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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.
Health Management Associates (HMA), a leading independent, national healthcare consulting firm today announced that it has successfully completed a Service Organization Control Type 2 (SOC 2 Type 2) audit.
The SOC 2 Type 2 audit was developed by the American Institute of Certified Public Accountants to evaluate an organization’s information security controls over a period of time. It assessed both the suitability of HMA’s controls and its operating effectiveness, covering the HMA organization as a whole, service offerings, resources used to deliver client work, and technical (cybersecurity) and non-technical controls (administrative strengths such as excellent training and a culture that promotes anti-fraud and ethical behaviors).
“Increasingly, completing a SOC 2 Type 2 audit is an important distinction for many of our clients and partners,” said Doug Elwell, chief executive officer. “Achieving this with no material findings across the firm is yet another way to meet client needs and further demonstrates our commitment to our core values of accountability, client commitment and integrity.”
Founded in 1985, HMA is an independent, national research and consulting firm specializing in publicly funded healthcare and human services policy, programs, financing, and evaluation. Clients include government, public and private providers, health systems, health plans, community-based organizations, institutional investors, foundations, and associations. With offices in more than 30 locations across the country and over 700 multidisciplinary consultants coast to coast, HMA’s expertise, services, and team are always within client reach. Learn more about HMA at healthmanagement.com, or on LinkedIn and X.
This week our In Focus section reviews the Rhode Island statewide, capitated risk-bearing Medicaid managed care program request for proposals (RFP), which the Rhode Island Executive Office of Health and Human Services (EOHHS) released December 15, 2023. New program changes will include carving in long-term services and supports (LTSS) as an in-plan benefit for all populations and expanding managed care to include people who are dually eligible for Medicare and Medicaid. Contracts are expected to be worth $2.3 billion.
Background
Rhode Island’s Medicaid managed care program, which operates under the authority of a Section 1115 waiver and Section 1932(a) state plan amendment, consists of the following programs:
RIteCare, which serves children and families, including children with special healthcare needs
Rhody Health Partners, which serves aged, blind, or disabled (ABD) adults
Medicaid expansion, which serves childless adults ages 19 to 64
At present, full-benefit dual eligible (FBDE) members are not covered through the Medicaid managed care organization (MCO) contracts.
RFP
New contracts will be implemented in three phases, starting with enrollment of core populations and the addition of LTSS in-plan benefits to Medicaid managed care for Medicaid-only enrollees beginning July 1, 2025. In the second phase, current fully dual eligible members will transition to Medicaid managed care plans on January 1, 2026. All bidders will be required to offer an integrated Dual Eligible Special Needs Plan (D-SNP) and managed LTSS (MLTSS) plan to dually eligible members, as Rhode Island transitions from the Financial Alignment Initiative (FAI) Medicare-Medicaid Plan (MMP) Demonstration, which sunsets December 31, 2025. In addition, beginning January 1, 2027, default enrollment will begin for Medicaid members who become newly eligible for Medicare.
EOHHS will award contracts to two or three MCOs.
Other changes in the RFP include increasing oversight and accountability for the use of pharmacy benefit managers (PBMs); requiring that EOHHS approve contracts for MCO major subcontractors; reducing unnecessary prior authorizations, particularly for behavioral health services; increasing financial sanctions for noncompliant MCOs; and increasing investments in population health and health equity with a focus on the identification of health disparities; and other changes.
Timeline
Proposals are due February 23, 2024. The new contracts will take effect July 1, 2025, and will run through June 30, 2030, with an option to extend the agreement for up to five additional years.
Current Market
Neighborhood Health Plan, Tufts Health, and UnitedHealthcare served approximately 313,000 members as of November 2023. These MCOs have signed contract extensions through June 30, 2025.
Evaluation
Rhode Island will not require cost proposals under this procurement, with capitation rates set by EOHHS actuaries. MCOs must meet the passing technical score of 85 points. Technical proposal requirements are shown below:
In her role at PBGH, a nonprofit coalition representing nearly 40 private employers and public entities across the U.S. that collectively spend $350 billion annually purchasing healthcare services for more than 21 million Americans and their families, Mitchell represents a coalition of large purchasers – private employers and public entities – across the U.S. mobilizing to create functional health care markets that support high-quality affordable care that produces measurable outcomes. She will talk about the successes and challenges of creating greater alignment on value-based approaches to the $350 billion annual private purchaser spend on healthcare services.
Her remarks – and the input of others engaged in improving our healthcare system – will be unvarnished and focused on solutions to advance value-based care. Be part of this exciting discussion among top industry experts, health plan executives, state and federal leaders, and policy experts in working sessions to generate new solutions and actions to get us to the next level of quality and value.
Is the concept of value-based care (VBC) still relevant in today’s healthcare landscape or just a buzzword? Some argue that the financial challenges brought about by the pandemic have steered our healthcare delivery systems away from prioritizing value. However, many experts remain optimistic that value-based care is the key to achieving our overarching objectives of a more equitable, sustainable, high-quality healthcare system.
Kelsey Stevens, a principal at Wakely, an HMA Company, led a session on value-based care at the HMA Fall Conference. Her panelists felt strongly that value is critical to a functional and patient-focused healthcare system because the alternative is out of control spending and poor health outcomes. In fact, value-based care is flourishing in new ways as we look to integrate behavioral health and address health related social needs. There are lessons to be learned from early experiments, new models being built, and new models to be designed. Both public and private payers are pursuing new ways to take financial risk to deliver improved healthcare outcomes, focusing on solutions for higher risk populations or circumstances where quality of outcomes are indefensibly poor (i.e., maternal outcomes).
This enthusiasm felt by the wide variety of executives present at that fall meeting has inspired HMA to focus an entire conference on value. But notjust another conference on value. Our internal experts felt strongly about hosting a forum for healthcare organizations to truly tackle the end-to-end challenges of VBC… so we are doing that.
Those who join us March 5-6 in Chicago will experience a workshop designed to “get real” about transforming healthcare quality and value. We are convening participants from all parts of the healthcare industry who have the collective experience to pinpoint common challenges and to build a path forward.
The workshop is organized into four cohorts:
Payment and Risk Management Models,
Policy and Strategy Frameworks,
Data and Technology, and
Care Delivery Frameworks
Each will produce concrete recommendations for action, as well as building new relationships among peers to sustain this change. In the cohort on Payment and Risk management, discussion will be focused on existing and new models for payment, pricing and attribution methodologies, risk mitigation levers along the value continuum, and approaches to engage employees in focusing on patient-centered value in the care they provide.
One of our fall panelists, Eric Mattelson, chief actuary at Zing Health, said “I’m still convinced that value-based care is the future of healthcare and the Sisyphean struggle to get there will ultimately be worthwhile.” We echo this sentiment wholeheartedly, and if you share this conviction, we encourage you to secure your spot today and become a part of this exciting and transformative event.
Our sessions and networking events offer an opportunity to delve into approaches to develop and manage risk-based contracting across sectors, establish effective partnerships with safety net providers and community-based organizations, apply a value lens to deployment of technology and data analytics, and develop health equity plans aligned with value principles and policies.
Future blogs in this series will touch on elements from the other 3 cohorts on VBC that make up the balance of the workshop. To learn more and register go to HMA’s 2024 Spring Workshop page.
Policymakers have been working to move the U.S. healthcare system away from the costly and inefficient framework of fee-for-service to patient-centered structures focused on value and quality. Financial pressures, government regulation, and improvements in managed care all contribute to the drive toward value-based care, and that creates challenges for providers, payers, manufacturers, government, and others supporting the industry. Though some stakeholders are hanging on to the old ways of doing things, others are rightly moving toward putting their emphasis on value, changing their payment and workforce structures, and improving quality.
Health Management Associates will host the spring workshop, Getting Real About Transforming Healthcare Quality and Value, March 5−6, 2024, at the Fairmont Chicago Millennium Park Hotel in Chicago. The workshop starts with a kickoff event the evening of March 5 designed to foster meaningful connections for attendees, regardless of their role as a government official, provider, health system representative, payer, or vendor in public or private healthcare markets.
The full-day program on March 6 will feature a compelling keynote speaker and include multiple interactive workshop sessions focused on four key pillars of value-based care: Policy & Strategy Frameworks, Payment & Risk Management, Data & Technology, and Care Delivery Measures. HMA has expertise in working with commercial payers; primary, specialty, and behavioral healthcare providers; and publicly sponsored health plans at the local, state, and federal levels. Session discussions will help participants adapt to the new value-based market and are designed to provide a comprehensive exploration of the intricacies involved in healthcare transformation. Attendees will discuss what to expect during the early phases of transformation, as well as strategies, collaborations, and actions that have moved them closer to adding value on the ground.
Participants will be challenged to think critically about their organization’s cultural and operational readiness to create additional value for patients within the healthcare ecosystem. Drivers of policy, innovation, population health, risk management, IT, and data, as well as enablers and other stakeholders working in public and commercial markets, will meet in smaller groups to discuss and analyze scenarios, pose challenging questions, and identify tactical steps and solutions to thorny issues.
Other groups focusing on value will address multi-sector issues and perspectives that affect value-based care, including behavioral health, primary, and specialty care. From navigating the complexities of employee insurance plans for businesses to advocating for the needs of individual consumers, this workshop will address the formidable challenge of reshaping the healthcare landscape.
Don’t miss this opportunity to gain valuable insights and contribute to genuine and productive discussions that will shape the future of healthcare.
Whether you attend on behalf of your organization or with a team of colleagues whose roles touch upon different links in the value-based chain, you will bring back ideas and strategies that can be implemented upon your return. Register today!
Health Management Associates consultants, including colleagues from Wakely and The Focus Group, will be attending the JP Morgan Healthcare Investor conference in San Francisco, January 8-10, 2024. In addition to meeting with clients, HMA will be cosponsoring a reception with Shepherd Mullin as well as participating on a panel hosted by KPMG.
“While we’ve acclimated to a more virtual business world, the JP Morgan conference represents a unique opportunity to get together in person with valued clients and partners to discuss healthcare policy dynamics, emerging investment themes, and the exciting capabilities HMA has added over the last year to support its investment clients,” said Greg Nersessian, Managing Director of HMA Investment Services. “Rain or shine, we look forward to getting together and learning more about the trends that will shape healthcare investing in 2024.”
Tim Murray, a former JPM analyst, and now a Principal and healthcare actuary at Wakely Consulting Group, an HMA Company, says “The one inalienable truth about JPM’s annual event is that it sets the stage and tone for health care investing in the upcoming year…I’ll be focused intensely on how investors see the myriad headwinds facing government-sponsored healthcare programs playing out in ’24…they will surely inhibit growth but may also set the stage for opportunistic deal flow.”
The Focus Group is a strategic consulting firm working on business transformation in healthcare and private equity portfolios, acquired by HMA in late 2021. Its Managing Director Alex Rich added “our team is eager to reflect on recent deals and provide perspectives on new theses. Based on our wide array of recent projects and experiences, we’re excited to share and prepare creative strategies for portfolio value creation in the year ahead.”
Also in attendance will be the following HMA consultants:
HMA was engaged by the Washington, District of Columbia Department of Health Care Finance (DHCF) to lead their Medicaid Business Transformation D.C. Initiative, assessing the technical assistance needs of Medicaid providers and organizations in the areas of legal analysis, budgeting, and business development as they move toward value-based care arrangements. HMA partnered with the D.C. Behavioral Health Association (BHA), Medical Society of the District of Columbia (MSDC), D.C. Primary Care Association (DCPCA), and DHCF to engage, recruit, and collaborate with organizations and stakeholders across the District.
The HMA team implemented a mixed-methods assessment approach that included a literature review of national value-based payment (VBP) best practices, focus groups, interviews, and a technical assistance (TA) survey of District organizations, agencies, and stakeholders. This strategy identified the TA needs of District healthcare providers that informed the design of an intensive 3-month technical assistance program that included a variety of tools, webinars, and trainings. All resources and tools are available on the Integrated Care DC webpage. https://www.integratedcaredc.com/medicaid-business-transformation-dc/ The report and other information about the program were published at https://dhcf.dc.gov/innovation.
Experts from HMA as well as Wakely Consulting Group and Lovell Communications, both HMA subsidiaries, contributed to this report. We offer our clients a wide range of deep technical, analytical, policy, and communications support to providers, state agencies, and recommendations on ways to improve value-based payment models.
Report authors include Caitlin Thomas-Henkel, Suzanne Daub, Art Jones, Hunter Schouweiler, Amanda White Kanaley, and Vicki Loner.
To learn more about this effort, contact Caitlin Thomas-Henkel.
Be sure to block off March 5-6 for HMA’s Spring Workshop in Chicago, IL, where our experts will be continuing the dialogue about value-based care. Early bird registration ends January 26, 2024 – Register Here.
This week, our In Focus section reviews the new Transforming Maternal Health (TMaH) Model, which the Centers for Medicare & Medicaid Services (CMS) Center for Medicaid and Medicare Innovation (the Innovation Center) announced on December 15, 2023. TMaH is the fourth major model that the Innovation Center has introduced to its payment portfolio since July.
Pregnancy-related deaths have more than doubled since 1987 to 17.6 deaths per 100,000 live births, with health disparities only worsening outcomes for different racial and ethnic groups. For example, the pregnancy-related mortality rates for Black and Native American and Alaska Native women are approximately two to three times higher than the rate for White women. In recent years, 38 states have extended post-partum coverage and 11 states now offer doula coverage for Medicaid enrollees. This initiative accelerates the focus on maternal outcomes and, with nearly 43 percent of births paid for by Medicaid, has the potential to impact health across generations.
This model is designed exclusively to improve maternal healthcare for people enrolled in Medicaid and the Children’s Health Insurance Program (CHIP). The last Innovation Center maternal health-focused model, Strong Start for Mothers and Newborns, ran from 2012 to 2016 with the goal of reducing preterm births and improving outcomes for newborns and pregnant women. The TMaH model takes a whole-person approach to pregnancy, childbirth, and postpartum care, addressing the physical, mental health, and social needs experienced during pregnancy.
Model Overview
Participating state Medicaid agencies (SMAs) will receive up to $17 million over the 10-year period to develop a value-based alternative payment model for maternity care services, with the intention of improving quality and health outcomes and promoting the long-term sustainability of services. TMaH will focus on three pillars, with a range of solutions outlined for each.
Pillar
Model Solutions
Access to care, infrastructure, and workforce capacity
Increase access to birth centers and midwives.Increase access to perinatal community health workers and doulasEnhance data collection, exchange, and linkage through improvements in electronic health records and health information exchanges
Quality improvement and safety
Implement patient safety bundles or specific protocols that promote the reduction of avoidable procedures and lead to improved outcomesPromote achieving “birthing friendly” designationIntroduce option to promote shared decision making between mothers and providers
Whole-person care delivery
Institute evidence-based medical and social risk assessment to drive risk-appropriate careDeliver care consistent with individual preferencesRoutinely screening and follow-up care for perinatal depression, anxiety, tobacco, and substance use during prenatal and postpartum periodsIncorporate home monitoring and telehealth technology for birthing people who have medical conditions, such as gestational diabetes and hypertension, that complicate pregnanciesRoutinely screening and follow-up care for health-related social needs (HSRNs)Establish reliable referral pathways to and from community-based organizations (CBOs) to address HSRNsDevelop and implement health equity plans as well as cultural competency technical assistance for providers
The TMaH model is designed to support birthing persons along their care journey, expanding continuity, and improving outcomes.
The Model will have two phases for participating SMAs:
Pre-Implementation: A 3-year period during which states receive targeted technical assistance to achieve pre-implementation milestones prior to the implementation phase.
Implementation: A 7-year period where the SMAs (as the awardee) implement the program with critical partners, such as Managed Care Organizations (MCOs), Perinatal Quality Collaboratives, hospitals, birth centers, health centers and rural health clinics, maternity care providers and community-based organizations.
The model also requires a health equity plan, which has been a consistent requirement across models from the Innovation Center. Awardees must develop a plan that addresses disparities among underserved populations, such as racial and ethnic groups and people living in rural areas, who are at higher risk for poor maternal outcomes.
TMaH Opportunities and Considerations
The model offers states resources and technical assistance to develop value-based alternative payment model to support whole-person pregnancy, birth, and post-partum care and improved outcomes. Many SMAs are already working on programs to innovate care and payment, and the TMaH is an opportunity to expand and accelerate those programs.
The model offers an opportunity for states that have not expanded post-partum coverage or added doula benefits to adopt these policies with the funding and technical assistance to support their efforts.
SMAs interested in this opportunity may want to evaluate their application readiness and pre-plan for the application.
What’s next?
CMS is expected to release a Notice of Funding Opportunity (NOFO) in Spring 2024, and the application will be due in Summer 2024.
The HMA team will continue to evaluate the TMaH model as more information becomes available. For more information, contact Amy Bassano ([email protected]), Melissa Mannon ([email protected]), and Andrea Maresca ([email protected]).
