Medicare beneficiaries, improves the financing of the Medicare program by addressing a payment distortion, and reinvests in hospitals through new targeted funding and inclusion of policy priorities.
If you have any questions, contact our expert below.
This week, our In Focus section covers Congress’s and the Administration’s parallel efforts to finalize fiscal year (FY) 2024 spending bills and begin the budget process for FY 2025.
Congress approved a bipartisan package for some of the FY 2024 spending bills, and on March 9, 2024, President Biden signed the Consolidated Appropriations Act of 2024 into law (PL 118-42). Programs funded through this measure include the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and other federal nutrition supports, rental assistance for safe and affordable housing, and veterans medical care and benefits.
Several mandatory funding extensions of public health programs and health-related policies also found their way into the 2024 consolidated appropriations package, including extending the Community Health Center Fund, delaying reductions in the disproportionate share hospital allotments, defining Certified Community Behavioral Health Centers (CCBHCs) as a Medicaid service, extending incentive payments for certain Medicare providers, and mitigating the impact of cuts to the Medicare physician fee schedule.
These policies, however, addressed a narrower set of issues than the expansive and bipartisan legislation that has been moving through both chambers of Congress. For example, House and Senate members have worked on respective bipartisan policies affecting price transparency, pharmacy benefit managers, and Medicare site-neutral policies, among others.
Meanwhile, President Biden released the FY 2025 Budget proposal March 11, 2024, kicking off the annual budget process. Like the administration’s FY 2024 budget proposal, the FY 2025 plan emphasizes deficit reduction and continues to make equity and Medicare solvency cornerstones of the budget. Health-related priorities include expanding access to affordable healthcare services, lowering drug costs, improving maternal health, addressing the mental health and substance use disorder crises, and enhancing biodefense and preparedness activities.
Check out the FY 2025 budget analysis from Leavitt Partners, a Health Management Associates, Inc. (HMA), company, and a deeper dive into the Consolidated Appropriations Act of 2024.
What We’re Watching
Congress is continuing negotiations on the outstanding spending bills, including the one that funds the Departments of Health and Human Services, Labor, and Education through September 2024. Lawmakers are working to reach an agreement before the next funding deadline of March 22.
The administration’s FY 2025 budget proposals are generally being characterized as a blueprint for President Biden’s re-election campaign and, if successful, a policy agenda for his second term. Though Congress has already begun holding hearings on the budget request, members on both sides of the aisle will likely focus on issues that resonate in an election year.
Regardless of the outcome of the November elections, Congress has an opportunity to address unfinished business during the lame duck session later this year.
HMA and Leavitt Partners collaborate to monitor legislative and regulatory developments in healthcare and adjacent spaces and to assess the impact of policy changes on the healthcare industry.
As Medicare, state Medicaid agencies, Medicare Advantage plans, Medicaid managed care organizations, and commercial insurers increasingly adopt alternative payment models (APMs), Health Management Associates (HMA) provides a range of innovative and successful approaches to value-based care (VBC).
Our subject matter experts can help you succeed with value-based payments (VBP).
WHAT WE DO
Offer insights for transforming the care delivery model to efficiently deliver optimal patient and population-level health outcomes while successfully managing total cost of care
Ensure quality is the primary goal of
VBP program design and implementation
Develop payment models that align the incentives of payers and providers
Integrate physical and behavioral healthcare, and close gaps related to social determinants of health and health equity
Help clients successfully transition from fee-for-service to value-based payments by providing expertise in change management, analytics, network engagement, and IT infrastructure
Improve the patient and provider experience
Qualify, manage, and monitor health insurance risk
Prepare for and succeed in accreditation for VBP capabilities
ORGANIZATIONS WE SUPPORT
Those engaged in VBP or interested in engaging in VBP
Payers
Providers
Purchasers
Those interested in advancing the broader movement to value
Federal, State & Local Governments
Associations
Foundations
Investment Firms
HMA Can Support You Through All Phases of Value-Based Care
From contract to care plan, we have the experience and guidance tools to support your organization’s move to value-based care and risk-based contracting.
This graphic showcases the capabilities needed to address the complexities of risk-based contracting and deliver value-based care. As your organization moves from left-to-right along the glidepath to risk, additional strategies and capabilities must be developed. For example, utilizing Institute for Healthcare Improvement frameworks for quality improvement, regulatory and credentialing needs, and specialty access within a clinically integrated network. NEJM Catalyst. (2017). What is value-based healthcare?
Our philosophy involves applying a health equity model to close social determinant gaps and health disparities. Value-based healthcare is all about the care delivery model. Under value-based care agreements, providers are rewarded for helping patients improve their health, reduce the effects of emerging/rising risks and incidence of chronic disease, and live healthier lives in an evidence-based way.
Our Comprehensive Approach
Our collaborative approach will be tailored and customized to your needs to help you successfully implement VBP.
Our integrated process is based on the following model:
WHAT HMA PROVIDES
Determine readiness across key building blocks for moving to value-based payments and achieving continuous improvement across healthcare organizations.
Implementation that includes benchmarks and measurements of success. We facilitate stakeholder input to capture and analyze data from these interactions through surveys, focus groups, and interviews.
Aligning incentives with providers is key to successful value-based care strategies. Understanding methods for identifying and closing gaps in care pathways for common chronic conditions or addressing rising/emergent risks as well as how to create buy-in among providers and other members of the care team.
Including actuarial expertise required for contracting in key areas such as financial projections, reserves, total cost of care analysis, and benchmarking. We provide an assessment of third-party software to support APMs.
Including methods for incorporating whole-person care into clinical algorithms that apply to every interaction with the patient and their families. Integrating behavioral health with physical health and addressing social determinants of health/health-related social needs into VBC programs.
Assist with identifying key performance indicators (KPIs) and quality measurement incentives for pay-for-performance or pay-for- value to support population health outcomes and support total cost of care in various VBP arrangements.
Provide support and consultation on scope of requirements to ensure VBC contract meets delegation requirements for operational, state, CMS regulatory and accreditation requirements.
OUR EXPERTS INCLUDE
Former CEOs, COOs, CFOs, and chief medical officers and other physician executives as well as executive quality leaders of the following organizations:
Providers including hospitals, academic medical centers, physician practices, community health centers, rural health centers, and federally qualified health centers
Medicaid, Medicare, Marketplace and Commercial MCOs
State and federal agencies
In addition, HMA offers expert actuaries, coders, analytic staff, and clinicians to support your transformation.
Craig Schneider is a leader in developing and implementing payment reform strategies, promoting all-payer claims databases (APCDs), and engaging stakeholders … Read more
Federal policy frameworks establishing alternative payment models in Medicare and Medicaid have been the kick-starter of value-based care (VBC) innovation in healthcare delivery. However, employers provide health insurance to most Americans, and very few employers – with the exception of jumbo, self-insured employers – have leaned heavily into VBC. Small- and medium-sized firms rely on brokers to find an affordable health insurance plan, and often lack the resources required to negotiate more. Though the tide has been changing, our fragmented payment system has yielded only a subset voluntarily taking substantial risk for patient outcomes.
It has been said that to truly transform our American healthcare system to pay for value – improved outcomes for lower cost – it would require better alignment across public and commercial payers to support care providers in shifting their business models to take risk.
Quality and cost information are critical to implement VBC payment and delivery systems. Federal initiatives in Medicare and Medicaid have opened the door for providers, payers, and innovators to use health information to improve outcomes, with patients more engaged and more in control; the “Universal Foundation” announced by the Centers for Medicare and Medicaid Services (CMS) in 2023 seeks to align quality measures across the more than 20 CMS quality initiatives; and policies included in the 21st Century Cures Act and CMS Interoperability and Patient Access rule are creating more transparency on price and quality.
By enabling an infrastructure to measure, digitize, and share cost and quality information, federal and state governments have set the stage for greater collaboration among all purchasers – including employers – and the healthcare delivery system to redesign care that addresses health related social needs and behavioral health, ensuring that healthcare is provided equitably and sustainably. As the care delivery system is better able to deliver high value care, more employers will demand this for their workforce to provide a better benefit to their workers.
These issues, and more, will be a part of the expert-led conversation on VBC at HMA’s 2024 Spring Workshop March 5-6, in Chicago. This workshop offers a unique opportunity for payers, government officials, community organizations, vendors, and providers to have an unvarnished conversation about the challenges, lessons, and opportunities in implementing VBC. The meeting is designed to share insights, change-oriented strategies and actions that advance VBC from top industry experts, health plan executives, state and federal leaders, and policy experts.
Our working sessions will feature solutions-focused conversations among peers:
Care delivery measures that drive outcomes, equity, population health
Payment & risk management models for payment, pricing, attribution
Data that is interoperable, consumer focused, deploying technology that is aligned to deliver on strategic objectives
Policy & Strategy Frameworks at federal, state, and local levels that incentivize VBC
The closing panel will look at ways to take action through policy and collaboration to move our industry toward more sustainable approaches to healthcare payment and delivery.
To learn more and register for this unique event, please visit HMA’s 2024 Spring Workshop page. Act fast – online registration ends Wednesday, February 28!
Within the healthcare sector, there is an imperative for a comprehensive understanding of the care delivery framework that will positively impact outcomes, equity, and the overall health of communities. Among the drivers for this imperative is renewed focus among Medicare officials and interest from states and employers to transition to alternative payment methods that focus on value for payers and patients. A variety of care delivery structures and metrics can be used, and all have a role in driving value-based care (VBC).
One critical element of VBC hinges on whether and how healthcare organizations focus their care delivery structures on patients. VBC also incorporates metrics that further validate the ability of the system to positively impact patient outcomes, reduce health disparities, and improve population health. Emphasizing technology, interdisciplinary collaboration, and streamlined communication can revolutionize the care delivery model.
The HMA workshop-style spring conference on March 5 and 6, is designed to delve deeply into the intricacies of these care delivery frameworks and metrics within the context of VBC. This unique workshop will challenge attendees to roll up their sleeves and actively engage to become part of the solution through an interactive conversation, allowing participants to discuss real-world scenarios, analyze data and metrics and, using small-group breakout sessions, engage in focused and in-depth knowledge sharing.
Break-out sessions facilitated and led by subject matter experts will challenge attendees to identify new solutions around care delivery structures and contractual metrics that improve outcomes, that may include:
Engaging providers around consistent approaches to enhance patient outcomes, optimize treatment plans, and ensure the delivery of evidence-based, high-quality care.
Developing approaches for patient engagement that improve care delivery and foster active involvement and collaboration between patients and healthcare providers.
Crafting strategies for seamless coordination among healthcare providers, spanning sectors, and involving non-traditional providers and community organizations.
Understanding components of effective provider network agreements and how they contribute to achieving healthcare goals through strong partnerships and collaborations.
The workshop promises to be a dynamic platform for professionals in the healthcare sector, offering valuable insights, practical strategies, and collaborative opportunities to secure a place for high-quality value-based care. By focusing on care delivery structures, patient engagement, care coordination services, and provider network agreements, attendees will be well-equipped to navigate the complexities of healthcare and contribute to a healthier, more equitable future.
To learn more about the HMA 2024 Spring Conference Workshop and to register, visit the conference website.
Money is always “top-of-mind” among non-profit leaders, from CEO’s at Federally Qualified Health Centers (FQHCs) to Executive Directors at Community-based Organizations. To supplement projects and retain the ability to further their missions, non-profit organizations (NPOs) need funding. When non-profits and funding sources are not well aligned, programs are cut, curtailed, or never launched. Assisting clients in pursuing alternative funding sources requires a creative yet methodical approach to promote success and boost organizational sustainability.
Devising a framework for non-profit funding presents challenges. Funding models/strategies cannot be too general nor too specific. There is not a single approach, a one size fits all model or sourcing strategy for non-profits to pursue. Instead, non-profit leaders must clearly articulate the funding model or strategy that best supports the growth of their organization and use that insight to examine the potential funding opportunities preeminently associated with organization-specific success. For example, a community health center serving patients covered by Medicaid and a non-profit organization doing development work in housing for the homeless are both funded by the federal government, yet the type of funding each receives and the decision makers controlling that funding are very different. Utilizing the same funding methodology for the two would not be productive. Fortunately, there are multiple methods and strategies to acquire funds. Non-profits should be strategic in seeking approaches suitable to their needs and capabilities and be creative in pursuing more than one model to acquire supplemental funds.
The core success of NPOs is based on a range of funding options, private grants and government grants, corporate sponsorships, private funding, endowments, and community fundraising. There is also a considerable amount of money available from the public sector, businesses, charitable trusts, foundations, in-kind donations, and local and state legislative bodies. The goal of any successful fundraising campaign is to convey fully what the money is or will be supporting and clearly articulate the projected positive outcomes that will be derived from the funding. Once the project is fully clarified, the next step is research. Many funding avenues exist. The NPO must decide which funding sources are best suited for each project and pursue those options.
When choosing potential funding sources, NPOs must consider the size of their organization, their mission, and various other defining characteristics. Once this internal due diligence is completed, revenue needs should be clarified, and a tactical fundraising strategy outlined. Creating a “ratio” with the end-result in mind allows for revenue diversification and avoids the too heavy reliance on one income source. For example, an NPO might project obtaining 50% of needed revenues from grants, 20% from a corporate sponsorship, and the remaining 30% from a foundation. Once the funding sources have been identified, the types of decision makers and the motivations of these decision makers must be evaluated. Then, a tactical roadmap designed to obtain the needed funding should be implemented.
As society looks to the non-profit sector to solve important problems, a realistic understanding of funding models is increasingly important to realizing these aspirations. As consultants whose mission is to turn challenges into triumph for our clients, championing efficacious, high-yielding funding models ensures long-term viability for the organizations we serve.
Success relies on planning. It is much better to be proactive than reactive. Consider your organization’s funding needs, do your research, and lay the groundwork before diving into any fundraising pursuit. An assessment of your organization’s current funding strategies is essential. What is working; what is not? Is the current funding source reflective of the organization’s mission and values? Use the answers to these questions to make decisions and recommendations on which fundraising strategies to source. Get creative! Brainstorm unconventional ways your organization will stand out to potential funders, but be analytical. Balance creativity with data, keeping in mind which funding strategy reflects the best return. Focus time and energy on the funding model that will be most reliable, profitable, and feasible.
The non-profit world rarely engages in a succinct conversation about an organization’s appropriate long-term funding strategy. That is because the different types of funding that fuel non-profits have never been clearly defined. More than a poverty of language, this represents and results in a poverty of understanding and clear thinking. As consultants, HMA can provide an outside perspective and sort through the minutia presenting a clear, methodical, appropriate path to fundraising success.
Potential links to aid in your fundraising endeavors:
HMA works with a wide variety of healthcare clients, including FQHCs, community-based organizations, hospitals, provider practices, behavioral health, and managed care organizations, and can help with:
Grant Writing
Technical Assistance
Strategic Planning
Financial planning, Implementation and Optimization
For more information about how HMA can help your organization’s grant and funding strategies, contact our experts below.
Health Management Associates (HMA), a leading independent, national healthcare consulting firm today announced that it has successfully completed a Service Organization Control Type 2 (SOC 2 Type 2) audit.
The SOC 2 Type 2 audit was developed by the American Institute of Certified Public Accountants to evaluate an organization’s information security controls over a period of time. It assessed both the suitability of HMA’s controls and its operating effectiveness, covering the HMA organization as a whole, service offerings, resources used to deliver client work, and technical (cybersecurity) and non-technical controls (administrative strengths such as excellent training and a culture that promotes anti-fraud and ethical behaviors).
“Increasingly, completing a SOC 2 Type 2 audit is an important distinction for many of our clients and partners,” said Doug Elwell, chief executive officer. “Achieving this with no material findings across the firm is yet another way to meet client needs and further demonstrates our commitment to our core values of accountability, client commitment and integrity.”
Founded in 1985, HMA is an independent, national research and consulting firm specializing in publicly funded healthcare and human services policy, programs, financing, and evaluation. Clients include government, public and private providers, health systems, health plans, community-based organizations, institutional investors, foundations, and associations. With offices in more than 30 locations across the country and over 700 multidisciplinary consultants coast to coast, HMA’s expertise, services, and team are always within client reach. Learn more about HMA at healthmanagement.com, or on LinkedIn and X.
Is the concept of value-based care (VBC) still relevant in today’s healthcare landscape or just a buzzword? Some argue that the financial challenges brought about by the pandemic have steered our healthcare delivery systems away from prioritizing value. However, many experts remain optimistic that value-based care is the key to achieving our overarching objectives of a more equitable, sustainable, high-quality healthcare system.
Kelsey Stevens, a principal at Wakely, an HMA Company, led a session on value-based care at the HMA Fall Conference. Her panelists felt strongly that value is critical to a functional and patient-focused healthcare system because the alternative is out of control spending and poor health outcomes. In fact, value-based care is flourishing in new ways as we look to integrate behavioral health and address health related social needs. There are lessons to be learned from early experiments, new models being built, and new models to be designed. Both public and private payers are pursuing new ways to take financial risk to deliver improved healthcare outcomes, focusing on solutions for higher risk populations or circumstances where quality of outcomes are indefensibly poor (i.e., maternal outcomes).
This enthusiasm felt by the wide variety of executives present at that fall meeting has inspired HMA to focus an entire conference on value. But notjust another conference on value. Our internal experts felt strongly about hosting a forum for healthcare organizations to truly tackle the end-to-end challenges of VBC… so we are doing that.
Those who join us March 5-6 in Chicago will experience a workshop designed to “get real” about transforming healthcare quality and value. We are convening participants from all parts of the healthcare industry who have the collective experience to pinpoint common challenges and to build a path forward.
The workshop is organized into four cohorts:
Payment and Risk Management Models,
Policy and Strategy Frameworks,
Data and Technology, and
Care Delivery Frameworks
Each will produce concrete recommendations for action, as well as building new relationships among peers to sustain this change. In the cohort on Payment and Risk management, discussion will be focused on existing and new models for payment, pricing and attribution methodologies, risk mitigation levers along the value continuum, and approaches to engage employees in focusing on patient-centered value in the care they provide.
One of our fall panelists, Eric Mattelson, chief actuary at Zing Health, said “I’m still convinced that value-based care is the future of healthcare and the Sisyphean struggle to get there will ultimately be worthwhile.” We echo this sentiment wholeheartedly, and if you share this conviction, we encourage you to secure your spot today and become a part of this exciting and transformative event.
Our sessions and networking events offer an opportunity to delve into approaches to develop and manage risk-based contracting across sectors, establish effective partnerships with safety net providers and community-based organizations, apply a value lens to deployment of technology and data analytics, and develop health equity plans aligned with value principles and policies.
Future blogs in this series will touch on elements from the other 3 cohorts on VBC that make up the balance of the workshop. To learn more and register go to HMA’s 2024 Spring Workshop page.