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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.

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Blog

HMA experts in data integrity and data governance presenting at NATCON24 in St. Louis, April 15-17

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At the upcoming NATCON24 convention, HMA principals Robin Trush and Jodi Pekkala will present “Achieving Data Integrity and Staff Satisfaction through Technology Data Governance.” Health equity, alternative payments, and social determinants of health are all healthcare “North Stars” in healthcare grounded in data collection. To achieve standard metrics and address patient care coordination, EHRs, population-health platforms and other technology innovations must be used accurately, consistently and be configured properly. Cross-department database governance is grounded in standards to ensure data integrity. Too often, organizations have been unable to successfully stand-up technology and maintain consistent use over time, resulting in staff dissatisfaction and turnover.

This presentation will provide an overview of proven methods for bringing technology governance and leadership into clinical planning and operations, resulting in staff satisfaction, and putting your organization on the path toward those North Stars. Presenters will share lessons in how to bring technology management into clinical planning and operation. This enhanced organizational integration model will drive better outcomes and support the staff experience.     

Learning Objectives:

  • Describe current industry initiatives with technology infrastructure requirements.
  • Define and address common technology pain points for organizations and staff.
  • Define guidance for data governance, data integrity, and staff satisfaction.
  • Provide tools to take an organizational “pulse” and create a path to improvement.

Please join this workshop at NATCON24 on Monday, April 15, 2024 from 4:15 – 5:15 PM CT Location: 100/101, Level 1, ACCC

As longtime leaders in health and human services, HMA’s behavioral health, IT and data experts bring front line and leadership experience to their work supporting Health and Human Services IT projects. Combine this with the broad programmatic and operations expertise of the HMA team—which includes former clinicians, Medicaid directors, and leaders of provider and payer organizations—and we are able to deliver targeted, relevant, actionable advice to our clients. We aim to advance equity and improve quality in state, county, and local program development. Contact us to learn more.

Solutions

Achieving and Sustaining Success in the Health Insurance Marketplaces: Considerations for States and Managed Care Organizations

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The successful operation of the health insurance marketplaces created by the Affordable Care Act remains a key federal and state policy priority and an important business opportunity for managed care organizations (MCOs). At Health Management Associates (HMA), we are prepared to support both states and MCOs to achieve success in the operation of and participation in the marketplaces as these markets continue to evolve in the coming months and years.

Our team is made up of former state-based and federal marketplace leaders, insurance commissioners, state Medicaid directors, other senior government officials, payer executives, and provider leaders—meaning that we have the first-hand experience to navigate the complexities of marketplace establishment, operations, and participation toward successful outcomes. Our consultants have had expansive experience in this market since its inception. We have worked as and for federal and state regulators, enabling us to understand regulator goals. Additionally, we have worked for and with local, regional, and national MCOs on market entry strategy and/or profitability strategy. Our team has looked at the same problems from many angles and has the broadest historical perspective on the challenges and opportunities in this market.

CONSIDERATIONS FOR STATES

For states, operating a state-based marketplace (SBM) that flexibly meets the health coverage needs of the population in an efficient and responsive way is a common and critical goal. HMA understands the importance of establishing and continually operating a strong and lasting SBM capable of weathering and protecting against current and future threats to access and affordability. Key SBM policy outcomes include:

Local Control and Better Coordination

SBMs can increase enrollment and reduce gaps in coverage for families through closer alignment with the Medicaid program, customer-centric policies and procedures, and local, tailored engagement and outreach.

Lower Costs and Improved Consumer Protections

SBMs can establish plan design standards, coverage requirements, and consumer protections to improve choice and competition, lower out-of-pocket costs, and protect access to the affordable care individuals need and deserve.

Universal Coverage

Through innovative enrollment initiatives, federal waivers, and affordability programs, SBMs can be a catalyst for additional reforms to put the state on the pathway to universal coverage.

To be able to successfully accomplish the policy aims outlined above, states must excel across and within a range of strategic and operational areas including: organizational development and implementation, governance and project management, vendor procurement and oversight, strategic policy development, maximizing federal funding and financial management, federal compliance, stakeholder engagement, and communications and training. HMA can support states in all these areas with services that enable operations, regulatory compliance, strategy, and policy advancement.

CONSIDERATIONS FOR MCOS

For MCOs, the marketplace represents a key business opportunity where existing capabilities can be leveraged as part of a successful growth strategy. With our extensive regulatory expertise and expansive state market knowledge, HMA understands that customized support is necessary to allow MCOs to succeed in the marketplace as either a new market entrant or an existing participant. For MCOs, the marketplace has the following features:

A Highly Regulated Environment

At the federal and state levels, the marketplace environment has strict standards in terms of plan design, rating rules, network adequacy, marketing practices, producer (broker and agent) activities, and marketing practices.

Significant Public Funding

As a result of the marketplace premium tax credits, most marketplace consumers qualify and as a result, significant public funding is involved.

An Evolving Market

The end of the Medicaid continuous enrollment condition as of March 31, 2023, which has been in effect throughout the Coronavirus Disease 2019 Public Health Emergency, makes providing coverage in the marketplace even more critical—as millions of individuals transition to this market after losing Medicaid coverage.

How HMA can help

HMA can support clients every step of the way in the planning and execution of efforts to participate in and optimize performance for the marketplace. To achieve and maintain success in the marketplace, MCOs must excel across strategic, operational, and analytical areas including:

Market analysis and feasibility

Operational gap analysis

Product management scoping

Vendor procurement

Regulatory filings development and implementation

Actuarial analytics

Provider contract reimbursement analysis, and

Network development

HMA can bring to bear a comprehensive continuum of services to solve your most pressing marketplace challenges.

If you have questions about how HMA can support your state or MCO related to the marketplace, please contact Zach Sherman, managing director or Patrick Tigue, managing director.

Contact our experts:

Zach Sherman

Zach Sherman

Managing Director

Zach Sherman is an Affordable Care Act (ACA) expert and Health Insurance Marketplace leader with extensive experience with start-ups and … Read more
Patrick Tigue

Patrick Tigue

Managing Director, Regional Managed Care Organizations

Patrick Tigue is an accomplished executive with experience leading and managing critical efforts to achieve strategic health policy goals on … Read more
Blog

CMS Innovation Center announces ACO PC Flex model to improve access for Medicare beneficiaries

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This week, our In Focus section looks at the voluntary Accountable Care Organization Primary Care Flex (ACO PC Flex) Model, which the Centers for Medicare & Medicaid Services (CMS) Innovation Center announced on March 19, 2024. This model is designed to increase the number of low revenue ACOs in the Medicare Shared Savings Program (MSSP). Model participants will receive a one-time advanced shared savings payment and monthly prospective population-based payments. The ACO PC Flex Model is intended aims to support care delivery transformation, innovation, and team-based approaches to improve quality and reduce costs of care.

The ACO PC Flex Model is structured to increase the number of low revenue ACOs (i.e., ACOs composed of physicians, a small hospital, and/or serve rural areas). CMS published results in August 2022 indicating  that low revenue ACOs generated $113 more per capita savings than their high revenue counterparts.  CMS wrote in July of 2023 that the agency was seeking new opportunities for ACOs to serve Medicare beneficiaries. With this model, the Innovation Center is providing flexible payment to support innovative, team-based, person-centered, and proactive approaches to care for a subset of ACOs that have historically generated savings.

ACO PC Flex Model payments are structured to provide advanced shared savings to support administrative activities necessary for the model and ongoing payments specifically for primary care. The payment approach includes:

  • A monthly prospective primary care payment consisting of 1) a county base rate determined by average primary care spending, and 2) payment enhancements to support increased access to primary care, provision of care, and care coordination, which are exempt from CMS recoupment
  • An advanced shared savings payment as a one-time advance the changes needed to support needed operations and administration

With the approach, the Innovation Center anticipates CMS will be able to improve access to primary care services, particularly for underserved communities, and empower providers through flexible, stable payments to innovate care delivery to better meet their patients’ needs.

The demonstration will start January 1, 2025, and run for five years. The request for applicants (RFA) is expected in the second quarter of 2024, and ACOs must apply for participation in MSSP as a new or renewing organization to be eligible for ACO PC Flex. Applications for MSSP close June 17, 2024.

More details are expected to be included in the RFA. If you are interested learning more about the ACO PC Flex Model, please contact Amy Bassano and Melissa Mannon.

Podcasts

Is food the missing link in healthcare’s cost crisis?

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R.J. Briscione is a principal with the HMA Strategy and Transformation Practice. R.J. shares insights gained from his experience in Medicaid managed care, CVS business development, and how he made the leap into healthcare from aeronautics. R.J. shares key insights on addressing food insecurity, nutrition education, and tailored food interventions that measurably drive better health outcomes. Join us as we highlight the vital role of food in healthcare and uncover actionable strategies for community organizations looking to impact patient outcomes by improving upstream determinants of health.

Podcasts

Can continuous quality improvement transform healthcare equity?

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Leticia Reyes-Nash is a principal in HMA’s community strategies practice and an expert in healthcare equity and innovation in healthcare service delivery. Leticia shares her inspiring journey from political and community organizing to her work in health policy, highlighting the importance of addressing health equity and the challenges within healthcare systems. She discusses strategies for integrating equity into business practices, emphasizing the need for continuous quality improvement, humility, and patience in healthcare initiatives.

Podcasts

What would it take to make the ACA more affordable?

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Liz Wroe is a principal at Leavitt Partners DC office and former Senate health policy director. Liz talks about the evolution of the Affordable Care Act (ACA), sharing her experiences during the ACA’s passage, repeal efforts, and stabilization of the individual market. She discusses challenges in bending the cost curve, the impact of ACA subsidies and silver loading, and the need for more honest conversations in healthcare policy.

Podcasts

Why is Behavioral Health So Hard to Fix?

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This episode of Vital Viewpoints on Healthcare features Dr. Gina Lasky, managing director at Health Management Associates, offering her unique perspective on the persistent challenges surrounding behavioral healthcare. Drawing from her extensive experience and research, Dr. Lasky delves into the complex reasons behind the fragmentation of our behavioral health system and the role incentives play in exacerbating this issue. This episode is for anyone exploring innovative strategies to reform the current reimbursement framework to align incentives for patient-centered outcomes to foster collaboration across disciplines to promote whole-person well-being.

Webinar

Webinar replay: Leavitt Partners – The future of Medicare Advantage supplemental benefits

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This webinar was held on April 4, 2024.

This webinar was offered by Leavitt Partners, an HMA company.

More than 30 million Americans are enrolled in MA plans and more than half of Medicare-eligible beneficiaries participate in the program—a number that was less than 30 percent just a decade ago. One reason Medicare beneficiaries opt to participate in MA plans is the ability to offer supplemental benefits, including dental, vision, hearing, transportation services, OTC items, an in-home support services. Initially limited to a core set of offerings, over the years, MA supplemental benefits have undergone significant changes that have led to a broader range of allowable benefits, an expansion of how benefits can be targeted, and, growth in the number of plans offering such benefits.

This webinar covered how to understand MA supplemental benefit growth and the current regulatory environment, including opportunities and threats; discovered the opportunities and challenges MA plans face in offering supplemental benefits; and learned about the issues supplemental benefit providers face in administering supplemental benefits.

Read the Leavitt Partners white paper discussed in the webinar: A Vision for the Future of Medicare Advantage Supplemental Benefits: Advancing Value, But Validating Results

Speakers:
Matt Gallivan, Director, Leavitt Partners, an HMA Company
Andrew Friedell, COO, The Helper Bees
Michael Bagel, Associate Vice President, Public Policy, Alliance of Community Health Plans

Webinar

Webinar replay: Substance Use Disorder (SUD) Ecosystem of Care-Pivoting to Save Lives Part 2: Empowering Change in the SUD Ecosystem

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This webinar was held on April 10, 2024.

As covered in the first webinar of this series, we have an imperative to think and act differently to change the trajectory of not just the long-standing opioid epidemic, but other existing and emerging harmful substance use and addiction. Grounded in equity, empowering change in the SUD ecosystem requires person-centered and community driven approaches to respond to individual wants and needs. We must meet each person where they are as well as consider how the ecosystem of each community can be leveraged to drive change.

In this webinar, we shared examples of best practices that could be improved upon by integrating a person-centered approach; explained how “meeting people where they are” applies to equitable practices, individualized care, and community solutions; and discussed “equity grounded” in the context of the SUD ecosystem including addressing structural barriers, dominant narratives, and incorporating community voices and partnerships.

Below is a report referenced during the webinar:

You may also be interested in the upcoming webinar, “Equity Considerations for Addressing Opioid Use Disorder”. Register now.

Watch previous webinars and register now for upcoming webinars in the series.