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Brief & Report

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


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


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


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


Senior Consultant Julia Elitzer, Managing Principal Jonathan Freedman, Senior 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


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


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.

Brief & Report

Governors’ Proposed Budgets for FY 2019: Focus on Medicaid and Other Health Priorities


This issue brief provides Medicaid highlights from governors’ proposed budgets for state fiscal year (FY) 2019 (July 1, 2018 through June 30, 2019 in most states). Proposed budgets reflect the priorities of the governor and are often blueprints for the legislature to consider. In total, 39 proposed state budgets and text from 46 state of the state speeches were reviewed. This review revealed that while state revenue collections improved in 2017 compared to 2016, considerable economic and regional variation persists, many states are facing significant budget challenges unrelated to Medicaid such as unfunded pension liabilities or falling oil prices, and the outlook for 2018 remains uncertain due, in part, to the impacts of the 2017 Federal Tax Reform Act.


Larisa Antonisse, Policy Analyst, Program on Medicaid and the Uninsured, Kaiser Family Foundation
Robin Rudowitz, Associate Director, Program on Medicaid and the Uninsured, Kaiser Family Foundation
Kathleen Gifford, Principal, Health Management Associates

Brief & Report

Four Briefs Examine New Home and Community-Based Services Settings Rules


The federal Center for Medicaid and Medicare Services (CMS) promulgated regulations in 2014 which established standards for the settings in which Medicaid-reimbursed home and community-based services (HCBS) may be provided (42 C.F.R. § 441.301). These regulations also pertain to the settings in which individuals who receive HCBS may reside, even if the Medicaid HCBS are provided in a different setting. The federal regulations focus on community integration, individual choice and privacy, and other factors that relate to an individual’s experience of the setting as being home-like and not institution-like. These regulations set a floor for Medicaid reimbursement, but states may elect to set more stringent requirements. States have been charged with developing a transition plan to ensure that state Medicaid programs come into compliance with the new HCBS expectations by March 2022. As of November 2017, seven states (Arkansas, Delaware, Kentucky, Oklahoma, Tennessee, Washington, and the District of Columbia) have received final CMS approval of their Transition Plans.

The four briefs below examine new settings rules for HCBS:

An Effective Person-Centered Planning Process Is Key for Memory Care Units

Community Integration Options and Resident Choice Are Key in Assessment of Co-Located Assisted Living Communities and Inpatient Facilities

Ensuring Individual Choice and Privacy

Resolving Differences Between State Assisted Living Licensure Requirements and HCBS Settings Rule

Brief & Report

Preliminary Look at Key Healthcare Proposals in 32 States from Governors’ Proposed Budgets for SFY 2019


The preliminary report presents key healthcare proposals from governors’ proposed state budget documents for state fiscal year (SFY) 2019, state-of-the-state speeches, news reports, and other budget-related documents, based on a review of these materials by the Kaiser Family Foundation and Health Management Associates. Proposed budgets reflect the priorities of the governor and are often blueprints for the legislature to consider, however, the level of detail presented in governors’ proposed budget documents varies significantly and in most cases does not capture all of the activity in a given state. As of the time of this publication, the table includes information from 32 governors’ proposed budgets and will be updated periodically as additional budgets are released and reviewed. The table captures proposals that fall into six categories:

  • Medicaid spending cuts
  • Medicaid enhancements
  • Medicaid work requirements
  • Other major Medicaid proposals
  • Opioid/behavioral health proposals (both within and outside of Medicaid)
  • Other major non-Medicaid healthcare proposals

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Brief & Report

Report Examines Emerging Innovations in Managed Long-Term Services and Supports for Family Caregivers


The paper—co-written by the AARP Public Policy Institute and Health Management Associates—highlights examples of how progressive managed care plans are supporting family caregivers who are caring for plan members with LTSS needs. The purpose of this paper is for plan administrators, policymakers, and community-based organizations to learn from one another and ultimately adopt these practices, resulting in better care for members and their family caregivers.

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Brief & Report

Annual Survey Finds Medicaid Enrollment Growth Slowing, Uptick in Spending Growth


Medicaid Moving Ahead in Uncertain Times: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2017 and 2018

Medicaid enrollment continues to slow in FY 2017 and FY 2018; however, states project an uptick in spending in FY 2018. This is just one finding in the 17th annual 50-state Medicaid Budget Survey conducted by The Kaiser Family Foundation and in collaboration with Health Management Associates (HMA) and the National Association of Medicaid Directors.

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