Solutions

Achieving and Sustaining Success in the Health Insurance Marketplaces: Considerations for States and Managed Care Organizations

The successful operation of the health insurance marketplaces created by the Affordable Care Act remains a key federal and state policy priority and an important business opportunity for managed care organizations (MCOs). At Health Management Associates (HMA), we are prepared to support both states and MCOs to achieve success in the operation of and participation in the marketplaces as these markets continue to evolve in the coming months and years.

Our team is made up of former state-based and federal marketplace leaders, insurance commissioners, state Medicaid directors, other senior government officials, payer executives, and provider leaders—meaning that we have the first-hand experience to navigate the complexities of marketplace establishment, operations, and participation toward successful outcomes. Our consultants have had expansive experience in this market since its inception. We have worked as and for federal and state regulators, enabling us to understand regulator goals. Additionally, we have worked for and with local, regional, and national MCOs on market entry strategy and/or profitability strategy. Our team has looked at the same problems from many angles and has the broadest historical perspective on the challenges and opportunities in this market.

CONSIDERATIONS FOR STATES

For states, operating a state-based marketplace (SBM) that flexibly meets the health coverage needs of the population in an efficient and responsive way is a common and critical goal. HMA understands the importance of establishing and continually operating a strong and lasting SBM capable of weathering and protecting against current and future threats to access and affordability. Key SBM policy outcomes include:

Local Control and Better Coordination

SBMs can increase enrollment and reduce gaps in coverage for families through closer alignment with the Medicaid program, customer-centric policies and procedures, and local, tailored engagement and outreach.

Lower Costs and Improved Consumer Protections

SBMs can establish plan design standards, coverage requirements, and consumer protections to improve choice and competition, lower out-of-pocket costs, and protect access to the affordable care individuals need and deserve.

Universal Coverage

Through innovative enrollment initiatives, federal waivers, and affordability programs, SBMs can be a catalyst for additional reforms to put the state on the pathway to universal coverage.

To be able to successfully accomplish the policy aims outlined above, states must excel across and within a range of strategic and operational areas including: organizational development and implementation, governance and project management, vendor procurement and oversight, strategic policy development, maximizing federal funding and financial management, federal compliance, stakeholder engagement, and communications and training. HMA can support states in all these areas with services that enable operations, regulatory compliance, strategy, and policy advancement.

CONSIDERATIONS FOR MCOS

For MCOs, the marketplace represents a key business opportunity where existing capabilities can be leveraged as part of a successful growth strategy. With our extensive regulatory expertise and expansive state market knowledge, HMA understands that customized support is necessary to allow MCOs to succeed in the marketplace as either a new market entrant or an existing participant. For MCOs, the marketplace has the following features:

A Highly Regulated Environment

At the federal and state levels, the marketplace environment has strict standards in terms of plan design, rating rules, network adequacy, marketing practices, producer (broker and agent) activities, and marketing practices.

Significant Public Funding

As a result of the marketplace premium tax credits, most marketplace consumers qualify and as a result, significant public funding is involved.

An Evolving Market

The end of the Medicaid continuous enrollment condition as of March 31, 2023, which has been in effect throughout the Coronavirus Disease 2019 Public Health Emergency, makes providing coverage in the marketplace even more critical—as millions of individuals transition to this market after losing Medicaid coverage.

How HMA can help

HMA can support clients every step of the way in the planning and execution of efforts to participate in and optimize performance for the marketplace. To achieve and maintain success in the marketplace, MCOs must excel across strategic, operational, and analytical areas including:

Market analysis and feasibility

Operational gap analysis

Product management scoping

Vendor procurement

Regulatory filings development and implementation

Actuarial analytics

Provider contract reimbursement analysis, and

Network development

HMA can bring to bear a comprehensive continuum of services to solve your most pressing marketplace challenges.

If you have questions about how HMA can support your state or MCO related to the marketplace, please contact Zach Sherman, managing director or Patrick Tigue, managing director.

Contact our experts:

Zach Sherman

Zach Sherman

Managing Director

Zach Sherman is an Affordable Care Act (ACA) expert and Health Insurance Marketplace leader with extensive experience with start-ups and … Read more
Patrick Tigue

Patrick Tigue

Managing Director, Regional Managed Care Organizations

Patrick Tigue is an accomplished executive with experience leading and managing critical efforts to achieve strategic health policy goals on … Read more

Privacy and Security Assessment and Support Services

One of the most important challenges for a health data organization is ensuring that its policies and procedures remain compliant with the dynamic landscape of federal and state privacy and security statutes, regulations, and industry standards.

HMA brings applicable experience and expertise to assist state agencies, non-profit organizations, and other entities that are responsible for all-payer claims databases, hospital discharge databases, and other datasets containing confidential and sensitive health data with:

Reviewing existing policies and procedures to identify gaps and needed updates to ensure compliance with regulations and adherence to best practices and industry standards.

Recommending revisions based on the assessment review and helping prioritize changes based on risk analysis.

Updating policies and procedures based on the approved recommendations.

Developing a training program for staff regarding the updated privacy and security policies and procedures via in person training, virtual training, and/or creating training videos.

HMA’s privacy and security assessment and support services capabilities include the following qualifications and expertise:

Holding leadership roles at state health data organizations and on the National Association of Health Data Organizations Board

Coordinating health information technology (HIT) for state Medicaid agencies

Leading state value-based purchasing agencies

Founding HIT strategic consulting firms

Experience with the National Association of County and City Health Officials

Project management and strategic planning support for multiple state agencies and data organizations

Privacy and security legal expertise

In addition, HMA offers the knowledge and experience of more than 700 consultants to supplement our privacy and security expertise with local healthcare knowledge and support to comprehensively address an organization’s needs.

Contact our experts:

Melissa Mannon

Melissa Mannon

Associate Principal

Melissa Mannon is an alternative payment model expert with experience developing, implementing, and evaluating alternative payment models in Medicaid and … Read more
Craig Schneider

Craig Schneider

Principal

Craig Schneider is a leader in developing and implementing payment reform strategies, promoting all-payer claims databases (APCDs), and engaging stakeholders … Read more
Stuart Venzke

Stuart Venzke

Managing Director, IT Advisory Services

Stuart Venzke has over 30 years of experience improving the effectiveness, efficiency and responsiveness of health and human services (HHS) … Read more

Helping Clients Succeed in Value Based Payments

As Medicare, state Medicaid agencies, Medicare Advantage plans, Medicaid managed care organizations, and commercial insurers increasingly adopt alternative payment models (APMs), Health Management Associates (HMA) provides a range of innovative and successful approaches to value-based care (VBC).

Our subject matter experts can help you succeed with
value-based payments (VBP).

WHAT WE DO

Offer insights for transforming the care delivery model to efficiently deliver optimal patient and population-level health outcomes while successfully managing total cost of care

Ensure quality is the primary goal of VBP program design and implementation

Develop payment models that align the incentives of payers and providers

Integrate physical and behavioral healthcare, and close gaps related to social determinants of health and health equity

Help clients successfully transition from fee-for-service to value-based payments by providing expertise in change management, analytics, network engagement, and IT infrastructure

Improve the patient and provider experience

Qualify, manage, and monitor health insurance risk

Prepare for and succeed in accreditation for VBP capabilities

ORGANIZATIONS WE SUPPORT

Those engaged in VBP or interested in engaging in VBP

Payers

Providers

Purchasers

Those interested in advancing the broader movement to value

Federal, State & Local Governments

Associations

Foundations

Investment Firms

HMA Can Support You Through All Phases of Value-Based Care

From contract to care plan, we have the experience and guidance tools to support your organization’s move to value-based care and risk-based contracting.

value based payment graph

This graphic showcases the capabilities needed to address the complexities of risk-based contracting and deliver value-based care. As your organization moves from left-to-right along the glidepath to risk, additional strategies and capabilities must be developed. For example, utilizing Institute for Healthcare Improvement frameworks for quality improvement, regulatory and credentialing needs, and specialty access within a clinically integrated network. NEJM Catalyst. (2017). What is value-based healthcare?

Our philosophy involves applying a health equity model to close social determinant gaps and health disparities. Value-based healthcare is all about the care delivery model. Under value-based care agreements, providers are rewarded for helping patients improve their health, reduce the effects of emerging/rising risks and incidence of chronic disease, and live healthier lives in an evidence-based way.

Our Comprehensive Approach

Our collaborative approach will be tailored and customized to your needs to help you successfully implement VBP.

Our integrated process is based on the following model:

WHAT HMA PROVIDES

Determine readiness across key building blocks for moving to value-based payments and achieving continuous improvement across healthcare organizations.

Implementation that includes benchmarks and measurements of success. We facilitate stakeholder input to capture and analyze data from these interactions through surveys, focus groups, and interviews.

Aligning incentives with providers is key to successful value-based care strategies. Understanding methods for identifying and closing gaps in care pathways for common chronic conditions or addressing rising/emergent risks as well as how to create buy-in among providers and other members of the care team.

Including actuarial expertise required for contracting in key areas such as financial projections, reserves, total cost of care analysis, and benchmarking. We provide an assessment of third-party software to support APMs.

Including methods for incorporating whole-person care into clinical algorithms that apply to every interaction with the patient and their families. Integrating behavioral health with physical health and addressing social determinants of health/health-related social needs into VBC programs.

Assist with identifying key performance indicators (KPIs) and quality measurement incentives
for pay-for-performance or pay-for- value to support population health outcomes and support total cost of care in various VBP arrangements.

Provide support and consultation on scope of requirements to ensure VBC contract meets delegation requirements for operational, state, CMS regulatory and accreditation requirements.

OUR EXPERTS INCLUDE

Former CEOs, COOs, CFOs, and chief medical officers and other physician executives as well as executive quality leaders of the following organizations:

Providers including hospitals, academic medical centers, physician practices, community health centers, rural health centers, and federally qualified health centers

Medicaid, Medicare, Marketplace and Commercial MCOs

State and federal agencies

In addition, HMA offers expert actuaries, coders, analytic staff, and clinicians to support your transformation.

Contact our experts:

Brent Barkett

Brent Barkett

Principal

A purpose driven leader and recognized expert in healthcare value transformation, Brent Barkett has a unique combination of clinical application, … Read more

Caprice Knapp

Managing Director, Quality and Accreditation

A health economist and evaluator, Caprice Knapp has more than 20 years’ experience working on Medicaid and Children’s Health Insurance … Read more
Craig Schneider

Craig Schneider

Principal

Craig Schneider is a leader in developing and implementing payment reform strategies, promoting all-payer claims databases (APCDs), and engaging stakeholders … Read more

Expanding Access to High Quality Sexual Health Care and STI Prevention

In 2022, more than 2.5 million cases of syphilis, gonorrhea, and chlamydia were reported in the United States. There were alarming increases in syphilis cases in particular – there has been an 80% rise in syphilis cases since 2016 and in 2022, there were 3,755 cases of syphilis among newborns reported (163% increase since 2018). While sexually transmitted infections (STIs) occur in all populations, some groups are more affected, including young people, gay and bisexual men, transgender individuals, and pregnant people. There are deep inequities in the rates of STIs including disproportionate rates among racial and ethnic minorities which are the result of longstanding social and economic structural inequities. 

Sexual health services are being threatened and have inequitable resources which further complicates care for those individuals with lived experience with STIs, HIV, and viral hepatitis. They often experience additional and intersecting sexual health, behavioral health, and social needs that must be addressed concurrently.

STI Graphic CDC

HMA brings together experts from a full spectrum of sexual health services including policy, clinical, operations, and research.

Our experts have significant experience with conducting needs assessments and gap analyses, supporting syndemic (HIV/STI/Hepatitis) planning, centering health equity, and leveraging policy and research findings to maximize impact and access. A syndemic is a situation in which two or more interrelated biological factors work together to make a disease or health crisis worse.

Illustration from the Centers for Disease Control and Prevention (CDC)

We work with clients to reach shared goals of supporting sexual health, expanding access to screening, vaccines and other preventative services, reducing high rates of STIs including HIV, and addressing deep and persistent racial disparities in STI rates and the inequities that drive them.

We can help organizations including:

State and municipal departments of health and public health

Health plans

Community-based organizations (CBOs)

Behavioral Health Service Organizations

Federally Qualified Health Centers

Title X Clinics

Planned Parenthood affiliates and other free-standing women’s health centers

Foundations

Associations and Coalitions

Our sexual health experts include:

Former senior officials from the Health Resources and Services Administration and the Center for Disease Control and Prevention.

Advocates and former senior leaders of community-based organizations, foundations, and other programs that support healthcare systems capacity to implement quality STI prevention, screening, diagnosis, surveillance, and treatment.

Clinicians with experience providing sexual health services and building programs at the intersection of sexual health, behavioral health, primary care and maternal and child health.

Social workers and behavioral health professionals working to integrate approaches that address social and behavioral health needs.

Program development, strategic planning, and technical assistance experts working to implement innovative solutions and evidence-based guidelines.

Researchers and evaluators with extensive experience examining the implementation and impact of policy and operational changes on sexual health services.

Our experts can support your work to expand equitable access to sexual health care.

With offices in more than 30 locations across the country and over 700 multidisciplinary consultants with a wide spectrum of industry experience, and longstanding expertise in all 50 states, HMA has experienced staff in syndemic needs assessments and planning, program evaluation, research and analysis, strategic/business planning, clinical services, stakeholder engagement, quality improvement, and workforce development. Our portfolio of companies also gives you access to actuarial, data analytics and communications expertise, and more.

OUR WORK

South Carolina Department of Health and Environmental Control (DHEC) contracted with HMA to conduct a statewide gap analysis to document the array of partner services and disease intervention STI inside and outside the department and identify gaps and duplication to improve services and strengthen the program. As part of this engagement, HMA conducted an analysis of South Carolina’s STI delivery system, staffing capacity and processes, and developed a service location map to highlight gaps and inequities. The final report summarized findings and included recommendations for closing gaps in service delivery, workforce development and improving the efficiency and effectiveness of service delivery.

HMA supported the Washington State Department of Health’s Office of Infectious Disease in taking a syndemic approach to ending the HIV, STI, and viral hepatitis epidemics. A key activity of this project included supporting the Office of Infectious Disease to establish a new planning body that reflects the populations served by transforming their Statewide HIV Planning Group and launching a new communicable disease (syndemic) planning group. This work included conducting research on other statewide planning group structures, collecting community and stakeholder input, developing and operating structure, charter, and bylaws; recruiting and onboarding a diverse membership; and creating organizational change management, all with a focus and commitment to advancing racial equity. Through this work, HMA also drafted the state’s integrated HIV Prevention and Care Plan and Requests for Applications to help distribute state funds to local intervention efforts that advance the goals of this plan.

As part of our extensive area of work in strategic planning with state and local agencies, providers of health and human services, community-based organizations and many more, HMA has worked with clients that provide sexual and reproductive health care services to assess potential opportunities and approaches for expansion, delivery, and financing of care to reach underserved communities.

HMA worked with the Wyoming State Department of Health to conduct their HIV needs assessment and developed their Integrated HIV Prevention and Care Plan. This work included collecting and analyzing data on HIV incidence and prevalence; developing HIV, STI, and viral hepatitis ecosystem maps; facilitating workgroup meetings; collecting additional community and stakeholder input through provider and community surveys and focus groups; and developing a written report of the assessment findings, all with a focus and commitment to advancing health equity.

HMA worked closely with the Boston Public Health Commission to conduct an extensive HIV needs assessment. Activities included key stakeholder interviews, focus groups, surveys and data collection and analysis. Emphasis was placed on the intersection of HIV and drug user health. 

HMA team members developed and implemented professional development training series entitled “The Intersection of HIV and SUD” on behalf of the Minnesota Department of Health. The 12-hour curriculum was developed in partnership with several community organizations representing Tribal, African American, and LGBTQIA+ communities. The training is delivered virtually and includes topics such as: understanding HIV; HIV risk reduction; SUD harm reduction; chemsex; HIV and stigma, pregnancy and HIV; and cultural, racial and sexual identities.

Contact our experts:

Julie Rabinovitz

Julie Rabinovitz

Principal

Julie Rabinovitz specializes in sexual and reproductive health policy, strategy, and operations. She assists healthcare organizations with program planning and … Read more
Charles Robbins

Charles Robbins

Principal

Charles Robbins has been transforming communities for the past three decades. His extensive community-based organization career spans healthcare, child welfare, … Read more
Kate Washburn

Kate Washburn

Associate Principal

Kate Washburn is a public health and program leader with over 20 years of experience in both public health departments … Read more

CalAIM Justice-Involved Reentry Initiative Planning and Implementation Services

Organizations are facing extensive challenges to improve health outcomes and healthcare quality through broad delivery, payment, and program reforms in CalAIM. With proven expertise in CalAIM policy, operations, and implementation, Health Management Associates (HMA) can help you with identifying needs, developing a strategy, and implementing those plans. We actively support clients across California implementing the CalAIM Section 1115 Waiver Demonstration Justice-Involved Initiative. Our team of Medi-Cal, managed care, and correctional healthcare experts – including physical and behavioral health clinicians, healthcare administrators, and former correctional leaders – are uniquely positioned to help clients navigate this delivery system transformation.

California is the first state in the nation to receive approval from the Centers for Medicare and Medicaid Services (CMS) to provide detained and sentenced individuals with 90-day pre-release healthcare services and behavioral health linkages. Through PATH JI grant funding, HMA is helping clients build administrative capacity, information technology, pre-release services, care management models, and Medi-Cal claiming infrastructure to meet their unique needs and leverage this significant opportunity. Our planning and implementation support spans the breadth of the CalAIM Justice-Involved Initiative including: the pre-release Medi-Cal application process, 90-day pre-release services, behavioral health links, Enhanced Care Management (ECM), and Community Supports services.

That’s why sheriffs’ departments, probation authorities, correctional health services agencies, behavioral health agencies, managed care plans, healthcare providers and community-based organizations see HMA as a trusted partner in helping to develop and implement 1115 waiver healthcare programs.

We provide:

Project management

State policy monitoring and compliance tracking

Current and future state process mapping

Partner and stakeholder collaboration and meeting facilitation

Process and quality improvement recommendations

Protocol development

Implementation plan and readiness assessment drafting

Training

Electronic health record recommendations

Contact our experts:

Rebekah Kharrazi

Rebekah Kharrazi

Associate Principal

Rebekah Kharrazi is an accomplished public health professional with a broad range of expertise and skills to help clients navigate … Read more
Julie White

Julie White

Principal

With more than 25 years of experience in comprehensive healthcare and justice-related service delivery, Julie White has developed policy, strategic … Read more

School-based Mental Health

Schools face resource challenges

Public schools face persistent pressure to serve as the central point for addressing children’s overall health and well-being. Behavioral health and access to care challenges were a growing concern affecting school populations even before the Covid pandemic.

Youth are experiencing behavioral health crises at an alarming rate, and schools are struggling with insufficient resources for students to receive the necessary person-centered care and support. Sustainable funding streams, including options like Medicaid and alternate funding methods, could help schools effectively cover expenses. New temporary funding streams are available (e.g., CMS School Based Health Services Program, Bipartisan Safer Communities Act, and multiple state funding initiatives) but schools often lack the necessary infrastructure, administrative support, and awareness of community resources to effectively utilize these funds.

Our Clients

HMA works with state and local education agencies, school districts, county offices of education, departments of public instruction, social service agencies, public health, school boards, and family and parent organizations to support school-based mental health initiatives. 

Through innovations in community partnerships, evidence-based programming, and design that support healthy children and promising futures, there is opportunity to enhance school outcomes. Students’ well-being and mental health directly impact their overall educational experience and achievement. By addressing these challenges and investing in comprehensive BH support within schools, we can help schools design an environment that furthers the well-being and success of all students.

HMA can help school systems:

Add capacity for project management support for whole-child approaches to improved health

Reduce duplication of services

Assess opportunities to better leverage new and existing resources and dollars through blended and braided funding and existing community-based supports to enhance utilization

Strengthen infrastructure and awareness and establish collaborations and partnerships to ensure effective utilization of available funding and shared resources

Break down bureaucratic silos and promote interagency cooperation

Improve information and data sharing

Emphasize preventative behavioral and physical care

Assess strategies for workforce shortages

Develop and implement evidence-based integrated care clinics within schools

Deliver training for administration, staff, parents, and community partners that helps achieve successful adoption

Implement targeted initiatives to address ongoing and pervasive stigma surrounding behavioral health, particularly in specific cultures and communities

HMA has the right team

With our expertise and collaborative approach, we empower schools and school districts to proactively address the youth behavioral health crisis and create a supportive educational environment for all students.

Our team members have extensive careers in school-based mental health, direct clinical behavioral health practice, healthcare systems, as well as government social services and public health, community organizations, and school-based leadership. Our experts have worked with every type of stakeholder, gaining invaluable insights and understanding. We meet schools where they are and help to right-size service offerings. HMA can bring a fresh perspective on school-based services, and help you shift from reactive to proactive.

Contact our experts:

Annalisa Baker

Annalisa Baker

Associate Principal

Along with a comprehensive understanding of the behavioral healthcare continuum, Annalisa Baker’s experience includes business operations, project management, finance, and … Read more
Michael Butler

Michael Butler

Associate Principal

During his career, Michael Butler has directed hundreds of program evaluation, organizational development, and technical assistance projects in a wide … Read more
John Eller

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
Jennifer Hodgson

Jennifer Hodgson

Principal

Jennifer Hodgson is a licensed marriage and family therapist who maintained a private practice and taught in higher education for … Read more
Trish Marsik

Trish Marsik

Principal

Trish Marsik has extensive experience supporting providers, healthcare organizations, and state and federal governments to provide quality behavioral healthcare.  Prior … Read more

Using Virtual Research Data Center (VRDC) Data to Answer Big Questions

Health Management Associates (HMA) is utilizing Virtual Research Data Center (VRDC) data to do what HMA does best: solve publicly funded healthcare’s most challenging problems. The combination of our deep analytics expertise and our nationally renowned subject matter experts can help you solve your toughest challenges.

We are committed to helping clients meet their needs through:

Market Analysis

Want to know how many psychologists are treating Medicaid patients in a county? Or how many duals got NEMT in a year? We can tell you that. How many folks on Medicare got drugs for Memory Loss last year? We can tell you that too. The VRDC allows us to examine the Medicaid and Medicare populations with significant precision to inform your decisions.

Consulting Services

We love hard questions. Carefully designed smaller queries can add up to answer big questions like “Does access to Non-Emergency Medical Transportation help patients managing challenging chronic medical conditions?” or, “Are services critical to patient success being delivered equitably to patient populations?” HMA can help you answer your hardest questions by breaking them into smaller questions that add up to big results. Outcomes Survey (HOS) specific to BH, and align data performance to quality improvement efforts.

Quality Improvement and KPI Benchmarking

HMA’s team of quality experts can help you identify metrics that matter internally to your organization as well as to your payers and providers. We can run metrics against these Medicaid and Medicare data to prepare you to manage risk through deep data analysis and creation of benchmarks that help manage access, cost, quality, and utilization.

HMA’s access to VRDC data through this agreement include:

Data representative of 100 percent of Medicare and Medicaid beneficiaries and their medical experience expressed as claims

Data representative of 100 percent of Part D Drug Event (PDE) data

Detailed Long-Term Care data for all Medicare and Medicaid beneficiaries through the MDS dataset

We can help organizations including:

State and municipal departments of health and public health

Health plans

Provider organizations

Analytics and technology vendors

Private equity

Correctional health

Contact our experts:

Jim McEvoy

Jim McEvoy

Data Analytics Resources Director

Jim McEvoy is accomplished in architecting robust technology solutions for state agencies, health plans and service providers. Jim understands the … Read more
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Eric Pfeifer

Data Analytics Resources Director

Consumer Assessment of Healthcare Providers Systems (CAHPS): Improving Member Experience

Medicare and Medicaid plans are faced with a barrage of regulations, including quality rankings. To improve rankings plans can, and should, work to improve their Consumer Assessment of Healthcare Providers Systems (CAHPS) scores.

The CAHPS annual survey measures member experience with providers and Medicare and Medicaid health insurance plans. It has also become a critical metric used by the Centers for Medicare and Medicaid Services (CMS).

Plans can work to improve CAHPS scores by developing a comprehensive improvement plan involving a holistic year-around approach that involves monitoring the member experience from enrollment through disenrollment. With score improvement comes incentive payments tied to high quality performance.

CAHPS SCORES ARE USED BY:

The National Committee for Quality Assurance (NCQA) to STAR rate health plans in accreditation scoring

Potential members to compare plan scores against one another on the NCQA website

Several state Medicaid programs that require plans to report these surveys and use scores as part of their incentive programs

CMS, which has increased its STAR rating, CAHPS-related measure from double weighted to quadruple weighted in contract year 2021

Medicare Advantage Prescription Drug (MAPD) plans, which use CAHPS to calculate 32% of the overall aggregate score

CAHPS COHORTS THAT ARE MEDICARE STAR MEASURES

PART C CAHPS MEASURES (WEIGHTS)

Getting needed care (4)

Getting appointment and care quickly (4)

Customer service (4)

Rating of healthcare quality (4)

Rating of health plan (4)

Care coordination (4)

Annual flu vaccine (1)

PART D CAHPS MEASURES (WEIGHTS)

Rating of drug plan (4)

Getting needed prescription drugs (4)

ADDITIONAL STAR MEASURES AND ACTIVITIES THAT RELATE TO MEMBER EXPERIENCE

PART C MEASURES (WEIGHTS)

Complaints about the health plan (2)

Member choosing to leave the plan (2)

Plan makes timely appeals decisions (2)

Reviewing appeal decisions (2)

Call center, language interpreter and TTY availability (2)

Health plan quality improvement (5)

PART D MEASURES (WEIGHTS)

Call center, language interpreter and TTY availability (2)

Complaints about the drug plan (2)

Member choosing to leave the drug plan (2)

Drug plan quality improvement (5)

Health Management Associates’ expert colleagues can help plans outline an organizational assessment of member experience and customize interventions and solutions to increase scores.

Our team of quality and accreditation experts can help organizations improve customer service and scores by:

Establishing a year-around effort

Using an organizational effort to break down department silos and improve cooperation between departments

Assessing core functions within the plan and contractors that contribute to member experience including marketing, enrollment, disenrollment, UM, QI, member service, grievances, appeals, etc.

Identifying and addressing patient frustrations with providers and plans before they become problematic

Leveraging information technology to make websites more user friendly

Addressing care and service gaps to ensure member outreach is calibrated and tailored throughout the year

Recognizing social determinants of health (SDOH) are often overlooked in access to care-related issues, such as lack of transportation or lack of funds for co-payments

Outlining techniques for obtaining point-of-service feedback to help address potential member experience issues before they arise

Contact our experts:

Sarah Owens

Sarah M. Owens

Principal

A diligent and forward-thinking leader with expertise in managed accountable care and operations that bridges health plan and provider sides … Read more
Mary Walter

Mary Walter

Principal

Mary Walter is an accomplished executive leader with more than 30 years of experience in healthcare including extensive work in … Read more
David Wedemeyer

David Wedemeyer

Principal

David Wedemeyer is an established data expert and a seasoned consultant with expertise developing Healthcare Effectiveness Data and Information Set … Read more

Star Rating: We Can Help You Navigate to a Higher Level

What is the VALUE of a Star in your plan(s)?

What initiatives have you introduced to prepare for the changes in the Star Rating that may impact your overall Star Rating results?

What are you doing for health equity focus? What data are you collecting for health equity?

What do you think are your organization’s financial implications when Star Rating requirements change?

What are your Star Rating strategies for increasing your organization’s market share and viability?

What sort of interventions, data sources, analytics and reporting have you found to be successful to improving your Star Rating?

WE CAN HELP YOU BY:

Establishing a year-around effort to improve Star Rating performance

Assessing core functions within the plan and contractors that contribute to understanding members

Identifying and addressing customer concerns with providers and plans before they become problematic

Leveraging information technology to make websites more user friendly

Addressing care and service gaps to ensure member outreach is calibrated and tailored throughout the year

Working on health equity issues including sharing techniques for obtaining data

Leveraging all data and intervention efforts (such as risk and quality) to drive decision and focus

Contact our experts:

Sarah Owens

Sarah M. Owens

Principal

A diligent and forward-thinking leader with expertise in managed accountable care and operations that bridges health plan and provider sides … Read more
Mary Walter

Mary Walter

Principal

Mary Walter is an accomplished executive leader with more than 30 years of experience in healthcare including extensive work in … Read more
David Wedemeyer

David Wedemeyer

Principal

David Wedemeyer is an established data expert and a seasoned consultant with expertise developing Healthcare Effectiveness Data and Information Set … Read more

HMA Can Help You Prepare for The Joint Commission (TJC) Accreditation and Certification

HMA’s team of experts have completed accreditation requirements with our clients as well as in our formal executive and operational leadership roles in the health care setting.  We work closely with our clients and with TJC and other accreditation programs with a focus on improving healthcare quality and favorable outcomes. Our team of seasoned healthcare executive consultants bring more than 100 years of experience in clinical, quality, and operations, with proven results. HMA offers a full continuum of accreditation services for hospitals, ambulatory surgical centers (ASCs), Federally Qualified Health Centers (FQHCs) and behavioral health (BH) care settings. We work closely with FQHCs to provide assistance for certifications and advanced certifications in health equity (HE). HMA can offer onsite or virtual mock survey and gap analysis preparation for TJC accreditation, as well as tactical and advisory support to prepare our client leadership teams for a winning accreditation survey results and supporting the development of a sustainable plan to achieve year over year success!

Our experts can help you by:

Assessing core functions supporting the implementation of the latest TJC standards and interpretation of the standards

Building the business case for TJC accreditation

Guiding your team through the new HE standards

Creating quality and assessment improvement plan (QAPI) to lead to a successful survey

Continuous survey readiness support via a sustainable plan

And so much more across the continuum

Contact us at [email protected]

Contact our experts:

Trisha Bielski

Trisha Bielski

Senior Consultant

A highly specialized critical care, trauma and flight nurse, Trisha Bielski has deep experience in nursing leadership, military healthcare, and … Read more
Ruth Danielzuk

Ruth Danielzuk

Senior Consultant

Driven by collaboration across the healthcare landscape, Ruth Danielzuk is a seasoned quality and innovation expert with experience managing programs … Read more
Matthew Sandoval

Matthew Sandoval

Principal

Matthew Sandoval is an accomplished leader in healthcare with a proven track record of managing the administration, operations, and quality … Read more
Mary Walter

Mary Walter

Principal

Mary Walter is an accomplished executive leader with more than 30 years of experience in healthcare including extensive work in … Read more