Solutions

HMA helps Justice Involved/Behavioral Health services implement the Sequential Intercept Model (SIM)

The Sequential Intercept Model (SIM) provides a framework to help local governments divert individuals with behavioral health issues from the criminal justice system into community resources.

The model serves communities by helping them identify opportunities for diversion programs, known as “intercepts”, with the highest potential for success based on community strengths and needs. Created by Policy Research Associates in 2004 and promoted by SAMHSA’s GAINS Center, SIM identifies critical diversion points tailored to each community’s strengths and needs.

Key Benefits of Implementing SIM

Guides ongoing stakeholder meetings and county programming by establishing a common language for justice and diversion programs to support sustainability and adaptability over time.

Supports community analysis and integration of new policies by providing a clear visualization of system resources and gaps.

Facilitates collaboration and ensure efficient use of resources by enhancing communication and relationships across systems.

Collects local data for system analysis to identify grant opportunities and funding for critical intercept program development.

Development of a SIM report that highlights current state, gap, and opportunities for improvement.

Educates county leaders on best practices to help assess new programs and identify areas for improvement.

Addressing Community Challenges

SIM supports development of community prevention programs that lower the chance of initial involvement into criminal justice for many, helping provide the needed level of treatment support. The framework further allows jurisdictions to develop meaningful and effective programs to address issues faced by justice-involved individuals, such as unstable housing and income, high overdose risks, and the impact of evolving policies. Many existing programs lack sustainability due to reliance on temporary funding, and traditional planning has been reactive rather than proactive. SIM offers a comprehensive framework for communities to support individuals with behavioral health issues, improving safety and resource efficiency.

HMA’s services include:

  • Facilitating stakeholder meetings and data collection.
  • Mapping current systems and identifying key intercepts.
  • Developing SIM reports to highlight gaps and opportunities.
  • Leading strategic planning for program development.
  • Setting measurable goals and evaluation plans.

If you are ready to talk about implementing a SIM and the next steps for your organization, reach out to our experts today.

Contact our experts:

Jessica Perillo

Jessica Perillo

Senior Consultant

Jessica Perillo is a driven healthcare professional with extensive experience in the behavioral health, public health and public safety fields. … Read more
Jon Rubin

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

HMA helps organizations prioritize, identify, win, and implement grant funding

Grants from both government and foundations can be an essential component of a provider’s growth strategy. Every year billions of dollars are distributed to support program growth, quality improvement, training, and other essential needs. HMA works with a wide variety of healthcare clients, including Federally Qualified Health Centers (FQHCs), community-based organizations, hospitals, provider practices, behavioral health, and managed care organizations.

How HMA can help

HMA’s Grant Prospector is a subscription service that provides clients with a customized and curated list of grant opportunities. Finding the right opportunities and applying for grants that are aligned with your organization’s strategic growth interests can be an essential catalyst for organizational development, service continuum growth, and quality improvements. HMA’s Grant Prospector monitors over 200 government agencies and nearly 100 foundations and sends appropriate opportunities to subscribers weekly.

HMA’s experience has taught us that grants can be a wonderful way to grow an organization if (and only if) the organization is strategic about what grants it pursues and what services it uses grant funding to build. Your strategy should guide your grant pursuits, not the other way around. HMA can help your organization devise a strategy for organizational growth using grants as a catalyst for long-term sustainability.

HMA’s deep pool of grant writers enables us to assign teams with precision, ensuring our clients have access to specific relevant expertise. HMA’s grant writing services are most valuable when a provider needs help designing a program model, complying with complex grant requirements, and navigating strategic challenges in grant writing.

During the 2023 round of CCBHC expansion grants, HMA clients invested $956,000 in HMA grant-writing support. Those clients won 20 awards totaling $80,000,000, for a return on investment of 8,272%.

For clients who prefer to write their own grants, HMA can provide subject matter expertise to enable strategic decision-making and program design. HMA consultants can join early calls to help the client design a program model that complies with the grant requirements, ensures operational sustainability, and addresses the complexities of the procurement.

For clients who prefer to write their own grant applications, HMA can provide a mock scoring service. HMA’s reviewers provide a detailed review and score for the submission, enabling the client to identify any place where points are likely to be deducted. We advise sending a draft to HMA at least a week or two before the application is due so that HMA’s feedback can be integrated before submission.

Many grant applications require a detailed assessment of the community’s need for the services being funded. Our experts can help gather both quantitative data and qualitative stakeholder input to ensure that the client’s grant application targets the populations, communities, and gaps in service for which grant funds will be most impactful.

HMA’s accounting and actuarial colleagues can provide budget and cost report development support when the demands of a grant application outstrip the capabilities and/or bandwidth of the client’s finance team.

Many grants come with complex implementation and reporting challenges. HMA’s experts have the benefit of the experience of hundreds of grant implementations, which enables us to help our clients comply with myriad implementation and reporting requirements. HMA’s project managers help our clients ensure that grants get implemented on time, on budget, and in compliance with funders’ requirements.

HMA has a team of experienced program evaluators who help our clients implement with fidelity, assess impact and outcomes, and comply with grant evaluation requirements. Our evaluators are facile with program outcome data as well as the demands of rigorous stakeholder input.

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Reach out to our experts for more information on how HMA can help your organization’s grant and funding strategies.

Contact our experts:

Heidi Arthur

Heidi Arthur

Principal

Kathleen Cahill

Kathleen Cahill

Associate Principal

Ruth Danielzuk

Ruth Danielzuk

Senior Consultant

Josh Rubin

Josh Rubin

Vice President, Client Solutions

HMA knows rural.

Some 47 to 60 million people live in rural areas in the U.S. Many rural residents must navigate healthcare system challenges people living in urban and suburban areas generally do not face. Developing and supporting rural health programs requires understanding the unique characteristics of rural settings and how these dynamics influence healthcare policy, providers, payers, consumers, and health equity.

HMA understands the multilevel challenges for delivery of quality healthcare and social services to rural populations. From workforce concerns to access issues such as lack of services, transportation difficulties, and socio-economic barriers, we know the difficulties that often keep rural providers and organizations from achieving their full potential to serve and support their communities’ needs.

Changing dynamics in many rural areas also create the need for building awareness and understanding of issues of equity and reducing disparities and how to effectively address them in rural communities. HMA has the hands-on knowledge for practical solutions.

HMA brings together industry-leading policy, program, financial, community, and clinical experts to provide comprehensive solutions that make healthcare and human services work better for people living in rural and frontier areas across the country. With deep experience and through skilled analysis, guidance and technical know-how, our consultants help a wide range of clients successfully navigate the healthcare space. Our team is more than 900 members strong and growing, with expertise that spans the healthcare industry and stretches across the nation.

We offer a full suite of professional health and human services consulting services to clients serving rural and frontier communities, such as:

Critical Access and PPS Hospitals

Federally Qualified Health Centers, Rural Health Clinics, & Provider Practice Groups

Health Plans

National, Regional and Statewide Associations

Federal, State, & Local Governments

Tribal nations & Tribal Health Organizations

Community Based Organizations

Foundations

Our national, multisector, multisystem experience in healthcare and human services enhances our ability to support rural clients in making sustainable, positive impacts in their local communities. Whether your project has run into a snag in the final stages or hasn’t even gotten off the ground, we can provide the expertise and guidance to help you make it a success.

Our areas of expertise include:

Analytics

Behavioral Health

Care Integration

Clinical Services

Community Strategies

Crisis Systems & 988

Government Programs & the Uninsured

Healthcare Actuarial Services

Healthcare Delivery Development & Redesign

Healthcare IT Advisory Services

Investment Services

Justice-Involved Healthcare

Long-Term Services & Supports

Managed Care

Opioid Crisis Response

Public Health

Quality and Accreditation Services

Value-Based Care

Workforce development

PROJECT SPOTLIGHT

Health Equity & Access for Rural Dually Eligible Individuals (HEARD) Toolkit

With funding from Arnold Ventures, HMA created the HEARD Toolkit, a robust discussion of the access challenges facing dually eligible individuals in rural areas and a portfolio of actionable solutions to address these challenges. Dually eligible individuals in rural areas reside at the intersection of a major public health crisis and a fragmented Medicaid and Medicare delivery system. They experience poor access to services and to integrated care programs (ICPs) to address their whole person needs.

HMA designed this Toolkit to help policymakers address access issue dually eligible individuals in rural areas have to navigate every day. For example, addressing access must encompass getting to a comprehensive Medicaid and Medicare services continuum that includes home- and community-based services (HBCS), as well as ICPs. A primary focus on equity can help states, local communities, payers, and providers begin to address issues of access for these very vulnerable individuals in rural communities. The Toolkit provides examples and ideas for rural providers and communities to address equity and improve services and supports for dually eligible individuals.

Learn More

For example, HMA can assist rural communities and the organizations that support their needs with:

Rural-specific workforce solutions

Programs addressing Social Determinants of Health/Health-related Social Needs

Payment system reforms

Development of integrated care programs for Dual Eligibles

Substance Use Disorder/Opioid Use Disorder prevention, treatment, and recovery services

Behavioral health services and supports

Justice-involved carceral healthcare and transitions

Long-term services and supports and home and community-based services

HMA understands the multilevel challenges for delivery of quality health care and social services to rural populations. From workforce and care access issues to transportation difficulties and technology barriers, to socio-economic differences, we can help rural providers and organizations overcome challenges and achieve their goals to serve and support their communities’ needs.

Other Rural Health Project Examples:

HMA is supporting review and reform of the primary care payment environment in New Mexico working under a contract with Mercer. New Mexico’s Medicaid program had identified multiple challenges the primary care providers faced across the state, including rural sustainability and fiscal soundness. HMA’s approach includes coupling data analysis with stakeholder engagement. Our work to date includes designing, testing, and evaluating new primary care alternative payment models (APMs); fiscal, policy, and/or programmatic implementation recommendations related to the multi-payor roll-out of a primary care APM; and supporting primary care practitioners related to NM Medicaid APM implementation. Additional project work will include more provider specific analysis, recruitment for pilot testing and provide education, analysis and training for providers, health plans and state regulators.

HMA is working with the Colorado Department of Health Care Policy and Financing (HCPF) to perform a dynamic heat mapping as the first phase of a three-phase project that includes an environmental scan of home and community-based services (HCBS)/Medicaid. HMA is creating a tool that HCPF can leverage to update and track progress to close provider gaps. In subsequent work HMA will identify potential geographic regions which would benefit from reimbursement structure changes, including geographic adjustment factors to apply to preexisting fee-for-service rates or other mechanisms to effectively address identified care gaps. Based on these results, HMA will recommend strategies and best practices to expand the provider network in rural areas to avoid care deserts and assure access to services for all Medicaid members.

Over the past six years, HMA has supported tribal communities in Montana with an array of data and evaluation expertise specific to behavioral health system assessments and evaluation activities. To date, we have conducted feasibility assessments for tribes considering options to 638 their behavioral health services, evaluated high-fidelity wraparound services in tribal communities through the Montana Systems of Care program, supported efforts to discern a concept design for a joint tribally operated Substance Use Disorder (SUD) Continuum of Care, and assisted tribally operated clinics in best practices in opioid prescribing and addiction treatment.

The Georgia Health Policy Center provides technical assistance for grantees of HRSA’s Rural Health Programs. HMA created a primer and additional tools, including a webinar, designed to inform and support rural provider leadership on Value-Based Care. The primer serves as a self-paced guide helping organizations consider national trends and experiences, assess their current state and readiness, understand benefits and barriers of Value-Based Care. The primer and tools are used by the technical assistance team and rural health grantees.

HMA has worked with HSHS for over 10 years, providing a wide range of services including:

Grant surveillance related to strategic plans, project management, grant program development, and narrative writing for multiple state and federal grants including USDA, HRSA, and SAMHSA. 

Expanding access to medication assisted treatment (MAT) in emergency departments by activating a team of HMA experts to implement a global assessment of readiness to adopt MAT, create a comprehensive training curriculum, assist with development of policies, workflows and standardized orders; and provide technical assistance required to address stigma and implement change. HMA also aided in writing the successful proposal for state funding for this project.

Stakeholder engagement for a hub-and-spoke model of telehealth network, assessed strategic priorities across multiple diverse stakeholders, and developed a strategic plan for HSHS’ Wisconsin rural healthcare provider telehealth network.

Development of the Illinois Telehealth network composed of 21 rural healthcare providers across Illinois. HMA provided technical expertise on the adoption of telehealth services and the development of clinical protocols and led strategic planning efforts. The network now functions to support the members in disseminating best practices, implementing telehealth service lines, sharing clinical protocols, removing barriers, and promoting evaluation.

HMA is currently assisting HSHS’ rural behavioral health team in devising new models of community-based withdrawal management processes consistent with recent changes in Wisconsin’s regulations. HMA experts on residential substance use disorder and integrated care provide technical assistance, training, and evidence-based policy development.

HMA supported the Texas Department of Agriculture, State Office of Rural Health (SORH) by leading SORH’s three-year strategic plan and design future programs. For the needs assessment, HMA conducted a systematic assessment that included an environmental scan of rural health key issues and trends, online survey of rural Critical Access Hospitals (CAHs) and prospective payment systems (PPS) hospitals in Texas identify needs and gaps, and an analysis of publicly available data to identify health needs and differences between rural and urban residents. Informed by this assessment and close collaboration with SORH staff, HMA developed a strategic plan to guide the next three years of SORH’s programming, as well as created work and evaluation plans for the SORH and Flex grant programs. Other tasks included assessment of Texas rural hospital telemedicine readiness, recommendations for value-based payment models for rural hospitals, and opportunities to support rural hospitals in reducing health disparities.

Our depth and breadth of experience has helped a diverse range of healthcare industry leaders focused on rural and frontier areas. What can we do for you?

Contact our experts:

Kathleen Cahill

Kathleen Cahill

Associate Principal

Kathleen Cahill is a solutions-driven C-Suite executive with more than 40 years of experience in healthcare operations, working for entities … Read more

Kenneth Cochran

Managing Director, Delivery Systems

Kenneth Cochran is a healthcare executive with more than 20 years leveraging his clinical, business and academic background to deliver … Read more
Dan Castillo

Dan Castillo

Managing Principal

Dan Castillo is a seasoned healthcare executive with over 20 years of experience in health administration. He specializes in health … Read more
Stephanie Denning

Stephanie Denning

Principal

Stephanie Denning has worked in healthcare and human services for more than 25 years. Her experience spans the public, non-profit, … Read more
Shannon Joseph

Shannon Brown Joseph

Senior Consultant

Shannon Brown Joseph is a dynamic and accomplished workforce development liaison with experience in federal and state funded programs, diversity … Read more
Rebecca Kellenberger

Rebecca Kellenberg

Principal

Rebecca Kellenberg specializes in assisting public and private health care organizations with Medicaid and CHIP policy analysis and implementation. With … Read more
Jill Kemper

Jill Kemper

Associate Principal

Jill Kemper has extensive experience improving access to care and care delivery, especially for vulnerable or complex patient populations and … Read more
Margaret Kirkegaard

Margaret Kirkegaard

Principal

Dr. Margaret Kirkegaard has extensive front line experience and an impressive breadth of knowledge about health care and its delivery. … Read more
Sarah Oachs

Sarah Oachs

Associate Principal

A collaborative health and human services professional, Sarah Oachs has vast experience in organizational leadership and assessments, operations management, and … Read more
Bill Snyder

Bill Snyder

Principal, Leavitt Partners, an HMA Company

Public Health Preparedness Services

“Public health problems pose special challenges. They are generally enormous in scale, stem from numerous and highly complex causes, play out in the public eye, impact a vast array of stakeholders, and require unusually long-term solutions. The massive scope and complexity of such problems, including conditions such as uncontrolled childhood mortality, suboptimal maternal health, HIV/AIDS, cardiovascular disease, and cancer, among others, affect millions worldwide. Furthermore, the health issues quickly trigger a host of other family, economic, and social problems that ruin lives, erode communities, and weaken countries.”

– Journal of Public Health, Fostering public health leadership article

Concerned about another crisis?

Health departments play a critical role in achieving health security, including preparing communities for potential threats, mitigating those threats, responding to emergencies, and aiding in the recovery process. Over the past few years, public health has been faced with heightened scrutiny, lack of trust, and the need to evolve and keep up with the latest natural disasters, environmental, and infectious disease threats.

How HMA can help

HMA assists state, local, territorial, and tribal health departments with:

Plan writing, including emergency operations, hazard mitigation, medical counter measures, mass fatality, pandemic, continuity of operations, and crisis communications.

Reviewing and synthesizing emergency plans, policies, and procedures into actionable and meaningful abbreviated checklists.

Training and exercise development, including tabletop exercises, full scale exercises, hot wash debrief facilitation, after action report writing.

Workforce analyses, including determining if your health department is adequately staffed to respond to an emergency and maintain the foundational public health functions.

Capacity building and strategic infrastructure investment, including spending plans, funding, and development of action plans.

Staff/workforce resilience and morale, including team building, workforce assessments, and strategic planning.

Equity and Inclusion, including access and functional needs.

Infection control, including facilitating trainings, plan writing, and compliance.

Our Colleagues and Expertise

HMA public health preparedness experts applicable experience and expertise to assist public health agencies in preparing, mitigating, responding to, and recovering from public health emergencies.

  • Managing and coordinating Public Health Emergency Preparedness (PHEP) grants and emergency response and recovery activities at state, local and territorial health departments.
  • Developing emergency operation plans, procedures, and guidelines for emergency response projects.
  • Multifaceted public health strategic planning, which incorporates health services access, social service integration, workforce sustainability, data modernization, and environmental considerations.
  • Former staff from the National Association of County and City Health Officials (NACCHO)’s public health preparedness program.
  • Supply chain management of medicines and other health technology resources.
  • Development of evidence-based infection control practice, policy, and procedures.
  • Colleagues educated via the Association of Professionals in Infection Control and Epidemiology (APIC) in infection control prevention practices and public policy.

Project Spotlight

HMA worked with El Paso County Public Health (EPCPH) leadership to extend the reach of EPCPH staff during this pandemic and support the quick development of a COVID-19 recovery plan and an After Action Report (AAR). HMA gathered background information, intelligence, and templates from EPCPH staff, drawing from the prior COVID-19 plans. HMA documented best practices from other counties where HMA currently supported COVID-19 response planning and conducted interviews with EPCPH staff as needed to provide input into the plans. HMA drafted two plans: 1) a COVID-19 recovery plan, including a review of the transition back after COVID-19, health department continuity of operations (COOP) as it moved back to normal and indicators for return to work, and 2) an AAR for EPCPH’s positives and negatives related to the following: variances, EH (masks, capacity) compliance (masks, capacity), case investigation/contract tracing, and data analytics as well as med surge.

HMA evaluated COVID-19 response activities within the Hospital Association of California (HASC) member facilities and partners across the regions served. HMA reviewed a representative sample of member facility and partner agency plans developed and utilized during the response. We reviewed relevant annexes, guidance from local and state public health, member facilities, and federal agencies activated, alongside open-source information. HMA also examined documentation developed during response and recovery, including situation reports, memorandums of understanding, messaging to facilities, memos about response, training, and exercise events to perform an analysis of activities and references. In addition, this project garnered input from other key healthcare and government stakeholders in the regional market, including emergency medical services, public health, city and county governments, transportation, and others via online surveys and small group interviews. The creation of a Mid-Action Report/Best Practices Plan was particularly important to document lessons learned, best practices, and improvement items to inform ongoing efforts and future readiness initiatives to improve HASC’s capabilities and the planning needs of its members.

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
Lisa Harrison

Lisa Harrison

Associate Principal

Lisa Harrison is a physician associate with more than 20 years of direct experience in clinical practice as a primary … Read more
Zipatly Mendoza

Zipatly V. Mendoza

Senior Consultant

Zipatly V. Mendoza is a results-driven public health professional with over 15 years of program management experience and a demonstrated … Read more
Yamini Narayan

Yamini Narayan

Senior Consultant

A diversified professional who thrives on solving the most complex questions in health policy, Yamini Narayan is a skilled researcher … Read more
Hannah Savage

Hannah Savage

Consultant

Hannah Savage is an experienced public health professional with skills in program evaluation, data analysis, survey development, survey analysis, and … Read more
Linda Vail

Linda Vail

Principal

Linda Vail is an accomplished public health leader, creative problem solver and strategic thinker. She has extensive experience in opioid … Read more
Helena Whitney

Helena Whitney

Associate Principal

Helena Whitney effectively bridges the policy and the politics of healthcare with her combination of public health, legislative affairs and … Read more
Emily Wilson

Emily Wilson

Associate Principal

A multi-disciplinary public health leader, Emily Wilson is passionate about bringing people together to solve the most pressing problems in … Read more

Summary of the CMS managed care final rule and its impact on states, managed care organizations and providers

On May 10, 2024, the Centers for Medicare & Medicaid Services (CMS) published the Medicaid and Children’s Health Insurance Program (CHIP) Managed Care Access, Finance, and Quality Final Rule (CMS-2439-F). 

CMS created a fact sheet which concisely reviews the final rule’s key provisions, as well as an applicability dates chart, which serves as a reference guide to the various applicability dates for different provisions in the final rule. The final rule creates new flexibilities and requirements aimed at enhancing accountability for improving access and quality in Medicaid and CHIP by principally addressing these topic areas:

  • ILOSs are defined as substitute services or settings for a service or setting covered under the state plan and can be leveraged by Managed Care Organizations (MCOs) to address unmet health-related social needs (HRSNs).
  • They must be offered to all members and must be voluntary as well as documented in MCO contracts.
  • ILOSs cannot exceed 5% of total capitation.
  • If ILOS costs exceed 1.5% of total capitation, states must provide additional documentation to CMS to demonstrate medical appropriateness and cost-effectiveness.
  • When an ILOS is terminated, states must develop a transition plan to arrange for state plan services and settings to be provided in a timely manner.
  • States must make available online a “one-stop-shop” where members can learn about and compare MCOs based on quality and other variables.
  • Mandatory quality measures are established.
  • The methodology for calculating the quality ratings displayed on each state’s MAC QRS is also established.
  • Although guidelines exist, states can submit their own version of a MAC QRS to CMS for approval.
  • Provider incentive payments must be tied to clearly defined, objectively measurable, and well-documented clinical or quality improvement standards to be classified as incurred claims (in alignment with private market MLR regulations).
  • Prohibits the inclusion of indirect administrative costs that are not directly related to improving quality as QIAs as incurred claims in the numerator (in alignment with private market MLR regulations).
  • Imposes additional expense allocation methodology requirements (in alignment with private market MLR regulations).
  • Requires SDPs to be included as both incurred claims (for payments made by MCOs to providers) and premium revenue (for payments made by states to MCOs).
  • Sets maximum appointment wait time standards of no more than 15 business days for routine primary care (adult and pediatric) and obstetric/gynecological services and 10 business days for mental health and substance use disorder services (adult and pediatric).
  • Enforces these standards using secret shopper surveys and requires states to contract for the secret shopper surveys.
  • Requires states to post the appointment wait time standards as well secret shopper survey results.
  • A remedy plan must be implemented for any MCO that fails to meet these required standards for access.
  • States must also conduct an annual enrollee experience survey for each MCO.
  • Codifies ACR payment ceiling, which applies to hospitals, practitioner services at academic medical, and nursing facility services.
  • Requires “hold harmless” attestation.
  • Allows for SDPs at 100% of Medicare without prior written approval.
  • Removes network provider requirement to receive payment.
  • Prohibits use of interim payments based on prior period data even if ultimately reconciled.
  • Prohibits use of separate payment term where SDPs are paid separate from capitation rates.
  • Explicitly states that SDPs must result in “stated goals and objectives.”
  • Requires states to submit detailed, provider level SDP data to the Transformed Medicaid Statistical Information System.

Implications for States

The final rule creates opportunities for states to leverage new flexibilities to further policy goals but also creates new administrative burdens. MCOs and providers will look to states to comprehensively understand final rule’s requirements and be prepared to manage the steps necessary to achieve compliance over a multiyear implementation process.

Implications for MCOs

As states move to comply with the final rule, MCOs will be immediately downstream from the steps taken by states to do so and MCOs need to prepare accordingly. Proactive actions by MCOs to not only engage with states early but also to prepare financially and operationally for the different provisions of the final rule over time will put them in the best position possible.

Implications for Providers

The most significant implications for providers in the final rule are related to SDPs, where a new level of accountability will be required. All topics covered by the final rule, however, have provider implications.

Looking ahead

The provisions of the final rule range in their effective dates from as early as the final rule’s effective date, July 9, 2024, to as late as the first rating period on or after four years after July 9, 2024.

Because of these variable effective dates, states, MCOs, and providers will need to comply with the final rule immediately in some cases, while having significant lead time to do so in other areas. Sub regulatory guidance is also forthcoming and must be monitored for and digested.

HMA stands ready to support states, MCOs, and providers in analyzing and responding to the strategic, financial, and operational impacts of the final rule’s provisions in specific markets and organizational contexts.

If you have questions or want to connect with our expert team members, e-mail [email protected].

HMA can help develop and operate PACE programs

The vast majority of hospitalizations are among patients 65 years and older due to their comorbid chronic illnesses and their requirement for age-appropriate care management. While the aging population increases, nursing home availability and state funding for home-and community-based services have decreased. As a result, the Centers for Medicare and Medicaid Services (CMS) care model Program of All-Inclusive Care for the Elderly (PACE), has boosted growth.

A program aimed at keeping low-income older adults living in the community and out of nursing homes, PACE has been a safe haven for many. Currently offered in 32 states, the program provides home care, prescriptions, meals, and transportation to participants.

The local PACE centers also bring enrollees together to socialize and receive a variety of medical services. Many PACE providers have reported high satisfaction rates among participants. Further, a 2021 report by the Health and Human Services Department found PACE enrollees were significantly less likely to be hospitalized, use emergency departments, or be referred to nursing homes compared to Medicare Advantage members.

Our clients

HMA works with national and state associations, managed care organizations, delivery systems, federal and state public health programs, as well as interested and existing PACE programs to support the promotion and continued improvement of the PACE model. Having led PACE programs, managed care organizations, delivery systems, and federal and state public health programs, the HMA team of multidisciplinary experts is skilled in PACE program design, strategy, growth, and operations. We have direct experience working in and with PACE organizations in policy, application processes, and operational readiness, day-to-day operations, and audit preparation and response.

How HMA can help:

HMA’s team can help organizations strategically identify, plan, and implement the development of a new PACE. HMA’s experts are experienced in leading an organization through the strategic planning processes, educating and orientating an interested sponsor organization in their PACE market of interest, and all of the variables, including the desired PACE service areas, federal and state waivers and licensure requirements, and restrictions, the state, and federal application timelines and processes, and pre- and post-implementation processes and as well as ongoing business operations.

The state and federal application process involves multiple steps and can feel daunting. HMA is well versed in these processes and has assisted many PACE programs across the county complete these applications. HMA will work with you side by side to navigate all of the application requirements including completing and submitting the Notification of Intent to Apply (NOIA), Navigating and Working with State Agencies, and completing the CMS Application.

Although many states operate in similar ways, there are nuances that make each a bit different. HMA consultants have worked with many state agencies across the country, both in states with PACE programs and states without. Whether your state(s) have existing PACE programs, or you are looking to be the first one in the state, HMA has the experience and expertise to help navigate those state-by-state differences. Our PACE team includes previous state Medicaid and federal leaders, providing valuable contacts and knowledge within the state systems.

Achieving performance targets requires advanced systems of care delivery and agile information technology tools for real-time monitoring and managing populations and participants. Effective operating and reporting systems are critical to the success of PACE organizations’ operations. HMA has evaluated system requirements for PACE and can help you identify, select, and implement operating processes and systems. To optimize operations efficiency, we also offer solutions for tracking and managing revenue, participant care costs, productivity, and downstream payments. We can also work to implement telehealth and remote patient monitoring technologies.

Contracting with specialty and ancillary healthcare providers along the continuum of care will be increasingly critical for managing participant care, outcomes, and costs under the PACE model. We can assess the scope and effectiveness of current contractual relationships, including contract language review, reimbursement, reporting requirements, and other elements critical to compliance and operational compliance and success, across a wide range of healthcare and social service providers.

HMA has extensive policy experience with the legislative requirements that govern PACE at both the state and federal level. We can help evaluate the impact of new requirements or legislation to inform your position with regulators. In addition, HMA team members have existing relationships with the National PACE Association as well as various state PACE Associations.

HMA experts are experienced and are well versed in providing data analytic services to both prospective and fully operational PACE programs. Using a full analytics suite, our experts can help with Part D needs including Bid preparation and Part D Reconciliations. Additionally, we can assist organizations with risk adjustment operations and support, forecasting, market analysis, vendor auditing, and strategic support. 

HMA is available to help organizations develop PACE capabilities from concept to implementation and beyond, including post-implementation and ongoing PACE operations. 

Contact our experts:

Debby McNamara

Debby McNamara

Associate Principal

Don Novo

Don Novo

Managing Principal

Jason Pettry

Jason Pettry

Senior Consultant

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

Senior Vice President, Practice Groups

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