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Blog

HMA celebrates Native American heritage month

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Health Management Associates (HMA) has a rich history of serving the healthcare infrastructure needs of Native American and Alaska Native communities – through healthcare IT support, clinical governance for change management, culturally competent stakeholder engagement, and revenue cycle management that implements an approach that is tailored to the provider and payer entities that deliver care in Native American and Alaska Native communities.

American Indian and Alaska Native (AI/AN) people experience disproportionately poorer health status compared to Americans as a whole. AI/ANs born today have a life expectancy that is 5.5 years less than the national average for all races. HMA has expertise with healthcare issues that uniquely impact American Indian and Alaska Native populations and is experienced in addressing these issues through American Indian and Alaska Native leadership engagement that is culturally sensitive and respectful.

Case Studies

Examples of HMA’s work with tribal health providers include:

Skokomish Tribal Health Center: Policy, Programs, Operations, And Training

HMA provided training and technical assistance to Skokomish Indian Tribal Health Center in Skokomish, Washington. This support includes the provision of clinical oversight services by one of HMA’s clinicians as Interim Medical Director.

HMA: (1) assessed the Tribal Health Center’s billing practices and assisted in the development of a procurement and contract with a new third-party billing vendor; (2) developed a screening and intervention program for medications for addiction treatment (MAT) of opioid and alcohol use disorders, including training for providers and administrative and medical staff; (3) established policies and procedures to support the clinic to move to a primary care medical home model of care, including development of a back office manual and trainings to clinic staff and providers; and (4) provided technical assistance to the Tribal Health Center as it developed telehealth programs for both video visits and remote patient monitoring (RPM), including development of policies and procedures for maintaining operations during emergencies, procedures and workflow approaches for working with IT vendors and potential purchase and implementation of a new electronic health record.

Fort Belknap Tribes: Assessing Behavioral Health Infrastructure

HMA conducted a feasibility assessment to determine how best Fort Belknap Tribal Health Department could take over administration of behavioral health services through a 638 contract with the Indian Health Service (IHS) agency. To do this, HMA conducted a review of select documentation, contracts, and data sets, including clinical and financial data. Through site visits, HMA conducted focus groups and interviews with tribal, IHS, and community stakeholders. HMA also provided research of other tribal behavioral health programs and interviews with tribes successfully delivering comprehensive behavioral health services.

Chickasaw Nation Department of Family Services: Implementing Practice Changes

HMA provided consultation regarding integration of behavioral health into primary care sites, sharing expertise and advice on privacy and confidentiality regulations and integrated care, how to manage during the transition from traditional behavioral health to integrated care, ideas for including medical family therapy more broadly in patient care, and the implementation of patient assessments.

Montana Healthcare Foundation: Identifying and Developing Opportunities with Tribal and Medicaid Leadership:

The Montana Healthcare Foundation (MHCF) convened tribal health care leaders to develop shared priorities to jointly pursue with the Montana Department of Public Health and Human Services (DPHHS) and the Legislature.  HMA was engaged by MHCF to help the group assess implementation options related to the Centers for Medicare and Medicaid Services’ (CMS) revised interpretation of the 100 percent federal match for state Medicaid programs for American Indian Medicaid enrollees for services. HMA proposed options for how DPHHS can use the new match funding to support IHS and tribal health facilities as they implement these new processes and support shared priorities. Priorities identified by the tribal health leaders included operational and policy issues such as improving health information technology capacity; identifying opportunities to compact aspects of health care delivery from IHS; and improving clinic operations through business management training.   

Montana Office of Public Instruction SAMHSA Tribal Systems of Care Grantee: Systems of Care Evaluation

HMA served as the independent evaluator for Montana Office of Public Instruction (OPI) Substance Use and Mental Health Services Administration (SAMHSA) Tribal Systems of Care Evaluation. The five-year evaluation assesses the impact of High-Fidelity Wraparound services being provided to American Indian students in schools on six tribal reservations throughout the state. Evaluation activities include tracking quantitative data to measure progress toward grant goals and tracking qualitative data to assess impact of wraparound activities through key informant interviews, small group listening sessions, and site visits. Evaluation findings are regularly reported to SAMHSA and presented locally to key stakeholders.

Montana Tribally Operated Substance Use Disorder (SUD) Continuum of Care Concept Brief

HMA worked in coordination with the American Indian Health Leaders (AIHL) workgroup, a group made up of leadership from Montana’s seven tribes representing tribal health departments and urban Indian health centers, to develop a SUD Continuum of Care Concept brief, describing potential approaches for design and financing of a jointly tribally operated SUD treatment facilities. This work was conducted through a contract with Montana Healthcare Foundation.

Montana Tribally Operated Substance Use Disorder Continuum of Care

HMA provides technical assistance and facilitation and consulting expertise to support the development of a statewide joint tribally operated SUD Continuum of Care. HMA facilitated discussions with AIHL and Chemical Dependency Center (CD) directors. HMA provided subject matter expertise on the various design options available based on American Society of Addiction Medicine (ASAM) service needs criteria as well as analysis support. HMA is also providing consulting support on financial and operational planning for the development of new facilities. This work could include methods for short-term and long-term forecasting and scenario modeling, identification, and negotiation of capital and operational financing for construction and start-up phase, and technical assistance on revenue cycle best practices to ensure satisfactory patient experience and sustainable revenue. This work is being conducted through a contract with the MHCF.

Health Policy and Advocacy

HMA consultants have worked with the following organizations associated with American Indian health policy and advocacy issues:

American Indian Health Commission of Washington State

A tribally driven non-profit organization with a mission of improving health outcomes for American Indians and Alaska Natives through a health policy focus at the Washington state level. AIHC works on behalf of the 29 federally recognized Indian tribes and two urban Indian health organizations.

Southcentral Foundation

An Alaska Native-owned, nonprofit health care delivery and advocacy organization serving nearly 65,000 Alaska Native and American Indian people living in Anchorage, Matanuska-Susitna Borough and 55 rural villages. Southcentral Foundation and the Alaska Native Tribal Health Consortium own and manage the Alaska Native Medical Center that serves the entire Alaska Native and American Indian population in the state. 

Northwest Portland Area Indian Health Board

Engaged in many areas of Indian health, including legislation, policy analysis, health promotion and disease prevention, as well as data surveillance and research. The Northwest Portland Area Indian Health Board (NPAIHB) is a non-profit tribal advisory organization serving the forty-three federally recognized tribes of Oregon, Washington, and Idaho. 

Messengers for Health

A non-profit organization located on the Apsáalooke (Crow) Reservation in Montana whose mission is to improve the health of individuals on the Crow Indian Reservation and outlying areas through community-based projects that empower communities to assess and address their own unique health-related challenges.

For more information about HMA’s Native American and Alaska Native support services, contact [email protected].

Blog

CMS finalizes 2023 landscape for Medicare payment and policy

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This week, our In Focus section reviews the remaining Medicare payment and policy rules, finalized over the last several days by the Centers for Medicare & Medicaid Services (CMS), that will shape the landscape for the Medicare program in 2023 and beyond. These include the Physician Fee Schedule (PFS), the Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System, the Home Health Prospective Payment System and Home Infusion Therapy Services updates, and the End Stage Renal Disease (ESRD) payment rules.

The final Medicare rules are directionally aligned with the agency’s policy priorities, including improving health equity and addressing the health and health-related needs of rural and underserved communities, promoting value-based, whole-person care, and removing barriers to behavioral health services, among other issues.

Across these rules, CMS took some steps where they have authority to mitigate reductions in payment rates for some provider types. Final payment and policy changes, however, will inform stakeholders’ federal advocacy efforts with Congress. Specifically, as part of an end of year legislative package lawmakers are considering legislative proposals to address the 2023 payment levels and their relationship to general inflation and the scheduled payment cuts for physicians. These issues and Medicare program solvency are expected to remain hot topics throughout 2023.

For today’s blog our HMA experts highlight a few of the finalized policy changes contained in the aforementioned regulations that will take effect on or after January 1, 2023. The HMA Medicare team will continue to analyze these policies for their immediate implications. Additionally, final policies and CMS’ response to commenters offer important insights that providers, vendors, and other stakeholders will want to incorporate in their future policy, financial, and operational strategies.

Medicare Physician Fee Schedule Final Rule

On November 1, 2022, CMS released final updates and policy changes for Medicare payments under the PFS, and other Medicare Part B issues. This rule largely finalizes many of the policies described in HMA’s earlier summary of the PFS proposed rule. Notably, CMS finalized updates to the Medicare Shared Savings Program (MSSP) largely as proposed. The agency expects these changes will renew and broaden provider interest in participating in the Medicare Shared Savings Program (MSSP). The new MSSP opportunities will support CMS’ work towards its goal that by 2030 100 percent of Medicare beneficiaries will be in a care relationship with accountability for quality and total cost of care. As expected, CMS also finalized proposals intended to enhance access to behavioral health services and strengthen the behavioral health model within the Medicare program. The changes represent a major shift in traditional Medicare’s coverage of services to identify and treat mental health conditions and substance used disorders. CMS plans to address payment for new codes that describe caregiver behavioral management training in CY 2024 rulemaking.

Notable policies that will be of interest to Medicare stakeholders include:

  • Payment Rates and Inflation: The conversion factor used to determine payments to physicians through the PFS will be $33.06 in 2023, a decrease of $1.55 from the 2022 conversion factor. The final payment update reflects the following dynamics:
    • Expiration of a statutory one-year 3 percent increase in payments,
    • A statutory 0 percent payment update for CY 2023, and
    • A budget neutrality adjustment across all billing codes resulting from modifications to PFS weights which increased the relative value of primary care billing codes.

This cut to the conversion factor is driven by statutory requirements. The physician community is actively advocating to Congress that they need an update to their payments given the high levels of inflation and the lack of automatic updates built in to the PFS.

CMS also updated the information under the PFS to account for current trends in the delivery of health care, especially concerning independent versus facility-based practices. CMS indicated the updates and improved public use files respond to requests the agency has received to provide more granular information that separates the specialty-specific impacts by site of service. According to CMS, stakeholders are seeking to better understand how Medicare payment policies are directly responsible for the consolidation of privately-owned physician practices and freestanding supplier facilities into larger health systems.

  • Medicare Shared Savings Program: CMS finalized significant updates to MSSP that are aligned with the agency’s overall value-based care strategy of growth, alignment, and equity. These policies include paying advance shared savings to certain new ACOs that can be used to support their participation in the Shared Savings Program, a health equity adjustment to an ACO’s quality score, a revised benchmarking methodology, and allowing longer periods of time for ACOs to transition to downside risk. This package of changes are intended to increase participation in MSSP and in particular participation in rural and underserved areas.
  • Behavioral health: The final rule expands the types of behavioral health providers eligible for reimbursement under Medicare Part B. Marriage and family therapists, licensed professional counselors, addiction counselors, certified peer recovery specialists, and others will be able to provide behavioral health services while being under general supervision rather than “direct” supervision. Psychologists and social workers that are part of a primary care team will also be eligible for payment to help manage behavioral health needs. Additionally, CMS confirmed that Opioid Treatment Programs may bill Medicare for services performed by mobile units without obtaining a separate registration and increasing payment rates to Opioid Treatment Programs.
  • Telehealth: CMS finalized several policies related to Medicare telehealth services, reflecting statutory requirements of the Consolidated Appropriations Act (CAA) of 2022 and the agency’s ongoing evaluation of temporarily available services. The changes related to the CAA of 2022 include extending for 151 days beyond the end of the Public Health Emergency (PHE) the following coverage provisions: allowing telehealth services to be furnished in any geographic area and in any originating site setting (including the beneficiary’s home); allowing certain services to be furnished via audio-only telecommunications systems; allowing physical therapists, occupational therapists, speech-language pathologists, and audiologists to furnish telehealth services; delaying the onset of the in-person visit requirements for mental health services furnished during the PHE; and making policy changes consistent with those named above under the payment systems for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHC).
  • Ground Ambulance: CMS affirmed that its expanded list of covered destinations for ground ambulance transports was for the duration of the COVID-19 PHE only. The regulation also finalized changes to the long awaited Medicare Ground Ambulance Data Collection Instrument, including clarifying to process for requesting exemption from reporting cost data through this collection device.

Outpatient Prospective Payment System and Ambulatory Surgical Care Payment System Final Rule

Also on November 1, 2022, CMS published the calendar year 2023 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System final rule. The rule presents new opportunities to address access to emergency services in rural communities and updates other outpatient and ASC policies.

  • Payment rates and Inflation: CMS increased hospital outpatient and ambulatory surgical center payments by 3.8 percent in 2023 above 2022 rates. This reflects a 4.1 percent hospital market basket increase plus a 0.3 percentage point reduction for productivity and is consistent with Medicare’s 2023 hospital inpatient payment increase. The hospital industry has expressed deep concern to Congress and CMS that although the 4.1 percent market basket increase is as high as it has been in many previous years, it lags behind the measure of general inflation (October 2022 consumer price Index = 8.2 percent)
  • Remote Behavioral health: CMS finalized its proposal to cover as an outpatient service remote behavioral health services provided by clinical staff of hospital outpatient departments, including critical access hospitals (CAHs), to beneficiaries in their homes. This policy was initially permitted under CMS’ COVID-19 PHE emergency rulemaking but this is now covered on a more permanent basis.
    • In 2023 beneficiaries would need to receive an in-person service within the 6 months prior to the first time hospital clinical staff provide the remote behavioral health services. CMS also is requiring an in-person service without the use of communications technology within 12 months of each behavioral health service furnished remotely.
    • The agency also finalized coverage of audio-only telehealth services in instances where the beneficiary is unable to use, does not wish to use, or does not have access to two-way, audio/video technology.
  • Algorithm driven services: CMS finalized policy to pay separately (rather than bundle payment) for Algorithm-driven services that assist practitioners in making clinical assessments. This includes clinical decision support software, clinical risk modeling, and computer aided detection (CAD).
  • Rural Emergency Hospitals (REH) : CMS finalized conditions of participation, payment rates, and Medicare enrollment procedures for the new REH provider type largely as proposed. The new REH program will be effective January 1, 2023. Federal policymakers believe the REH provider type could provide a more sustainable option for rural hospitals facing closure and to support access to care in rural and underserved communities. A previous HMA blog explains the payment and service parameters for the REH option.
    • Hospitals and health systems and the rural communities they serve will want to analyze the final requirements for health and safety standards, staffing, and physical environment and emergency preparedness and other expectations and balance these with community perspectives to determine the feasibility of this pathway.
  • Site neutral payment policy: CMS finalized its proposal to exempt Rural Sole Community Hospitals (SCHs) from the Medicare policy which pays clinic visit services 40 percent of the OPPS payment rate when provided at hospital outpatient departments. Instead, CMS will pay these providers full OPPS rates for clinic visits.
  • 340B Drug Program: CMS finalized a payment rate of Average Sales Price plus 6 percent under the 340B program.

Home Health Prospective Payment System Rate Update and Home Infusion Therapy Services Requirements

On October 31, 2022, CMS finalized the calendar year 2023 Home Health Prospective Payment System (HH PPS) payment rates. CMS projects that aggregate spending for home health agencies in 2023 will increase by 0.7 percent, compared to 2022. This is a significant update as compared to the 4.2 percent decrease the agency proposed earlier this year. The originally proposed payment cut was in part due to CMS’s requirement to implement at statutory budget neutrality requirement for the Patient-Driven Groupings Model. While there was fervent industry pushback and advocacy to eliminate the proposed payment adjustments, CMS instead used its discretionary authority to implement a phased approach to payment reductions. The first half will be effective in 2023, and the remaining permanent adjustment and any other potential adjustments needed to account for behavior change will be proposed in future rulemaking. CMS’ payment approach is expected to factor heavily in the overall stability and market dynamics within the home health agency industry in the months ahead.

Other notable final rule Home Health policies include:

  • CMS finalized a permanent cap on wage index decreases to promote predictability in payments and smooth year-to-year changes. This was also implemented within the Inpatient Prospective Payment System.
  • CMS finalized the Expanded Home Health Value-Based Purchasing (HHVBP) Model home health agency baseline year to CY 2022 and the Model baseline year to CY 2023.
  • CMS will begin collecting data on the use of telecommunications technology on home health claims voluntarily starting on January 1, 2023, and on a mandatory basis beginning on July 1, 2023. Further details are expected to be issued in January 2023.

ESRD Prospective Payment System Final Rule

Also on October 31, 2022, CMS released the calendar year 2023 ESRD Prospective Payment System Final Rule. In addition to updating the payment rates, the rule updates requirements for the ESRD Quality Incentive Program (QIP). Looking ahead CMS plans to consider comments in response to several requests for information as it updates the ESRD QIP, works to align resource use with payment, ensure equitable access to technologies that improve health and quality of life.

Additional impactful policies for providers and stakeholders include:

  • CMS did not approve any of the three new technologies which applied for pass-through payment. While CMS has created a payment mechanism to promote innovation, it has proved challenging to actually access this payment mechanism. That may slow investment in the space if CMS continues to set such a high bar.
  • As laid out in the final rule, CMS remains on track to fold all oral drugs including phosphate binders into the bundle when the statutory ban expires in 2025.
  • CMS received many comments for its RFI regarding TDAPA, the new drug pass-through payment program in ESRD. It is likely that CMS will dedicate significant attention to this topic in the next rulemaking cycle. In particular, the RFI focused on how CMS might add new money to the ESRD bundle when new drugs exit pass-through, including the potential for accounting for other drugs which are replaced by the new products.

While providers and stakeholders must analyze the immediate impact of the final rules, it is also essential to consider the broader context of CMS’ reimbursement and policy decisions.

Notably, there is more urgency for the provider community, Medicare Advantage plans, and the broader Medicare stakeholder community to prepare for the imminent end of the federal COVID-19 Public Health Emergency (PHE) declaration. Congress and the Administration have already begun to identify and make permanent certain flexibilities afforded during the COVID-19 PHE. Other flexibilities will be phased out or ended. Looking ahead to this transition, thoughtful preparation and consideration of the Medicare policy context and opportunities will be critical.

For additional information, please contact Amy Bassano, Mark Desmarais, Zach GaumerAndrea Maresca, and Aaron Tripp.

HMA News

Leavitt Center for Alliances, an HMA Initiative, Drives Collaboration and Solutions

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Today, Health Management Associates (HMA) launched the Leavitt Center for Alliances, an HMA Initiative, which aims to elevate the national discourse on healthcare and help healthcare organizations solve their most complex challenges through consensus-based alliances.

The Leavitt Center for Alliances (Leavitt Center) is home to expert conveners who have decades of experience in the private sector and government. They have spent years fine tuning the process for building successful alliances that bring multi-sector stakeholders to the table with a commitment to reaching consensus, real-world solutions. Governor Mike Leavitt served as Secretary of the United States Department of Health and Human Services (HHS). Rich McKeown, served as Chief of Staff at HHS. The two of them founded Leavitt Partners, where they advanced the science of alliance building. Their book “Finding Allies, Building Alliances” mapped out eight crucial elements of successful alliances, providing a framework for the work and resources that now serve as the foundation for the Leavitt Center.

“Now more than ever, alliances offer a proven way forward, beyond the divisiveness, partisanship and uncivil discourse that too often stagnates momentum toward tangible progress,” said Leavitt, HMA co-chairman and Leavitt Partners chairman, Board of Managers. “Our approach to multi-sector consensus-based alliances, rooted in collaboration, has consistently helped organizations identify and develop solutions to some of the most complicated issues. It is a roadmap for bridging divides and realizing results.”

The Leavitt Center guides stakeholders through each step of the process to form alliances, develop consensus within those alliances, and then put a strategic plan into action that drives results. Expertly convened alliances solve the tough problems that are too big for individual organizations to tackle alone, leverage shared resources and expertise, and provide for “strength in numbers.”

“The expertise our Leavitt Center colleagues have when it comes to both the art and the science of creating and deploying alliances to develop innovative solutions is unmatched,” said Jay Rosen, founder, president, and co-chairman of HMA. “I see great potential for combining that know-how with our on-the-ground experts throughout all of HMA to expand this proven alliance approach beyond the federal landscape and into communities across the country.”

Leavitt Center experts have helped more than 50 alliances achieve impactful outcomes, including the Dual Eligible Coalition founded in 2017 to develop actionable, long-term policy and programmatic solutions to improve the delivery of care and outcomes for the dual eligible population. Other alliances include the CARIN Alliance, focused on improving access to digital health information, the Pharmaceutical Distribution Security Alliance (PDSA), and the COVID Patient Recovery Alliance. Other examples of alliances in action can be found here. Currently Leavitt Center experts are drawing from their past decade of alliance work to share insights in a new book, scheduled for release in 2023.

Founded in 1985, HMA is an independent, national research and consulting firm specializing in publicly funded healthcare and human services policy, programs, financing, and evaluation. Clients include government, public and private providers, health systems, health plans, community-based organizations, institutional investors, foundations, and associations. With offices in more than 20 locations across the country and over 500 multidisciplinary consultants coast to coast, HMA’s expertise, services, and team are always within client reach.

Leavitt Center for Alliances: https://leavittcenterforalliances.com/

Blog

Advancing health equity and integrated care for rural dual eligibles

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This week, our In Focus section highlights the Health Affairs article, Advancing Health Equity and Integrated Care for Rural Dual Eligibles, authored by  Ellen Breslin, Samantha Di Paola, Susan McGeehan, Rebecca Kellenberg, and Andrea Maresca, Health Management Associates.

A public health crisis is growing more acute in rural America, disproportionately impacting individuals with both Medicaid and Medicare (the “dually eligible”). The rural health crisis is a health equity concern that affects all rural residents, including dually eligible individuals. There are 47 to 60 million people residing in rural areas. Twenty-one percent of dually eligible individuals live in rural areas—that’s about 2.6 million people. Based on these numbers, the authors calculate that the dual eligible population residing in rural communities accounts for about 5 percent of the total rural population. Dually eligible individuals living in rural areas are at risk of falling through the cracks.

Dually eligible individuals lack access to adequate medical, behavioral health, home-and community-based services (HCBS) and other social services; those living in rural areas face even steeper challenges. Since dually eligible individuals are among the poorest of all individuals covered under Medicare, they are at significant risk of paying a steep rural mortality penalty.

With these challenges there are opportunities for innovation for the dually eligible population living in rural communities. The US can reverse the mortality-disparity rate trajectory. Public and private entities are interested in revitalizing rural America, confronting the rural health crisis, and harnessing the power of rural communities. Investment in the rural health care sector is essential given it is a major economic driver of rural communities.

HMA is creating a toolkit with actionable solutions to improve access to services and integrated care and health equity for individuals dually eligible for Medicare and Medicaid who live in rural areas across the country. ​This project is a follow-on project to a previous HMA project supported by Arnold Ventures. ​In 2021, HMA prepared a brief, Medicare-Medicaid Integration: Essential Elements for Integrated Care Programs for Dually Eligible Individuals, to increase and promote enrollment in integrated care programs (ICPs) meeting dually eligible individuals’ needs and preferences. Interviewees including dually eligible individuals helped HMA to identify “access to needed services in rural areas” as an essential element of ICPs. In response, HMA started a new project to create a toolkit with actionable strategies to improve access to needed services and improve integrated care opportunities, specific to dually eligible rural residents’ needs.

HMA designed the toolkit around four values: 1) rural health equity is an imperative for dually eligible individuals, 2) actionable solutions and innovations must come from the community, 3) there is no single pathway to integration, and 4) Medicare and Medicaid flexibilities are critical to inspiring innovations to advance health equity, access, and integration. The toolkit will provide actionable solutions for states with and without integrated care programs for dually eligible individuals to increase access to needed supports and services, care coordination, and integrated care programs. We expect that states and rural communities will use the toolkit as a foundation for mapping a holistic plan to advance access to care coordination and integrated programs for dually eligible individuals residing in rural communities. Other states may employ contractual tools listed in the toolkit to expand access to providers and new services; strengthen partnerships among entities serving the community such as community-based organizations, providers, and health plans; and increase community-wide accountability for meeting dually eligible individuals’ whole person-centered needs. The toolkit is scheduled for an early 2023 release.

Link to Health Affairs article.

Brief & Report

The 22nd annual Medicaid budget survey released: pandemic continues to shape priorities

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The 22nd annual Medicaid Budget Survey conducted by The Kaiser Family Foundation (KFF) and Health Management Associates (HMA) was released on October 25, 2022, in the report: How the Pandemic Continues to Shape Medicaid Priorities: Results from an Annual Medicaid Budget Survey for State Fiscal Years 2022 and 2023.

The report was prepared by Kathleen Giff­ordAimee Lashbrook, and Matt Wimmer from HMA; Mike Nardone; and by Elizabeth Hinton, Madeline Guth, Jada Raphael, Sweta Haldar, and Robin Rudowitz from the Kaiser Family Foundation. The survey was conducted in collaboration with the National Association of Medicaid Directors (NAMD).

Blog

HMA consultants pen Health Affairs blog post, “Advancing Health Equity And Integrated Care For Rural Dual Eligibles”

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HMA Consultants Ellen Breslin, Samantha Di PaolaSusan McGeehanRebecca Kellenberg, and Andrea Maresca recently wrote the Health Affairs blog post, “Advancing Health Equity And Integrated Care For Rural Dual Eligibles.”

This article was the latest in the Health Affairs Forefront series, Medicare and Medicaid Integration which features analysis, proposals, and commentary that inform policies on the state and federal levels to advance integrated care for those dually eligible for Medicare and Medicaid.

Read the full article here.

Brief & Report

System integration across child welfare, behavioral health, and Medicaid

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Children and families involved in the behavioral health and child welfare systems are often the most vulnerable and in need of intensive supports. Fragmented systems of care across child welfare, behavioral health, and Medicaid often cause families “to fall through the cracks,” leading to increased use of high-cost services that separate families and results in poorer outcomes.  These siloed approaches perpetuate and exacerbate trauma to children and families. In the second in a series of briefs focused on enhancing the youth behavioral health system, the HMA team of Uma Ahluwalia, Caitlin Thomas-Henkel, Roxanne Kennedy, and Courtney Thompson propose four core design elements – and related KPIs – for establishing a high-functioning integrated system of care for children, youth, and their families, child welfare, Medicaid, and behavioral health systems.

Blog

West Virginia releases RFP for foster children, youth in Medicaid Managed Care

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This week, our In Focus section reviews the Mountain Health Promise request for proposals (RFP) released by the West Virginia Department of Health and Human Resources on September 30, 2022, for specialized Medicaid managed care for children and youth in foster care.

Mountain Health Promise RFP

The selected managed care organization (MCO) will provide physical and behavioral health services to children and youth in the foster care system, individuals receiving adoption assistance, youth formerly in foster care up to age 26 who aged out of foster care while on Medicaid in the state of West Virginia, and children eligible under the children with serious emotional disorders (CSED) waiver. Potential expansions could include, but are not limited to, children at risk for foster care placement and the family of youth in crisis. Additionally, the MCO will act as an administrative services organization (ASO) and provide statewide administrative services for all individuals accessing socially necessary services (SNS).

Some of the goals of the program include:

  • Enhance coordination and access to services
  • Enhance quality of care and minimize barriers for youth and families/improve access to treatment
  • Reduce fragmentation and offer seamless continuity of care
  • Improve health and social outcomes for youth and impacts on families
  • Help reduce the number of children removed from the home and reduce lengths of stay per episode of care through increased family-centered care that provides necessary and coordinated services to all members of the family
  • Decrease children involved with the juvenile justice and corrections systems
  • Reduce out-of-home and out-of-state placements
  • Develop new or enhance existing services, such as children’s mobile crisis response (CMCR), inState Psychiatric Residential Treatment Facilities (PRTF) to reduce the need for out-of-state placements, and intensive home-based treatment

Physical and behavioral health services will be reimbursed through a Medicaid per member per month (PMPM) capitation payment. For SNS administration, the Bureau for Social Services (BSS) will provide a fixed monthly rate. The PMPM capitation rate will not include carved out SNS costs.

It is encouraged, but not required, that the MCO subcontract with regional child welfare organizations, residential mental health treatment facilities (RMHTFs), and organizations that provide home and community-based services for children with serious emotional disorders to assist in the care coordination of services for this population.

Market

There are nearly 28,000 individuals currently enrolled in Mountain Health Promise, with about 13,000 eligible for SNS. Enrollment, however, is expected to decrease following the end of the Public Health Emergency (PHE). CVS Health/Aetna is the incumbent plan. Aetna had contracted with Kepro to serve as the ASO for SNS.

Timeline

Proposals are due November 1, 2022. The contract is anticipated to run from July 1, 2024, through June 30, 2025, with three one-year options.

Evaluation

The winning MCO will be chosen based on the highest score of a possible total 1,000 points. The technical evaluation will be a total of 700 of 1,000 points. Cost represents 300 of 1,000 total points.

Mountain Health Promise RFP