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The HMA colleagues note that two recent healthcare industry trends are converging to change the admission criteria and clinical practices that some skilled nursing facilities (SNFs) use. Driving one movement is the opioid epidemic in which increased prevalence of fentanyl and its medical complications are spurring the need for posthospital discharge SNF admissions. The other stems from the low occupancy rates in many SNFs since the pandemic. As a result, more SNFs are considering filling beds by admitting individuals with opioid use disorder (OUD) for the first time.
In many respects, this a positive development. The need for skilled nursing care, such as medication-assisted treatment (MAT), for individuals with OUD has never been greater. A March 23, 2023, US Drug Enforcement Administration public safety alert reported that recently analyzed fentanyl samples in 48 of the 50 states had been adulterated with xylazine, or “tranq,” a veterinary sedative added to prolong an opioid high. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), extensive xylazine use commonly causes severe skin wounds requiring weeks of intravenous antibiotics and skilled wound care to prevent amputations. Providing well-managed post-acute care for these patients could lead to improved outcomes.
But admitting and treating individuals with OUD now poses multiple challenges for SNF staffs and administrators. Many of these healthcare workers lack training in OUD pharmacological and support care. Some have stigmatizing attitudes toward individuals with OUD. To address these concerns, SNFs across the country have developed different practice models. Examples include:
Laguna Honda in San Francisco trains its staff to understand OUD, recognize the signs of resident opioid use, and work closely with nearby OUD providers to provide all OUD treatment.
At Highbridge Woodycrest Center in the Bronx, NY, the storage and administration of MAT is managed by the SNF staff through a collaborative relationship with a community-based provider, Bronx Care Health System, which prescribes the medications and then delivers them to the facility.
At other SNFs, SNF physicians and nurse practitioners prescribe buprenorphine with consultation as needed from community-based OUD providers.
HMA’s experts in OUD and SNFs are working collaboratively to assist SNFs interested in exploring the clinical, financial, and operational opportunities and challenges with this emerging line of business. For questions or inquiries, please contact Barry J. Jacobs.
This week, our In Focus checks in on the Medicaid unwinding work and key issues HMA experts are watching as more states resume their normal policies and processes for determining eligibility. A total of 19 states started disenrollments effective for April or May coverage, and 22 additional states plan to start ending coverage this month. States are scheduled to submit the next monthly report by June 8, 2023.
As explained in earlier In Focus articles, (here, here and here) federal COVID-19 relief laws allowed states to receive higher federal funding for Medicaid as long as the state did not terminate Medicaid coverage for anyone enrolled in Medicaid during the public health emergency (PHE). One result of the continuous coverage policy was sustained growth in Medicaid enrollment; more than 21 million additional individuals were continuously enrolled in Medicaid for up to three years between February 2020 and March 2023. In December 2022, Congress ended the Medicaid continuous coverage policy after March 31, 2023. States were allowed to begin processing redeterminations as early as February 2023 and start disenrolling ineligible individuals as early as April 2023.
Preparations for the Medicaid unwinding have been under way for well over two years. The Centers for Medicare & Medicaid Services (CMS), states, Medicaid health plans, providers, beneficiary advocates, and other interested stakeholders have been working to ensure that the policies, outreach, and assistance are in place to support this massive eligibility renewal and redetermination initiative.
What Do We Know… Or Not Know?
Most of the available forecasts project between 10-15 million enrollees will lose Medicaid coverage. The Health Management Associates (HMA) insurance mix model projects that more than 10 million of the approximately 90 million Medicaid enrollees are at risk for disenrollment. HMA’s model illustrates the variety in state approaches to managing the resumption of eligibility redeterminations as well as key insights related to the differential impact by Medicaid eligibility categories.
Based on published information, the number of individuals who were disenrolled from Medicaid in April through May is likely to approach 500,000. In these early days of the unwinding period, HMA experts are closely reviewing the reports and engaging with key stakeholders in individual states. Several issues already are garnering more attention, such as the impact on child enrollment, churn and experiences in states using the extended reconsideration period flexibility, among others. Stakeholders will want to monitor how these and other program nuances evolve over the next year.
We do not yet have robust or consistent data from the states that have resumed their normal processes for determining eligibility. States must submit disenrollment reports to CMS each month, and CMS must publish this information. The states are not, however, required to publish this information on their website. While some states have chosen to publish the data or plan to do so, there is no consistent approach to the specific data states post. For example, while most states publishing a state data dashboard are sharing the number of renewals they are processing each month, only slightly more than half also are sharing the number of renewals resulting in coverage terminations. CMS is not expected to publish the state data before the end of June. Once this information is available, the state unwinding reports may provide a more comprehensive and consistent picture of enrollment over the next year.
In addition, the total number of “procedural terminations” currently is difficult to determine. Lack of consistent public reporting creates gaps in the data about the number of individuals disenrolled because they did not provide a timely response to the state’s request for more information (or for other procedural reasons). As Medicaid stakeholders know, the procedural disenrollment number is critical because these individuals could still be eligible for the program.
Early disenrollment numbers should be analyzed carefully and in the context of the state. As noted earlier, the full eligibility renewal and disenrollment reports are unavailable at this time. We do know, however, that the available data is best analyzed in the context of the state’s unwinding plan (e.g., how the state is sequencing its eligibility reviews). The sequencing, pace, staffing, messaging consistency, partner outreach and assistance, and other factors will result in variation in state experiences. States are actively analyzing the data as the information is released and considering course corrections that may be needed, which could affect enrollment.
Ongoing federal and state collaboration is improving preparations and allowing partners to address concerns as they arise. CMS and states have been transparent about the magnitude of the Medicaid unwinding and the fact that challenges will be inevitable throughout this process. The experiences reported by the first tranche of states to begin their unwinding period reinforce those points. They also provide important lessons for states that are or will shortly resume normal eligibility operations.
What to Watch
HMA’s experts are working with states, Medicaid health plans and their partners, providers, and advocacy organizations to identify and implement solutions to some of the known challenges. We also are looking ahead to forthcoming data, qualitative input, and other important developments that may inform federal and state policies and operations beyond the unwinding period.
Unwinding trends. Though it is too early to definitively identify trends, HMA experts are monitoring the early state data, and we are prepared to analyze the CMS reports once they are published. We anticipate the CMS published data could be more instructive regarding the impact of the unwinding on enrollment, including states or regions that could benefit from additional outreach and assistance strategies, disproportionate impacts on certain demographic groups, new flexibilities that states may want to consider, and steps that health plans, hospitals and health systems, providers, and other partners could advance.
State operational plans. As of late May, CMS officials reported they have not asked any state Medicaid agency to develop a corrective action plan related to the unwinding; however, this does not mean that federal officials do not have concerns about the experiences and data being reported out of certain states. States, their business partners, and advocates will all benefit from monitoring shifts in state plans, potential future CMS resources and direction to states such as additional reporting or modifying eligibility processes.
Coverage Program Transitions. Significant attention has been appropriately placed on the Medicaid disenrollment numbers. HMA experts also are closely watching for new data on the number of individuals who successfully transition and enroll in qualified health plans offered in the Health Insurance Marketplaces. In the short term, the Medicaid unwinding could have a notable impact on total enrollment in Marketplace plans as well as provider payer mix. This could affect longer-term policy, strategy, and operational decisions for officials at the federal and state levels, managed care organizations, providers, and other stakeholders. For example:
Health insurers should assess the opportunity to participate in the Marketplace program. Other insurers may need to develop new strategies to remain competitive in the Marketplace.
Providers have similar assessments to conduct related to changes in the number of uninsured people to whom they deliver care, as well as their payer mix and the Marketplace plan networks in which they participate.
Policymakers may revisit Marketplace regulations and standards in response to enrollment growth, enrollee demographics, and acuity of enrollees in Marketplace plans.
Medicaid agencies, health plans, all types of Medicaid providers, and advocacy organizations should continue to analyze their immediate needs during the Medicaid unwinding. They should also be planning to identify and incorporate lessons from this transition period, as well as preparing for policy and operations changes in the post-unwinding environment.
On June 8, 2023, the Health Care Payment Learning & Action Network (LAN) will hold a virtual meeting focused on accountable primary care. The LAN — an initiative supported by the Centers for Medicare & Medicaid Services (CMS) Innovation Center — is a group of public and private health care leaders that provide thought leadership, strategic direction, and ongoing support to accelerate our care system’s adoption of alternative payment models (APMs). During the session, CMS Administrator Chiquita Brooks-LaSure and the Innovation Center’s Deputy Administrator and Director Liz Fowler will share their vision for accountable primary care.
Over the past several months CMS leaders have discussed their intent to accelerate the transition to value-based care and more accountable primary care. They have identified key principals and hinted at certain components of a potential new primary care model. Additionally, the Innovation Centers’ earlier strategy documents have highlighted the imperative to include payers beyond Medicare, importantly Medicaid and commercial insurers, in models to achieve person-centered accountable and equitable care.
This meeting is notable because the Innovation Center’s models can drive transformational shifts in health care delivery and payment across public and private payers at the system and practice levels. Providers, health systems, insurers, and other interested stakeholders will want to closely monitor the LAN discussion for more information about CMS’ evolving thinking and future opportunities related to a potential model for accountable primary care. HMA experts are available to work with health care organizations and stakeholders to interpret and respond to developments flowing from the LAN session.
LAN meeting registration and information is available here.
On May 31, the House passed H.R. 3746 – the Fiscal Responsibility Act of 2023, otherwise known as the “debt ceiling” bill, which increased the federal debt limit, established new discretionary spending limits, rescinded unused funds, and expanded work requirements for federal programs. It was passed by the Senate on June 1 and will soon be signed into law. What does all this have to do with healthcare workforce? Well, part of the rescindment plan comes from $28 billion in unused pandemic funding, with a substantial portion of those funds that were allocated for healthcare workforce efforts. This includes funds set to be used for mental health and substance use disorder training, grants to improve mental health and burnout in the healthcare workforce, and additional educational and training grants for promoting future workforce. Overall, part of $28 billion specifically includes removal of $1.7 billion from the Centers for Disease Control and Prevention (CDC) and $13.4 billion from the Department of Health and Human Services (DHHS), including $10.4 billion from public health and social services emergency funds.
So, what does this mean for the healthcare workforce? It means healthcare organizations will need to continue to optimize their current and future workforce plans, without additional funding that could provide some relief.
At Health Management Associates (HMA), our healthcare workforce experts have not only partnered with health system leaders to identify real-world solutions, we have directly experienced the same challenges, because our team includes physicians, nurses, advanced practice providers, and former health system operations and financial executives who share the same lived experiences.
HMA offers a number of workforce solutions to healthcare communities across the spectrum. We cannot fill all your staffing gaps tomorrow, however, we can give you an innovative, model-of-care plan designed to lower costs, increase revenue, and position organizations for long-term financial success and operational sustainability.
An experienced team of health system leaders, bedside clinicians, and workforce subject matter experts with real-world experience and modern health care delivery solutions
A thorough quantitative and qualitative assessment including:
Workforce capacity, needs, and gap analysis.
Leadership and governance structure evaluation.
Key regulatory and policy gap analysis.
Compensation and benefits review.
Clinical and/or non-clinical workflow evaluation.
Provider billing practices and quality metric capture.
Provider and staff utilization analysis.
What organizations receive is:
A customized, comprehensive phased implementation plan that:
Improves cash flow and maximizes revenue.
Reduces turnover, increases retention, and improves health system culture.
Optimizes the ‘Model of Care’ delivery while still maintaining quality and safety.
Provides solutions for long-term financial success and operational sustainability.
Offers on-going executive and leader coaching services to help provide support through the change management process.
Today’s healthcare workforce challenges are unwavering, especially given the recent passage of the “debt ceiling” bill. From significant workforce shortages, to rising costs and competition, to decreasing employee engagement and burnout, today’s health systems face tremendous challenges. But by understanding workforce and health system needs and identifying gaps and inefficiencies, employers can fully utilize the employees they have to their highest potential and deliver care more effectively and efficiently. Here at HMA, our delivery system optimization team can help health care communities struggling with workforce challenges do just that.
Contact our healthcare delivery system experts, who can partner with your organization to design a custom workforce solution for you.
Roxane Townsend MD, Managing Director, Delivery Systems
Melinda Estep, Managing Director, Delivery Systems
Jennifer M. Orozco, DMSc, PA-C, DFAAPA, Principal, Delivery Systems
This webinar has been postponed and will be rescheduled.
Health Management Associates (HMA) is offering a 3-part series of webinars looking at the effect of proposed regulations on delivery of opioid treatment services to the population facing addiction issues. In this third and final webinar, HMA consultants will highlight opportunities for state regulators to shape policy and regulation of SUD treatment.
New federal regulations encourage significant changes to how opioid treatment is provided, with the goal of expanding access and improving patient-centered care. State regulators will need to adapt their regulatory practices and work closely with Medicaid agencies and treatment providers so the new regulations can achieve their intended goals. This webinar will discuss how State Opioid Treatment Authorities (SOTAs), licensing entities, and state Medicaid agencies will need to work together to craft updated regulations, facility licensing, and reimbursement practices that advance person-centered care.
New Regulatory Requirements – Overview of state rules around opioid treatment vs the new requirements.
How to Improve SUD Treatment Access – Specific recommendations on statutory and regulatory changes that could lead to more patient centered treatment options.
States Leading the Way – Examples from states that are leading the way to expand access and reduce stigma.
HMA’s webinar series, 1115 Medicaid Justice Demonstration Waivers: Bridging Healthcare, focused on helping stakeholders optimize the continuity of care for persons in carceral settings and during their transition back to the community.
Part 3 focused on optimizing key partnerships before, during and after transition from a carceral setting into the community to ensure the best outcomes for individuals eligible for 1115 approved waiver services.
Health Assessments and Transition Planning: Understand the health and resource needs of returning citizens (health, behavioral health and social issues).
Collaboration with Community Providers: Identify key partners and formalize collaborations to strengthen the quality of transitions care and support provided to individuals transitioning to the community.
Insurance Enrollment Strategies: Develop Medicaid enrollment strategies that apply to your state and local framework.
Innovations in Publicly Sponsored Healthcare: How Medicaid, Medicare, and Marketplaces Are Driving Value, Equity, and Growth
Pre-Conference Workshop: October 29, 2023 Conference: October 30−31, 2023 Location: Fairmont Chicago, Millennium Park
Health Management Associates has announced the preliminary lineup of speakers for its sixth annual conference, Innovations in Publicly Sponsored Healthcare: How Medicaid, Medicare, and Marketplaces Are Driving Value, Equity, and Growth.
Hundreds of executives from health plans, providers, state and federal government, investment firms, and community-based organizations will convene to enjoy top-notch content, make new connections, and garner fresh ideas and best practices.
A pre-conference workshop, Behavioral Health at the Intersection of General Health and Human Services, will take place Sunday, October 29.
Confirmed speakers to date include (in alphabetical order):
Jacey Cooper, State Medicaid Director, Chief Deputy Director, California Department of Health Care Services
Kelly Cunningham, Administrator, Division of Medical Programs, Illinois Department of Healthcare and Family Services
Karen Dale, Chief Diversity, Equity, and Inclusion Officer, AmeriHealth Caritas
Peter Lee, Health Care Policy Catalyst and former Executive Director, Covered California
John Lovelace, President, Government Programs, Individual Advantage, UPMC Health Plan
Julie Morita, MD, Executive Vice President, Robert Wood Johnson Foundation
Anne Rote, President, Medicaid, Health Care Service Corp.
Drew Snyder, Executive Director, Mississippi Division of Medicaid
Tim Spilker, CEO, UnitedHealthcare Community & State
Stacie Weeks, Administrator/Medicaid Director, Division of Health Care Financing and Policy, Nevada Department of Health and Human Services
Lisa Wright, President and CEO, Community Health Choice
Publicly sponsored programs like Medicare, Medicaid, and the Marketplaces are leading the charge in driving value, equity, and growth in the U.S. healthcare system. This year’s event will highlight the innovations, initiatives, emerging models, and growth strategies designed to drive improved patient outcomes, increased affordability, and expanded access.
HMA is pleased to welcome new experts to our family of companies in April 2023.
Jed Abell – Consulting Actuary Wakely
Jed Abell is a professional health insurance actuary with over 20 years of experience focusing on Medicare Advantage, Part D, and commercial employer group plans.
Surah Alsawaf – Senior Consultant HMA
Surah Alsawaf is a senior consultant with experience in creating and implementing regulatory strategies and workflows, conducting reviews and audits, and leading cross-functional teams to complete complex deliverables.
Elrycc Berkman – Consulting Actuary Edrington
Elrycc Berkman is experienced in Medicaid managed care rate development including managed long-term services and supports (MLTSS) and program of all-inclusive care for the elderly (PACE) rate development.
Monica Bonds – Associate Principal HMA
Monica Bonds is an experienced managed care professional with over 15 years of experience working in large and diverse organizations.
Yucheng Feng – Senior Consulting Actuary Wakely
Yucheng Feng has over 15 years of experience providing actuarial support for Medicare Advantage clients, including bid preparation, reserve, actuarial analytics and providing strategic recommendations. Read more about Yucheng.
Melanie Hobbs – Associate Principal HMA
Melanie Hobbs is an accomplished healthcare executive, consultant, and thought leader specializing in Medicare, Medicaid, and Special Needs Plans (SNPs).
Daniel Katzman – Consulting Actuary Wakely
Daniel Katzman is experienced in Medicare Advantage bid pricing and modeling as well as claims trend analytics and affordability/cost-savings analysis. Read more about Daniel.
Supriya Laknidhi – Principal HMA
Supriya Laknidhi has over 20 years of experience in the healthcare industry and a proven track record in driving growth and innovation for companies.
Donald Larsen – Principal HMA
Dr. Donald Larsen is a C-suite physician executive with over 30 years of experience spanning complex academic medical centers, community health systems, acute care hospitals, and research institutes.
Ryan McEntee – Senior Consultant Wakely
Ryan McEntee is an experienced managed care executive specializing in strategic leadership within Medicare Advantage plans. Read more about Ryan.
Nicole Oishi – Principal HMA
Nicole Oishi has over 30 years of experience in senior leadership roles as a healthcare clinician and executive.