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Blog

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

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

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

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

Market Landscape

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

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

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

A Growing Market

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

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

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

Guiding Principles and Policy Recommendations

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

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

Link to Report

What’s Next

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

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

HMA News

Nine States Selected for Children’s Behavioral Health Policy Lab

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State behavioral health and children’s welfare agency officials from Georgia, Kansas, Kentucky, Maryland, Missouri, Pennsylvania, Texas, Utah, and Wisconsin selected to participate.

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

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

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

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

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

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

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

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

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

For more information email: [email protected]

Blog

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

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

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

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

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

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

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

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

Brief & Report

Analyzing the Expanded Landscape of Value-Based Entities: Implications and Opportunities of Enablers for the CMS Innovation Center and the Broader Value Movement

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New Report Analyzes the Expanding Landscape of Value-Based Entities    

Research from HMA and LP VBP experts segments and sizes the growing enabler market, considering benefits and risks, and proposing guiding principles and policy recommendations for the CMS Innovation Center

A new in-depth HMA report analyzes the landscape of emerging value-based entities and the implications for accelerating the adoption of accountable care.

In recent years, the value-based care market has expanded to include a variety of risk-bearing care delivery organizations and provider enablement entities with capabilities and business models aligned with the functions and aims of accountable care. Despite their prevalence, there has been little formal research into the role, growth, and impact of these entities to date and publicly available information is limited.

The report, “Analyzing the Expanded Landscape of Value-Based Entities: Implications and Opportunities of Enablers for the CMS Innovation Center and the Broader Value Movement,” represents a nine-month research effort leveraging the combined VBP policy and market expertise of HMA and Leavitt Partners, an HMA Company with support from Arnold Ventures.

The report offers a detailed overview of this evolving landscape by introducing a novel framework for classifying these entities and estimating the size of the market.

The authors interviewed 60 entity leaders, providers, and policymakers and conducted extensive secondary research into approximately 120 organizations, generating report insights that detail the common offerings, partnership models, and growth strategies of these entities. Authors examined providers’ experiences selecting and collaborating with enablement partners and the role of these entities within Medicare accountable care models and the broader value movement.

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

As this landscape evolves and expands, CMS and its Innovation Center should continue to carefully consider how these entities participate in its models while also leveraging these important partners for learning and advancing accountable care.

With its acquisition of Leavitt Partners and Wakely Consulting, along with its strong and growing Medicare policy practice, HMA is developing a diverse and robust set of solutions for entities engaging in value-based care and payment. In March, HMA will be devoting its spring event to the topic, with the report authors featuring prominently among discussion leaders and presenters. More information about the Spring Workshop, “Getting Real about Transforming Healthcare Quality and Value”, can be found here.

Report authors include Kate de Lisle, Amy Bassano, Jared Staheli, Spencer Morrison, and Melissa Mannon. Data collection and analysis was supported by Thomas Gubbay, Tom Williams, and Lucas Asher.

Blog

CMS announces innovation in behavioral health model

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

IBH Model Overview  

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

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

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

Opportunities and Considerations  

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

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

What’s Next  

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

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

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

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

Blog

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

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

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

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

Funding

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

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

HRSN

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

HERO

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

Workforce

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

Medicaid Hospital Global Budget Initiative

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

IMD Waiver for SUD

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

Curious About What the Waiver Means for Your Organization?

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

Webinar

Webinar replay – Navigating change: exploring the opportunities of New York’s 1115 Medicaid waiver amendment

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This webinar was held on January 24, 2024.

During this webinar, HMA panel guides you through the newly approved key provisions of New York’s 1115 Medicaid waiver amendment. This groundbreaking development opens doors to transformative changes in healthcare delivery, impacting both providers and beneficiaries alike, including enhanced Health Related Social Needs (HRSN) benefits, workforce and hospital investments, and further commitment to Value Based Payment (VBP).

Gain valuable insights into the innovative strategies and opportunities presented by the waiver amendment, paving the way for new social care networking activities, funding opportunities, and regulatory flexibilities that will improve access to vital services.

This webinar shared information on waiver-specific details and what they mean, what potential opportunities will become available, and heard from national experts on similar models implemented nationally.

Blog

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

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LEARN MORE ABOUT HMA’S SPRING WORKSHOP

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

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

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

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

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

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

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

CLICK HERE TO REGISTER