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Blog

Focus on equitable access at 2023 HMA conference

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Access to care is not as simple as obtaining an insurance card. Some people find access to care is limited by geography or distance, others are limited by their native language or cultural awareness. In other ways, care can be limited by who is in the insurance network. All of these inequities can cause gaps in care that undermine health outcomes. In a system that is increasingly paying for outcomes, elimination of inequities is a matter of financial performance, as well as a sign of clinical excellence. Finding and reducing inequities in access to care requires an operational commitment to change workflows, leverage technology, and train staff at all levels to align incentives and culture.

Providing equitable access to care is subject to ever-changing policy and regulatory requirements, and it is increasingly tied to funding, work force staffing and many other operational requirements. This topic will thread through several discussions and panels during the 2023 HMA fall conference with federal policy leaders, health system administrators, and other industry leaders all poised to address the pain points of achieving and maintaining equitable access.

Key sessions (full agenda here):

  • Leading the Charge on Value, Equity and Growth: The Future of Publicly Sponsored Health Care – A discussion on how these public programs came to be the industry standard bearers and what this shift means for outcomes, affordability, policy, and the overall direction of U.S. health care. (Monday 8:30am keynote by Alan Weil)
  • Understanding and Meeting New Health-Related Social Needs Requirements – An environmental overview, including a look at what’s driving these demands and how organizations are specifically working to address the new mandates. (Monday 1:30pm breakout session featuring Bryan Buckley of NCQA, Richard Ayoub of Project Angel Food, and Paul Leon of National Healthcare & Housing Advisors)
  • Practical Approaches to Ensuring Equity in Publicly Sponsored Healthcare Programs This session will provide practical approaches to addressing equity, including an overview of efforts by policymakers, health plans, and providers to make equity the central component of all initiatives to improve healthcare outcomes, access, and health-related social needs. (Tuesday 8:30am keynote by Karen Dale of Amerihealth Caritas)
  • Medicaid in a Post-Pandemic World: Challenges, Opportunities, and a Renewed Focus on Equity State Medicaid directors will provide a status report on all this and more, including a special emphasis on how equity plays into planning and policy decisions. (Tuesday 9:15am plenary featuring Jacey Cooper of the California Department of Health Care Services, Kelly Cunningham of the Illinois Department of Healthcare and Family Services, Drew Snyder of the Mississippi Division of Medicaid, and Stacie Weeks of the Nevada Department of Health and Human Services)

HMA consultants and our speakers look forward to engaging with participants as they delve into these topics to gain a better understanding of the gains we are making as industry leaders and where we still need to innovate. 

To learn more about our Equity work, please contact Leticia Reyes-Nash; to learn more about our Managed Care work, please contact Michael Engelhard or Patrick Tigue.

Blog

New CMS dementia care model emphasizes role of caregivers

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This week, our In Focus section reviews the new Guiding an Improved Dementia Experience (GUIDE) Model, announced by the Centers for Medicare & Medicaid Services (CMS) Center for Medicaid and Medicare Innovation (the Innovation Center) on July 31, 2023.

In addition to announcing the Innovation Center’s GUIDE Model, CMS released five final fiscal year (FY) 2024 payment rules this past week. Of note, these regulations set higher than anticipated reimbursement rates for many providers:

CMS also released the 2024 projected Medicare Part D premium and bid information, which may provide early indications on the effects of the Inflation Reduction Act’s drug pricing policies.

GUIDE Model: Parameters and Opportunities

President Biden signed an Executive Order in April 2023 on Increasing Access to High-Quality Care and Supporting Caregivers. The order directed the Innovation Center to develop a payment and delivery system model for dementia care. The program is intended to improve the quality of life for people living with dementia, reduce strain on unpaid caregivers, and help people remain in their homes and communities through improved care coordination and management, caregiver education and support, and respite services.

The announcement this week outlines the basic parameters of the model, which track with CMS’s focus on reducing health disparities, supporting innovation, and addressing affordability. CMS expects that the model’s additional support for caregivers will reduce federal spending on hospitalizations and post-acute care. Notably, CMS projects savings will come from reduced long-term nursing facility placement through a decrease in Medicaid spending on the federal medical assistance percentage (FMAP). Helping Medicare enrollees stay in their homes may also lower state spending on long-term care.

Additional information, including the application to participate, will be available this fall. In the meantime, CMS is accepting letters of interest through September 15, 2023. The model will begin on July 1, 2024, and run for eight years.

HMA’s experts identified the below list of policies that will be important for provider organizations, caregivers, and other stakeholders considering participation in the model:

  • GUIDE Model participants will be Medicare Part B enrolled providers/suppliers, excluding durable medical equipment (DME) and laboratory suppliers, that are eligible to bill for Medicare physician fee schedule services and agree to meet the care delivery requirements.
  • The GUIDE Model comprises two tracks for participation—one for established programs and another for new programs.
    • Established programs must have an interdisciplinary care team, including a care navigator, use an electronic health record (EHR) platform that meets the standards for certified EHR technology, and meet other care delivery requirements as outlined in the request for applications.
  • If a participant cannot meet the GUIDE healthcare delivery requirements alone, CMS will allow the provider or supplier to partner with other Medicare organizations, to meet the mandates.
  • The model also includes policies designed to reduce disparities in dementia care. For example, CMS plans to conduct outreach with organizations that do not yet offer comprehensive dementia care or lack prior experience with alternative payment models such as safety net providers. Participants also will need to develop health equity plans, and a “health equity adjustment” will be made to payments for providers that serve disadvantaged beneficiaries.
    • CMS will support model participation for these organizations by providing technical assistance and learning support as well as a pre-implementation year to prepare for participation.
  • CMS will test an alternative payment methodology for participants that deliver key care management and coordination services to people with dementia and their family caregivers, including comprehensive, person-centered assessments and care plans; 24/7 access to a helpline; and caregiver support and education, such as training on how to best care for a relative with dementia. CMS clarifies that GUIDE is not a shared savings or total cost of care model and does not address coverage of novel Alzheimer’s drugs.
  • Participants will assign Medicare fee-for-service beneficiaries, including people who are dually eligible for Medicare and Medicaid, living with dementia and their caregivers to a care navigator. This individual will help people access services and supports, including clinical services and non-clinical services such as meals and transportation through community-based organizations. Model participants will also help caregivers access respite services, which enable them to take temporary breaks from their caregiving responsibilities. Evidence demonstrates that respite enables caregivers to care for individuals with dementia at home for a longer period, thereby forestalling institutional placement.

CMS will host a webinar with more details about the model on Thursday, August 10, from 2:00−3:00 pm.

The HMA team will continue to evaluate the GUIDE model and other Innovation Center opportunities. If you have any questions about the model, contact Amy Bassano, Barry Jacobs, or Maddy Shea.

We also can assist with questions about any of the new regulations. Contact Zach Gaumer, Andrea Maresca or Amy Bassano.

We also would like to remind our readers that the HMA team hosted a webinar last week on the Medicare Behavioral Health proposed changes. We previously discussed those changes in the July 19, 2023 In Focus. If you missed the webinar, you can find the recording and slides on the HMA website.

HMA News

New experts join HMA in June 2023

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HMA is pleased to welcome new experts to our family of companies in June 2023.

Anthony Federico – Senior Consultant
HMA

Anthony Federico is a seasoned government and non-profit leader with 12 years of expertise in housing, homelessness, and healthcare. He excels in developing and implementing innovative programs, executing Medicaid waivers, and cultivating cross-sector partnerships.

Melanie Johnson – Senior Consultant
HMA

Melanie Johnson is a seasoned public healthcare professional with over 15 years of experience working in federal and state government roles. Melanie’s expertise includes Medicaid state plan and waiver development, continuous quality improvement, and ongoing monitoring of policies and operations of federal and state programs.

Marcel Loh – Principal
HMA

Marcel Loh is an accomplished healthcare executive and leader with extensive experience collaborating with government leaders, insurers, and stakeholders to deliver value and achieve results.  His expertise extends to many diverse hospital structures including military, for profit, not for profit, religious, rural, urban, large systems and safety net hospitals.

Erin Russell – Principal
HMA

Erin Russell is a dedicated harm reduction expert with an unwavering commitment to public health and equity.  

Andrew Schalk – Senior Consultant
HMA

Andrew Schalk is an accomplished professional with extensive experience in Medicaid programs and hospital reimbursement policy.

Andrew Schwarze – Consulting Actuary
Wakely

Andrew Schwarze is an actuary with expertise in Medicaid rate analysis and risk adjustment. Read more about Andrew.

Zach Sherman – Principal
HMA

Zach Sherman is an Affordable Care Act (ACA) expert and Health Insurance Marketplace leader with extensive experience with start-ups and turnarounds. He is a strategic organizational leader who excels in building and enhancing team performance and has an impeccable ability to foster consensus among government leaders, insurers, and stakeholders to deliver value and achieve results.

Read more about our new HMA colleagues

Anthony Federico

Senior Consultant

Melanie Johnson

Melanie Johnson

Senior Consultant

Marcel Loh

Marcel Loh

Principal

Erin Russell

Erin Russell

Principal

Andrew Schalk

Andrew Schalk

Senior Consultant

Zach Sherman

Zach Sherman

Managing Director

Blog

CMS plans to improve incentives for Medicare providers in accountable care arrangements

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This week, our In Focus section is the second in a summer series of analysis and insights from Health Management Associates (HMA) on recent Medicare payment and policy developments. This week we dig deeper into the potential changes to the Medicare Shared Savings Program (MSSP) that were included in the 2024 Medicare Physician Fee Schedule proposed rule released earlier this month. Specifically, we highlight the impact these modifications could have on financial and operational decisions across the healthcare industry.

The proposed rule builds on the changes CMS finalized last year with the goal of increasing participation in the MSSP. The recommended changes are designed to appeal to more clinicians who treat a high proportion of underserved individuals. CMS estimates that the proposal will increase participation in MSSP by 10−20 percent. These changes are technical in nature and include:

  • Expanding the physician lookback window for beneficiary assignment (also known as the pre-step) for primary care service to 24 months from 12 months
  • Adding a third step to the claims-based beneficiary assignment methodology to recognize the role of nurse practitioners (NPs), physician assistants (PAs), and clinical nurse specialists (CNSs) in delivering primary care services
  • Modifying the definition of “assignable beneficiary” to reflect the changes above

The overall impact of these modifications, which augment the existing methodology, is to increase the number of beneficiaries assigned to accountable care organizations (ACOs) under MSSP. More assignable beneficiaries could mean:

  • More ACOs will meet minimum beneficiary requirements.
  • Changes in assignable population may affect the hierarchical condition category (HCC) risk scores for the national assignable population, as well as the factors used to normalize risk scores and other risk adjustments.
  • Changes in population distribution within regions that result in adjustments to ACO market share, benchmark trends, and update factors.

For ACOs participating in multiple programs, expanded assignment rules for MSSP, combined with the MSSP superseding other programs in assignment, may have downstream effects on programs in terms of assignment and performance.

Following is a more detailed explanation of the proposed changes.

24-Month Lookback for Primary Care Services

Extending the lookback for primary care services with a physician to 24 months from 12 will allow providers to capture additional primary care services codes related to the COVID-19 public health emergency (PHE) for benchmark and performance years. If the assignment window for a benchmark or performance year includes any month(s) during the PHE, then the additional primary care services codes must apply to all months in that window.

Three-Step Assignment Process

CMS plans to update its current two-step claims-based beneficiary assignment process to a three-step process, which would be effective for performance years beginning January 1, 2025. The proposed third step only would apply to beneficiaries who do not meet the pre-step requirement contingent upon whether they received at least one primary care service during the expanded window for assignment from an ACO-participating primary care or specialist physician or received at least one primary care service from a non-physician ACO healthcare professional during the 12-month assignment window.

Assignable Beneficiary Definition

The proposed rule includes updates to the definition of an assignable beneficiary to reflect the expanded 24-month lookback window for assignment and the new third step of a primary care service within the 12-month assignment window from a non-physician ACO professional (i.e., NP, PA, CNS).

The table below compares the current and proposed assignment processes.

Comparison of the Two- and Three-Step Processes

StepCurrent Two-Step Beneficiary Assignment ProcessProposed Three-Step Beneficiary Assignment Process
Pre-Step Requirement  to Identify Assignable BeneficiaryCMS identifies beneficiaries who received at least one primary care service from a primary care physician or a physician with a primary specialty designation participating in an ACO in the 12-month lookback window. CMS determines whether these individuals are eligible for assignment to an ACO.CMS identifies beneficiaries who received at least one primary care service from a primary care physician or a physician with a primary specialty designation participating in an ACO in the 24-month lookback window.
Step 1 Determine if beneficiaries received the plurality of their primary care services from primary care physicians, NPs, PAs, and CNSs in the participating ACO.No change
Step 2If not assigned in Step 1, determine whether beneficiaries received the plurality of primary care services from specialists in the participating ACO.No change
Step 3Not applicableFor beneficiaries not assigned through Steps 1 and 2:·         Determine if beneficiary received at least one primary care service with a non-physician ACO professional (e.g., NP, PA, or CNS) in the ACO during the applicable 12-month assignment window; AND·         Confirm beneficiary received at least one primary care service with a primary care physician or specialist who is an ACO professional in the ACO and who is a primary care physician or a non-physician ACO professional (i.e., NP, PA, CNS) during the applicable 12- month expanded window for assignment.

Financial Considerations

The proposed rule outlines that the expenditure lookback will remain 12 months. With a 24-month primary care service window and a 12-month expenditure lookback, ACO revenues could change. As a result, minimum savings rates could drop and the per-member per-month amount might change. In addition, the extended lookback could affect the regional average risk-adjusted spending, expenditure thresholds, and more.

Enhanced MSSP Track

CMS is seeking comment on a new track in MSSP with a higher level of risk and potential reward (e.g., somewhere between 80−100 percent). The purpose of the new MSSP track is to encourage ACOs that would not have otherwise participated in MSSP because of limitations on upside rewards. Higher potential rewards may also incentivize ACOs to develop new strategies, focus on specialty care integration, and reduce healthcare fragmentation to achieve savings.

CMS is seeking comment on the following:

  • Policy/model design elements that could be implemented so that CMS could offer a higher risk track without increasing program expenditures
  • Approaches to protect ACOs that serve high-risk beneficiaries from expenditure outliers and reduce incentives for ACOs to avoid high-risk beneficiaries
  • The impact that higher risk sharing could have on care delivery redesign, specialty integration, and ACO investment in healthcare providers and practices

The HMA Medicare and value-based care experts will continue to analyze these proposals alongside other policy and reimbursement changes that affect Medicare providers. We have the depth and breadth of expertise to assist with tailored analysis, to model policy impacts, and to support clients that intend to draft comment letters on this proposed rule. For more information or questions about these policies and other changes in the 2024 Medicare physician fee schedule proposed rule, contact Amy Bassano ([email protected]), Andrea Maresca ([email protected]), and Melissa Mannon ([email protected]).

Webinar

Webinar replay: Medicaid 1115 justice waivers and special populations: meeting the needs of justice-involved youth

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This webinar was held on August 17, 2023. 

HMA’s webinar series, 1115 Medicaid Justice Demonstration Waivers: Bridging Healthcare, focused on helping stakeholders optimize care for persons in carceral settings and during their transition back to the community.

Youth in juvenile correctional settings often have complex medical, behavioral health, developmental, social, and legal needs. Many youth have been exposed to adverse childhood experiences, unsupervised home environments and have lacked access to behavioral health services. Transitioning youth from correctional facilities require high quality transition planning services for successful reentry into the community.  Part 5 of this webinar series delved into the types of care and services needed for youth, so that a whole-person approach can be applied to facilitate successful reentry to the community.

Learning objectives:

  • Understand the unique needs of juveniles in correctional settings
  • Discuss opportunities under CMS State Medicaid Director Level 1115 guidance to support reentry for justice involved youth
  • Discuss effective state models for justice-involved youth
  • Learn how to create a whole-person approach to health needs of juveniles in the justice setting

Other webinars in this series:

Blog

Medicare’s 2024 proposed payment rules offer a mix of opportunities and policy changes for physicians and hospitals

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This week’s In Focus section is the first in a summer series of analysis and insights from Health Management Associates (HMA) on recent Medicare payment and policy developments. Our series kicks off with a big-picture take on the slew of regulations the Centers for Medicare & Medicaid Services (CMS) has released over the past two weeks. In future posts, we will dig deeper into several of the planned changes to highlight their potential impact on financial and operational decisions across the healthcare industry.

In July, CMS published three significant proposed Medicare rules for calendar year (CY) 2024: the Physician Fee Schedule (PFS) Proposed Rule, which includes proposed changes to the Medicare Shared Savings Program (MSSP); a proposed remedy to 340B-acquired drug payment policy for CY 2018−2022; and the Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System (OPPS-ASC) Proposed Rule. Comments on these proposals are due to CMS in early September.

HMA’s experts note several trends across these three Medicare payment regulations:

  • Health equity remains a significant focus of CMS and the Biden Administration.
  • The agency is expanding its coverage of behavioral health services under Medicare and enhancing payment and access for these services.
  • The long-term focus of CMS continues to be the transition toward value-based care.
  • Medicare is incrementally moving toward supporting care that is delivered where and how Medicare beneficiaries prefer, for example moving away from reimbursing largely for face-to-face services and supporting reimbursement for telehealth services in more situations.
  • CMS is creating pathways for reimbursement for a broader range of clinicians and caregivers who are addressing Medicare beneficiaries’ care needs.
  • CMS continues its efforts to improve hospital price transparency with policies aimed at encouraging providers to publicly report data.

Medicare policy experts at HMA and is affiliate, The Moran Company, summarize details on these regulations below. These colleagues work collaboratively to monitor legislative and regulatory developments in the physician, 340B, and outpatient and ASC policy arenas and to assess the impact of changes in these reimbursement systems. HMA’s Medicare experts interpret and model policy proposals and use these analyses to assist clients in developing their strategic plans and comment on proposed regulations. Moran annually replicates the methodologies CMS uses to set payments and recommends alternative payment policies to help support its clients’ comments on various rules and to help clients understand the impact of specific policies. In addition, HMA’s other partner companies, including Wakely and Leavitt Partners, are monitoring these issues from their unique perspectives.

For more information or questions about the policies described below, please contact Amy Bassano ([email protected]), Zach Gaumer ([email protected]), Andrea Maresca ([email protected]), Kevin Kirby ([email protected]), or Rachel Kramer ([email protected]).

Medicare Physician Fee Schedule Proposed Rule (CY 2024)

The Medicare PFS establishes payments and policies for physicians and other healthcare professionals. By statute, PFS payment rates will decline by 1.25 percent from CY 2023 to 2024. However, when coupled with budget neutrality adjustments for other policy changes, the proposed PFS conversion factor will decline by 3.34 percent. The impact of this reduction will vary by physician specialty.

Behavioral Health Services: CMS implements provisions in the Consolidated Appropriations Act (CAA), 2023, which would allow Medicare coverage and payment for the services of marriage and family therapists (MFTs) and mental health counselors (MHCs). CMS proposes to classify addiction counselors who meet certain requirements as MHCs. The rule outlines how these practitioners can enroll in Medicare and bill for services starting January 1, 2024. CMS is establishing new codes and payment for psychotherapy for crisis services and proposed refinements to Health and Behavior Assessment/Intervention codes to allow additional practitioners to bill for these services and to increase the valuations of timed behavioral health services. CMS seeks comment on ways to expand access to behavioral health services. CMS specifically is looking for information on digital therapies, remote physiologic monitoring, and remote therapeutic monitoring services.

Evaluation and Management (E/M) Office Visit Services: CMS proposed to implement separate payment for an add-on billing code to account for the additional resources associated with primary care or ongoing care related to a patient’s single serious or complex chronic condition. This complexity-based add-on code may be reported with all office and outpatient (O/O) and evaluation and management (E/M) visit level codes, and CMS estimates it will be reported for 38 percent of all O/O E/M visits initially. This estimate contributes to a significant portion of the relative value unit (RVU) budget-neutrality adjustment applied to the conversion factor. CMS also requests comments on evaluating E/M services more regularly and comprehensively including ways to improve data collection and methodologies to establish more timely improvements and accurate payments for E/M and other services.

Telehealth: CMS proposes several additions to the list of covered telehealth services and implements the various telehealth provisions included in CAA 2023, such as allowing the patient’s home to serve as an originating site. This provision would expand the scope of permitted telehealth providers and allow rural health clinics and federally qualified health centers (FQHCs) to provide telehealth services until December 31, 2024. In addition, CMS proposes opportunities for teaching physicians and medical residents to continue to use telehealth services to meet the supervision requirements via telehealth.

Caregiver Training Services: CMS proposed a new payment for practitioners who train caregivers to implement a treatment plan and support patients with diseases like dementia.

Payment for Community Health Integration, Social Determinants of Health (SDOH) Risk Assessment, and Principal Illness Navigation Provided by Social Workers, Community Health Workers, Care Navigators, and Peer Support Specialists: CMS is establishing opportunities for these services to be paid separately and account for the specific resources necessary to provide these services.

Dental Services: Although Medicare generally is prohibited from paying for dental services, CMS proposed to pay for certain dental services related to the treatment of head and neck cancers and when linked to other covered services used to treat cancer.

Discarded Drugs: The proposed rule continues the implementation process for a statutory requirement that drug and biological manufacturers refund amounts paid for discarded single-use prescription drug vials. CMS provides the list of products for which refunds would have been due in 2021, and the number of products included is expected to increase over time.

340B and Outpatient Offset Proposed Rule

In the 340B proposed rule, CMS proposed retrospective payments to 340B hospitals for incorrect payments made in CYs 2018−2022. After extensive litigation and a Supreme Court ruling, CMS will return to paying 340B hospitals for drugs using the formula of the average sales price (ASP) +6 percent, rather than the formula of the ASP −22.5 percent. In this proposed rule, CMS proposes to correct past underpayments to 340B hospitals by making lump sum payments to affected 340B hospitals. These retrospective payments are estimated to amount to $9 billion, and we anticipate payments will be made to hospitals at the beginning of CY 2024.

In addition, CMS proposed a corresponding prospectively budget neutrality offset to the 340B spending increase that will reduce hospital outpatient payments for non-drug outpatient services by 0.5 percent each year beginning in 2025. Specifically, CMS proposes to maintain this reduction until $7.8 billion in spending has been offset, which it estimates will take 16 years. The impact of this policy on the hospital industry will be significant and will create groups of winners and losers. Winners will include 340B hospitals, despite the fact that the outpatient offset will also affect their payment rates. Losers will include non-340B hospitals, particularly if their service mix is heavily focused on outpatient surgical services. Overall, the industry will observe a reduction in outpatient spending of roughly $300 million to $600 million per year for each of the 16 years the policy is in place.

Hospital Outpatient Proposed Rule (CY 2024)

Under the OPPS proposed rule, CMS would update payments for outpatient and ASC services by 2.8 percent in CY 2024 from CY 2023. This change will increase payments for hospital outpatient services by $1.9 billion and for ASC services by $170 million. In addition, if the 340B proposal is finalized, the 0.5 percent payment offset would not reduce CY 2024 OPPS payment rates but would begin reducing outpatient payments in CY 2025.

Behavioral Health: CMS proposes to establish the Intensive Outpatient Program (IOP) for behavioral health services provided to Medicare beneficiaries. The IOP proposal addresses one of the main gaps in behavioral health coverage in Medicare and promotes access to related services. CMS will define IOP as a distinct outpatient program of psychiatric services provided to individuals with acute mental illness or substance use disorder. Services could be provided at hospital outpatient departments, community mental health centers, FQHCs, and RHCs. Further, the agency proposed to establish two IOP service codes for each provider type—one for days with three services per day and another with four or more services per day.

Price Transparency: CMS proposes to increase the rigidity of its price transparency reporting program in an effort to improve hospital industry compliance with the reporting of hospital charge data to the public.

The HMA Medicare team and Moran Company reimbursement experts will continue to analyze these proposal alongside other policy and reimbursement changes that affect Medicare providers. We have the depth and breadth of expertise to assist with tailored analysis, to model policy impacts, and to support clients that intend to draft comment letters on this proposed rule.