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Brief & Report

50-state Medicaid director survey released: states focus on quality and outcomes amid waiver changes

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Results of the 18th annual Medicaid Budget Survey were released Oct. 24, 2018 and examine changes taking place in Medicaid in all 50 states and the District of Columbia. The Kaiser Family Foundation (KFF) and HMA conduct the survey in partnership with the National Association of Medicaid Directors.

Key findings of the study include:

  • A growing number of states are implementing or planning to implement Section 1115 waivers
  • Risk-based managed care continues to be the predominant deliver system for Medicaid services
  • States are working to address social determinants of health
  • Expansion of people served in in-home and community-based settings
  • States are planning provider rate increases, increase in benefits for mental health and substance use disorder treatment and efforts to address rising prescription drug costs and management strategies to address the opioid crisis.

The report was prepared by Kathleen Giff­ord, Eileen Ellis, Barbara Coulter Edwards, and Aimee Lashbrook from HMA, and by Elizabeth Hinton, Larisa Antonisse, and Robin Rudowitz from the Kaiser Family Foundation.

Brief & Report

HMA Denver office evaluates jail-based behavioral health services program in Colorado

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HMA partnered with the Colorado Office of Behavioral Health and Correctional Treatment Board to conduct a statewide program evaluation report for The Jail Based Behavioral Health Services (JBBS) program. The JBBS program is administered by the Office of Behavioral Health and is funded through Colorado House Bill 10-1352 and was expanded through Colorado Senate Bill 12-163 creating the Correctional Treatment Cash Fund.  The JBBS program provides resources for the county jails to address the needs of individuals with substance use disorders and co-occurring mental health disorders. Initiated in 2011 with twenty- four counties, the program is in its seventh year and has grown to 46 counties across the State.  This initial JBBS program evaluation examined both process elements of how the program is implemented across the counties as well as the outcomes and impact of the services provided.

Brief & Report

MACPAC contracted with HMA to better understand how states develop their hospital payment policies

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Health Management Associates was contracted by MACPAC to better understand how states develop their hospital payment policies. State, hospital, and managed care representatives from five states that vary in their use of supplemental payments and financing approaches (Arizona, Louisiana, Michigan, Mississippi, and Virginia) were interviewed. The three key findings from the study include:

  1. The availability of financing for the non-federal share of Medicaid payments has affected states’ use of base and supplemental payments;
  2. The use of Medicaid managed care has not substantially affected Medicaid payments to hospitals; and,
  3. The adoption of prospective payment systems and value-based payment models is slow.

MACPAC presented this information at its September 2018 Commission meeting.

Brief & Report

HMA reviews state assisted living licensing regulations and statutes for 2018 NCAL state regulatory review

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From March 2017 through April 2017, HMA reviewed each state and the District of Columbia’s assisted living licensing regulations and statutes, relying on the resources published on state licensure agency web pages.  According to the NCAL’s 2018 edition of “Assisted Living State Regulatory Review,” assisted living regulations, statutes, and policies in 29 states were updated between June 2017 and June 2018. The report found that the most common changes to state regulations were in the area of staffing, such as additional training requirements and expanded background check requirements.

Brief & Report

HMA Report Examines Needs Assessment for Denver Residents with Intellectual and Developmental Disabilities

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The City and County of Denver’s Department of Human Services (DHS) contracted with HMA, between March and August 2018, to conduct a needs assessment of services and supports for individuals with intellectual and/or developmental disabilities (IDD). Denver will use findings from this assessment to inform decisions regarding the governance and distribution of a Denver property tax (mill levy) dedicated to funding services for residents with IDD.

The primary goals of the needs assessment were:

  1. Inventory current services for Denver County residents with IDD and the existing capacity in and around Denver to provide these services.
  2. Identify service gaps and potential ways to address these gaps by engaging stakeholders ‐ including clients, families, caregivers, service providers, city and state agencies, employers, and the public, with the intent to form the basis of how dedicated mill levy funding is programmed going forward.
  3. Research possible governance models for determining/overseeing the disbursement of dedicated revenue, gathering stakeholder feedback on the governance models, and evaluating pros and cons of preferred models to form the basis of the process through which dedicated funding is allocated going forward.

The report summarizes the findings in the three areas identified above, including recommendations on the most pressing service gaps to address and features of the governance model.

Brief & Report

Hospital Charges and Reimbursement for Medicines: Analysis of Cost-to-Charge Ratios

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This report is an update to a previous report examining hospital markups for separately paid drugs. Our prior analysis examined hospital charges and reimbursement for 20 drugs and found that hospitals marked up charges for those drugs, on average, 487 percent of their acquisition cost. We also found that hospitals receive 252 percent of estimated hospital acquisition cost from commercial payers. Hospital reimbursement data was obtained from the Magellan Rx Management Medical Pharmacy Trend Report™: 2016 Seventh Edition (the Magellan report) and charges were calculated from Medicare claims data. For more information, please refer to our prior analysis.

Brief & Report

HMA Contributes to CPEHN Report on California’s Mental Health Equity Act

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Principal Jeff Ring and Senior Consultant Helena Whitney recently coordinated and facilitated an advisory committee which provided recommendations for the implementation of California’s Mental Health Equity Act (AB 470, 2017). Using the Advisory Committee recommendations, they developed the California Pan-Ethnic Health Network (CPEHN) report, “Measuring Mental Health Disparities.”

AB 470 was proposed to mandate the Department of Health Care Services (DHCS) update the performance and outcome reporting system on mental health outcomes and utilization for beneficiaries receiving Specialist Mental Health Services in order to focus the Performance Outcomes System (POS) on disparities. Following the passage of the statute, CPEHN created an Advisory Committee of behavioral health and healthcare experts to develop recommendations for the DHCS to consider during its stakeholder engagement process.

After reviewing DHCS’ existing data and quality measures, the Advisory Committee identified data elements that the state performance outcome reporting system on mental health should include to further the work of tracking mental health disparities and achieving health equality.

Also considered was information obtained through interviews with selected subject matter experts who directed the Advisory Committee to additional performance measures and datasets, such as those currently in use by health plans that are participating in state and national pilot programs such as the Public Hospital Redesign and Incentives in Medi-Cal (PRIME) Program, the Health Homes for Patients with Complex Needs Initiative, and the Whole Person Care Program.

Special consideration was given to measures that were (1) developed by nationally-recognized organizations such as the National Committee for Quality Assurance and the Consumer Assessment of Healthcare Providers and Systems Consortium, (2) are endorsed by the National Quality Forum, (3) are widely used by other states, (4) and/or are cited in the literature as “disparity-sensitive,” meaning that the measurements help identify inequities in health outcomes and access to services.

Per the requirements of the statute, the Advisory Committee organized its measure recommendations into two phases:

  1. Those that are currently available from county mental health plans or the state and should be included in the initial POS reports (“Phase I”).
  2. Those that could be added to county reporting systems and/or may be available from Medi-Cal managed care plans and should be included in future POS reports (“Phase II”).
Brief & Report

Report Examines the Models and Issues of Behavioral Heath Crisis Services

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In a report prepared for the Michigan Health Endowment Fund, HMA Principal Steve Fitton and Senior Consultant Esther Reagan examine the models and issues of behavioral health crisis services.

Many people with behavioral health (mental illness and/or substance use disorder [SUD]) issues are arriving in hospital emergency departments (EDs) and not being well served in that setting. The ED is the wrong place at the wrong time for many patients – and for many reasons. These include being discharged prematurely, long waits in noisy EDs may exacerbate symptoms, the EDs may not have the professional staff best suited to provide services, and the ED itself is an expensive setting and can result in unnecessary and costly admissions for public and private insurers.

A number of models have been developed with the goal of improving the behavioral health emergency response environment. This report explores several models, including mobile crisis teams, co-located and dedicated behavioral health crisis emergency services units, behavioral health staffing in hospital EDs, and standalone behavioral health crisis centers. Strategies for moving forward, including addressing challenges in multiple areas are outlined as well.

Brief & Report

HMA Prepares Report Describing Strategies to Increase MAT Prescribing

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Senior Consultant Julia ElitzerManaging Principal Jonathan FreedmanSenior Consultant Mary Russell, and Managing Principal Margaret Tatar recently prepared the report “Strategies to Increase MAT Prescribing,” for the Association of Community Affiliated Plans through a grant from the Open Society Foundations.

The report examines how to address opioid use disorder through the promotion of medication-assisted treatment (MAT). MAT is an approach that combines behavioral therapy and the administration of three medications – methadone, buprenorphine, and naltrexone – to treat addiction.

Brief & Report

HMA Contributes MLTSS Research to MACPAC Report

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Principal Sarah Barth, Principal Karen Brodsky, Principal Sharon Lewis and Senior Consultant Rachel Patterson and other HMA colleagues contributed research under contract to MACPAC on standards for home and community-based services network adequacy in managed care for long-term services and supports (MLTSS) programs and on tailoring MLTSS programs for individuals with intellectual or developmental disabilities.

Brief & Report

Report Provides Indigent Healthcare Community Investment Analysis for Florida County

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In late 2017, the Marion County Hospital District commissioned a study to define the medically indigent, identify the current volume and costs of healthcare for the medically indigent population in Marion County, describe the providers that comprise the health care safety net, summarize the investments made in the health care safety net, outcomes of this level of investment, and identify ways the community might better invest in this system. In the context of a recent reduction in federally funding to Marion County hospitals, and a decrease in the local Department of Health (DOH) funding and hospital funding to support the multi-site Federally Qualified Health Center (FQHC) in the county (Heart of Florida), community investment in the FQHC was a particular area of interest. A series of questions generated by the Marion County Hospital District guided the study and framed the report. To answer these questions, HMA analyzed publicly available data and reports, obtained quantitative and qualitative data from over 40 key stakeholders.

In terms of a definition for medically indigent, HMA recommends that Marion County consider uninsured individuals with an income less than 200 percent of the Federal Poverty Level to be considered “medically indigent.” This equates to 30,988 individuals in Marion County.  This definition is used by the state of Florida for several major programs, has been approved by the federal government, and is routinely used by hospitals in defining indigent care.

HMA found that the hospitals – Munroe Regional Medical Center and Ocala Health – provide services to approximately the same proportion of Medicaid patients on an inpatient basis, and that Munroe serves a disproportionate number of Medicaid patients compared to the State-wide average in their Emergency Department and in Labor and Delivery. Both hospitals combined incur $3 million in unreimbursed charity care cost for the medically indigent in Marion county.

Heart of Florida (HOF) is the single largest primary care provider in the county and has limited behavioral health services.  Ocala Community Care (the county jail health service provider) is the next largest provider of indigent primary care and outpatient behavioral health, followed by Langley Health Center that has one primary care site in the county and offers some behavioral health services.  HOF’s proportion of paying patients is less (66%) than Langley (80%) and HOF provided approximately 24,000 in uninsured visits to Langley’s 5,000.

The Centers is the traditional safety net behavioral health provider in the community and is the only provider that receives state funding for serving residents who are indigent; accessibility is an issue for many given the location of the main site. The Vines delivers inpatient, residential, and partial hospitalization services; they receive no funds from the state or county and report having delivered $4 million in charity care last year. Meridian Behavioral Health in Alachua County is serving nearly 600 Marion County residents, many who report access issues in Marion County. This led Meridian to begin a telemedicine relationship with HOF to address the need for more local behavioral health services.

Marion County budgets over $9 million for indigent health care (excluding an estimated $7 million for the county jail). This is primarily for statutorily required payments for Medicaid and funding for The Centers and the Department of Health. The Marion County Hospital District funded $1.6 million in local projects in its 2017 grant cycle.

The entirety of Marion County is federally designated as a Health Professions Shortage Area; demand exceeds supply of primary care and community behavioral health. There is an average of about 2 months wait for new patients to be seen at Heart of Florida, and Munroe Medical Center has a particularly high rate of low acuity Emergency Department visits (27.4%), many of which are likely individuals who are unable to access care in the community.  The Centers reports that they have instituted a walk-in system for initial assessments, and that an appointment for outpatient therapy is typically scheduled within 2-3 weeks. The Medication Clinic is also walk-in but maximum capacity is reached about one-third of clinic days such that patients arriving after the maximum capacity is reached cannot be seen that day; these patients are given priority status for the next clinic day.

In the report, we present challenges and opportunities for the safety net provider organizations individually and collectively. A particular challenge has been HOF’s continued management of the three former Department of Health primary care sites given that these sites have particularly high rates of uninsured patients ranging from 43 – 61 percent.  We present an analysis that concludes that these sites fill a community need and should continue to operate unless other alternatives become available. By contract, HOF will receive $800,000 from the DOH to help support operations of these three sites, but funding is scheduled to be reduced by 20% each year over a five-year period ending on September 30, 2021. In addition, the two hospitals are planning to discontinue their contributions to the HOF. Given the funding reductions anticipated, HMA’s opinion is that the county should continue to fund HOF at the current level of $380k at least for Fiscal Year (FY) 2019. We recommend that HOF be required to develop an operational plan to present to the county in FY 2019 to detail strategies to address the loss of their other funding streams. If HOF requires continued funding from the county it should clearly articulate how that funding would be utilized and the benefit it would bring to the community.

Given the primary care and behavioral health provider shortages in the county, HMA also analyzed and highlighted where new primary care/behavioral health sites might best be located and presented justifications with supporting maps.

Finally, HMA conducted an environmental scan to identify indigent care funding models and delivery system best practices. We developed a set of recommendations for the community that identifies particular models and best practices that drive care to the outpatient setting and reduces preventable and costly hospital utilization. The recommendations also call for a process to bring key provider groups and other stakeholders together to collaboratively plan and implement strategies to strengthen the health care safety net.