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Child and family wellbeing

Child welfare services face challenges every day to prevent, treat, and reduce risk of maltreatment, neglect, trauma, housing instability, and violence in communities. These issues need to be seen as a priority for public health and community wellbeing and not just the jurisdiction and responsibility of child welfare agencies.

There are many opportunities for improvement in this area, including:

Integrating prevention services within the human services system to help support families and youth experiencing child welfare interventions

Providing technical assistance and supports to systems serving child welfare and justice-involved youth, including: policy and practice reviews, workforce and workload analyses, process re-engineering

Increasing Medicaid providers who offer more community based Evidenced Based and Informed Practices (EBP) among Community Based Organizations (CBO), Providers, and Local Government entities

Developing the workforce to enable prevention programs and building competencies to engage in meaningful interactions with children, youth, and families

Addressing disparities in both experiences and outcomes for children, youth and families, rather than focusing on responding through merely a transactional and compliance driven approach

If your organization works to help meet the needs of children, youth and families impacted by issues like mental health and substance abuse, domestic violence, child abuse and neglect, food insecurity, housing instability, incarceration, and other traumas, Health Management Associates (HMA) can help make your efforts more effective.

Together we can help you move programs upstream with strong prevention and family strengthening approaches and integrate payment models with the human services delivery system to streamline and improve resources.

HMA can help in the following ways:

Developing system integration models

Strategies to improve school-based mental health support implementation

Provide technical assistance and consulting support regarding service access and expansion of Medicaid utilization for implementation of evidence-informed programs

Workforce planning and strategy

Assist states, counties, hospitals, providers, and MCO’s address the challenges of hospital overstays and behavioral health placements

Provide technical assistance to state and local governments regarding limiting exposure to class action lawsuits or providing expert witness services

Strategic planning

Program evaluation, research and analysis including cost/benefit analysis of programs

Leadership development

Stakeholder engagement

A longtime leader in health and human services, HMA experts have front line and executive level experience providing direction to child welfare programs.

We consult with public and private sector entities who serve children and families to improve, streamline and integrate essential services. We ground our work in human-centered design, lived expertise, and change management and leadership principles in state and county program development.

Contact our experts:

Uma Ahluwalia

Managing Principal

Uma Ahluwalia is a respected healthcare and human services professional with extensive experience leading key growth initiatives in demanding political … Read more

John Eller

Managing Principal

John Eller is a seasoned executive with more than 23 years of service in public administration and health and human … Read more

Jon Rubin

Principal

Jon Rubin is a human services leader with over 20 years of experience in strategic planning, identifying and analyzing problems, … Read more

Doris Tolliver

Principal

Doris Tolliver is a strategic thinker specializing in racial and ethnic equity, organizational effectiveness, change management, and business strategy development. She … Read more

Child and family wellbeing: family resilience

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This is part of an ongoing series highlighting efforts in human services and family wellbeing.

For decades, practitioners have recognized that child neglect was often interconnected in some families with stressors associated with familial poverty. Poverty is often a stressor in cases of child neglect, poor health, and even youth incarceration. Food insecurity, housing instability, and family stressors often related to unemployment, incarceration, and domestic violence can in some circumstances, result in parental burnout and lead to poor parenting decisions. There is also a perverse disincentive for families to experience career and wage progression which often results in steep fiscal cliffs with benefits that are needed to stabilize families and guide them towards economic self-sufficiency[1]. There is advocacy and increasing recognition through efforts such as Universal Basic Income Pilot programs and experiments with expanding Earned Income Tax Credits and Child Tax Credits attempting to mitigate catastrophic benefits cliffs that impact child and family wellbeing and economic self-sufficiency.

Public Safety Net programs such as Temporary Assistance to Needy Families, Supplemental Nutrition Assistance Program, WIC, Free and Reduced School Meals, Child Care Subsidies, Earned Income Tax Credit, Eviction Prevention Grants, and a host of other federal, state, and local programs are intended to support and strengthen families and increase protective factors for children[2].

Recent investments in the safety net including the childcare tax credit and the Pandemic Electronic Benefit Card (P-EBT) have shown that when concrete supports are provided to families, child maltreatment rates significantly decrease.[3]

During the height of the COVID-19 pandemic, the federal government implemented a One-Year Expansion of the Child Tax Credit which extended the eligibility to families with little to no income. It helped increase the credit amount families received from $3,600 per qualifying child younger than six years old and $3,000 for qualifying child between the ages of 6 and 17. It also provided monthly payments of $250 to $300 per qualifying child as opposed to an annual payment which aligned with monthly living expenses. According to the US Census Bureau, 2021 saw a historic decline in child poverty which lifted one million children under the age of six out of poverty, and 1.9 million for children between the ages of six and 17.

More recently States are experimenting with Universal Basic Income projects aimed at reducing child poverty, improving protective factors in families and reducing child maltreatment.[4] These experiments are currently being evaluated, but early research is showing promising signs of reduced child poverty in jurisdictions where these projects have gone live.

There is considerable literature that shows that changes in income alone, holding all other factors constant, have a major impact on the numbers of children being maltreated. Conversely, reduction in income or other economic shocks to the family increase incidents of child maltreatment.

A study performed by the Nuffield Foundation noted that internationally, evidence has shown a much stronger relationship between poverty and child abuse and neglect. Research has shown that without government and service providers responding to increased pressures on family life will lead to the risk of more children suffering harm, abuse and neglect.[5]

Another study by Casey Family Programs on predicting chronic neglect, found that the strongest predictors of chronic neglect were parent cognitive impairment, history of substitute care, parent mental health problems, and a higher number of substantiated allegations in the first CPS report[6]. This suggests that families at risk for chronic neglect face multiple challenges and significant financial insecurity that require significant support.

Other significant predictors include:
- Younger parents
- Families with a higher number of children
- Families with a child under age 1

Recognizing these challenges to strengthening the protective factors for young moms, there have been several successful efforts around the country to focus on pregnant and parenting teen and young adult moms. From Health Families America, Nurse Home Visiting Programs, there has been a body of evidence created that shows the strengths of providing wrap around services and home-based interventions for moms and babies. These supports strengthen the mom-baby nurturing relationship and reduce risk of maltreatment and increase protective factors.

One such organization that has demonstrated significant success in disrupting the cycle of generational poverty is The Jeremiah Program. This is a national organization that aids single mothers and their children to provide coaching and assistance in navigating barriers to education, college access and career support, safe and affordable housing, early childhood education and childcare, and empowerment, leadership, and career training. This supportive program helps build up single mothers to achieve their educational and career goals and gain long-term economic prosperity.

As child welfare and poverty policies intersect, the current thought leadership is focused on recognizing that economic and concrete supports reduce involvement in child welfare.[7] As the science and voices of children and families with lived experience intersect and rise up, the federal and state policy landscape around alleviating poverty to improve child wellbeing will continue to gain momentum. Family and Child Well-Being indicators significantly reflect racial and ethnic inequalities both in child welfare and across the poverty landscape. Economic stability is also a key strategy to address racial and ethnic inequalities and closing the opportunity gap for all. Over the next 3-5 years we believe there will be a fundamental shift in policy, financing, and outcomes tracking that reflect our commitment to our society’s most vulnerable children and families. That is why it is crucial for States and Local governments to enact policies that would support programming to alleviate poverty and improve child and family resilience and protective factors.

HMA consultants have decades of experience working hand-in-hand with public health, social services, behavioral health, Medicaid, and human services agencies. We help strengthen relationships surrounding policy, practice and revenue maximization in the human services space. Our experts work to help support programs in areas of Nutrition: Women, Infants & Children (WIC), Supplemental Nutrition Assistance Program (SNAP); Financial Support: Child Support, Temporary Assistance for Needy Families (TANF); Child and Adult Welfare Services; Medicaid; Housing and Weatherization; Early Education: Childcare Subsidy, Child Care and Development Block Grant (CCBDG) programs; and Workforce Development and Workforce Innovation and Opportunity Act (WIOA) programs.

If you have questions on how HMA can support your efforts in Child and Family Wellbeing, please contact Uma Ahluwalia, MSW, MHA, Managing Principal or Kathryn Ngo, MPH, BSN, Project Manager.

[1] What Are Benefits Cliffs? – Federal Reserve Bank of Atlanta (atlantafed.org)

[2] Economic Supports Chapin Anderson Nov 2020b (chapinhall.org)

[3] Research Reinforces: Providing Cash to Families in Poverty Reduces Risk of Family Involvement in Child Welfare | Center on Budget and Policy Priorities (cbpp.org)

[4] Understanding The Difference Between Guaranteed Basic Income Vs Universal Basic Income – Orange and Blue Press

[5] https://www.nuffieldfoundation.org/news/relationship-between-poverty-and-child-abuse-and-neglect

[6] Predicting Chronic Neglect – Casey Family Programs

[7] Economic Supports Chapin Anderson Nov 2020b (chapinhall.org)

Resources for Medicaid 1115 Waivers: creating new programs for justice-involved individuals

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HMA created a comprehensive series of webinars discussing the potential for using 1115 demonstrations to expand and improve healthcare services for the justice-involved population. Replays of the webinars and other justice-involved healthcare resources are now available.

Part 1: Medicaid Authority and Opportunity to Build New Programs for Justice-Involved Individuals
Part 2: 1115 Justice Waivers to Improve Carceral Healthcare Delivery Information
Part 3: 1115 Justice Waivers: Connecting Community Partners to Improve Transitions of Care
Part 4: 1115 Justice Waivers: Medication Assisted Treatment for Substance Use Disorder in Carceral Settings
Part 5: Medicaid 1115 Justice Waivers and Special Populations: Meeting the Needs of Justice-Involved Youth
Checklist for applying for 1115 demonstration waivers
New white paper “Implementing the National Diabetes Prevention Program Lifestyle Change Program in Correctional Settings”

What’s next for 1115 Waivers in your organization?

If your organization or state agency is ready to create new initiatives to improve carceral healthcare delivery and facilitate smoother transitions back into communities, HMA can help. Our consultants bring unparalleled expertise in Medicaid policy and correctional health as well as a deep understanding of the unique needs of this population. We have the operational knowledge and experience with technology and digital health solutions – and the ability to collect and analyze the right data to drive meaningful improvements in equity and access to care.

If you have questions or want to discuss options, please contact any of the speakers from the series:

Linda Follenweider, Managing Director, Justice Involved Services
Tonya Moore, Senior Consultant
Margaret Tatar, Managing Principal
John Volpe, Principal
Julie White, Principal
Michael DuBose, Principal
Rich VandenHeuvel, Principal
Bren Manaugh, Principal
Caitlin Thomas-Henkel, Principal
Jon Rubin, Principal

Register today for HMA’s 6th annual conference on Trends in Publicly Sponsored Healthcare, Oct. 30-31 in Chicago. The event will feature the session, Medicaid and Individuals in Carceral Settings: Improving Coordination, Managing Transitions. Register now: https://conference.healthmanagement.com/

CMS AHEAD model offers a flexible framework for state-led total cost of care initiatives

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This week, our In Focus section reviews the new States Advancing All-Payer Health Equity Approaches and Development (AHEAD) Model, which the Centers for Medicare & Medicaid Services (CMS) Center for Medicaid and Medicare Innovation (the Innovation Center) announced on September 5, 2023. AHEAD is the third major model that the Innovation Center has introduced to its payment portfolio since July, clearly signaling that CMS has transitioned from conducting its internal review to laying the groundwork for action on approaches that will be tested over the next decade.

CMS views this model as the next iteration of earlier total cost of care (TCOC) models that were designed and tested in three states—Maryland, Vermont, and Pennsylvania. The AHEAD model includes several important updates based on its experience with these earlier models. For example, the AHEAD model is designed to be scalable in multiple states. Although it most certainly will be adapted to state-specific markets, landscapes, and provider needs, CMS intends to apply a consistent framework across participating states.

Additionally, though Medicare has been involved in formulating some state-level total cost of care initiatives, the AHEAD model promises specific investments in primary care and enhanced member engagement to support all-payer movement toward patient-centered care.

AHEAD Model Parameters

The goal of the AHEAD Model is to improve population health and health equity in states that apply and that CMS selects for participation. CMS plans to select up to eight pilot states, each eligible to receive up to $12 million to support statewide implementation over a six-year period. States will be accountable for constraining overall growth in healthcare expenditures. Requirements centered on health equity mirror other CMS policies and are integrated throughout the model.

The model focuses heavily on strengthening primary care. The primary care AHEAD component includes Medicare reimbursement for care management, a commitment to align with ongoing Medicaid transformation efforts, and expectations for primary care practices to achieve certain goals on quality measures.

The investments in primary care are paired with global budgets for hospitals. Participating hospitals will receive a fixed payment that will include both Medicare fee-for-service and Medicaid. States will need to ensure participation among other payers, including at least the state employee health plan, Marketplace Qualified Health Plans, or other commercial payers in the state or sub-state region. Other payers will have the option to pay participating hospitals based on a global budget.

All-Payer Health Equity Approaches and Developments (AHEAD)

Source: https://www.cms.gov/files/document/ahead-infographic.pdf

The model will be in operation 2024−2034, and three cohorts will be to accommodate variation in readiness among participating states and providers. The first cohort pre-implementation period is scheduled to begin in summer 2024, and the performance period is scheduled to begin as soon as January 2026. CMS expects to release additional details in fall 2023.

AHEAD Opportunities and Considerations

The AHEAD Model will need significant gubernatorial leadership and possibly from state legislators, depending upon the particular state’s related healthcare laws, and the model does provide flexibility for interested states and relevant stakeholders to develop programs that are adaptable to their needs.

Health Management Associates (HMA) experts have identified the following list of policies and considerations that states; hospitals, health systems, and provider organizations; other payers, including employers; and other stakeholders will need to bear in mind when determining whether to participate in the program.

States will need to describe their partners and provide an assessment of their readiness to implement the AHEAD model. CMS will expect states to address whether they have legislation in place related to primary care investment and/or cost growth. Potential participating states should be able to describe their vision for population health improvement and primary care transformation, a proposed strategy for hospital and primary care provider recruitment, a plan for Medicaid and multi-payer alignment, and their current population health and health equity activities. Interested states will need early input from hospitals and health systems, providers, and other payers to define, develop, and implement a model that accommodates their healthcare landscape.
States will develop a Medicaid hospital global budget methodology that must have CMS approval. Medicaid hospital global budgets must be implemented in the first performance year. CMS will develop a standardized Medicare fee-for-service (FFS) hospital global budget methodology, that also accommodates critical access hospitals (CAHs).
CMS will set the parameters for quality measurement, but states will have significant flexibility to establish the metrics that will be applied for accountability and bonus purposes. CMS will use the current CMS hospital quality programs as the basis for determining eligibility for a health equity improvement bonus. CAHs will have a similar opportunity. States will work with CMS to set quality measures for participating primary care practices.
The model requires a statewide health equity plan. Additionally, participating hospitals will need to create their own health equity plans in alignment with statewide priorities and activities.
Participating states will need to generate savings. CMS will identify state-specific factors to determine the level of expected savings. All-payer cost growth targets include Medicare FFS, Medicare Advantage, Medicaid, commercial, state employee health plans, and marketplace-qualified health plans. States will also be responsible for performance on all-payer and Medicare FFS primary care investment targets.

The HMA team will continue to evaluate the AHEAD model as more information becomes available. We also can answer questions about the Innovation Center’s other recently announced models and the linkages with new Medicare and Medicaid regulations. For more information, contact Amy Bassano, Caprice Knapp, and Andrea Maresca.

Crisis and Managed Care

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Managed Care Organizations (MCOs) are key partners in ensuring members have access to integrated physical and behavioral health care, which includes a robust, coordinated crisis care continuum. MCOs can also manage early intervention and help prevent crises and high-cost utilization through care coordination.

CRISIS SYSTEM AND SERVICES

Mental health and substance use distress has increased nationally and has been exacerbated by COVID-19. The Federal government in partnership with States and localities around the country are working to expand access to effective crisis interventions. The creation of the national 988 suicide and crisis hotline combined with new funding and guidance on mobile crisis services are critical to preventing and responding to behavioral health crises.

Health Management Associates (HMA) consultants have deep experience and expertise designing, operating, and overseeing crisis services. This includes a broad portfolio of current projects, working with a range of state and local policymakers, payers, providers, first responders, and communities to implement robust crisis continuums.

Opportunities for MCOs

MCOs can play an important role in informing how crisis services meet the needs of their members, and reduce high cost utilization of emergency departments and inpatient care. HMA can help you identify innovative ways to collaborate with States and community-based organizations to drive real access to crisis prevention and intervention services for individuals and families. This work includes building robust crisis continuum networks that include the full array of options, and best practices in crisis response including diversion from and alternatives to expensive emergency department and hospital visits.

This presents an opportunity for MCOs to play a pivotal role in driving better population health outcomes, expanded health equity, improved member experience, and to ultimately reduce the total cost of care.

Our Expertise and Capabilities:

Evidence-based and leading edge clinical and operational practices

Cross-sector partnerships with law enforcement, emergency service providers and community partners

System change by connecting policy to practice

Defining and measuring key performance indicators and outcomes

Developing sustainable financing models (e.g., rate setting, reimbursement strategies)

Identifying effective workforce strategies including training and maximizing of multi-disciplinary teams (e.g., peers, behavioral health providers, nurses, licensed health care providers)

Maximizing virtual and technology interventions

988 state planning and implementation support

Designing and implementing crisis receiving and stabilization facilities

Conducting certified community behavioral health clinic (CCBHC) readiness and implementation support

Cross-sector crisis collaboration and partnerships, including emergency management services (EMS) and law enforcement

Crisis call hotline and 911 centers collaboration

Individuals with Medicaid and justice system involvement (e.g., 1115 waivers, reentry, and care coordination during transition from jail/prison into the community)

Approaches, programs, and strategies for individuals with complex care needs and high utilizers

Identifying cross-sector technology and information sharing solutions and best practices

Crisis transportation services and financing models, including least restrictive alternatives to law enforcement transport

How HMA can assist MCOs:

Strategic
Planning

Understanding emerging trends and federal and state policies that impact managed care plans, including maximizing funding streams at state and county levels, 1115 justice waivers and school-based mental health, and including key stakeholders in the planning process.

Design and Implementation

Adopting state Medicaid criminal justice reforms (e.g., in reach, care coordination, Medicaid eligibility); engaging local and county stakeholders in building partnerships with health plans; designing and developing requests for proposals (RFPs), procurement support and readiness reviews; and developing utilization management programs and care coordination strategies.

Training
and Support

Assessing benefit design, and developing standards for network development, management, and adequacy; identifying quality, key performance indicators, monitoring and compliance strategies; identification and implementation of evidence-based practices across the age continuum; and developing training standards and oversight.

HMA Crisis Portfolio Clients:

Health plans

Federal, state & local governments

Health and behavioral health care providers

Hospitals & health systems

Educational settings and academic institutions

Coalitions and advocates

Associations and foundations

Investors

Criminal justice stakeholders and facilities

Law enforcement

Emergency management services (EMS)

Public health departments

Contact our experts:

John Volpe

Principal

John Volpe is an experienced senior health official with a demonstrated record of success at the intersection of health, social … Read more

Supporting state and local public health collaborative efforts with communities to improve birth outcomes and end racial disparities

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HMA has valued recent opportunities to support public health departments to collaborate with communities working to identify and address root causes and ultimately reduce maternal and infant mortality and racial disparities in birth outcomes in Delaware and Maryland.

In partnership with the Delaware Department of Health and Social Services’ Division of Public Health, HMA is in its fourth year of administering a mini-grant program and providing backbone services to community-based organizations. These entities provide wraparound services and a variety of other supports to pregnant and parenting people and their families, with the goal of improving maternal and infant health and reducing racial disparities. We also lead a collective impact evaluation of the programs, working closely with the participating organizations to help them build their capacity to collect and analyze data, developing interim and annual reports, and providing frequent updates to the Division of Public Health and other stakeholders in the state that are collaborating to improve health and wellbeing. HMA provides fiscal and administrative oversight, coaching and evaluation, and convenes the participating organizations for quarterly learning collaboratives, which have contributed to stronger relationships and collaboration among the mini-grantees. In addition, we are implementing and evaluating a guaranteed basic income program as part of the Social Determinants of Health committee of the Delaware Healthy Maternal Infant Consortium (DHMIC). This project is a long-term commitment to collaborating with community-based organizations to build their capacity to address racial disparities and support their work, which is driven by the needs of the people they serve and know best. Grantees are selected through a streamlined process with low administrative burden, prioritizing community input on needed services. Through a collective impact evaluation, the participating organizations are finding positive effects on the self-reported health and wellbeing of program participants.

Launch of the first cohort of Healthy Women Healthy Babies Zones Mini-grantees in 2019. Photo Credit: Division of Public Health – Delaware Health and Social Services

With the Frederick County, Maryland Health Department, HMA conducted a study in 2022 using a community-based participatory research (CBPR) approach to understand and articulate drivers of maternal and infant health disparities experienced by Black women in Frederick County. In collaboration with the health department and newly formed Community Advisory Board (CAB), we facilitated a series of in-person retreats to: collect, analyze, and share quantitative and qualitative data regarding disparities and the drivers of those disparities with stakeholders; understand the data and the story behind the health disparity numbers; and develop and deploy additional research methods, such as surveys, key informant interviews, and focus groups, to further explore the lived experience of Black Frederick County mothers. This iterative approach to conducting mixed-methods research uses the CBPR framework to ensure sustained and meaningful community engagement from project start to end. HMA also developed a driver diagram to illustrate how the root cause, systemic racism, directly influences other drivers of Black maternal health disparities such as historic disinvestment in Black maternal health, historical trauma navigating healthcare, low social capital, health insurance availability, and a perceived lack of emotional and physical safety in clinical settings. The diagram will be shared with relevant stakeholders and inform next steps.

In our reproductive health-related work, HMA has guided groups through decision-making processes, with transparency and without bias, and we understand the importance of group dynamics. Bringing decades of real-world public policy and community and key stakeholder facilitation experience, HMA collaborates with a variety of stakeholders and community members to develop and implement public policy at the local and state levels, as well as to evaluate these efforts. Our experience ranges from national, state, and county agencies, to private sector and community-based organizations that partner with governments to implement policy. Our team has extensive experience working with and within organizations to facilitate discussions, listen to and build consensus across sectors, develop strategic plans, and bring diverse perspectives together to promote health and wellness for communities.

HMA colleagues participating in these projects include: Sarah Arvey, Brandin Bowden, Ana Bueno, Liddy Garcia Buñuel (Delaware project director), Akiba Daniels, Marci Eads, Michelle Ford, Allie Macdonald, Kristan McIntosh, Yamini Narayan, Diana Rodin, Hannah Savage, and Maddy Shea (Frederick County project director). The Frederick County project was done in consultation with Dr. Chidinma Ibe, Assistant Professor of General Internal Medicine at Johns Hopkins University School of Medicine with expertise in community-engaged research.

As part of recognizing Women’s History Month, HMA colleagues reflected on recent work to support maternal and infant health and reduce racial disparities in birth outcomes in collaboration with health departments and communities in Delaware and Maryland. More information on our recent projects supporting reproductive health can be found here.

Value-Based Payment (VBP) – Is your organization ready?

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Utilization of value-based payment (VBP) strategies continues to expand, with states and health plans recognizing the benefits of rewarding outcomes over volume. This includes population based VBP initiatives intended to address disparities. Health Management Associates (HMA) is at the center of these initiatives, supporting payers with development and implementation, as well as supporting providers through the transition from a traditional FFS model to maximizing reimbursement through effective care delivery, supported by the necessary administrative infrastructure and resources. As our clients in health care communities move forward with alternative payment models, we have developed tools and strategies to achieve the essential milestones to successful implementation.

Milestone 1: Provider Readiness Assessment

Successful planning for the transition to VBP begins with an understanding of where your organization is starting from, informing the targeted milestones associated with each providers’ unique strengths and challenges.

Understanding that success under VBP models requires adjustment of both clinical and administrative practices, HMA has created an assessment tool that considers the programmatic, financial, and technology resources necessary for VBP implementation. In addition to the ability to leverage these resources, organizations must have the capacity for VBP components such as cost reporting, revenue cycle management, and real time risk monitoring through the collection and analysis of data.

“With VBP on the horizon for our organization, HMA helped us to determine our readiness and to devise a strategy to remediate gaps in operations in order to be successful with the new payment model.”

– Tamara Player, CEO; Polara Health, AZ

Milestone 2: Strategy Development and Change Management

A change in reimbursement methodology requires organizational realignment of administrative and programmatic approaches. Assessing and supporting staff through these changes is a key milestone for success. Activities in which HMA have supported our clients include:

Creating leadership and governance buy-in

Preparing the Board and Staff for VBP

Aligning mission and vision with payment models and accountability metrics

Project Management, including development and monitoring of implementation plans

Cross functional team support

Milestone 3: Data Collection and Reporting Capabilities

The ability to collect and report meaningful outcomes is at the core of successful engagement in VBP. Following an assessment of current capabilities, HMA has supported provider organizations in maximizing electronic health record and other data system capabilities to capture data essential for reimbursement, as well as increasing analytic capabilities that are essential for monitoring outcomes to ensure programs can pivot when data indicates outcome achievement may be at risk. Activities include:

Technology and Data Enterprise configuration to support analytics and reporting

Creating real-time access to data

Benchmarking current outcomes against proposed VBP metrics

Alignment of current framework to payer metrics

Creation of internal clinical leadership infrastructure to support proactive monitoring and action in response to data

Milestone 4: Business Office and Finance

All aspects of an organization’s financing can be impacted by transitions in payment methodology, including cash flow, impacting cash on hand for capital and other expenses. Anticipating these changes and adjusting accordingly are key to readiness for VBP and importantly, mitigating risk during the transition. HMA can assist with:

Assessing organizational ability to accept risk

Developing a risk corridor based on organizational readiness

Negotiating alternative payment arrangements with payers

Milestone 5: Clinical Programmatic Approaches under VBP

VBP arrangements provide opportunities for organizations to move closer to the goal of achieving outcomes for their clients, rather than productivity targets and units of service. This includes incorporating approaches that could not receive reimbursement under an FFS model. With this flexibility comes the opportunity to review and adapt clinical approaches and programming, including population specific strategies. HMA is ready to support these efforts through:

Workforce analysis

Re/design of clinical workflows

Implementation of measurement-based care

Optimization of clinical templates within the EHR to support data collection and reporting

Understanding the opportunities of value-based payment across the continuum of payment models

While these activities may seem overwhelming, HMA is ready to support your organization to receive reimbursement based on meaningful improvement for your clients through technical assistance and training on each of the core elements outlined above.

Contact our experts:

Rachel Bembas

Principal

Rachel Bembas is a results-driven leader in behavioral health quality and population health analytics who has worked extensively to advance … Read more

Roxanne Kennedy

Principal

Dr. Roxanne Kennedy is a licensed clinical social worker (LCSW) with more than thirty years of experience providing clinical and … Read more

Debbi Witham

Principal

Debbi Witham is a seasoned executive with experience delivering high quality, mission driven healthcare. During her career, she has focused … Read more

Health Management Associates selected as CalAIM Technical Assistance vendor

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One of only two firms selected in all seven domains out of 46 vendors.

The California Department of Health Care Services (DHCS) has developed a multi-year initiative whose goal is to improve health outcomes and health care quality through broad delivery, payment, and program reforms known as California Advancing and Innovating Medi-Cal (CalAIM). This includes the introduction of new programs and changes to existing programs that will occur over the span of five years. CalAIM further expands upon prior initiatives, such as Whole Person Care, the Health Homes Program, and the Coordinated Care Initiative, and strives to integrate California’s delivery systems to better facilitate the overall Medi-Cal program.

With the rollout of these programs and the vast requirements associated with them, DHCS and California’s Medi-Cal managed care health plans are now tasked with the challenge of implementing CalAIM and enabling the participation of community providers and partners in these opportunities. To support these partners, DHCS developed a funding initiative, known as Providing Access and Transforming Health (PATH) to aid in strengthening capacity and infrastructure of Community Based Organizations, public hospitals, county agencies, and others to stand up CalAIM. This five-year, $1.85 billion initiative includes the creation of a virtual Technical Assistance (TA) Vendor Marketplace that organizations can use to request resources and support from approved vendors through services that are fully paid for by the State.

Health Management Associates (HMA) is recognized as a valued partner to Payers, Community Based Organizations, public hospitals, and county agencies and has deep expertise in CalAIM policy, operations and implementation. Recognized for our extensive capabilities in the field, HMA is one of only two firms out of 46 vendors that received State approval to serve as a technical assistance vendor on the PATH Technical Assistance (TA) Marketplace for all seven domains:

Domain 1: Building Data Capacity: Data Collection, Management, Sharing, and Use
Domain 2: Community Supports: Strengthening Services that Address the Social Drivers of Health
Domain 3: Engaging in CalAIM Through Medi-Cal Managed Care
Domain 4: Enhanced Care Management (ECM): Strengthening Care for ECM Population of Focus
Domain 5: Promoting Health Equity
Domain 6: Supporting Cross-Sector Partnerships
Domain 7: Workforce

HMA also has expertise in and hands-on experience with addressing the unique challenges experienced by providers and partner agencies serving rural communities. Please visit the PATH Technical Assistance (TA) Marketplace to access TA resources that can help strengthen capacity to provide high quality Enhanced Care Management (ECM) and Community Supports services for Medi-Cal members.

New Hampshire releases Medicaid Managed Care RFP

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This week, our In Focus section reviews the New Hampshire Medicaid Care Management (MCM) request for proposals (RFP), which the state’s Department of Health and Human Services released on September 8, 2023. The new contracts will be worth approximately $1.1 billion and will provide full-risk, fully capitated Medicaid managed care services to approximately 190,000 beneficiaries. Implementation will begin September 2024.

MCM Program

The MCM program covers traditional Medicaid, the Children’s Health Insurance Program (CHIP), and the state’s adult Medicaid expansion Granite Advantage Health Care Program. MCM provides integrated acute care, behavioral health, and pharmacy services. Managed long-term services and supports are not included in the program.

Incumbents are AmeriHealth Caritas, Boston Medical Center/WellSense, and Centene/New Hampshire Healthy Families.

RFP

New Hampshire will award contracts to three Medicaid managed care organizations (MCOs). MCOs will cover the populations outlined in Table 1.

Table 1. New Hampshire MCM Program Enrollment as of July 1

The state outlines several key areas of focus within the RFP, including introducing a primary care and preventive services model of care—an approach centered on patient-provider relationships and provider-delivered care coordination. The RFP also will have a greater emphasis on priority populations, such as individuals with inpatient admissions for behavioral health diagnoses; children in the child welfare system; babies with low weight or neonatal abstinence syndrome; and people who are incarcerated and eligible for the Community Reentry demonstration program, pending approval from the Centers for Medicare & Medicaid Services.

Timeline

Mandatory letters of intent are due September 18, 2023, and a mandatory conference will take place September 21. Proposals are due October 30, 2023. An award date has yet to be announced, but the state contract discussions with selected MCOs will occur November 20−December 11, 2023. Contracts will run from September 1, 2024, through August 31, 2029.

Evaluation

MCOs will be scored on their ability to meet a possible 2,160 points. The technical proposal comprises a possible 1,510 points, as shown in Table 2.

Table 2. Technical Proposal Scoring

The cost component sections will make up 650 points, as shown in Table 3.

Table 3. Cost Component Scoring

Link to RFP

Virginia releases Cardinal Care Medicaid Managed Care RFP

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This week, our In Focus section reviews the request for proposals (RFP) for the Virginia Cardinal Care Medicaid managed care program, released by the Department of Medical Assistance Services (DMAS) on August 31, 2023. The RFP includes a new foster care specialty plan. Implementation is scheduled to begin July 1, 2024.

Cardinal Care

Cardinal Care launched in January 2023 as a rebranding of the state’s Medicaid program and Children’s Health Insurance Program—Family Access to Medical Insurance Security Plan (FAMIS). Cardinal Care Managed Care (CCMC) will combine the state’s existing Medallion 4.0 managed care program for traditional Medicaid and the Commonwealth Coordinated Care Plus (CCC Plus) managed long-term services and supports (MLTSS) program to serve 1.9 million Medicaid managed care members.

RFP

The state will award statewide fully capitated, risk-based contracts to a maximum of five health plans. A separate foster care specialty plan contract will also be awarded to one of the winners. If none of the plans win the separate foster care specialty program, all plans awarded a CCMC contract will be required to cover all services.

Selected plans will provide acute care, behavioral health, and MLTSS services to all Virginians who are eligible for Medicaid, including children, adults, and pregnant women in low-income households; children and adults with disabilities; low-income older adults; and individuals receiving LTSS, including dual-eligible populations. The foster care plan will cover children in foster care, individuals younger than 26 years old who were formerly in foster care, and children eligible for adoption assistance.

The RFP contains several targeted focus areas and changes to the managed care program. For example, it emphasizes improvements to the state’s behavioral health care system and improved health outcomes through a focus on health-related social needs such as housing stability and food insecurity for CCMC members.

Contracted plans will be required to operate a dual-eligible special needs plan (DSNP) in Virginia.

Market

CVS/Aetna, Elevance/Anthem, Sentara/Optima Health, Molina, and UnitedHealthcare are the current incumbents. Effective with the new RFP, DMAS intends to reassign most CCMC members as part of an enrollment process. At present, Optima holds the largest market share of enrollment at 37 percent, followed by Anthem at 30 percent.

Timeline

Letters of intent are due by September 20 and proposals are due on October 27. As previously mentioned, new contracts will begin July 1, 2024. Contracts will have a six-year initial term, with two two-year renewal options. Award dates have not been announced.

Evaluation

Plans will be awarded up to 1,000 points during the evaluation process based on the categories shown below.

Link to RFP

CMS Takes Next Major Step in Medicare Drug Price Negotiation Program

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This week’s In Focus centers on the U.S. Department of Health and Human Services (HHS) August 29, 2023, announcement of the first 10 prescription medications that will be subject to price negotiation for Medicare coverage. This week, Health Management Association (HMA) experts offer their perspective on what this change means and what to expect next.

Background

Medicare was granted the authority to negotiate prescription drug prices through the Inflation Reduction Act (IRA), which the president signed into law on August 16, 2022. HHS, acting through the Centers for Medicare & Medicaid Services (CMS), will lead negotiations and enter into agreements with manufacturers for these products, negotiating a maximum fair price (MFP) for each selected drug in the Medicare program. HHS is required to negotiate on a certain number of drugs each year: 10 drugs in 2026, 15 drugs in 2027 and 2028, and 20 drugs in 2029 and subsequent years. Up to 60 drugs could be negotiated by 2029. Manufacturers that are noncompliant will face an excise tax that could far exceed the cost of drugs sold over time and civil monetary penalties.

Medicare Drug Negotiations: The Latest Development

Since passage of the IRA, CMS has been working to establish the regulatory infrastructure and policies to support implementation of Medicare’s new drug price negotiation authority on an expedited timeline. Guidance on the approach the agency will take in negotiating MFPs, along with other provisions of the act, has been issued.

With this week’s action, CMS will begin the first round of negotiations. Table 1 lists the drugs CMS has identified for the first round of negotiations. Products selected for negotiation (with prices effective in 2026) are medications that represent the highest spending in the Part D drug benefit, excluding products with generic or biosimilar competition as well as certain orphan drugs and other products that qualify for a small biotechnology exemption.

Alongside CMS’s announcement, HHS’s Office of the Assistant Secretary for Planning and Evaluation (ASPE) released its analysis of prescription drug use and out-of-pocket spending for each of the 10 drugs for all Part D enrollees and separately by whether an enrollee receives the low-income subsidy (LIS). The report also examines demographic information about enrollees who use the selected products.

Takeaways

The products selected were largely in line with initial modeling that Moran Company analysts and others performed, but with some surprises. Variation from earlier projections could be expected for a number of reasons, including:

The June 2022−May 2023 data CMS used were not generally available to outside analysts, and it is clear that several products had spending increases (whether because of volume or price increases) relative to prior years that moved them up the list.
Some higher spending products have seen generic or biosimilar competitors launch, making them ineligible for selection for negotiation.
- For the top 30 products identified in previous dashboard data, at least 10 have evidence of generic or biosimilar competition.
CMS’s decision to treat multiple products together for purposes of negotiations also affected the products included on the list.
For a few other products, it is still unclear how CMS decisions were made.

What to Expect Next

The drug negotiation policy is highly controversial and is the subject of litigation that could delay the process. If litigation does not affect the timeline for implementation, manufacturers of selected drugs have until October 1 to agree to negotiate and provide initial information to CMS. If a manufacturer opts out of the negotiations, the company must pay either an excise tax or withdraw all its products from the Medicare and Medicaid programs. CMS and participating companies will then meet to discuss manufacturer submissions, and CMS will receive information from other stakeholders. Several listening sessions will take place.

CMS will make initial price offers by February 1, 2024. After a counteroffer process, negotiations may continue into the summer of 2024, but final determinations will be made by August 1, 2024. CMS plans to publish any agreed-upon negotiated prices for the selected drugs by September 1, 2024. Those prices take effect starting January 1, 2026.

In addition to the short-term impact on prices for specific drugs, several questions about the potential effects of the policy are worth monitoring over the long-term:

How will research and development of new products and trends in the type of products prioritized change as a result of these policies?
How will the policies affect pricing for competitor products and the launch prices of products in the future?
Beyond the Medicare population, for whom the prices are directly applicable, how will MFPs affect negotiations on costs and supplemental rebates for other payers. including state Medicaid programs, state employee programs, drug purchasing pools, and commercial insurers?
Will negotiations affect the design of standalone Prescription Drug Plans (PDPs) and Medicare Advantage PDPs.

The IRA included several other changes to the Medicare program, which we discussed in a previous In Focus.

HMA recognizes unseen populations on International Overdose Awareness Day 2023

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In honor of International Overdose Awareness Day (IOAD), August 31, 2023, we take time to pause and reflect on this year’s theme of “recognizing those people who go unseen.” HMA stands with those affected by overdose and promotes an ecological approach to addressing substance use, one that acknowledges the many facets of the crisis that leads to approximately 300 overdose deaths every day in the United States.

We recognize that many Americans experience the repercussions of overdose in ways that are often unseen: friends and family members who act as first responders by reversing an overdose with naloxone; seniors and older adults experiencing addiction; pregnant and parenting people who use drugs and/or medications for opioid use disorder; those who are often unable to access resources due to structural barriers such as homelessness or those living in rural and frontier communities; and, the justice-involved population, who serve as a salient example and often go unseen. Research has confirmed that overdose is the leading cause of death among people leaving carceral settings, as well as the third leading cause of deaths in custody in U.S. jails.

We also recognize that many of the racial disparities in U.S. overdose deaths are unseen and underrepresented in national dialogue about the crisis. At a time when people of color are dying at a higher rate than non-Hispanic White people, the International Overdose Awareness Day theme of recognizing those unseen is timely, and apt. Non-Hispanic American Indian or Alaskan Native people had the highest drug overdose death rates in both 2020 and 2021. Rates of overdose among Black or African American men outpace other groups. Racial disparities extend beyond overdose fatality rates and into the broader substance use disorder continuum of care. People of color are offered medications for opioid use disorder at a rate almost 50% lower than non-Hispanic White people, and the duration of their treatment tends to be shorter; ultimately leading to increased risk of returning to use. These statistics only reinforce the need for an expanded, comprehensive, and equity-centered approach to care.

Finally, we recognize that the overdose landscape is developing unseen changes, as overdose deaths involving psychostimulants such as methamphetamine are increasing with and without synthetic opioid involvement. Polysubstance use is the norm, not the exception. The healthcare sector must broaden and expand services to meet the current needs, including incorporating harm reduction strategies for stimulants, especially in states with high concentrations of deaths such as Nevada, West Virginia, Maine, and among non-Hispanic American Indians or Alaskan Natives.

HMA honors the often-unseen work and expertise of those leading advances in the field including peers, public health professionals, people who use drugs, and friends and family who become first responders. In remembrance of those impacted by overdose, our call to action is to honor unseen populations affected by this crisis, to elevate existing work by and for these communities, and to continuously seek innovative approaches that ensure we carry everyone forward into a responsive system of care.

Someone you know or may have seen may be struggling with addiction. Help is always available. The Substance Abuse and Mental Health Services Administration (SAMHSA) offers free, confidential, and 24/7 support in both English and Spanish at 1-800-662-HELP (4357).

For more information on HMA overdose prevention services, visit HMA’s Behavioral Health page.

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Background

Medicare Drug Negotiations: The Latest Development

Takeaways

What to Expect Next