February 26, 2025
Spotlight on Development of President Trump’s Children’s Health Strategy
1320 Results found.
Can Stable Housing Unlock Better Health Outcomes?
Maddy Shea is a public health leader and passionate advocate for housing as a critical component of community health. In this episode of Vital Viewpoints on Healthcare, she shares insights on how housing and healthcare sectors can break down silos to improve outcomes for vulnerable populations. Drawing from her experience at the CMS Office of Minority Health and her work with health plans, affordable housing organizations, and policymakers, Maddy explores the challenges and opportunities in aligning incentives, leveraging policy tools such as Medicaid waivers, and fostering public-private partnerships. Join us as we discuss innovative solutions to housing instability, aging in place, and how data connectivity can drive better care coordination.
State Cost Growth Benchmarking Programs: An Evaluation of Eight States’ Experiences and the Lessons Stakeholders Have Learned
Background
In 2024, Health Management Associates (HMA) evaluated programs implemented by eight states (California, Connecticut, Delaware, Massachusetts, New Jersey, Oregon, Rhode Island, and Washington) aimed at controlling healthcare cost growth. In recent years, these states have tried to address the trend of escalating healthcare costs using an approach referred to as cost growth benchmarking (CGB). This is the act of setting a target for annual healthcare cost growth and measuring actual performance against the target. Since 2018, the Peterson-Milbank Program (PMP) for Sustainable Health Care Costs has invested in state-based CGB efforts by funding program development, implementation, and technical assistance. HMA evaluated the Peterson Center on Healthcare’s cost growth benchmarking efforts across the eight states.
Methodology
HMA’s evaluation for the Peterson Center on Healthcare included a detailed landscape review for each of the eight states and interviews with 45 state officials, providers, payers, and other stakeholders in these states. The HMA team synthesized findings from the landscape review and the key informant interviews and produced an internal evaluation report.
Analytic Approach
The landscape review captured the state’s CGB program chronology, governance structure, growth targets, enforcement authority, and performance against the target. The interviews examined the contextual factors, stakeholder influence, implementation developments, capacity to control costs, facilitators and barriers to developing cost control capabilities, and the lessons learned based on the states’ experience. The interview discussion guide included a scoring component which enabled quantitative analysis in addition to the qualitative findings. HMA analyzed these findings by state, category of interviewee (state officials, payers, providers, or others) and implementation stage (early vs. more recent adopters).
Findings
States’ efforts to engage and gather stakeholders, establish cost growth targets, collect and report data, and identify cost drivers have been successful, but states have had challenges to date in developing policies aimed at containing costs.
Utility
The findings from this analysis can be useful to the existing states in enhancing their CGB programs and to states interested in launching new CGB initiatives.
Why housing insecurity is a critical public health issue
More than ever, facing the challenges of housing insecurity is becoming a top priority for communities nationwide. Here’s why.
- Direct impact on health: The quality of housing directly affects physical and behavioral health. People experiencing homelessness are at higher risk for illness, mental health issues, and death. Substandard housing leads not only to higher incidence of illness, but also greater exposure to toxins like lead and asbestos that exacerbate health problems.
- Cost burdens of housing issues: Overcrowding, substandard housing, eviction, and homelessness all lead to poor economic outcomes, lower infant birthweights, mental health challenges, chronic disease, and higher mortality.
- Effects on healthcare access: Due to high housing costs,half of renters delay medical care because they can’t afford it. And people experiencing homelessness or housing insecurity have a much harder time accessing healthcare.
- Rise in homelessness: After homelessness hit a record high in 2023, it increased another 18% from 2023 to 2024. More than 771,800 people in the U.S. lived without housing in 2024.
To address these issues, we are announcing the launch of the HMA Housing and Health Solutions team. HMA has brought together a team of experts who understand the challenges that homelessness and housing insecurity present to community health. Bringing together partners across all sectors, we help craft effective solutions for populations that lack access to stable housing and healthcare.
Our team includes former directors of national, state, and municipal government housing departments, nonprofit affordable housing organizations, and housing financing and investment.
We’re pleased to announce the addition of two well-renowned housing experts to the team. Andy McMahon joins HMA after spending over seven years at UnitedHealthcare and UnitedHealth Group. Andy has over two decades of executive experience spanning healthcare, housing, human services and community development, and worked with UHC Medicaid plans nationwide on various policy issues to improve care for the most complex populations. Doug Shoemaker joins HMA after leading Mercy Housing California for 13 years. Prior to Mercy Housing, Doug directed the Mayor’s Office of Housing and Community Development in San Francisco. Doug focuses on the intersection of housing, community development and healthcare to advance projects and policy that improve outcomes for lower-income individuals and communities.
Come meet some of our team members at the NAEH conference Feb 26 and 27 in Los Angeles, CA and visit us at the HMA booth in the exhibit hall. HMA’s Dena Hasan will be presenting, “Does Secret Domestic Violence Housing Lead to Unsheltered Homelessness?” on 2/26 at 2:30 in San Gabriel ABC, and “Does Medicaid Hold the Key to Housing?” at 3:45pm in Santa Anita AB.
Housing and Health Solutions
Meet our housing and health experts:
Healthcare Quality Goes Digital: Navigating Challenges and Opportunities
This week, our In Focus section highlights insights from a new Health Management Associates (HMA) issue brief, Digital Quality Transformation. The brief, released in January 2025, explores the transition from traditional manual data extraction for use in quality measurement to fully automated digital quality measurement (dQM). It examines the challenges, benefits, and policy changes that are driving this transformation with a focus on how payers and providers can leverage digital tools and open data standards to improve efficiency, reduce costs, and enhance patient care and value-based payment models.
Following is a summary of key points from the brief about the evolution of traditional quality reporting in healthcare, which has depended on structured claims, administrative data, and manual chart abstraction. This process tends to be expensive, inefficient, and unable to capture data from a population perspective. We highlight the challenges and strategic steps that organizations should be taking now to prepare for the federally required dQM transition.
Current State
Traditional manual quality measurement methods are costly and inefficient. Generally, providers are expected to submit a sample of medical records (usually about 400 charts per measure). Once received, trained staff extract key data fields from those charts and enter them into another database, where the data are then used to augment claims data. This process results in significant gaps in and delays in information regarding quality of care, is prone to manual entry errors, and represents only a small portion of the patient population. Accreditation bodies like the National Committee for Quality Assurance (NCQA) are moving away from these outdated methods, signaling a shift toward more comprehensive and automated collection of clinical data. Facilitating this movement is the increasing availability of digital tools, APIs, and interoperability standards designed to streamline data exchange.
Federal Policy Landscape
The 21st Century Cures Act, the Office of the National Coordinator for Health IT (ONC) Cures Act Final Rule, and the Centers for Medicare & Medicaid Services (CMS) Interoperability and Patient Access Rule collectively are contributing to improve the ability of providers, payers, and applications to access health information using HL7 FHIR APIs. Although it is unclear whether the Trump Administration will revise aspects of certain existing regulatory policies, the commitment to interoperable, standardized, reusable data has been a bipartisan issue and was supported by the previous Trump Administration. This transition to digital health measures could even accelerate to meet changing expectations for efficiency and improved quality.
Key federal and state efforts include:
Roadmap for Digital Quality Measurement
The CMS Digital Quality Measurement Strategic Roadmap outlines necessary actions for a transition to fully digital measures by 2030. Organizations like the NCQA already are converting healthcare quality measures (e.g., HEDIS®) into digital formats using non-claims-based data sources in preparation for a full transition to digital measures in 2030. Key stakeholders, including the Digital Quality Implementation Community (DQIC) led by Leavitt Partners, an HMA company, are driving industry alignment with these new federal mandates. Organizations that proactively invest in digital quality measurement will be well-positioned for future compliance and improved healthcare outcomes.
Digital Health Advances in the States
States are also starting to plan for the implementation of these digital requirements. The One Utah Health Collaborative Digital Health Interoperability Pilot, led in partnership with Gov. Spencer Cox and Leavitt Partners is one example of state-level leadership to support and maximize the use of digital health measures. The pilot is designed to enable providers, payers, and individuals to aggregate and share clinical and claims information from anywhere in Utah’s healthcare ecosystem. The statewide Fast Healthcare Interoperability Resources (FHIR)-based ecosystem leverages modern application programming interface (API) standards as required at the federal level. This pilot will aid Utah in its fully digital quality measurement transition by ensuring that health data are standardized and easily accessible, which is crucial for accurate and efficient quality measurement.
Challenges and Opportunities in Digital Quality Transformation
As the industry moves toward full adoption of dQM by 2030, healthcare organizations should be focusing on how to strategically leverage this transformation. Though the transition to digital quality measurement presents significant opportunities, key challenges include:
- Workforce adaptation: Healthcare professionals accustomed to traditional reporting methods may need significant training to effectively use real-time data for decision making.
- Shifts in payer-provider dynamics: With greater data transparency, reimbursement models may evolve rapidly, demanding more agile contract negotiations.
- Data governance: Ensuring that the influx of newly accessible clinical data are properly validated and interpreted.
- Vendor management: Organizations will need to rethink their relationship with vendors, specifically as plans reduce their reliance on manual processes.
- New vendor requirements may pivot toward data validation and analytic tools to ensure compliance with NCQA’s standards.
- Compliance with FHIR-based data exchange and CMS’s Interoperability & Patient Access Rule, which mandates standardized data sharing across different systems.
- Data standardization: Different healthcare systems will need to use common data formats and terminologies to ensure interoperability.
What’s Next
As federal policies and regulations accelerate the transition to dQM, healthcare stakeholders must prepare by investing in interoperable technologies and adapting their quality reporting business processes accordingly. They should track developments and new opportunities at the federal and state levels and direct organizational attention and resources to the multiyear transition through the following approaches:
- Evaluating of the current landscape, envisioning future pathways for dQM, and establishing achievable objectives for their organization
- Developing strategic plans with the achievable objectives and enumerating tactical and implementation plans that address identified risks
- Focusing on implementation, identifying and dashboarding your key performance indicators and metrics, making adaptations based on your evaluation
Connect With Us
Providers, payers, patients, and states all have a vested interest in ensuring fully digital quality measurement, as it will be essential to staying ahead in this rapidly evolving landscape. For details about this analysis, its implications for states and other organizations, and additional information, contact our experts below.
February 19, 2025
Healthcare Quality Goes Digital: Navigating Challenges and Opportunities
Medicare Hospital Inpatient Device-Intensive Payment Policy
Medicare’s fee-for-service (FFS) payment system includes payment policies that support providers’ use of innovative medical device technologies. The continued evolution of these policies is necessary to keep pace with current and future medical innovation. In this report, HMA summarizes models testing the implementation of a newly proposed policy for the hospital inpatient system which aims to eliminate systemic bias that may slow hospitals’ adoption of innovative technologies. HMA concludes that targeted policies that eliminate the use of the hospital wage index to standardize device costs can result in more accurate reimbursement for hospitals and increase beneficiary access to innovative technologies.
HMA helps navigate dQM to improve health outcomes
The healthcare industry is undergoing a seismic shift in how quality data are collected and reported, creating opportunities to use digital quality measures (dQM) to significantly improve health outcomes and efficiency. Starting in January 2027, new federal interoperability and prior authorization rules will promote widespread data exchange, enabling full digital quality measurement. Payers and providers must invest early to be well-positioned to undergo major strategic and operational changes to optimize healthcare data and transform their business processes.
This issue brief explains the federal policies and national changes that make digital quality measurement possible, explores challenges facing the health insurance industry, and highlights opportunities for payers and providers.
Our HMA dQM team helps health plans, providers, health & hospital systems, federal, state and local payers such as Medicare and Medicaid navigate the transformation to dQM and broader interoperability—from early planning through strategy development, implementation, and impact evaluation.
Highlights from HMA Analysis of Specialty Services in Medicaid
This week, our In Focus section highlights key insights from a new Health Management Associates (HMA), white paper, Concentration of Specialty Services in Medicaid. Experts from HMA and Wakely, an HMA company, used the national Transformed Medicaid Statistical Information System (T-MSIS) database to learn more about specialty provider networks and examine the provision of specialty services across various states.
The analysis, released in January 2025 with support from the Robert Wood Johnson Foundation, focuses on three representative services that are relatively common, potentially difficult for Medicaid beneficiaries to access, significantly affect quality of life, typically accessed as elective procedures, and unlikely to be provided by other clinicians, such as primary care or mid-level practitioners.
T-MSIS Analysis Overview
T-MSIS analytic files are a comprehensive resource for Medicaid encounter, beneficiary demographics, program enrollment, service utilization, and payment data. Individual states compile their Medicaid claims data and submit monthly files to the Centers for Medicare & Medicaid Services (CMS). As each state submits data individually, numerous state-specific variations occur in data availability and quality. Currently, T-MSIS data are available for 2016−2023. HMA data scientists have permission to use the T-MSIS files for healthcare services research.
This paper examines services in 10 states that met a threshold of data integrity in the T-MSIS dataset for 2022. Other important design aspects of the analysis are as follows:
- The three service procedures included in the analysis are total knee replacement (TKA), cataract removal, and impacted tooth extraction.
- Selected states represented a diverse sample of geographic, socioeconomic, and other demographic factors.
- The analysis includes non-dually eligible adult populations, ages 22−64 years.
- The data cover all services provided in 2022 for each procedure and the providers who rendered the service; facilities are excluded.
Concentration of Specialty Providers
Table 1 summarizes findings about the concentration of specialty services.
The authors further analyzed the provision of services and, building on a previous study, examined network concentration. Findings were as follows:
- When looking at the same procedure across states, no consistent pattern emerged regarding which states had the highest and lowest concentration of services in the top 10/25 percentile of providers.
- However, when looking at the same procedure across multiple states, TKA tended to have the lowest concentration of services among those studied.
- Regardless of procedure and state, the 50 percent of providers with the lowest number of procedures tended to provide fewer than 10 percent of the total services combined.
These findings suggest that the specialty networks within each state are highly nuanced, and state policymakers need to look at individual specialty networks when considering health policy. State policymakers and managed care organizations (MCOs) need to examine each specialty individually to assess the distribution of services and access to care.
Looking Ahead
Timely access to healthcare services is critical for ensuring optimal health outcomes. The report authors’ analysis of T-MSIS data showed significant concentration of selected specialty services among providers, which may affect appropriate access to these services.
The analysis of concentration of specialty services among Medicaid specialty providers can guide MCOs and state policymakers in developing strategies to improve network adequacy, including clarifying the level of network adequacy and developing policies to assess and regulate access to specialty care. Addressing gaps in access to specialty care can contribute to better health outcomes for Medicaid beneficiaries and may be aligned with provisions in value-based contracts.
Connect with Us
Medicaid consumers, providers, MCOs, and states all have an interest in ensuring access to specialty care for Medicaid beneficiaries. The methodology applied in the analysis for the HMA white paper can be applied and adapted for future analysis to monitor network stability and to compare access among various payers.
For details about this analysis, its implications for state and local policies, and additional research using T-MSIS, contact our experts below.
February 12, 2025
In Focus: Highlights from HMA Analysis of Specialty Services in Medicaid
Webinar Replay: Medicaid in Motion – Navigating Post-Election Policy Changes and Opportunities
This webinar was held February 26, 2025.
During this webinar, our experts as discussed the latest developments in Medicaid financing and policy. With Congressional leaders and new U.S. Department of Health and Human Services officials focusing on Medicaid, significant changes are on the table during the budget reconciliation process. These changes create both risks and opportunities for Medicaid stakeholders. Learn what Congress and the Administration are considering and how it impacts Medicaid markets.
Learning Objectives:
- Understand recent and potential federal statutory and regulatory policy changes affecting Medicaid.
- Identify potential impacts of these policy changes on Medicaid programs, payers, healthcare providers, industry, and beneficiaries.
- Explore changes in Medicaid funding structures and reimbursement mechanisms resulting from federal policy updates.
- Discover feasible practices and strategies to adapt to the evolving federal policy landscape.