Insights

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.

Show All | Podcast | Blogs | Webinars | Weekly Roundup | Videos | Case Studies | Reports | News | Solutions

Filter by topic:

Receive timely expert insights on topics you care about.

Select Topics

523 Results found.

Blog

Pennsylvania releases community HealthChoices (CHC) Medicaid managed care RFA

Read Blog

This In Focus section reviews the request for applications (RFA) that the Commonwealth of Pennsylvania Department of Human Services (DHS) released January 30, for the Community HealthChoices (CHC) Program. CHC is the mandatory managed long-term services and supports (MLTSS) program, which serves five CHC zones that cover all 67 counties in the commonwealth.  

Notably, this procurement, as compared to the original CHC procurement in 2018, has increased emphasis on innovative approaches to address health equity and the Social Determinates of Health (SDOH). The health equity focus goes beyond traditional health-related social needs such as access to housing, transportation, food, and employment, and addresses some SDOHs that have a particular impact on the CHC population, such as environmental conditions and addressing hazardous or unsafe living conditions.  

Behavioral health remains carved-out to separate behavioral health managed care organizations (BH-MCOs). Instead, CHC applicants will need to articulate how they will coordinate with the BH-MCOs to ensure access to appropriate BH services, which continues to be an area of significant interest for state Medicaid officials.  

Background 

The CHC Program serves individuals who are dually eligible for Medicare and Medicaid and people with physical disabilities who receive home and community-based waiver services or nursing facility care.  

Participants may receive LTSS in the community or in a nursing facility.

CHC is the sole program option for fully dual eligible beneficiaries and most nursing facility clinically eligible (NFCE) individuals who reside in the five zones. The regional CHC zones are as follows:  

  • Southwest zone: Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Fayette, Green, Indiana, Lawrence, Somerset, Washington, and Westmoreland counties.  
  • Southeast zone: Bucks, Chester, Delaware, Montgomery, and Philadelphia Counties.  
  • Remaining zones and respective counties, including
    • Lehigh/Capital zone: Adams, Berks, Cumberland, Dauphin, Fulton, Franklin, Huntingdon, Lancaster, Lebanon, Lehigh, Northampton, Perry, York
    • Northeast zone: Bradford, Carbon, Centre, Clinton, Columbia, Juniata, Lackawanna, Luzerne, Lycoming, Mifflin, Monroe, Montour, Northumberland, Pike, Schuylkill, Snyder, Sullivan, Susquehanna, Tioga, Union, Wayne, Wyoming.
    • Northwest zone: Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Forest, Jefferson, McKean, Mercer, Potter, Venango, Warren 

RFA

Medicaid managed care organizations (MCOs) may submit applications for one or more zones. Applications are due March 15, 2024. The department anticipates awarding agreements to three to five CHC-MCOs in each of the five CHC zones. Selected applicants must provide CHC services in all counties in the zone(s) for which they are selected to participate and improve the accessibility, continuity, and quality of services for participants in the CHC program. The contract will run for five years and will have three one-year renewal options.  

DHS indicates that the awarded CHC-MCOs must have an aligned dual-eligible special needs plan (D-SNP) and a current Medicare Improvement for Patients and Providers Act (MIPPA) agreement with the department. The aligned D-SNP must be operational and the MIPPA agreement must be in place by the anticipated implementation date (January 1, 2025).

DHS indicates selected MCOs must be as flexible and adaptable as possible and demonstrate the ability to coordinate services for multiple populations and across multiple programs, including programs with a focus that is broader than the delivery of healthcare services and LTSS. 

Other RFA highlights include the following:  

  • Does not require a cost submittal. 
  • Includes small diverse business (SDB) or veteran business enterprise (VBE) goals of 11 percent and 3 percent respectively. Applicants must include separate SDB and VBE submittals for each zone in its application.  
  • Includes a contractor partnership program (CPP) which requires entities that are awarded a contract or agreement with DHS to establish a hiring target to support Temporary Assistance for Needy Families (TANF) beneficiaries in obtaining employment with the contractor, grantee, or their subcontractors. 

Notably, DHS has provided itself flexibility within the RFA to implement a pay-for-performance incentive to MCOs. Under this policy, DHS could make incentives available to MCOs that help participants successfully complete the financial eligibility redetermination process with their local County Assistance Offices (CAOs). The department may implement additional pay-for-performance incentives in later years. 

Timeline

Evaluation 

For an applicant to be considered responsible for this RFA and eligible for selection of best and final offers (BAFOs) and negotiations:  

  • The total score for the technical submittal of the application must be greater than or equal to 75 percent of the available raw technical points  
  • The applicant’s financial information must demonstrate that the organization possesses the financial capacity to fulfill the good faith performance of the agreement 

The evaluation committee will evaluate technical submittals for each zone separately. For each zone, DHS must select for negotiations the applicants with the highest overall score. The weight for the technical criterion is 100 percent of the total available points. Technical evaluation will be based on soundness of approach, applicant qualifications, personnel qualifications, and understanding the project. 

The final technical scores will be determined by giving the maximum number of technical points available to the application with the highest raw technical score. The remaining applications will be rated by applying the formula located at RFP Scoring Formula

Financial information will not be scored as part of the technical submittal. It will be reviewed only to determine an applicant’s financial responsibility. 

SDB and VBE participation submittals will not be scored, however, if an applicant fails to satisfy the SDB or VBE requirements described, and DHS will reject the application. 

DHS will not score the CPP submittal. Once an applicant has been selected for negotiations, DHS will review the CPP submittal.

Current Market

The CHC incumbents are AmeriHealth Caritas, Centene, and University of Pittsburgh Medical Center (UPMC), serving 411,034 CHC members as of October 2023.

DHS has published a historical data summary for the CHC program along with other DHS reports at: Community HealthChoices Historical Data

Link to solicitation: All files on PA eMarketplace 

Link  to RFP 

Want to know more about how the next phase of Community Health Choices will impact your organization?

HMA’s Pennsylvania-based teams can assist organizations seeking to understand the implications of this important procurement, key program changes and what the outcome may mean for providers, community base organizations, and other stakeholders. Please contact Dianne Bisacky with questions or if you are seeking more detailed analysis of this procurement or the Community Health Choices program generally. 

Nine States to Participate in Children’s Behavioral Health Policy Lab

LANSING, MICH. – Health Management Associates (HMA), in partnership with the Annie E. Casey Foundation, Casey Family Programs, National Association of State Mental Health Program Directors (NASMHPD), the Child Welfare League of America (CWLA), the American Public Human Services Association (APHSA), National Association of Medicaid Directors (NAMD) and the Centene Foundation, will convene a Children’s Behavioral Health (CBH) State Policy Lab, Feb. 7-9 in Baltimore. HMA today announced that Georgia, Kansas, Kentucky, Maryland, Missouri, Pennsylvania, Texas, Utah, and Wisconsin will participate in the policy lab. MITRE, which previously hosted a related federal convening, will also take part in this state convening.

This pioneering effort, made possible by the partner organizations, aims to convene state interagency teams – including child welfare, juvenile justice, behavioral health, Medicaid, and K-12 public education – to collectively strategize, learn from innovators in the sector and promote cross-system alignment to drive outcomes for children, youth, and families.

COVID-19 has exacerbated long-standing system collaboration challenges across state child welfare, behavioral health, and Medicaid that lead to unsatisfactory outcomes for the most vulnerable children in our communities. Most worrisome is the worsening of behavioral and physical health challenges and trauma because of uncoordinated or fragmented care. This lack of coordinated strategy and policy leads to higher costs of treatment and also increasingly exposes states and local jurisdictions to threats or filings of class action lawsuits, and related settlements or those arising from Department of Justice investigations. Fortunately, federal and state efforts and investments to address the youth systems of care – including schools, community, delivery systems, and community-based child placing agencies – are in motion.

In November, a call for applications was released to U.S. states and territories for potential participation in the State Policy Lab. Applicants were required to identify demonstrated need, existing state agency governance structures focused on children and youth, technical assistance needs, and outcomes for attending the policy lab. The applications required demonstrated participation from Medicaid, child welfare and behavioral health agencies; a commitment to creating sustainable interagency solutions for children, youth, and their families and had to certify formal support from the Governor/Cabinet level.

An external independent panel reviewed applications for state agency participation using a standardized rubric that covered four domains:

  • Gaps and opportunities analysis
  • Intent of collaborative partnerships
  • Approach to engagement of youth and adults with lived experience
  • Imminent risks to public agency operations as a result of poor outcomes for children, youth, and their families

This convening is aimed at assisting child welfare, juvenile justice, behavioral health, Medicaid, and K-12 public education where possible to build upon existing efforts to improve outcomes for children, youth, and families, strategically layering on missing components and promoting alignment between them and with other agency priorities. Examples of what could be co-designed with state partners:

  • Build a shared strategic vision for a comprehensive continuum of care that ensures access to the “right service, at the right time based on individual and family need.” This vision can strengthen prevention initiatives and ensure the full array of evidence-based community-based interventions including use of crisis response and stabilization models.
  • Develop policies and strategies for improving the engagement of children, youth, and families with lived experiences to the “right part of the system for the right level of care,” agnostic of the door through which they enter any coordinated child serving system, while ensuring that all aspects of this system are anchored in equity.

Following the event, learnings and findings will be disseminated to help states and counties adopt innovative solutions to improve outcomes for children, youth, and their families.

For more information email: [email protected]

Blog

New HMA report analyzes the expanded landscape of value-based entities and market growth opportunities

Read Blog

This week, our In Focus section highlights a new report released on January 25, 2024, Analyzing the Expanded Landscape of Value-Based Entities: Implications and Opportunities of Enablers for the CMS Innovation Center and the Broader Value Movement. The analysis explores the growing ecosystem of new entities designed to assume accountability for the total cost and quality of care in order to understand the growth of this market and consider the role these entities play in advancing accountable care in Medicare, Medicaid, and the broader healthcare sector. The report combines the value-based payment (VBP) policy and market expertise of Health Management Associates (HMA) and Leavitt Partners, an HMA company, with support from Arnold Ventures.

At the start of the movement, value-based arrangements primarily involved traditional providers and payers engaging in relatively straight-forward and limited contractual arrangements. In recent years, the value-based care market has expanded to include a variety of risk-bearing healthcare delivery organizations and provider enablement entities, with capabilities and business models aligned with the functions and aims of accountable care. Despite their prevalence, little formal research has been conducted to determine the role, growth, and impact of these entities to date, and publicly available information is limited.

The report introduces a framework for classifying these entities and estimates the size of this market for the first time. Using insights from 60 interviews with entity leaders, providers, and policymakers, and extensive secondary research into approximately 120 organizations, the report details the common offerings, partnership models, and growth strategies of these entities. The research investigated primary care-focused entities as well as risk-bearing delivery organizations and VBP enablers focused on select specialty areas that align with total cost of care models (i.e., kidney care, oncology, cardiology, behavioral health, and palliative care). Authors examined providers’ experiences selecting and collaborating with enablement partners and the role of these entities within Medicare accountable care models, as well as the broader value movement, to inform a set of guiding principles that help providers and policymakers evaluate the attributes of ideal partners.

Market Landscape

For the past decade, the Centers for Medicare & Medicaid Services (CMS), through its Innovation Center (CMMI), has been leading the movement toward value. Going forward, the agency is focused on scaling accountable care adoption to achieve its 2030 goal, but also seeks to ensure that transformation is equitable and sustainable. These entities are helping providers to engage in accountable care, but our guiding principles and policy recommendations aim to support CMS in ensuring that their growth aligns with provider and patient priorities.

In assessing the value-based care market, the report divided the organizations into three main categories by their core business model: VBP enablers (which are not involved in the direct provision of care, but in assisting others to adopt VBP models); risk-bearing delivery organizations (entities designed to deliver value-based care and assume payment risk for the cost of care); and organizations that are a hybrid of the two (companies that own assets that enable other organizations and those that deliver care).

From risk-bearing delivery organizations with business models that hinge on effective population health management and longitudinal patient relationships, to VBP enablers that provide the population health functions needed to succeed in accountable care while sharing responsibility for those outcomes, these entities are creating more opportunities for clinicians to deliver the type of coordinated, proactive, whole-person care that is unsupported in a fee-for-service system.

A Growing Market

Fueling the growth of value enablers are signals from federal and state policymakers that value-based payment (VBP) is here to stay. The certainty of this approach is already leading to increased focus on underserved populations and safety net providers as CMS places greater focus on expanding VBP contracts in Medicaid and other public insurance programs.

As the market matures and pressure to participate in accountable care mounts, organizations will have several paths forward to implementation of alternative payment models. The growth and availability of enablement entities that are designed with the explicit purpose of helping providers overcome barriers to participation – and whose own financial success hinges on the success of their provider partners – could represent a promising gateway toward achieving accountable care.

The research found several similarities across most entities in this space, demonstrating a highly competitive market, with organizations focused on similar priorities in target providers, geographies, and key populations. Entities often use hybrid, high-touch clinical models to support physicians with patient navigators and other clinical extenders and support staff. They heavily rely on health information technology, and often develop homegrown, proprietary tech assets to better address provider pain points. Finally, most entities depend on outside capital and investment to fuel growth, and investor interest in the space seems to be robust and growing, along with the evolution of value-based care models.

Guiding Principles and Policy Recommendations

The report concludes by proposing a set of guiding principles to describe the optimal attributes of value-based enablement entities aligned with CMS, provider, and patient goals. Authors point to steps CMS can take to best engage with this expanded ecosystem in support of its efforts to scale accountable care while ensuring appropriate guardrails are in place to protect patients and providers.

As CMS works to accelerate adoption of accountable care to achieve its 2030 goal and beyond, the agency must find ways to bring in new providers who have yet to engage meaningfully in these models, while retaining current participants and advancing model designs for the next phase of VBP and delivery reform. The report makes policy recommendations to 1) drive new and sustained provider participation and 2) ensure high-quality partnerships for CMS and providers.

Link to Report

What’s Next

With its acquisition of Leavitt Partners and Wakely Consulting, along with its strong and growing Medicare policy practice, HMA is developing a diverse and robust set of solutions for entities engaging in value-based care and payment. On March 5 and 6, HMA will be devoting its spring event to the topic. The report authors will be featured prominently and will lead a session on the report’s implications. More information about the Spring Workshop, Getting Real about Transforming Healthcare Quality and Value, can be found here.

For details about this research, please contact report authors Kate de Lisle or Amy Bassano.

Blog

Driving change in healthcare delivery: HMA Spring Workshop on value-based care examines advancements in data analytics and technology

Read Blog

In the constantly changing healthcare environment, data analytics and technology are key tools to assist in controlling the burden of increased costs and identifying gaps in quality. As digital health tools and technology advance to include wearable devices, mobile health apps, telemedicine platforms, and other innovations, this enables the integration of digital solutions and real-time patient data. Artificial intelligence, still largely untapped, may have a significant impact as well.

Ideally better data will result in higher quality, better health outcomes, and an increase in provided value. To achieve this, effective health information technology platforms need to be interoperable and truly facilitate the exchange of patient information among providers and care coordinators. Data analytics tools and technology also must be consumer focused and focus on collecting and sharing data that is analyzable. These tools are a vital component of establishing new payment structures, allowing plans and providers to share some of the risk and the cost savings from producing better health outcomes. Identifying a core set of metrics that are patient-focused, measurable, and actionable along with optimizing data analytics tools can provide more efficient pathways to providing healthcare. Any company working in healthcare must elevate data and technology as a fundamental part of corporate strategy across all objectives.

You can explore best practices and emerging opportunities for data and technology at HMA’s 2024 Spring workshop on value-based care (VBC) March 5-6, in Chicago. Breakout discussions offer a unique forum for payers, government officials, community organizations, vendors, and providers to have an unvarnished conversation about the challenges, lessons, and opportunities in implementing value-based care. You will engage with HMA experts and peers in an intimate setting and come away with new ideas and new allies.

CLICK HERE TO REGISTER

The Data and Technology cohort will include two small group discussions facilitated by HMA leaders Ryan Howells, Stuart Venzke, and David Lee, as well as former US Chief Technology Officer Aneesh Chopra. The sessions are designed to arrive at specific recommendations as to how stakeholders can advance their own data and technology capabilities and jointly address systemic barriers to better meet the needs of those taking risk for outcomes:

  • Making Data More Patient Centric: Opportunities in Trusted Exchange Framework and Common Agreement (TEFCA) implementation in producing and supporting FHIR APIs to create a more patient-centered data ecosystem that achieves a tangible return on investment.
  • Making Data Central to Strategy: Developing a strategic organizational technology roadmap that will support both current and future data and technology priorities

Other cohort discussions will delve into approaches to develop and manage risk-based contracting across sectors, establish effective partnerships with safety net providers and community-based organizations, and navigating changes in local market and policy conditions that are shaping value-based care adoption and innovation.

To learn more go to HMA’s 2024 Spring Workshop page.

Blog

CMS announces innovation in behavioral health model

Read Blog

This week, our In Focus section highlights the Innovation in Behavioral Health (IBH) model, which the Centers for Medicare & Medicaid Services (CMS) announced January 18, 2023. It is the third state-based alternative payment model that the CMS Center for Medicare and Medicaid Innovation (Innovation Center) has released in recent months. HMA wrote about the Transforming Maternal Health (TMaH) Model here and States Advancing All-Payer Health Equity Approaches and Development (AHEAD) Model here.  

IBH Model Overview  

This model is designed to improve the quality of care and health outcomes for people with moderate to severe behavioral health conditions through person-centered care that integrates physical health, behavioral health, and health-related social needs (HRSN). Its objective is to improve care through healthcare integration, care management, health equity, and health information technology. 

CMS will select up to eight state Medicaid agencies for participation in this eight-year model that will begin in fall 2024. Participating states must partner with the agencies that are responsible for mental health and/or substance use disorder treatment to ensure coordination and alignment of policies. Model participants will develop and implement the IBH model in partnership with at least one Medicaid managed care organization or another intermediary as applicable. 

Community-based behavioral health organizations and providers in selected states can choose to engage as practice participants in the model. Community-based providers can include safety net providers, community mental health centers, public or private practices, and opioid treatment programs. Practice participants will be responsible for coordinating with other members of the care team to comprehensively address behavioral and physical health needs and HRSN, such as housing, food, and transportation for patients. Practice participants will conduct HRSN screenings, refer patients to specialists and community-based resources, and more. They will be compensated based on the quality of care provided and improved patient outcomes. 

Opportunities and Considerations  

The model will include three pre-implementation years during which states and practice participants will receive Medicaid and Medicare funding for development and capacity building. Medicare will provide practice participants with a per-beneficiary-per-month payment in pre-implementation years to support health IT, electronic health records (EHR), practice transformation, new workflows, and staffing investment necessary to implement the model. Starting in year four, the Medicaid alternative payment model must be implemented, and Medicare will begin making performance-based payments. 

Notably, the announcement materials do not indicate the maximum funding amount selected state Medicaid agencies are eligible to receive in IBH. The cooperative agreement funding for selected states will support implementation preparations, such as statewide health IT infrastructure, supporting practice participants, stakeholder convening, and developing the Medicaid alternative payment model.  

What’s Next  

The Innovation Center expects to release a Notice of Funding Opportunity (NOFO) in spring 2024. More details on the requirements, including payment methodologies and funding, are expected to be included in the NOFO.  

The HMA Behavioral Health and federal policy teams will continue to monitor developments in IBH and analyze the opportunities for states and providers in this model. HMA experts are also assessing the relative opportunities of the IBH model alongside other Innovation Center opportunities and initiatives already underway in states.  

The core design elements and objectives of the IBH are illustrative of the issues that HMA’s experts and industry leaders plan to discuss at HMA’s Spring Workshop, The HMA Spring Workshop: Getting Real About Transforming Healthcare Quality and Value.  

For more information on the IBH model, contact Amy Bassano, Melissa Mannon, Barry Jacobs, and Jennifer Hodgson. 

Blog

CMS approves next phase of New York’s Medicaid 1115 waiver journey

Read Blog

This week, our In Focus section describes New York State’s Medicaid Section 1115 waiver amendment authorizing at least $6.7 billion in funding for new programs and initiatives in the state’s Medicaid program. The Centers for Medicare & Medicaid Services (CMS) approved New York’s application for the amendment January 9, 2024, which is effective retrospectively to April 1, 2022, through March 31, 2027.

New programs and initiatives are intended to improve access to services for Medicaid enrollees and include:

  • Regional social care networks (SCNs) responsible for screening, referring, and providing new health-related social needs (HRSN) services to eligible Medicaid beneficiaries
  • A statewide health equity regional organization (HERO), which will provide data analysis, regional needs planning, stakeholder engagement, value-based payment recommendations; and program analyses
  • Workforce initiatives, including student loan repayment (SLR) and career pathways training (CPT) to recruit and retain healthcare professionals in high-need fields
  • Medicaid hospital global budget initiative (MHGBI) to provide funding to safety-net hospitals with negative operating margins to support their participation in waiver-related services
  • An institution for mental diseases (IMD) waiver for substance use disorder (SUD) services
  • A commitment from the states to sustain and enhance Medicaid provider payment rates to ensure access to services

Funding

CMS authorized at least $6.7 billion in funding. Some waiver components are without specific monetary valuation (i.e., IMD waiver, payment rate increases).

 DY 25 (ends 3/31/24)DY 26 (ends 3/31/25)DY 27 (ends 3/31/26)DY 28 (ends 3/31/27)Total
HRSN Infrastructure$0$260,000,000$190,000,000$50,000,000$500,000,000
HRSN Services$3,173,000,000
HERO$50,000,000$40,000,000$35,000,000$125,000,000
Workforce: Student Loan Repayment$12,080,000$24,150,000$12,080,000$48,310,000
Workforce: Career Pathways Training$175,770,000$310,480,000$159,500,000$645,750,000
Medicaid Hospital Global Budget Initiative$550,000,000$550,000,000$550,000,000$550,000,000$2,200,000,000
 $6,692,060,000

HRSN

  • NY will implement 13 SCNs in nine regions, which are expected to establish networks of community-based organizations (CBOs) that provide HRSN services.
  • Contracted SCNs, which will be awarded pursuant to a recently published request for applications, will receive infrastructure funding to invest in technology, business and/or operational practices, workforce development, and outreach and stakeholder engagement.
  • SCNs will be reimbursed according to a state-published fee schedule for delivering HRSN services on a fee-for-service basis.
  • SCNs are responsible for screening for HRSN and determining Medicaid beneficiaries’ eligibility level for enhanced HRSN services, spanning case management, nutrition supports, housing supports, and transportation.

HERO

  • NY will contract with a single statewide Health Equity Regional Organization (HERO), which is independent of state or other government entities.
  • The HERO will be responsible for five activities:
  • Collect, aggregate, analyze, and report data
  • Conduct regional needs assessments and planning
  • Convene regional stakeholders
  • Make recommendations to support advanced VBP arrangements and develop options for incorporating HRSN into VBP methodologies
  • Conduct program analyses

Workforce

  • The waiver approval identifies two pathways for workforce investment:
  • SLR program for people who will serve in certain healthcare workforce shortage professions
  • CPT program to support recruitment and advancement in healthcare careers

Medicaid Hospital Global Budget Initiative

  • The MHGBI will be available to certain safety-net hospitals that meet governance, solvency, and geographic requirements.
  • The MHGBI provides incentive payments to these hospitals if they:
    • Collect and report data
    • Meet milestones for transitioning to alternative payment models
    • Demonstrate improvement in healthcare quality and equity
  • As a condition of MHGBI, New York will apply for participation in the CMS Innovation Center’s AHEAD model.

IMD Waiver for SUD

  • CMS approved an IMD waiver for SUD services. As a result, NY will be eligible to receive federal financial participation for Medicaid members who are short-term residents in IMDs for services that would not otherwise be matchable
  • The state anticipates 50 providers will enroll within the first year

Curious About What the Waiver Means for Your Organization?

HMA’s New York Team can assist organizations assessing opportunities and understanding implications tied to these new, significant waiver investments. They have been working with key stakeholders to help inform the design of foundational components of the new wavier initiatives. HMA’s team of experts anticipate that the terms and conditions agreed to in the New York amendment provide important policy insight and direction for other states pursuing similar initiatives. Please contact Cara Henley and Josh Rubin with questions or if you are seeking more detailed analysis of the state’s waiver amendment.

Blog

Driving change in healthcare delivery: HMA Spring Workshop provides deep dive into metrics, coordination, and partnerships for value-based care

Read Blog
LEARN MORE ABOUT HMA’S SPRING WORKSHOP

Within the healthcare sector, there is an imperative for a comprehensive understanding of the care delivery framework that will positively impact outcomes, equity, and the overall health of communities. Among the drivers for this imperative is renewed focus among Medicare officials and interest from states and employers to transition to alternative payment methods that focus on value for payers and patients. A variety of care delivery structures and metrics can be used, and all have a role in driving value-based care (VBC).

One critical element of VBC hinges on whether and how healthcare organizations focus their care delivery structures on patients. VBC also incorporates metrics that further validate the ability of the system to positively impact patient outcomes, reduce health disparities, and improve population health. Emphasizing technology, interdisciplinary collaboration, and streamlined communication can revolutionize the care delivery model.

The HMA workshop-style spring conference on March 5 and 6, is designed to delve deeply into the intricacies of these care delivery frameworks and metrics within the context of VBC. This unique workshop will challenge attendees to roll up their sleeves and actively engage to become part of the solution through an interactive conversation, allowing participants to discuss real-world scenarios, analyze data and metrics and, using small-group breakout sessions, engage in focused and in-depth knowledge sharing.

Break-out sessions facilitated and led by subject matter experts will challenge attendees to identify new solutions around care delivery structures and contractual metrics that improve outcomes, that may include:

  • Engaging providers around consistent approaches to enhance patient outcomes, optimize treatment plans, and ensure the delivery of evidence-based, high-quality care.
  • Developing approaches for patient engagement that improve care delivery and foster active involvement and collaboration between patients and healthcare providers.
  • Crafting strategies for seamless coordination among healthcare providers, spanning sectors, and involving non-traditional providers and community organizations.
  • Understanding components of effective provider network agreements and how they contribute to achieving healthcare goals through strong partnerships and collaborations.

The workshop promises to be a dynamic platform for professionals in the healthcare sector, offering valuable insights, practical strategies, and collaborative opportunities to secure a place for high-quality value-based care. By focusing on care delivery structures, patient engagement, care coordination services, and provider network agreements, attendees will be well-equipped to navigate the complexities of healthcare and contribute to a healthier, more equitable future.

To learn more about the HMA 2024 Spring Conference Workshop and to register, click here.

Blog

Devising a framework for non-profit fundraising

Read Blog

Money is always “top-of-mind” among non-profit leaders, from CEO’s at Federally Qualified Health Centers (FQHCs) to Executive Directors at Community-based Organizations. To supplement projects and retain the ability to further their missions, non-profit organizations (NPOs) need funding. When non-profits and funding sources are not well aligned, programs are cut, curtailed, or never launched. Assisting clients in pursuing alternative funding sources requires a creative yet methodical approach to promote success and boost organizational sustainability.

Devising a framework for non-profit funding presents challenges. Funding models/strategies cannot be too general nor too specific. There is not a single approach, a one size fits all model or sourcing strategy for non-profits to pursue. Instead, non-profit leaders must clearly articulate the funding model or strategy that best supports the growth of their organization and use that insight to examine the potential funding opportunities preeminently associated with organization-specific success. For example, a community health center serving patients covered by Medicaid and a non-profit organization doing development work in housing for the homeless are both funded by the federal government, yet the type of funding each receives and the decision makers controlling that funding are very different. Utilizing the same funding methodology for the two would not be productive. Fortunately, there are multiple methods and strategies to acquire funds. Non-profits should be strategic in seeking approaches suitable to their needs and capabilities and be creative in pursuing more than one model to acquire supplemental funds.

The core success of NPOs is based on a range of funding options, private grants and government grants, corporate sponsorships, private funding, endowments, and community fundraising. There is also a considerable amount of money available from the public sector, businesses, charitable trusts, foundations, in-kind donations, and local and state legislative bodies. The goal of any successful fundraising campaign is to convey fully what the money is or will be supporting and clearly articulate the projected positive outcomes that will be derived from the funding. Once the project is fully clarified, the next step is research. Many funding avenues exist. The NPO must decide which funding sources are best suited for each project and pursue those options.

When choosing potential funding sources, NPOs must consider the size of their organization, their mission, and various other defining characteristics. Once this internal due diligence is completed, revenue needs should be clarified, and a tactical fundraising strategy outlined. Creating a “ratio” with the end-result in mind allows for revenue diversification and avoids the too heavy reliance on one income source. For example, an NPO might project obtaining 50% of needed revenues from grants, 20% from a corporate sponsorship, and the remaining 30% from a foundation. Once the funding sources have been identified, the types of decision makers and the motivations of these decision makers must be evaluated. Then, a tactical roadmap designed to obtain the needed funding should be implemented. 

As society looks to the non-profit sector to solve important problems, a realistic understanding of funding models is increasingly important to realizing these aspirations. As consultants whose mission is to turn challenges into triumph for our clients, championing efficacious, high-yielding funding models ensures long-term viability for the organizations we serve.

Success relies on planning. It is much better to be proactive than reactive. Consider your organization’s funding needs, do your research, and lay the groundwork before diving into any fundraising pursuit. An assessment of your organization’s current funding strategies is essential. What is working; what is not? Is the current funding source reflective of the organization’s mission and values? Use the answers to these questions to make decisions and recommendations on which fundraising strategies to source. Get creative! Brainstorm unconventional ways your organization will stand out to potential funders, but be analytical. Balance creativity with data, keeping in mind which funding strategy reflects the best return. Focus time and energy on the funding model that will be most reliable, profitable, and feasible.

The non-profit world rarely engages in a succinct conversation about an organization’s appropriate long-term funding strategy. That is because the different types of funding that fuel non-profits have never been clearly defined. More than a poverty of language, this represents and results in a poverty of understanding and clear thinking. As consultants, HMA can provide an outside perspective and sort through the minutia presenting a clear, methodical, appropriate path to fundraising success.

Potential links to aid in your fundraising endeavors:

https://www.fqhc.org/funding-opportunities
https://www.samhsa.gov/grants
https://www.usgrants.org/business/mental-health-services
https://www.ruralhealthinfo.org/topics/mental-health/funding
https://about.bankofamerica.com/en/making-an-impact/grant-funding-for-nonprofits-sponsorship-programs
https://theathenaforum.org/grants

HMA works with a wide variety of healthcare clients, including FQHCs, community-based organizations, hospitals, provider practices, behavioral health, and managed care organizations, and can help with:

  • Grant Writing
  • Technical Assistance
  • Strategic Planning
  • Financial planning, Implementation and Optimization

For more information about how HMA can help your organization’s grant and funding strategies, contact our experts below.

Blog

Rhode Island releases Medicaid managed care program RFP

Read Blog

This week our In Focus section reviews the Rhode Island statewide, capitated risk-bearing Medicaid managed care program request for proposals (RFP), which the Rhode Island Executive Office of Health and Human Services (EOHHS) released December 15, 2023. New program changes will include carving in long-term services and supports (LTSS) as an in-plan benefit for all populations and expanding managed care to include people who are dually eligible for Medicare and Medicaid. Contracts are expected to be worth $2.3 billion.

Background

Rhode Island’s Medicaid managed care program, which operates under the authority of a Section 1115 waiver and Section 1932(a) state plan amendment, consists of the following programs:

  • RIteCare, which serves children and families, including children with special healthcare needs
  • Rhody Health Partners, which serves aged, blind, or disabled (ABD) adults
  • Medicaid expansion, which serves childless adults ages 19 to 64

At present, full-benefit dual eligible (FBDE) members are not covered through the Medicaid managed care organization (MCO) contracts.

RFP

New contracts will be implemented in three phases, starting with enrollment of core populations and the addition of LTSS in-plan benefits to Medicaid managed care for Medicaid-only enrollees beginning July 1, 2025. In the second phase, current fully dual eligible members will transition to Medicaid managed care plans on January 1, 2026. All bidders will be required to offer an integrated Dual Eligible Special Needs Plan (D-SNP) and managed LTSS (MLTSS) plan to dually eligible members, as Rhode Island transitions from the Financial Alignment Initiative (FAI) Medicare-Medicaid Plan (MMP) Demonstration, which sunsets December 31, 2025. In addition, beginning January 1, 2027, default enrollment will begin for Medicaid members who become newly eligible for Medicare.

EOHHS will award contracts to two or three MCOs.

Other changes in the RFP include increasing oversight and accountability for the use of pharmacy benefit managers (PBMs); requiring that EOHHS approve contracts for MCO major subcontractors; reducing unnecessary prior authorizations, particularly for behavioral health services; increasing financial sanctions for noncompliant MCOs; and increasing investments in population health and health equity with a focus on the identification of health disparities; and other changes.

Timeline

Proposals are due February 23, 2024. The new contracts will take effect July 1, 2025, and will run through June 30, 2030, with an option to extend the agreement for up to five additional years.

Current Market

Neighborhood Health Plan, Tufts Health, and UnitedHealthcare served approximately 313,000 members as of November 2023. These MCOs have signed contract extensions through June 30, 2025.

Evaluation

Rhode Island will not require cost proposals under this procurement, with capitation rates set by EOHHS actuaries. MCOs must meet the passing technical score of 85 points. Technical proposal requirements are shown below:

Link to RFP

Blog

Driving change in healthcare delivery: payment models and managing risk at HMA Spring Workshop on value-based care

Read Blog

Is the concept of value-based care (VBC) still relevant in today’s healthcare landscape or just a buzzword? Some argue that the financial challenges brought about by the pandemic have steered our healthcare delivery systems away from prioritizing value. However, many experts remain optimistic that value-based care is the key to achieving our overarching objectives of a more equitable, sustainable, high-quality healthcare system.

Kelsey Stevens, a principal at Wakely, an HMA Company, led a session on value-based care at the HMA Fall Conference. Her panelists felt strongly that value is critical to a functional and patient-focused healthcare system because the alternative is out of control spending and poor health outcomes. In fact, value-based care is flourishing in new ways as we look to integrate behavioral health and address health related social needs. There are lessons to be learned from early experiments, new models being built, and new models to be designed.  Both public and private payers are pursuing new ways to take financial risk to deliver improved healthcare outcomes, focusing on solutions for higher risk populations or circumstances where quality of outcomes are indefensibly poor (i.e., maternal outcomes).

This enthusiasm felt by the wide variety of executives present at that fall meeting has inspired HMA to focus an entire conference on value. But not just another conference on value. Our internal experts felt strongly about hosting a forum for healthcare organizations to truly tackle the end-to-end challenges of VBC… so we are doing that.

Those who join us March 5-6 in Chicago will experience a workshop designed to “get real” about transforming healthcare quality and value. We are convening participants from all parts of the healthcare industry who have the collective experience to pinpoint common challenges and to build a path forward.

The workshop is organized into four cohorts:

  1. Payment and Risk Management Models,
  2. Policy and Strategy Frameworks,
  3. Data and Technology, and
  4. Care Delivery Frameworks

Each will produce concrete recommendations for action, as well as building new relationships among peers to sustain this change. In the cohort on Payment and Risk management, discussion will be focused on existing and new models for payment, pricing and attribution methodologies, risk mitigation levers along the value continuum, and approaches to engage employees in focusing on patient-centered value in the care they provide.

One of our fall panelists, Eric Mattelson, chief actuary at Zing Health, said “I’m still convinced that value-based care is the future of healthcare and the Sisyphean struggle to get there will ultimately be worthwhile.” We echo this sentiment wholeheartedly, and if you share this conviction, we encourage you to secure your spot today and become a part of this exciting and transformative event.

Our sessions and networking events offer an opportunity to delve into approaches to develop and manage risk-based contracting across sectors, establish effective partnerships with safety net providers and community-based organizations, apply a value lens to deployment of technology and data analytics, and develop health equity plans aligned with value principles and policies.

Future blogs in this series will touch on elements from the other 3 cohorts on VBC that make up the balance of the workshop. To learn more and register go to HMA’s 2024 Spring Workshop page.

Blog

Discover the challenges and opportunities associated with implementing value-based care at the HMA Spring 2024 workshop

Read Blog

Policymakers have been working to move the U.S. healthcare system away from the costly and inefficient framework of fee-for-service to patient-centered structures focused on value and quality. Financial pressures, government regulation, and improvements in managed care all contribute to the drive toward value-based care, and that creates challenges for providers, payers, manufacturers, government, and others supporting the industry. Though some stakeholders are hanging on to the old ways of doing things, others are rightly moving toward putting their emphasis on value, changing their payment and workforce structures, and improving quality.  

Health Management Associates will host the spring workshop, Getting Real About Transforming Healthcare Quality and Value, March 5−6, 2024, at the Fairmont Chicago Millennium Park Hotel in Chicago. The workshop starts with a kickoff event the evening of March 5 designed to foster meaningful connections for attendees, regardless of their role as a government official, provider, health system representative, payer, or vendor in public or private healthcare markets.  

The full-day program on March 6 will feature a compelling keynote speaker and include multiple interactive workshop sessions focused on four key pillars of value-based care: Policy & Strategy Frameworks, Payment & Risk Management, Data & Technology, and Care Delivery Measures. HMA has expertise in working with commercial payers; primary, specialty, and behavioral healthcare providers; and publicly sponsored health plans at the local, state, and federal levels. Session discussions will help participants adapt to the new value-based market and are designed to provide a comprehensive exploration of the intricacies involved in healthcare transformation. Attendees will discuss what to expect during the early phases of transformation, as well as strategies, collaborations, and actions that have moved them closer to adding value on the ground.  

Participants will be challenged to think critically about their organization’s cultural and operational readiness to create additional value for patients within the healthcare ecosystem. Drivers of policy, innovation, population health, risk management, IT, and data, as well as enablers and other stakeholders working in public and commercial markets, will meet in smaller groups to discuss and analyze scenarios, pose challenging questions, and identify tactical steps and solutions to thorny issues.  

Other groups focusing on value will address multi-sector issues and perspectives that affect value-based care, including behavioral health, primary, and specialty care. From navigating the complexities of employee insurance plans for businesses to advocating for the needs of individual consumers, this workshop will address the formidable challenge of reshaping the healthcare landscape.  

Don’t miss this opportunity to gain valuable insights and contribute to genuine and productive discussions that will shape the future of healthcare.  

Whether you attend on behalf of your organization or with a team of colleagues whose roles touch upon different links in the value-based chain, you will bring back ideas and strategies that can be implemented upon your return. Register today! 

Blog

HMA, Wakely, The Focus Group Consultants Available for Meetings at the JPM Healthcare Conference in January 2024

Read Blog

Health Management Associates consultants, including colleagues from Wakely and The Focus Group, will be attending the JP Morgan Healthcare Investor conference in San Francisco, January 8-10, 2024. In addition to meeting with clients, HMA will be cosponsoring a reception with Shepherd Mullin as well as participating on a panel hosted by KPMG.

“While we’ve acclimated to a more virtual business world, the JP Morgan conference represents a unique opportunity to get together in person with valued clients and partners to discuss healthcare policy dynamics, emerging investment themes, and the exciting capabilities HMA has added over the last year to support its investment clients,” said Greg Nersessian, Managing Director of HMA Investment Services. “Rain or shine, we look forward to getting together and learning more about the trends that will shape healthcare investing in 2024.”

Tim Murray, a former JPM analyst, and now a Principal and healthcare actuary at Wakely Consulting Group, an HMA Company, says “The one inalienable truth about JPM’s annual event is that it sets the stage and tone for health care investing in the upcoming year…I’ll be focused intensely on how investors see the myriad headwinds facing government-sponsored healthcare programs playing out in ’24…they will surely inhibit growth but may also set the stage for opportunistic deal flow.”

The Focus Group is a strategic consulting firm working on business transformation in healthcare and private equity portfolios, acquired by HMA in late 2021. Its Managing Director Alex Rich added “our team is eager to reflect on recent deals and provide perspectives on new theses. Based on our wide array of recent projects and experiences, we’re excited to share and prepare creative strategies for portfolio value creation in the year ahead.”

Also in attendance will be the following HMA consultants:

To set up a meeting with any of our team, please click here. For further information on HMA Investment Services, please contact Greg Nersessian.

Blog

Medicaid Business Transformation DC: recommendations for technical assistance

Read Blog

HMA was engaged by the Washington, District of Columbia Department of Health Care Finance (DHCF) to lead their Medicaid Business Transformation D.C. Initiative, assessing the technical assistance needs of Medicaid providers and organizations in the areas of legal analysis, budgeting, and business development as they move toward value-based care arrangements. HMA partnered with the D.C. Behavioral Health Association (BHA), Medical Society of the District of Columbia (MSDC), D.C. Primary Care Association (DCPCA), and DHCF to engage, recruit, and collaborate with organizations and stakeholders across the District.

The HMA team implemented a mixed-methods assessment approach that included a literature review of national value-based payment (VBP) best practices, focus groups, interviews, and a technical assistance (TA) survey of District organizations, agencies, and stakeholders. This strategy identified the TA needs of District healthcare providers that informed the design of an intensive 3-month technical assistance program that included a variety of tools, webinars, and trainings. All resources and tools are available on the Integrated Care DC webpage. https://www.integratedcaredc.com/medicaid-business-transformation-dc/  The report and other information about the program were published at https://dhcf.dc.gov/innovation.

Experts from HMA as well as Wakely Consulting Group and Lovell Communications, both HMA subsidiaries, contributed to this report. We offer our clients a wide range of deep technical, analytical, policy, and communications support to providers, state agencies, and recommendations on ways to improve value-based payment models.

Report authors include Caitlin Thomas-Henkel, Suzanne Daub, Art Jones, Hunter Schouweiler, Amanda White Kanaley, and Vicki Loner.

To learn more about this effort, contact Caitlin Thomas-Henkel.

Link to Medicaid Business Transformation DC: Recommendations for Technical Assistance Report

Be sure to block off March 5-6 for HMA’s Spring Workshop in Chicago, IL, where our experts will be continuing the dialogue about value-based care. Early bird registration ends January 26, 2024 – Register Here.