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.
The Lake County Behavioral Health Services Department and the residents of Lake County, California.
Background
In 2021, opioid manufacturer Janssen Pharmaceuticals along with three opioid distributors, McKesson, Amerisource Bergen, and Cardinal Health (collectively known as The Distributors) reached settlements for their roles in the opioid epidemic that amount to $26 billion. These settlements will be distributed to states that participated in the joint lawsuits. It is estimated that California will receive approximately $2.05 billion over 18 years to focus on opioid abatement activities within the state. As a participating subdivision, Lake County is set to receive a portion of California’s Abatement Fund and began receiving payments on November 15, 2022. The County will receive approximately $18 million over the course of eighteen years.
HMA was tasked with creating an expenditure plan for the opioid abatement settlement funds distributed to the Lake County Behavioral Health Services Department and the residents of Lake County. HMA facilitated community engagement to gather stakeholder feedback and align community priorities with the High Impact Abatement Activities (HIAA) and goals as defined by the California Department of Healthcare Services.
Following the 2024 election, incoming federal officials have begun to lay the groundwork for significant changes in the federal policy landscape and agency operations. In 2025, Republicans will control the executive branch and both chambers of Congress, a trifecta of power that affords more opportunity for advancing their federal healthcare agenda over the next two years. HMA consultants are available to help organizations understand, inform, and plan for future federal policy initiatives and the impact for publicly funded programs and the healthcare sector.
Experts from HMA and from Wakely and Leavitt Partners, both HMA companies, collaborated to host three webinars that examine key issues and considerations for different parts of the healthcare sector.
This webinar explored insights on the election results, discussed both confirmed outcomes and remaining uncertainties, along with the mandate for change that has emerged. Panelists from HMA and Leavitt Partners provided an overview of what to expect from Congress and the Administration, focusing on key legislative priorities and executive actions, and shared their prediction for what to watch over the first 100 days.
With a Republican majority in Congress and presidency, healthcare priorities are expected to include revisiting ACA tax subsidies, addressing Medicaid allotments, and reexamining Medicare’s system for reimbursing providers. Powerful tools like budget reconciliation could drive major changes in tax and healthcare entitlement programs, however, this tool can be limited by parameters of the Senate’s procedural rules, known as the Byrd Rule.
Panelists also addressed the regulatory policy landscape which could include reinstating Trump-era policies like the 1332 waivers, allowing non-ACA plans, and altering Medicare and Medicaid policies to emphasize transparency and fiscal responsibility.
With Medicare Advantage (MA) a key area of focus for incoming federal agency leaders, experts from HMA, Leavitt Partners, and Wakely discussed how the election results will impact what policy changes could be considered in the coming year.
As the MA program expands, conversations about its future reveal a mix of partisan priorities and bipartisan opportunities. Partisan changes are likely to include moderation of regulatory oversight, and the possibility of easing the audit process and restrictions on payment models. Other strategies and policies may shift the emphasis away from health equity initiatives and revise the federal approach to competitive prescription drug pricing negotiations.
There are, however, certain reforms that are likely to garner bipartisan support, such as the expansion of telehealth services and increased access to behavioral healthcare. Ongoing discussions about health plans’ approaches to prior authorization and management of prescription drug will likely remain a bipartisan priority.
The 2024 elections may lead to significant changes in the ACA Marketplace. Enhanced ACA subsidies available during the COVID-19 pandemic are set to expire in 2025, and the new CMS administrator will shape policy and regulatory components that affect marketplace and consumer dynamics.
Key insights highlight anticipated changes to the Meaningful Difference Rules for non-standard plans, an increase in Marketplace user fees, and a proposal to codify silver loading into regulation. Additionally, it’s important to monitor policy areas focused on improving compliance among agents and brokers in the Marketplace the unveiling of a new Risk Adjustment model and coefficients to reflect costs that are not related to active medical conditions.
Our consultants are ready to meet with you to discuss any projects or ideas to help you navigate the evolving landscape in 2025.
This week’s In Focus section reviews new state initiatives to cover traditional healing services through Medicaid for American Indian/Alaska Native (AI/AN) individuals and communities.
Overview
In October 2024, The Centers for Medicare & Medicaid Services (CMS) approved Medicaid Section 1115 demonstration amendments for Arizona, California, New Mexico, and Oregon, allowing Medicaid and Children’s Health Insurance Program (CHIP) coverage of traditional healing services delivered at or through Indian Health Service facilities, Tribal facilities, and urban Indian organizations (I/T/U facilities).
This demonstration approval enables state Medicaid agencies to acknowledge traditional healthcare practices as important components of the wellness continuum of care for Native American populations. Medicaid funding will help strengthen and expand access to these services and support integration of these services into primary care, substance use disorder (SUD) treatment, and other behavioral health care in a way that I/T/U providers have designed and developed to meet the unique needs of their community.
Demonstrations for Arizona and Oregon are approved through September 30, 2027, New Mexico’s demonstration is authorized through December 31, 2029, and California’s through December 31, 2026.
Traditional Health Services: Providing Culturally Relevant Care
AI/AN populations generally experience worse health disparities compared with non-AI/AN populations, particularly in terms of obesity, diabetes, tobacco addiction, and cancer. AI/AN populations also face higher rates of mental health disorders, SUDs, and suicide.
Using Transformed Medicaid Statistical Information System (T-MSIS) claims and demographics data, Health Management Associates, Inc. (HMA), staff assessed the incidence of specific chronic diseases in the Native American and non-Native American population in the four states approved to cover traditional healing services through their Medicaid program. For example, in these states, the prevalence of diabetes in AI/AN populations ranged from 27 percent to 87 percent higher than among non-AI/AN groups. Figure 1 shows the percentage of three chronic conditions among these groups in the four states.
Figure 1. Percentage of AI/AN vs. Non-AI/AN Medicaid Beneficiaries Living with Chronic Conditions in AZ, CA, NM, and OR (2022)
Source: HMA analysis of 2022 T-MSIS (Transformed Medicaid Statistical Information System)
The demonstration approval is expected to improve access to culturally appropriate healthcare to address these disparities in chronic conditions for Tribal communities. Traditional healthcare practices vary widely across the 574 federally recognized Tribes in the United States, and many see traditional healthcare practices as a fundamental element of well-being that can help patients with specific physical and behavioral health conditions. For example, commonly offered traditional practices in Native American communities include talking circles, sweat lodges, and smudging. Studies show that incorporating traditional healthcare practices may improve mental health symptoms, outcomes, and quality of life, including among individuals with SUD.
Considerations for Key Partners
AZ, CA, NM, and OR are the first states to receive federal approval and will lay the groundwork for integrating time-honored healing practices into their Medicaid systems. They also could serve as a model for other states that choose to pursue this demonstration. I/T/Us were integral to shaping the demonstration design and are poised to continue shaping the program details and implementation of traditional approaches to care into their Medicaid systems.
HMA experts identified some key considerations for partners, such as states and Medicaid managed care organizations (MCOs), to follow as these services are incorporated into Medicaid:
Collaborate with I/T/U facilities and communities. Traditional healing practices are sacred and ceremonial, so flexibility will be essential in determining how Medicaid funding can be best allocated to support providers who offer traditional practices. Communities will be critical in helping identify the specific traditional healing practices that are needed.
Support operational changes needed in I/T/U facilities. Compliant and efficient billing practices will be essential to the success of the demonstrations. States can support I/T/U facilities to develop necessary trainings, workflows, and administrative processes. For example, the provider qualification criteria and implementation is central to meeting federal compliance and reporting requirements. Facilities also will need to meet Medicaid billing requirements to collect 100 percent of the federal medical assistance percentage (FMAP).
Partner with I/T/U facilities. To facilitate proper care coordination, states, health plans, and non-I/T/U providers should partner with I/T/U facilities to ensure patients experience the best health outcomes.
Connect With Us
HMA has learned the value and importance of working with Native American and Alaska Native populations and respecting their unique approaches to improving healthcare. HMA has expertise on healthcare issues that uniquely affect AI/AN populations and is experienced in addressing these challenges through AI/AN leadership and engagement that is culturally sensitive and respectful. Our experience working directly with Tribes encompasses extensive and applicable knowledge of healthcare operations in rural and urban settings to support infrastructure needs, including data management, IT, staffing, policies and procedures, training, and eligibility and enrollment processes.
Contact our featured expert below to learn more about HMA’s work to support Native American and Alaska Native communities.
This week’s In Focus section addresses post-election implications and initial considerations for understanding President-Elect Donald J. Trump’s possible federal healthcare policy agenda. Though healthcare was not the highest priority campaign issue, the president-elect and his team have signaled the policy agenda could include changes to the Affordable Care Act (ACA), Medicaid, and the nation’s public health programs.
Additionally, President Trump’s first term policy agenda and how these policies fared, provide critical insights into the policy direction for his second term, including policies on Medicare drug pricing, ACA marketplaces, and interoperability. Also vital to understanding and planning for a second term will be the appointees to key healthcare positions at the Department of Health and Human Services and in the White House.
Policy officials and specific policy agendas are still nascent, and Health Management Associates, Inc., federal and state experts are continuing to monitor these developments. The remainder of this article focuses on a few key considerations for the Marketplace, Medicaid, and Medicare healthcare insurance programs heading into 2025.
ACA Marketplace Issues to Watch
President-Elect Trump signaled he is uninterested in revisiting a legislative initiative to repeal and replace the ACA. However, one of the major defining issues facing the president-elect and the next Congress is the temporary policy providing enhanced tax credits that lower ACA premiums, which expires at the end of 2025. This and other tax policies are very likely to be on the table, particularly as budget reconciliation is an available tool in unified government.
Key considerations for healthcare stakeholders regarding the subsidy policy and federal funding for Marketplace outreach and education programs include:
The Congressional Budget Office (CBO) estimates that extending the present enhanced subsidy policies would cost more than $300 billion over 10 years. The CBO also reports that ACA marketplace enrollment would drop from 22.8 million in 2025 to 18.9 million in 2026 if the subsidy policy is not renewed.
The loss of subsidies would increase the number of uninsured individuals in the United States, but the size of the increase would depend on the state-specific landscape. For example, states that have not adopted the ACA’s Medicaid expansion for adults are expected to have a higher increase relative to states that have more expansive Medicaid eligibility. One potential approach is for lawmakers to modify the enhanced subsidy policy, rather than let it expire entirely.
Marketplace plans should be prepared for a change in the acuity mix of enrollees while providers should expect a change in their payer mix, with more uninsured individuals in states that have not expanded Medicaid.
Federal and state policymakers may pursue a combination of alternatives to fill gaps in access to healthcare coverage and services. For example, the president-elect and incoming congressional leaders may focus on alternative coverage options and other state-driven reforms to Marketplace programs. Alternatives that could become part of the regulatory policy agenda include:
Supporting association health plans (AHPs) and high-risk pools
Reverting to a federal regulatory environment that supports short-term limited-duration healthcare insurance (STLDI) plans
Approving Section 1332 waivers to allow state-designed programs
Medicaid Policy Outlook
During Mr. Trump’s first term, one of his administration’s signature Medicaid initiatives was approving Section 1115 demonstrations that allowed states to apply work requirements to certain populations, including adult expansion populations. The first Trump Administration also revised the demonstration parameters for Section 1115 Institutions for Mental Disease (IMD), allowed coverage lockout for beneficiary noncompliance with premium payments, and approved a pilot program to test interventions addressing health-related social needs (HRSNs).
Key considerations for healthcare stakeholders regarding Medicaid flexibilities and funding include:
Officials in the first Trump Administration approved North Carolina’s Medicaid 1115 demonstration program to address HRSNs. President Biden’s Administration expanded these policies and approved demonstrations in more than 10 states, with additional state applications pending. Incoming officials may maintain the overall policy direction with regard to HRSNs. However, they could pivot to narrow the scope of future state HRSN proposals. Another approach could include directing states to use in lieu of services (ILOS) authority in managed care delivery systems to address HRSN.
During President-Elect Trump’s first term, Centers for Medicare & Medicaid Services (CMS) officials prioritized work requirements and capped allotments for certain components of a state’s Medicaid program. Some states might consider revisiting these options, with modifications. If this policy direction is refreshed, federal and state officials would benefit from the foundational work conducted during the first term.
New CMS officials could prioritize work on transparency in Medicaid financing and reimbursement to providers. Federal officials, regardless of political affiliation, historically have sought to improve their understanding of the flow of Medicaid funding. Incoming officials could prioritize this issue again, which would have a varied effect on health plans and providers.
Medicare Priorities:
Relative to Marketplace and Medicaid, first term Trump Medicare policies were advanced with less conflict. Notable policy initiatives included a focus on healthcare-related challenges in rural communities, improving transparency, and reducing provider burden —all of which were also cross-cutting issues that encompassed policy work beyond Medicare and could continue to be central to the next Medicare policy agenda.
Key considerations for healthcare stakeholders regarding Medicare policy are as follows:
The president-elect’s first term approach to Medicare Advantage (MA) plans sought to maximize enrollment in MA and encourage innovation and value-based design. It’s reasonable to expect second term CMS officials to maintain an overall favorable approach to MA too. Incoming officials could narrow their scrutiny of MA plans to bipartisan concerns, for example MA plans’ prior authorization policies.
While improving outcomes for dually eligibles beneficiaries generally is a bipartisan issue, state agencies, MA and Medicaid managed care plans, and other interested stakeholders should monitor the incoming Administration’s policy agenda for dually enrolled beneficiaries in Medicare and Medicaid. During the Biden Administration, CMS issued final rules for Medicare Advantage Dual Eligible Special Needs Plans (D-SNPs) to improve integration for the Medicare-Medicaid dually eligible population., Incoming Trump officials could revisit the approach, including the breadth of requirements and compliance timelines.
During his first term, President Trump was highly engaged in elevating concerns about prescription drug prices and HHS and CMS announced models and policies to lower drug prices for patients. In his second term, however, the President could seek to rein in certain aspects of the Inflation Reduction Act (IRA), while revisiting some of his prior proposals.
What to Watch
The incoming Administration and its transition team are moving expeditiously to nominate new Cabinet Secretaries and to identify key staffers. The individuals appointed to departmental, agency, and advisory leadership positions will have significant leeway in shaping the federal and state healthcare policy landscapes – determining which existing policies to review and potentially revise, new policies to develop, and the approach to working with state and local officials and stakeholders. This includes the Secretary of Health and Human Services, CMS Administrator, Director of the Centers for Disease Control and Prevention, Food and Drug Administration Commissioner, and Director of the National Institutes of Health, all of which require Senate confirmation. Additionally, healthcare stakeholders should continue to monitor the leadership races for the House and Senate and the primary congressional committees with jurisdiction over healthcare programs. These leaders will be key to a second term Trump legislative policy agenda.
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This article focuses in on a subset of issues within Marketplace, Medicaid, and Medicare and in the overall healthcare sector. Our 2024 Political Checkpoint webinar features our experts discussing these and other insights on the election results. They provided an overview of what to expect from Congress and the Administration, focusing on key legislative priorities and executive actions.
Join us for our next two webinars in the series exploring the election results:
In the 2024 Political Checkpoint hosted by Leavitt Partners, an HMA company, we explored up-to-the-minute insights on the election results, discussed both confirmed outcomes and remaining uncertainties, along with the mandate for change that has emerged. Our expert panelists provided an overview of what to expect from Congress and the Administration, focusing on key legislative priorities and executive actions, and shared their prediction for what to watch over the first 100 days:
2024 Wrap Up Lame duck session in Congress, end of year regulatory action
A New President Implementing campaign promises through appointments
2025 Policy Agendas Where committees, agencies may set their sights
Key Issues Healthcare priorities that could see the spotlight
The sections below review results and share key takeaways. On November 12, during NAMD’s 2024 Fall Conference, KFF experts and state Medicaid directors will delve into survey findings on policies in place or planned for fiscal year (FY) 2024 and FY 2025, including state experiences with reduced state revenues and the unwinding of the pandemic-related continuous enrollment provision.
Several of HMA’s former Medicaid directors and Medicaid experts will be in attendance at the NAMD meeting to provide additional context and address questions about FY2025 Medicaid policies in the post-election landscape. Visit our Medicaid team at our exhibit hall booth, where we will have executive summaries on hand.
Medicaid Enrollment and Spending Growth
During the COVID-19 pandemic, Medicaid enrollment reached record highs as a result of the Families First Coronavirus Response Act, which authorized a 6.2 percentage point increase in the federal match rate, also known as the or Federal Medical Assistance Percentage until the public health emergency ended, provided that states did not disenroll people with Medicaid coverage. During this time, Medicaid and Children’s Health Insurance Program (CHIP) enrollment rose to 94 million in April 2023 from 71 million in February 2020. In FY 2024 and into FY 2025, states are concluding their Medicaid unwinding eligibility redeterminations.
Medicaid enrollment declined by 7.5 percent year over year in FY 2024 and is expected to further decline by 4.4 percent in FY 2025. However, net Medicaid enrollment remained above pre-pandemic levels. Total Medicaid spending growth slowed to 5.5 percent in FY 2024 and is expected to slow further to 3.9 percent in FY 2025. State shares of spending, however, rose by 19.2 percent in FY 2024 and is estimated to slow to 7 percent in FY 2025. According to FY 2025 enacted budgets, most states anticipate revenue growth will continue to flatten and expect state general fund spending growth to slow. More than half of responding states anticipated a state revenue shortfall to some degree (see Figure 1).
Figure 1. Percent Change in Medicaid Spending and Enrollment, FY 1998−2025
Source: FY 2024−2025 spending data and FY 2025 enrollment data are derived from the annual KFF survey of state Medicaid officials conducted by HMA, October 2024. All 50 states submitted survey responses by October 2024; state response rates varied across questions. FY 2025 projections based on enacted budgets. Historic data reflects growth across all 50 states and DC and comes from various sources.
Managed Care and Provider Rates
Capitated managed care remains the predominant delivery system for Medicaid in most states. Specifically:
A total of 46 states operated some form of Medicaid managed care (managed care organizations [MCOs] and/or primary care case management [PCCM]).
42 states contracted with risk-based MCOs.
States use a variety of risk mitigation tools to ensure appropriate payment levels for MCOs, including risk-sharing arrangements, risk and acuity adjustments, medical loss ratios, or incentive and withhold arrangements (see Figure 2).
Of the 41 responding MCO states, 25 reported seeking approval from the Centers for Medicare & Medicaid Services (CMS) for a capitation rate amendment to address shifts in the average risk profile of MCO members in FY 2024 and/or FY 2025 because of the unwinding.
Separate from the KFF report, HMA tracks state Medicaid managed care rate certifications. In addition, Wakely, an HMA Company, published a paper summarizing approaches taken by actuaries in 27 states, and considerations for how they relate to the biggest enrollment shift in Medicaid since the implementation of the Affordable Care Act.
Figure 2. States Seeking Capitation Rate Amendments to Address Acuity Shifts Resulting from the Unwinding for the Rating Periods Beginning in FY 2024 and/or FY 2025
Source: Annual KFF survey of state Medicaid officials conducted by HMA, October 2024
States also are implementing a range of fee-for-service (FFS) rate increases across provider types. More than half of states reported increasing both inpatient and outpatient hospital FFS base rates in FY 2024. States reported rate increases for nursing facilities and home and community-based service providers more often than for other provider categories, reflecting ongoing staffing challenges for long-term services and supports (LTSS). Most states also reported rate increases for outpatient behavioral health providers, primary care professionals, and dentists.
Social Determinants of Health and Reducing Health Disparities
States are increasingly addressing social determinants of health (SDOH) and associated health-related social needs (HRSN) using several types of Medicaid authorities. For example:
A total of 39 states reported leveraging Medicaid MCO contracts to promote at least one strategy to address SDOH, including screening enrollees for behavioral health or social needs, providing referrals to social services, partnering with community-based organizations, and requiring providers to capture SDOH data and employ community health workers. See Figure 3 for details.
Figure 3. MCO Contract Requirements Related to SDOH, FY 2024−25
Source: Annual KFF survey of state Medicaid officials conducted by HMA, October 2024
Nearly all states also had least one specified MCO requirement related to reducing racial and ethnic health disparities in FY 2025. About one-third of states reported at least one MCO financial incentive tied to reducing racial/ethnic disparities in place in FY 2024, most commonly linking capitation withholds or pay for performance incentives to improving health disparities.
Medicaid Section 1115 demonstrations are also being used to expand flexibilities by adding HRSN services and supports, including coverage of rent/temporary housing, utilities, and meal support. CMS has approved ten states under the new HRSN Section 1115 framework.
Benefits
In all, 41 states reported new or enhanced benefits in FY 2024, and 38 states reported plans to add or enhance benefits in FY 2025. Benefit enhancements continue to outpace benefit cuts.
States especially continue to expand behavioral health benefits, particularly for mental health and substance use disorder services.
A total of 11 states reported benefit actions related to the addition or expansion of crisis services, including mobile crisis responses and crisis services for youth.
Prescription Drugs
Rising prescription drug costs are an ongoing concern for states and nearly three-quarters of states reported at least one new or expanded initiative to contain prescription drug costs in FY 2024 or FY 2025.
Efforts to implement or expand value-based arrangements with pharmaceutical manufacturers were the most frequently mentioned cost-containment initiative across states.
Weight-loss prescription drugs also are a hot topic in the states; 13 states now cover GLP-1s (glucagon-like peptide-1s) prescribed to treat obesity. Most state Medicaid programs reported that cost was a key factor contributing to their decisions.
Key Opportunities, Challenges, and Priorities in FY 2025 and Beyond
Medicaid directors are focused on behavioral health, LTSS, and key initiatives related to SDOH or reentry services for justice-involved populations in FY 2025 and beyond. In addition, state-reported priorities included maternal and child health, rural initiatives, school-based services, continuous coverage for children, value-based payment and quality initiatives, and network monitoring and oversight.
Budget pressures and workforce shortages are among the main challenges for Medicaid. States noted adequate staffing and systems are obstacles for compliance with recently promulgated federal regulations, particularly the access and managed care rules, which present new reporting, oversight, and beneficiary protection responsibilities for states. Many states also reported a notable increase in per enrollee costs due to the greater healthcare needs of enrollees who retained coverage during the unwinding, adding pressure to budgets.
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The KFF Medicaid budget report provides important policy insights for federal and state government decisionmakers and Medicaid stakeholders. HMA’s Medicaid experts know the impact and planning needed to navigate these policies and to inform new decisions in 2025 and beyond. For more information about the key takeaways from the KFF report and HMA’s Medicaid solutions, contact our experts below.
To better support family caregivers and the older adults who they care for, Area Agencies on Aging and other aging network agencies are creating Community Care Hubs (CCH) to address social determinants of health, integrate health and social care, and reduce care costs. In this webinar with LTSS policy experts and providers, we described the implementation of the CCH model in projects in Massachusetts and New York.
Learning Objectives:
Describe the Community Care Hub (CCH) model for integrating health and social care
Identify key CCH features to enhance family caregiver support services
Illustrate the implementation of the CCH model for supporting family caregivers with projects in Massachusetts and New York
Featured Speakers:
Kristie Kulinski, MSW, Director of Office for Network Advancement, Administration for Community Living
Nikki Kmicinski, MS, RD, CDH, Chief Executive Officer, Western New York Integrated Care Collaborative
Jennifer Raymond, JD, MBA, Chief Strategy Officer, AgeSpan
Medicare Advantage (MA) Star ratings are more than a quality score—they shape the financial and operational success of MA plans. These ratings hinge on factors that every plan can impact by developing continuous improvement processes. The Consumer Assessment of Healthcare and Provider Systems (CAHPS) survey, Healthcare Effectiveness Data and Information Sets (HEDIS) ratings, and the Member Retention rate are all significant levers affecting Star ratings.
The importance of member retention rate
Member retention rate is a measure of member satisfaction but also impacts plan scale. One Medicare Advantage (MA) plan typically reports 0% voluntary disenrollment each year. Another plan is reporting 60% voluntary disenrollment. The voluntary disenrollment threshold is currently set at 18% for a 4-star rating and 10% for a 5-star rating on the measure. The average MA plan is losing more than $60 million in Medicare premium annually due to voluntary disenrollments. The voluntary disenrollment measure excludes members moving out of the service area or sponsor-initiated contractions of the service area.
CAHPS survey impact on Star ratings
CAHPS metrics are an important factor in the Centers for Medicaid and Medicare Services (CMS) Star rating system. MA plans need to develop strong companywide focused member experience processes to help them navigate the healthcare delivery system and community resources available. Evaluating the entire member experience from enrollment through access to care, messaging, outreach, customer service, to disenrollment, involves mapping out every member touchpoint, from a population health approach, to ensure the plan has a caring, approachable, supportive, and balanced experience with the member. Opportunities to eliminate frustrative process steps include identifying health related social needs and disparities that provide easier and time-sensitive access to care and services that are essential to increasing member satisfaction and engagement.
Health plans need a process to identify members who are most likely to be dissatisfied due to events and contact these members to understand the needs and resolve issues quickly. A dissatisfying process issue will repeat if not addressed. Understanding what data the health plan should be continually monitoring and the steps to effectively address any issues is essential to increasing trust with members. It is imperative that members get the opportunity to express their concerns to the health plan with the opportunity to resolve issues satisfactorily before they receive a CAHPS survey.
HEDIS and Star ratings
MA plans need to develop focused processes to proactively monitor HEDIS metrics and drive improvement interventions to keep up with the competition. Having a holistic approach to monitoring, understanding the status and what gaps persist, and a year-round strategy for addressing these gaps is essential to being able to focus efforts on improvement.
As the National Committee for Quality Assurance (NCQA) is moving from a hybrid sampled process to an administrative whole population calculation system, it’s essential that MA plans are addressing each measure in its entirety throughout the year. Digital measurement and Electronic Clinical Data Sets (ECDS) measures are increasing with CMS having a goal of interoperability and implementation of digital quality measures by 2030. Changes with CMS Star metric weightings has increased the total percentage that HEDIS impacts the overall calculation.
Partnering with Pharmacy Benefit Manager to improve Stars
Medicare Part D measures are among the most highly weighted measures in the CMS Stars performance program. Having a strong Pharmacy Benefit Manager (PBM) p artner is a necessity for success. Measures include medication adherence for high blood pressure, cholesterol, and diabetes. Successful plans ensure that members have sufficient prescription fills and re-fills to cover 80% of the days during the year. Measures are scored based on the percentage of members in the denominator who are compliant by the end of the measurement year. Member satisfaction with the plan’s pharmacy program is a key determinant in plan rating by the member and plan retention, impacting other parts of the CMS Stars program, whether Part D is measured alone or as part of an MA-PD plan.
Accelerating Star Rating Performance
The HMA Stars Accelerator Solution offers a comprehensive, results-oriented approach to Star Rating performance improvement that addresses the multifaceted challenges faced by health plans. It examines your plans leadership structure, operational processes, technology, reporting, member-centric engagement, provider partnerships, and develops a strategy for your organization using a data-driven approach for continuous improvement. Multiple “what-if” scenarios are developed that identify top priorities. Measure thresholds that are too far to reach are replaced by measures that are within reach during the final months of the year.
The Accelerator approach includes “all-hands-on-deck” – care coordination, customer service, network development, marketing, analytics, and others. Accelerator plans introduce provider and member incentives and/or fee schedule adjustments to increase interest. These plans also provide information to providers on those attributed members who have measure gaps to facilitate provider outreach that is coordinated with plan outreach.
HMA Accelerator plans experience a reduction in members choosing to leave, attributed more to prevailing cultural changes over time than to enhanced benefits or member rewards. This program is a cultural transformation designed to strengthen star performance. Click here to learn more about the HMA Stars Accelerator Solution’s capabilities, where you can request a copy of the HMA Stars Accelerator Playbook. Let’s have a conversation about how your plan can improve member retention for increased star rating and increased enrollment scale.
