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HMA Insights: Your source for healthcare news, ideas and analysis.

HMA Insights – including our new podcast – puts the vast depth of HMA’s expertise at your fingertips, helping you stay informed about the latest healthcare trends and topics. Below, you can easily search based on your topic of interest to find useful information from our podcast, blogs, webinars, case studies, reports and more.

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Blog

HMA presented at 2024 Opioid & Fentanyl Abuse Management Forum in New Orleans

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HMA Principal Teresa Garate, PhD presents at the 2024 Opioid & Fentanyl Abuse Management Forum sponsored by the World Conference Forum. She is standing at the front of a room next to a screen.

On February 15, 2024, HMA Principals Teresa Garate, PhD and Anika Alvanzo, MD, MS presented at the 2024 Opioid & Fentanyl Abuse Management Forum sponsored by the World Conference Forum. Their presentation focused on enhancing outreach strategies for reaching and engaging people suffering from opioid use disorder in their communities. Participants were able to learn about public health approaches, harm reduction and low-barrier treatment, as well as an understanding of the considerations needed when building community driven strategies that are person-centered.

Dr. Garate also served as chairperson for the two-day event, providing opening remarks on the first day, engaged panelists in provocative conversations, and closed out the gathering with a summary of the presentations. With a deep understanding that addiction is a disease of the brain, the presentations focused on biopsychosocial approaches and highlighted the use of multiple and diverse interventions. The compilation of the event’s presentations resulted in robust discussions on research, model programs, model strategies, and the critical role of policy, funding, innovation, and data sharing. The overarching message was that as a collective group of advocates, we must continue to use every resource we have at our disposal to push the envelope and challenge the status quo so that we can stop the increase in overdoses and overdose deaths.

At HMA, consultants on our opioid team have unique expertise and more than 30 years of experience tackling every part of the substance use disorder system. They have led the development of comprehensive prevention, evidence-based treatment, and recovery solutions at the state, county and community level.  We have experience working with states and community organizations to develop impactful, sustainable responses to opioid crisis issues. Our team is ready to help clients create actionable and sustainable programs to address the opioid epidemic and addiction treatment.

Contact us to learn more about how we can help your organization develop programs to help combat the opioid crisis.

Solutions

Helping Clients Succeed in Value Based Payments

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As Medicare, state Medicaid agencies, Medicare Advantage plans, Medicaid managed care organizations, and commercial insurers increasingly adopt alternative payment models (APMs), Health Management Associates (HMA) provides a range of innovative and successful approaches to value-based care (VBC).

Our subject matter experts can help you succeed with
value-based payments (VBP).

WHAT WE DO

Offer insights for transforming the care delivery model to efficiently deliver optimal patient and population-level health outcomes while successfully managing total cost of care

Ensure quality is the primary goal of VBP program design and implementation

Develop payment models that align the incentives of payers and providers

Integrate physical and behavioral healthcare, and close gaps related to social determinants of health and health equity

Help clients successfully transition from fee-for-service to value-based payments by providing expertise in change management, analytics, network engagement, and IT infrastructure

Improve the patient and provider experience

Qualify, manage, and monitor health insurance risk

Prepare for and succeed in accreditation for VBP capabilities

ORGANIZATIONS WE SUPPORT

Those engaged in VBP or interested in engaging in VBP

Payers

Providers

Purchasers

Those interested in advancing the broader movement to value

Federal, State & Local Governments

Associations

Foundations

Investment Firms

HMA Can Support You Through All Phases of Value-Based Care

From contract to care plan, we have the experience and guidance tools to support your organization’s move to value-based care and risk-based contracting.

value based payment graph

This graphic showcases the capabilities needed to address the complexities of risk-based contracting and deliver value-based care. As your organization moves from left-to-right along the glidepath to risk, additional strategies and capabilities must be developed. For example, utilizing Institute for Healthcare Improvement frameworks for quality improvement, regulatory and credentialing needs, and specialty access within a clinically integrated network. NEJM Catalyst. (2017). What is value-based healthcare?

Our philosophy involves applying a health equity model to close social determinant gaps and health disparities. Value-based healthcare is all about the care delivery model. Under value-based care agreements, providers are rewarded for helping patients improve their health, reduce the effects of emerging/rising risks and incidence of chronic disease, and live healthier lives in an evidence-based way.

Our Comprehensive Approach

Our collaborative approach will be tailored and customized to your needs to help you successfully implement VBP.

Our integrated process is based on the following model:

WHAT HMA PROVIDES

Determine readiness across key building blocks for moving to value-based payments and achieving continuous improvement across healthcare organizations.

Implementation that includes benchmarks and measurements of success. We facilitate stakeholder input to capture and analyze data from these interactions through surveys, focus groups, and interviews.

Aligning incentives with providers is key to successful value-based care strategies. Understanding methods for identifying and closing gaps in care pathways for common chronic conditions or addressing rising/emergent risks as well as how to create buy-in among providers and other members of the care team.

Including actuarial expertise required for contracting in key areas such as financial projections, reserves, total cost of care analysis, and benchmarking. We provide an assessment of third-party software to support APMs.

Including methods for incorporating whole-person care into clinical algorithms that apply to every interaction with the patient and their families. Integrating behavioral health with physical health and addressing social determinants of health/health-related social needs into VBC programs.

Assist with identifying key performance indicators (KPIs) and quality measurement incentives
for pay-for-performance or pay-for- value to support population health outcomes and support total cost of care in various VBP arrangements.

Provide support and consultation on scope of requirements to ensure VBC contract meets delegation requirements for operational, state, CMS regulatory and accreditation requirements.

OUR EXPERTS INCLUDE

Former CEOs, COOs, CFOs, and chief medical officers and other physician executives as well as executive quality leaders of the following organizations:

Providers including hospitals, academic medical centers, physician practices, community health centers, rural health centers, and federally qualified health centers

Medicaid, Medicare, Marketplace and Commercial MCOs

State and federal agencies

In addition, HMA offers expert actuaries, coders, analytic staff, and clinicians to support your transformation.

Contact our experts:

Brent Barkett

Brent Barkett

Principal

A purpose driven leader and recognized expert in healthcare value transformation, Brent Barkett has a unique combination of clinical application, … Read more

Caprice Knapp

Managing Director, Quality and Accreditation

A health economist and evaluator, Caprice Knapp has more than 20 years’ experience working on Medicaid and Children’s Health Insurance … Read more
Craig Schneider

Craig Schneider

Principal

Craig Schneider is a leader in developing and implementing payment reform strategies, promoting all-payer claims databases (APCDs), and engaging stakeholders … Read more
HMA News

New experts join HMA in November 2023

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HMA is pleased to welcome new experts to our family of companies in November 2023.

Ken Cochran – Principal
HMA

Kenneth Cochran is a healthcare executive with more than 20 years leveraging his clinical, business and academic background to deliver strategic planning, operational excellence, top-line revenue growth, positive physician relations and organizational alignment.

Matt Smith – Consulting Actuary I
Wakely

Matt Smith, ASA, has experience with population health analytics, total cost of care analysis, value-based care contracts, financial modeling, pricing and reserving, and risk adjustment. Read more about Matt.

Jimmy Mans – Consulting Actuary I
Wakely

Jimmy Mans, FSA, MAAA, has extensive experience working with health plans, providers, state and federal governments, and pharmaceutical manufacturers. Read more about Jimmy.

Read more about our new HMA colleagues

Blog

North Carolina releases foster care specialty plan program RFP

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This week, our In Focus section reviews the statewide North Carolina request for proposals (RFP) for the new Children and Families Specialty Plan (CFSP), which the North Carolina Department of Health and Human Services (DHHS) released on February 7, 2024. The plan will provide physical health, behavioral health, intellectual and developmental disability, long-term care, and pharmacy services to children, youth, and families that the child welfare system serves. Implementation is scheduled for December 1. 

Background 

North Carolina implemented Medicaid managed care on July 1, 2021, after working on a plan to transition individuals from fee-for-service to managed care since 2015. CFSP is one of the four types of integrated Medicaid managed care plans the state will contract with to serve Medicaid beneficiaries. The other three are Standard Plans, the Behavioral Health and Intellectual/Developmental Disability (BH IDD) Tailored Plans, and the Eastern Band of Cherokee Indians Tribal Option.  

Standard Plans are operated by one of two types of Medicaid managed care organizations (MCOs): statewide commercial plans (CPs) or regional provider-led entities (PLEs). The state awarded contracts to four CPs, the maximum allowed under the procurement, and one PLE. AmeriHealth Caritas North Carolina, Blue Cross and Blue Shield of North Carolina, UnitedHealthcare of North Carolina, and WellCare of North Carolina serve beneficiaries across six Medicaid managed care regions. A regional contract with provider-led Carolina Complete Health, a partnership between the North Carolina Medical Society and Centene, covers Regions 3, 4, and 5. The total value of the contracts is approximately $6.4 billion. The plans serve more than 2 million members as of year-end 2023. 

The state plans to implement BH IDD Tailored Plans July 1. Tailored plans will be provided through the awarded local management entity-managed care organizations (LME-MCOs): Alliance Health, Partners Health Management, Trillium Health Resources, and Vaya Health. Implementation has been delayed multiple times since 2022. As a result, the state issued a directive last year to dissolve the Sandhills Center and consolidate Eastpointe and Trillium Health Resources to hasten the delayed rollout. The tailored plans are expected to cover approximately 160,000 beneficiaries. 

Details about the CFSP 

The following populations will be enrolled automatically in CFSP: 

  • Beneficiaries who are in foster care 
  • Beneficiaries who are receiving adoption assistance 
  • Beneficiaries enrolled in the former foster youth eligibility group 
  • The minor children of enrolled parents 

The following populations will be eligible for enrollment in CFSP during contract year two: 

  • Parents, caretaker relatives, guardians and custodians with children in foster care 
  • Minor siblings of beneficiaries in foster care 
  • Adults identified on an open Child Protective Services (CPS) In-Home Family Services Agreement case and any minor children living in the same household 
  • Adults identified in an open Eastern Band of Cherokee Indians Department of Public Health and Human Services Family Safety program case and any children living in the same household 
  • Any other beneficiary that has been involved with the child welfare system who could benefit from enrollment  

RFP 

The state will award the contract to a single statewide managed care plan. Applicant MCOs will need to develop strategies for engaging with historically marginalized populations, addressing health disparities, and incorporating health equity. Technical proposals will be evaluated based on the following criteria: 

  • Medicaid Managed Care Qualifications and Experience 
  • Medicaid Managed Care Program Administration
    • Administration and management 
    • Program operations 
    • Claims and encounter management 
    • Financial requirements 
    • Compliance 
    • Technical specifications 
    • Historically underutilized businesses 
    • Diversity, equity, and inclusion 
  • Integrated and Coordinated Delivery of Services
    • Members and recipients 
    • Benefits and services 
    • Providers 
    • Stakeholder engagement 
  • Comprehensive Care Management
    • Care management 
    • Quality and value 

Timeline 

The CFSP data book and capitation rate methodology will be released March 1, with an overview for presentation at a pre-proposal conference on March 7. Proposals are due May 1 and awards are expected to be announced August 15. Contracts are scheduled to run December 1, 2024, through June 30, 2028, with one additional option year. The RFP indicates that the Department will work with awardee to establish an appropriate launch date. 

Link to RFP 

Blog

Driving change in healthcare delivery: HMA Spring Workshop builds towards policy and strategy frameworks necessary to implement value-based care

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Federal policy frameworks establishing alternative payment models in Medicare and Medicaid have been the kick-starter of value-based care (VBC) innovation in healthcare delivery. However, employers provide health insurance to most Americans, and very few employers – with the exception of jumbo, self-insured employers  – have leaned heavily into VBC. Small- and medium-sized firms rely on brokers to find an affordable health insurance plan, and often lack the resources required to negotiate more. Though the tide has been changing, our fragmented payment system has yielded only a subset voluntarily taking substantial risk for patient outcomes.

It has been said that to truly transform our American healthcare system to pay for value – improved outcomes for lower cost – it would require better alignment across public and commercial payers to support care providers in shifting their business models to take risk.

Quality and cost information are critical to implement VBC payment and delivery systems. Federal initiatives in Medicare and Medicaid have opened the door for providers, payers, and innovators  to use health information to improve outcomes, with patients more engaged and more in control; the “Universal Foundation” announced by the Centers for Medicare and Medicaid Services (CMS) in 2023 seeks to align quality measures across the more than 20 CMS quality initiatives; and policies included in the 21st Century Cures Act and CMS Interoperability and Patient Access rule are creating more transparency on price and quality.

By enabling an infrastructure to measure, digitize, and share cost and quality information, federal and state governments have set the stage for greater collaboration among all purchasers – including employers – and the healthcare delivery system to redesign care that addresses health related social needs and behavioral health, ensuring that healthcare is provided equitably and sustainably. As the care delivery system is better able to deliver high value care, more employers will demand this for their workforce to provide a better benefit to their workers.

These issues, and more, will be a part of the expert-led conversation on VBC at HMA’s 2024 Spring Workshop March 5-6, in Chicago. This workshop offers a unique opportunity for payers, government officials, community organizations, vendors, and providers to have an unvarnished conversation about the challenges, lessons, and opportunities in implementing VBC. The meeting is designed to share insights, change-oriented strategies and actions that advance VBC from top industry experts, health plan executives, state and federal leaders, and policy experts. 

CLICK HERE TO register

Our working sessions will feature solutions-focused conversations among peers:

  • Care delivery measures that drive outcomes, equity, population health
  • Payment & risk management models for payment, pricing, attribution
  • Data that is interoperable, consumer focused, deploying technology that is aligned to deliver on strategic objectives
  • Policy & Strategy Frameworks at federal, state, and local levels that incentivize VBC

The closing panel will look at ways to take action through policy and collaboration to move our industry toward more sustainable approaches to healthcare payment and delivery.

To learn more and register for this unique event, please visit HMA’s 2024 Spring Workshop page. Act fast – online registration ends Wednesday, February 28!

Solutions

Expanding Access to High Quality Sexual Health Care and STI Prevention

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In 2022, more than 2.5 million cases of syphilis, gonorrhea, and chlamydia were reported in the United States. There were alarming increases in syphilis cases in particular – there has been an 80% rise in syphilis cases since 2016 and in 2022, there were 3,755 cases of syphilis among newborns reported (163% increase since 2018). While sexually transmitted infections (STIs) occur in all populations, some groups are more affected, including young people, gay and bisexual men, transgender individuals, and pregnant people. There are deep inequities in the rates of STIs including disproportionate rates among racial and ethnic minorities which are the result of longstanding social and economic structural inequities. 

Sexual health services are being threatened and have inequitable resources which further complicates care for those individuals with lived experience with STIs, HIV, and viral hepatitis. They often experience additional and intersecting sexual health, behavioral health, and social needs that must be addressed concurrently.

STI Graphic CDC

HMA brings together experts from a full spectrum of sexual health services including policy, clinical, operations, and research.

Our experts have significant experience with conducting needs assessments and gap analyses, supporting syndemic (HIV/STI/Hepatitis) planning, centering health equity, and leveraging policy and research findings to maximize impact and access. A syndemic is a situation in which two or more interrelated biological factors work together to make a disease or health crisis worse.

Illustration from the Centers for Disease Control and Prevention (CDC)

We work with clients to reach shared goals of supporting sexual health, expanding access to screening, vaccines and other preventative services, reducing high rates of STIs including HIV, and addressing deep and persistent racial disparities in STI rates and the inequities that drive them.

We can help organizations including:

State and municipal departments of health and public health

Health plans

Community-based organizations (CBOs)

Behavioral Health Service Organizations

Federally Qualified Health Centers

Title X Clinics

Planned Parenthood affiliates and other free-standing women’s health centers

Foundations

Associations and Coalitions

Our sexual health experts include:

Former senior officials from the Health Resources and Services Administration and the Center for Disease Control and Prevention.

Advocates and former senior leaders of community-based organizations, foundations, and other programs that support healthcare systems capacity to implement quality STI prevention, screening, diagnosis, surveillance, and treatment.

Clinicians with experience providing sexual health services and building programs at the intersection of sexual health, behavioral health, primary care and maternal and child health.

Social workers and behavioral health professionals working to integrate approaches that address social and behavioral health needs.

Program development, strategic planning, and technical assistance experts working to implement innovative solutions and evidence-based guidelines.

Researchers and evaluators with extensive experience examining the implementation and impact of policy and operational changes on sexual health services.

Our experts can support your work to expand equitable access to sexual health care.

With offices in more than 30 locations across the country and over 700 multidisciplinary consultants with a wide spectrum of industry experience, and longstanding expertise in all 50 states, HMA has experienced staff in syndemic needs assessments and planning, program evaluation, research and analysis, strategic/business planning, clinical services, stakeholder engagement, quality improvement, and workforce development. Our portfolio of companies also gives you access to actuarial, data analytics and communications expertise, and more.

OUR WORK

South Carolina Department of Health and Environmental Control (DHEC) contracted with HMA to conduct a statewide gap analysis to document the array of partner services and disease intervention STI inside and outside the department and identify gaps and duplication to improve services and strengthen the program. As part of this engagement, HMA conducted an analysis of South Carolina’s STI delivery system, staffing capacity and processes, and developed a service location map to highlight gaps and inequities. The final report summarized findings and included recommendations for closing gaps in service delivery, workforce development and improving the efficiency and effectiveness of service delivery.

HMA supported the Washington State Department of Health’s Office of Infectious Disease in taking a syndemic approach to ending the HIV, STI, and viral hepatitis epidemics. A key activity of this project included supporting the Office of Infectious Disease to establish a new planning body that reflects the populations served by transforming their Statewide HIV Planning Group and launching a new communicable disease (syndemic) planning group. This work included conducting research on other statewide planning group structures, collecting community and stakeholder input, developing and operating structure, charter, and bylaws; recruiting and onboarding a diverse membership; and creating organizational change management, all with a focus and commitment to advancing racial equity. Through this work, HMA also drafted the state’s integrated HIV Prevention and Care Plan and Requests for Applications to help distribute state funds to local intervention efforts that advance the goals of this plan.

As part of our extensive area of work in strategic planning with state and local agencies, providers of health and human services, community-based organizations and many more, HMA has worked with clients that provide sexual and reproductive health care services to assess potential opportunities and approaches for expansion, delivery, and financing of care to reach underserved communities.

HMA worked with the Wyoming State Department of Health to conduct their HIV needs assessment and developed their Integrated HIV Prevention and Care Plan. This work included collecting and analyzing data on HIV incidence and prevalence; developing HIV, STI, and viral hepatitis ecosystem maps; facilitating workgroup meetings; collecting additional community and stakeholder input through provider and community surveys and focus groups; and developing a written report of the assessment findings, all with a focus and commitment to advancing health equity.

HMA worked closely with the Boston Public Health Commission to conduct an extensive HIV needs assessment. Activities included key stakeholder interviews, focus groups, surveys and data collection and analysis. Emphasis was placed on the intersection of HIV and drug user health. 

HMA team members developed and implemented professional development training series entitled “The Intersection of HIV and SUD” on behalf of the Minnesota Department of Health. The 12-hour curriculum was developed in partnership with several community organizations representing Tribal, African American, and LGBTQIA+ communities. The training is delivered virtually and includes topics such as: understanding HIV; HIV risk reduction; SUD harm reduction; chemsex; HIV and stigma, pregnancy and HIV; and cultural, racial and sexual identities.

Contact our experts:

Julie Rabinovitz

Julie Rabinovitz

Principal

Julie Rabinovitz specializes in sexual and reproductive health policy, strategy, and operations. She assists healthcare organizations with program planning and … Read more
Charles Robbins

Charles Robbins

Principal

Charles Robbins has been transforming communities for the past three decades. His extensive community-based organization career spans healthcare, child welfare, … Read more
Kate Washburn

Kate Washburn

Associate Principal

Kate Washburn is a public health and program leader with over 20 years of experience in both public health departments … Read more
Webinar

Webinar replay: Compassionate Overdose Response Summit and Naloxone Dosing Meeting

Watch Now

The Compassionate Overdose Response Summit and Naloxone Dosing Meeting, held on March 18-19, 2024, was a two-day summit where naloxone experts built consensus on the definition of a compassionate bystander overdose response.

Day 1 (March 18) was an invitation-only for a small group of researchers, people with lived experience of overdose, those who have reversed multiple overdoses, and medical providers tasked with drafting an issue brief that will be the basis for the remainder of the summit.

Day 2 (March 19) was an open virtual summit. On this day, we shared the issue brief with the audience for feedback and host multiple presentations that covered emerging research on this topic, including:

  • The impact of different naloxone doses and formulations on people who receive them
  • The role of oxygen in community overdose response
  • Communication strategies for bystander overdose response steps

The event produced clear guidance on naloxone dosing and the role of oxygen in overdose response:

  1. There is no real-world evidence for high-dose or long-acting opioid antagonists; therefore, until there is community experience with those regimens, they should not be included in standing orders or made available for broad community use.
  2. Rescue breathing is standard overdose response protocol and should be included in educational materials and training.
  3. People who use drugs must be central to the design, development, purchasing and distribution of all overdose reversal products

Additional materials from this event are below:

For justification for the above statements or for questions, please contact Erin Russell.

 

Blog

HMA keynote speakers preview themes, imperatives for March 5-6 Value-Based Care Workshop

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HMA’s Spring Workshop on Value-Based Care, March 5-6 in Chicago, is just a few weeks away. Listen to why our speakers are so excited to engage with attendees on value-based care.

Elizabeth Mitchell, CEO, Purchaser Business Group on Health will deliver the keynote speech on “The Purchaser’s Dilemma: Why Employers Should Demand Value (and Why They Don’t).”

Our March 5 dinner headliner Katie Kaney, CEO of LovEvolve will discuss her “Whole Person Index” and how we can collaborate in new ways to transform the healthcare system to deliver better health at a lower cost for all.

Katie Kaney video

Hurry – online registration ends February 28!

Register here.

Blog

Interoperability and patient access final rule: the next phase in the data exchange journey

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This week, our In Focus section reviews the Centers for Medicare & Medicaid Services (CMS) Interoperability and Prior Authorization Final Rule, published on January 17, 2024. This is CMS’s latest effort to flesh out regulations mandating payer interoperability and fully electronic prior authorization (PA) policies. The 2024 final rule also represents a new phase in the agency’s work to advance interoperability as it moves beyond policymaking focused on building interoperable systems to policies centered on the applications and usage of shared data.

The new requirements affect a large segment of the nation’s public health insurance programs, including Medicare Advantage (MA) organizations, state Medicaid fee-for-service (FFS) programs, state Children’s Health Insurance Program (CHIP) FFS programs, Medicaid managed care plans, CHIP managed care organizations, and qualified health plan (QHP) issuers on the federally facilitated exchanges (FFEs). These payers must implement and adhere to Health Level 7® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) application programming interfaces (APIs). These APIs were developed by the DaVinci project and the CARIN Alliance which are both HL7 FHIR accelerator programs. Leavitt Partners, an HMA company, leads the work of the CARIN Alliance.

The final rule demonstrates a commitment to information sharing across the industry landscape and confidence in the FHIR standard to support health data exchange across all required APIs. Ultimately, FHIR APIs are creating a more patient-centered data ecosystem that can provide a tangible return on investment.

Following are details about the requirements, opportunities, and next steps for stakeholders.

Prior Authorization API and Process

Payers must build and maintain PA APIs by January 1, 2027, allowing providers to ask payers whether PA is required for a patient’s procedure, what documents must be submitted to attain authorization, and to receive the final decision and reason for denied requests electronically within a specified timeframe (seven days for standard procedures and three days for expedited decisions).

The rule finalizes requirements for the PA process, regardless of whether the payer receives the PA request through the Prior Authorization API. Specifically, CMS is requiring that:

  • Affected payers send notices to providers when they make a prior authorization decision, including a specific reason for denial when they deny a PA request
  • Payers, other than QHP issuers on the FFEs, respond to prior authorization requests within specific timeframes
  • Affected payers publicly report certain metrics about their PA processes

These prior authorization process requirements become effective January 1, 2026. The last 12 months of PA information also must be shared with patient, providers, and other payers when the member switches a plan through the respective APIs.

To promote adoption of electronic prior authorization processes, CMS is adding an Electronic Prior Authorization measure for Medicare clinicians who participate in the Merit-based Incentive Payment System (MIPS) and hospitals and critical access hospitals in the Medicare Promoting Interoperability Program as an attestation measure.

Payer to Payer FHIR API

To support continuity of care and value-based programs, payers must be able to send, receive, and incorporate enrolled member data from previous and concurrent payers if members are dually enrolled.

To comply with the new electronic data sharing, the final rule requires payers to build and use FHIR API by January 1, 2027. Payer-to-payer (P2P) data sharing will include the last five years of claims/encounters, clinical data, and the active and pending PA requests. The data collected through the P2P APIs will need to be available to the other APIs (i.e., provider, patient, and prior authorization). The rule requires payers to request data from previous payers within a week after the patient opts in to sharing data. For dually enrolled members, data sharing will incur at least quarterly.

Patients must opt in and agree to the P2P data sharing. To this end, health plans must adjust their enrollment administrative process to allow members to easily share previous and concurrent payer information and consent to data sharing. CMS allows Medicaid or CHIP agencies to contract with entities, such as Health Information Exchanges (HIEs), for the digital access and transfer of a patient’s medical records, which supports the Payer-to-Payer API.

Provider Access FHIR API

Payers also must build and maintain a Provider Access API to share patient data with in-network providers with whom the patient has a treatment relationship, enabling continuity and coordination of care, by January 1, 2027. Affected payers must maintain an attribution process to associate patients with the appropriate in-network providers responsible for the patient care. The data from the payer via the Provider Access API must be added to a provider’s electronic health record, practice management solution, or any other technology solution that a provider uses for treatment purposes.

The Provider Access API includes the same data covered in the Payer to Payer Access API (claims/encounters, clinical data, and prior authorizations). The payer has one business day to deliver the required information. Payers must offer a mechanism for members to opt out from making their data available to the attributed providers.

Patient Access FHIR API

The final rule further enhances patient access to data to improve their treatment and shopping experience. In addition to claims and clinical data, as of January 1, 2027, payers must make PA data available through the Patient Access API to inform patients on their plan’s PA process and the status of requests.

In addition, affected payers must report annual metrics about Patient Access API usage and data requests to CMS beginning January 1, 2026.

Key Considerations and Early Results

The rule presents a significant opportunity to improve patient experiences and outcomes and to address some of the administrative burden on clinicians. Though CMS made some adjustments to timeframes in the proposed rule, immediate attention is needed to evaluate technological solutions available to payers, assess gaps between current and future required state, and develop policies to comply with new requirements and measures reporting.

Commercial payers may also leverage the improved electronic data sharing but are not required to do so. CMS-funded payers must respond to any inquiries from commercial payers and must require commercial payers to provide the same information as affected payers. Commercial payers, state governments, and other stakeholders have an opportunity to collaborate around the electronic data exchange.

This rule may have positive downstream application to other areas beyond PA, including quality measurements, risk adjustment, and population health. Early adopters who have implemented the prior authorization APIs have, on average, recorded a 150% – 300% return on investment (ROI). The implementation of API-based prior authorization represents a demonstrable increase in efficiency and significantly reduced provider burden. Given the measurable ROI, state-based regional collaboratives being led by Leavitt Partners are forming between payers and providers to implement the core tenants of the CMS rule well in advance of the 2027 deadline.

Similar initiatives are taking place in the technology space, like the Digital Quality Implementers Community, which was recently convened by Leavitt Partners and National Committee for Quality Assurance (NCQA) to build industry readiness for transitioning to FHIR-based digital measurement that hinges on improved electronic data sharing

What to Watch

The HMA team will continue to analyze the CMS’s Interoperability and Patient Access rule in the context of other federal and state policy changes affecting MA organizations, Medicaid FFS programs, state CHIP FFS programs, Medicaid and CHIP managed care programs, and QHPs.

The work and opportunities afforded with the Interoperability and Patient Access final rule will be featured prominently at The HMA Spring Workshop: Getting Real About Transforming Healthcare Quality and Value, March 5-6. In addition to rich discussions, HMA and HMA companies, including Leavitt Partners and Wakely Consulting LLC, are available to support planning and implementation and related system redesign initiatives. If you have questions about these topics, contact Ryan Howells ([email protected]) and Daniela Simpson ([email protected]).