On May 31, the House passed H.R. 3746 鈥� the , otherwise known as the 鈥渄ebt ceiling鈥� bill, which increased the federal debt limit, established new discretionary spending limits, rescinded unused funds, and expanded work requirements for federal programs. It was passed by the Senate on June 1 and will soon be signed into law. What does all this have to do with healthcare workforce? Well, part of the rescindment plan comes from $28 billion in unused pandemic funding, with a substantial portion of those funds that were allocated for healthcare workforce efforts. This includes funds set to be used for mental health and substance use disorder training, grants to improve mental health and burnout in the healthcare workforce, and additional educational and training grants for promoting future workforce. Overall, part of $28 billion specifically includes removal of $1.7 billion from the Centers for Disease Control and Prevention (CDC) and $13.4 billion from the Department of Health and Human Services (DHHS), including $10.4 billion from public health and social 杏吧视频 emergency funds.
So, what does this mean for the healthcare workforce? It means healthcare organizations will need to continue to optimize their current and future workforce plans, without additional funding that could provide some relief.
At 杏吧视频 (HMA), our healthcare workforce experts have not only partnered with health system leaders to identify real-world solutions, we have directly experienced the same challenges, because our team includes physicians, nurses, advanced practice providers, and former health system operations and financial executives who share the same lived experiences.
HMA offers a number of workforce solutions to healthcare communities across the spectrum. We cannot fill all your staffing gaps tomorrow; however, we can give you an innovative, model-of-care plan designed to lower costs, increase revenue, and position organizations for long-term financial success and operational sustainability.
An experienced team of health system leaders, bedside clinicians, and workforce subject matter experts with real-world experience and modern health care delivery solutions
A thorough quantitative and qualitative assessment including:
Workforce capacity, needs, and gap analysis.
Leadership and governance structure evaluation.
Key regulatory and policy gap analysis.
Compensation and benefits review.
Clinical and/or non-clinical workflow evaluation.
Provider billing practices and quality metric capture.
Provider and staff utilization analysis.
What organizations receive is:
A customized, comprehensive phased implementation plan that:
Improves cash flow and maximizes revenue.
Reduces turnover, increases retention, and improves health system culture.
Optimizes the 鈥楳odel of Care鈥� delivery while still maintaining quality and safety.
Provides solutions for long-term financial success and operational sustainability.
Offers on-going executive and leader coaching 杏吧视频 to help provide support through the change management process.
Today鈥檚 healthcare workforce challenges are unwavering, especially given the recent passage of the 鈥渄ebt ceiling鈥� bill. From significant workforce shortages, to rising costs and competition, to decreasing employee engagement and burnout, today鈥檚 health systems face tremendous challenges. But by understanding workforce and health system needs and identifying gaps and inefficiencies, employers can fully utilize the employees they have to their highest potential and deliver care more effectively and efficiently. Here at HMA, our delivery system optimization team can help health care communities struggling with workforce challenges do just that.
Contact our healthcare delivery system experts, who can partner with your organization to design a custom workforce solution for you.
Innovations in Publicly Sponsored Healthcare: How Medicaid, Medicare, and Marketplaces Are Driving Value, Equity, and Growth
Pre-Conference Workshop: October 29, 2023 Conference: October 30鈭�31, 2023 Location: Fairmont Chicago, Millennium Park
杏吧视频 has announced the preliminary lineup of speakers for its sixth annual conference, Innovations in Publicly Sponsored Healthcare: How Medicaid, Medicare, and Marketplaces Are Driving Value, Equity, and Growth.
Hundreds of executives from health plans, providers, state and federal government, investment firms, and community-based organizations will convene to enjoy top-notch content, make new connections, and garner fresh ideas and best practices.
A pre-conference workshop, Behavioral Health at the Intersection of General Health and Human Services, will take place Sunday, October 29.
Confirmed speakers to date include (in alphabetical order):
Jacey Cooper, State Medicaid Director, Chief Deputy Director, California Department of Health Care Services
Kelly Cunningham, Administrator, Division of Medical Programs, Illinois Department of Healthcare and Family Services
Karen Dale, Chief Diversity, Equity, and Inclusion Officer, AmeriHealth Caritas
Peter Lee, Health Care Policy Catalyst and former Executive Director, Covered California
John Lovelace, President, Government Programs, Individual Advantage, UPMC Health Plan
Julie Morita, MD, Executive Vice President, Robert Wood Johnson Foundation
Anne Rote, President, Medicaid, Health Care Service Corp.
Drew Snyder, Executive Director, Mississippi Division of Medicaid
Tim Spilker, CEO, UnitedHealthcare Community & State
Stacie Weeks, Administrator/Medicaid Director, Division of Health Care Financing and Policy, Nevada Department of Health and Human Services
Lisa Wright, President and CEO, Community Health Choice
Publicly sponsored programs like Medicare, Medicaid, and the Marketplaces are leading the charge in driving value, equity, and growth in the U.S. healthcare system. This year鈥檚 event will highlight the innovations, initiatives, emerging models, and growth strategies designed to drive improved patient outcomes, increased affordability, and expanded access.
Early bird registration ends July 31. Group rates, government discounts, and sponsorships are available.
HMA is pleased to welcome new experts to our family of companies in April 2023. This diverse team brings significant expertise in Medicare, Medicaid, regulatory strategies, and managed care, strengthening HMA鈥檚 capabilities in healthcare consulting across areas like actuarial support, regulatory compliance, and strategic leadership in Medicare Advantage and Medicaid programs.
This is part of an ongoing series highlighting efforts in Human Services and Family Wellbeing.
During the month of May, National Foster Care Month provides an opportunity to raise awareness on issues related to foster care and to celebrate those who are dedicated to serving our children, youth, and families. Yet it is important to note that unfortunately issues surrounding children and youth experiencing foster care are not limited to one month a year. As noted in our recent child well-being blog, Child welfare 杏吧视频 face challenges every day to prevent, treat, and reduce risk of maltreatment, neglect, trauma, housing instability, and violence in communities. All these issues contribute to the significant number of children and youth who enter or remain in the foster care system. These issues are year-round and decades in the making. They need to be seen as a priority for public health and community wellbeing and not just the jurisdiction and responsibility of child welfare agencies.
To positively impact the number of children and youth experiencing foster care, there are some strategies that can be implemented now to promote change:
We must meaningfully elevate the voices of those with lived experience to help us design systems that meet their needs. For foster care, working to hear and understand the voices of youth based on how they have experienced foster care will help create opportunities to improve the system from those most impacted. Further, the meaningful elevation of these voices helps to ensure their input is not contributing towards tokenism and re-traumatization.
Multi-system involvement is important. We can work together to enhance access, increase prevention-oriented 杏吧视频, improve community health, and well-being, and achieve better outcomes using an equity lens, but proposed system reforms cannot be successful without shared ownership within the community and across government agencies. This requires building a responsive and integrated system of care approach to allow communities to seek solutions with the necessary support of the highest leadership within their organizations.
Continue to find ways to assure that mandated reporters and staff who work within child welfare understand that poverty is not neglect, and poverty alone should not be a reason children and youth are removed from their home(s).
System redesign is needed. From front end reporting and assessment, to working with court systems, to building up networks of caring service providers, each component of the current child welfare system and human 杏吧视频 partners can strive to find areas needing improvement and collectively change the experiences for children and youth engaged in the child welfare system.
Focus on mental health. This year鈥檚 theme from the Children鈥檚 Bureau for national foster care month is 鈥淪trengthening Minds, Uplifting Families鈥� and is dedicated to supporting children and youth mental and behavioral health as the largest unmet need related to foster care. According to the Children鈥檚 Bureau, , compared with approximately 18 to 22 percent of the general population.[1]
HMA can help public sector and community partners align themselves to improve and develop new delivery systems that will work to address inequalities and disparities as communities strive to meet the needs of children, youth and families impacted by issues like mental health and substance use disorder, domestic violence, child abuse and neglect, food insecurity, housing instability, incarceration and other traumas that impact them greatly.
HMA can help support foster care prevention or reunification program efforts in the following ways:
Creating additional human service system integration of prevention 杏吧视频 to help support families and youth experiencing child welfare interventions or foster care.
Increasing Medicaid providers who offer more Evidenced Based and Informed Practices (EBP) among Community Based Organizations (CBO), Providers, and Local Government.
Supporting Managed Care Organizations to develop programs specifically designed to support the wellbeing of children and youth in the foster care system and their families.
Connecting the Family First Prevention Services Act (FFPSA) & Medicaid funding together to ensure that funding supports the need and enhance service implementation.
Working to implement School Based Mental Health programs in communities. We can help convene stakeholders, create process flows, and support the development of sustainable funding for such programs.
Increasing the meaningful use of youth voice for true collaboration in system redesign.
Enhancing judicial engagement with the child welfare system in a way that supports meaningful youth and family voice and representation in court while maintaining the child welfare system鈥檚 responsibilities around assuring child safety. Making the court process less traumatic for children and youth and more part of a solution for them will support better outcomes.
Recognizing longstanding racial inequities in foster care experiences that can and should be addressed holistically in communities and supporting efforts to understand the root causes for the disparities in foster care placement.
The public health workforce is in the midst of a crisis, dealing with staff shortages, accelerated retirements and unfilled positions.
The current climate was exacerbated by Covid-19, but many challenges began long before 2020鈥檚 pandemic. The public health system underwent a significant contraction following the Great Recession in 2008-2009, losing more than 40,000 positions in state and local governments across the country. While some of those positions were regained with Covid-19 funds during the pandemic, recruitment, diversity and retention remain as challenges, especially for hard to fill positions in nursing and epidemiology. Public health staff report high rates of burnout due to the Covid-19 response and the political climate that resulted, including suffering symptoms of post-traumatic stress disorder. It is likely that there will be staff shortages for the foreseeable future, increased retirements, and departures to other parts of the healthcare industry competing for skills with higher compensation.
New Funding Streams Available
State and local health departments have been receiving significant amounts of one-time money, including the Centers for Disease Control and Prevention (CDC) recent allocation of $3.5 billion specifically for governmental public health efforts.
Health Resources and Services Administration (HRSA) has created a new workforce research center for public health. The AmeriCorps program has developed a specific public health component. These new initiatives were designed to build and support the workforce in governmental public health. As state and local health departments receive or apply for these various sources of workforce development funding, HMA can provide existing technical assistance and training to minimize inefficiencies and duplication of efforts that might be created by a fragmented approach across state and local units of government developing independent approaches to the utilization of WFD funds.
HMA Workforce Expertise
The public health group at 杏吧视频 (HMA) is made up of more than 100 colleagues with expertise in public or population health improvement, experienced working with national, state or local organizations seeking to improve public health outcomes. If your organization is looking to improve your public health workforce efforts, it is important to utilize expertise and consolidate efforts across the country so each unit of government is not 鈥渞einventing the wheel.鈥� HMA can help multiple organizations in developing plans and coordinating processes for recruiting, training and development of the public health workforce.
HMA understands the skills that are needed to achieve high-performing public health and accountable care. Our expertise developing workforce within safety net delivery systems and accountable care organizations involve transferrable skills for the current challenges in building and developing the public health workforce. We have expertise in recruiting and are creating new training and retraining methods to meet the needs of public health teams, accountable care organizations, graduate medical education, nursing education, learning collaboratives, online training and team simulation training. We understand the care coordination, care management and IT support systems needed to backstop the workforce and meet quality and equity goals.
This week our In Focus section reviews the Illinois Healthcare Transformation 1115 Waiver Extension request, posted for review on May 12, 2023.
In pursuing this waiver extension, Illinois joins a growing list of states taking advantage of new Centers for Medicare & Medicaid Services (CMS) policy flexibilities to address health-related social needs (HRSNs) through Medicaid and test community-driven initiatives that are focused on improving health equity, improving access to care, and promoting whole-person care.
The Illinois waiver incorporates two of the most significant new opportunities in the CMS demonstration waiver flexibilities by proposing to incorporate housing supports for people who are experiencing or at risk of homelessness. The waiver also would extend community reintegration 杏吧视频 for justice-involved adults and youths for up to 90 days before their release from incarceration. For a full list of proposed benefits and demonstrations, see Table 1.
Table 1. Summary of Illinois Medicaid 1115 Waiver Extension
Source: Illinois Department of Health and Family Services. .
The Illinois waiver represents an unprecedented opportunity to demonstrate the long-term, positive impact of providing HRSN 杏吧视频 to achieve health equity and create a sustainable, community-driven system for delivering those 杏吧视频. The demonstration proposes to offer a range of HRSN 杏吧视频 that are focused on the unmet needs of people who are homeless and housing insecure, are justice-involved, have behavioral health conditions, are pregnant, are unemployed, are food insecure, and/or have been exposed to violence or are at risk of violence with the goal of eliminating health disparities.
The waiver projects a five-year total of $4.4 billion in HRSN 杏吧视频 expenditures and another $800 million in HRSN-related infrastructure, indicating Illinois鈥� long-term commitment to healthcare transformation and to building an equitable, accessible, and high-quality delivery system.
Healthcare executives gathered with HMA leaders in March to learn and share about new initiatives in quality improvement. Panels and discussions were led by esteemed experts, who provided important insight into the multitude of opportunities to improve quality and equity:
From the Experts: CMS has doubled down on its commitment to improve healthcare quality, equity, and access.
The HMA Point of View: Current leadership in Washington has set very clear goals to improve health equity, aligning federal policy as a lever to improve healthcare outcomes. Federal dollars passed along to states are including new rules and objectives to improve quality in an equitable manner. Therefore, those applying for federal contracts and grants must include a strategy to improve quality, equity, affordability, and access.
From the Experts: Interventions need to be robustly evaluated to address equity and social determinants of health (SDOH).
The HMA Point of View: Governments, care providers, and payers have been experimenting with approaches to SDOH, but the bar is now higher and results have to be measurable. New investments that address SDOH and aim to improve equity must include a strategy to measure and analyze results of interventions, including evaluation of critical subpopulations to address disparities. Although experiments will continue, we have reached the point where a robust analysis of outcomes is an expectation.
From the Experts: Quality is playing a central role in operationalizing equity.
The HMA Point of View: While there are many reasons for disparities in health, quality metrics and programs must be designed to improve quality for all patients. Identifying inequities is only the first step; successful programs will advance equity by reducing barriers to care. Measurable quality programs should be designed for population health, but personalized for individuals with clear provider incentives to not only identify disparities but also minimize them. Quality is the tool by which we achieve health equity.
From the Experts: We are on the precipice of doing great things in quality.
The HMA Point of View: Our ability to integrate data from multiple sources is finally getting to a place where patients can get the quality care they need, and providers can give the right care at the right time to improve outcomes. Policymakers have broken down barriers to data sharing, enabling a new economy of information sharing that promises to empower patients and reduce costs. It is no longer enough to have a separate IT or data strategy; anyone working to improve healthcare quality needs to have data strategies within and across every operational function across their organization.
From the Experts: Being rewarded for doing what’s right for the patient is central to continuous quality improvement.
The HMA Point of View: Quality care for the patient means creating the right incentives for payment and care delivery that focus on outcomes and experience. Every point of care in the patient’s health journey needs to be evaluated and designed from the point of view of providing a quality experience. Not every patient has the same journey, and our healthcare system must meet them where they are, delivering for their unique needs. Convenience, personalization, accuracy, simplification, and affordability are nearly as important as clinical outcomes in the mind of most patients and addressing barriers to health can have clinical benefits.
HMA has a long history of working with clients to achieve their quality improvement goals including securing accreditation for both payer and provider organizations, driving clinical practice transformation, and improving the overall value of care. We strongly believe that there is no quality without equity, access, and measurement, and are investing in people and resources to support these needs. Together we are working with clients to advance value-based care, develop programs demonstrating quality, value, and equity in behavioral health, and implement new quality and accreditation programs to better serve their communities.
Learn more about HMA鈥檚 continuing work in quality and accreditation and join the conversation on LinkedIn and Twitter using #HMAtalksQuality.
This week鈥檚 In Focus is the second in a two-part look at the Centers for Medicare & Medicaid Services鈥� (CMS鈥檚) recently proposed changes to the Medicaid program. Last week we covered CMS鈥檚 proposed changes to the federal (CMS-2439-P). This week we review the proposed rule (CMS-2442-P).
As we discussed last week, the managed care and access to care rules include significant changes to core structural and financing aspects of the Medicaid program. Though state agencies, providers, health plans, consumer groups, and other stakeholders will want to understand the distinct requirements and expectations in each rule that apply to them, the proposed changes cannot be viewed in isolation.
The Access to Care rule addresses a range of challenges that shape the experience of Medicaid enrollees, regardless of whether they are in managed care programs or traditional fee-for-service (FFS). The proposed policy changes also are designed to create an updated federal framework for Medicaid鈥檚 home and community-based 杏吧视频 (HCBS) programs. These proposals come at a pivotal time, as states are facing workforce shortages, particularly among HCBS direct care workers (DCWs).
The remainder of this In Focus delves into notable components of the proposed changes and includes analysis of the implications of these policies for stakeholders. CMS will benefit from stakeholder input; the deadline for submitting comments is July 3, 2023.
Table 1. Access to Care Regulations: Overview of Proposed Changes
Key Themes and Considerations
Ensuring Payment Adequacy for Key HCBS Services Experiencing Workforce Shortages. One of the most notable proposed changes that would directly impact DCWs is a requirement that at least 80 percent of Medicaid payments be spent on compensation. The proposed rule would apply to homemaker, home health aide, and personal care 杏吧视频, as they represent a large portion of HCBS 杏吧视频 that DCWs provide. The proposal is based on feedback from states that have implemented similar provisions, which have ranged from 75 to 90 percent compensation requirements.
CMS specifically seeks stakeholder feedback on the percentage that should be adopted. This policy provision also is important from an equity perspective, given that 90 percent of DCWs are women and 60 percent are members of racial or ethnic minority populations. However, increased or mandated DCW rates may make it difficult for HCBS providers to sustain their businesses as they manage the increased administrative pressures of electronic visit verification, the complexity of filing claims for managed long-term 杏吧视频 and supports (MLTSS), and the additional work that HCBS quality measurement may create. Smaller HCBS providers, some of which may have deep cultural expertise, may struggle to sustain themselves and meet these requirements.
Table 2. Access to Care Regulations: Snapshot of Proposed Rate, Access, and Payment Changes
Payment Alignment. CMS is seeking to align access to care strategies and payment rate transparency more closely across the FFS and managed care delivery systems. The proposed rule includes several changes that CMS has developed achieve this goal. For example:
CMS plans to require that states publish more detailed rate information in a consistent format. States, health plans, providers, and other interested stakeholders will want to consider the implications by delivery system. Additional transparency requirements could create a new opportunity to understand rates across payers and states and use this information in addressing access challenges for 杏吧视频.
The proposed rule also would require extensive comparative analysis of Medicaid FFS rates and Medicare rates. CMS proposes to use Medicare non-facility payment rates as a benchmark to determine if states are meeting federal Medicaid access State analyses will be vital to CMS oversight as well as advocacy efforts within states to monitor and update FFS rates as needed.
Strengthening the Focus on Quality in State HCBS Programs. Over the last several decades, states and Medicaid stakeholders have made significant progress toward increasing participation in HCBS programs and community integration initiatives to counter Medicaid鈥檚 institutional bias. CMS is proposing more consistency in the expectations and reporting for HCBS quality measures to further the impact and create a consistent foundation for the recently mandated HCBS quality initiatives starting to take root.
In the short-term, the proposed changes will require states, and likely downstream providers and Medicaid agencies, to immediately change their quality reporting policies and systems. States and their stakeholders will want to map out processes for cyclical updates to HCBS quality measures, including cross-walking the future measures with existing ones, making systems changes, and updating dashboards. Targeted attention and focus will be needed to identify realistic HCBS performance targets that yield successful improvement strategies in the midst of a workforce crisis. Longer term, it will be necessary to map out when updates and reporting will be required to strengthen the rigor and accountability for state performance in the HCBS quality measure set, as well as reinforce the information available to make policy, clinical, and operational improvements to Medicaid programs.
HCBS Access Measurement. CMS is proposing new FFS HCBS payment and access transparency requirements to ensure compliance with Medicaid provider payment rules that require payments to be adequate to enlist at least the same number of providers that the overall geographic population can access. Because the targeted HCBS 杏吧视频 do not have a comparable Medicare rate, CMS proposes implementation of a payment rate disclosure approach that would standardize data and monitoring across service delivery systems, with the goal of improving access. In addition to proposed payment transparency changes, CMS proposed new reporting on HCBS waiver waiting lists and timelines for the start of related 杏吧视频 once authorized.
These new reporting requirements will provide stakeholders with more information to benchmark their state鈥檚 experience with other providers across the nation. This information could be influential to policymakers and legislators and help uncover some of the core contributors to our nation鈥檚 HCBS workforce shortage.
Improving Health Equity with Medicaid Beneficiary Input. CMS proposes overhauling the scope and membership of the state Medical Care Advisory Committee. The new Medicaid Advisory Committee (MAC) would continue to advise the state on health and medical matters and play an expanded advisory role on matters of policy development and effective administration of the program. CMS also plans to require that states establish a Beneficiary Advisory Group (BAG) composed of current or past Medicaid beneficiaries. A subset of BAG members would serve on the MAC to ensure their perspectives are integrated into the committee鈥檚 recommendations to states.
Under the new federal requirements, MAC representatives could have greater relative input and influence on policies and actions each state Medicaid agency advances. Medicaid stakeholders will want to ensure the MAC鈥檚 minimum federal requirements support effective structures and processes in states.
What鈥檚 Next
CMS plans to reframe Medicaid access as one of three parts of the continuum of care, along with enrollment and maintenance of coverage. The proposals in the Access to Care rule would have a meaningful impact on the volume and type of data available to evaluate the relationship between Medicaid payment rates and access across all delivery systems.
States, managed care organizations, providers, Medicaid enrollee advocacy organizations, and other interested stakeholders should analyze the proposals and consider submitting comments to CMS on the feasibility, potential impact, and, where applicable, alternatives to the proposed changes. They also can use this time to begin planning and determine which resources and tools they may need to prepare for implementation of changes across delivery systems in the Medicaid program.
HMA鈥檚 experts are taking a wholistic approach to reviewing the Access to Care and Managed Care proposed rules in tandem and identifying key points of intersection.
For more information on the access to care proposed rule, contact our experts below.
Policy crossroads and the end of the public health emergency due to COVID-19
This is part of a three-part series on significant implications of the end of the Public Health Emergency (PHE).
The end of the Public Health Emergency on May 11, 2023 is likely to mark a transitional point in the rapidly evolving arena of virtual care 杏吧视频 and not a dramatic end of coverage. Coverage of virtual care 杏吧视频 will continue to evolve significantly over the next five years given the exponential growth in the public鈥檚 awareness of, and comfort with, these 杏吧视频 — all hastened by the COVID-19 Federal Public Health Emergency.
The U.S. Congress and the Centers for Medicare and Medicaid Services (CMS) used its authority during the PHE to significantly expand Medicare coverage for virtual care 杏吧视频, covering telehealth visits in urban areas and from patient鈥檚 homes. In addition, Medicare began covering a wide range of clinical 杏吧视频 virtually such as behavioral health and physical therapy; it also expanded coverage for different service delivery modalities to include audio-only visits. As a result of the changes, Medicare became a leading payer for virtual care nationally between 2020 and 2022. Over this same period, private insurers and state Medicaid programs largely followed Medicare鈥檚 lead by expanding their own virtual care coverage.
One of the consequences of the PHE is that most payers have embraced Medicare鈥檚 basic definitional structure for types of virtual care 杏吧视频. As a part of this typology, virtual care 杏吧视频 are divided into two general buckets of 杏吧视频: telehealth visits (physician office visits conducted via audio and video technology), which are typically prohibited by statute in urban areas or a patient鈥檚 home; and Communication Technology-Based Services (CTBS) which can be conducted anywhere. CTBSs include: remote patient monitoring (RPM); virtual check-ins (brief patient-to-clinician exchanges); e-visits (online portal or email visits); and e-consults (clinician to clinician interaction).
With the end of the PHE on May 11, Medicare coverage of virtual care 杏吧视频 and coverage offered by other payers will change. The details and scope of this change have many stakeholders concerned and confused. HMA has a keen sense for which virtual care 杏吧视频 may get a new lease on life in the coming months and which are likely to be hotly debated in the years ahead. The one certainty is that the last 3 years have altered the landscape for virtual care 杏吧视频 for years to come.
Shift in Virtual Care Landscape
As a result of the statutory geographic limitations and restrictions placed on traditional fee-for-service (FFS) Medicare coverage, use of telehealth 杏吧视频 was minimal most of the last decade, with only one-quarter of 1 percent (0.25%) of beneficiaries in FFS Medicare using virtual care 杏吧视频.[1] Even among Medicare Advantage plans and Medicare Accountable Care Organizations (ACOs), neither of which which face the same restrictions, virtual care was utilized very rarely before 2019.
This sluggish use of telehealth was radically altered when HHS used its PHE authority to relax constraints on the use of use virtual care 杏吧视频 by Medicare beneficiaries and providers.[2],[3] Among the most consequential changes made by policymakers at the outset of the PHE were:
Enabling telehealth 杏吧视频 to be provided anywhere (e.g., urban areas and patients鈥� homes);
Allowing Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC) to conduct virtual care 杏吧视频;
Granting various types of clinicians permission to deliver virtual care 杏吧视频;
Enabling new patients to receive virtual care 杏吧视频;
Authorizing audio-only 杏吧视频;
Permitting telehealth 杏吧视频 for more than 200 different types of clinical 杏吧视频 (e.g., mental health, emergency department, physical and occupational therapy, critical care, inpatient care);
Relaxing HIPPA rules to enable the broad use of smartphones for virtual care.
Due to these policy changes, rates of virtual care skyrocketed during the PHE (Figure 1). In April of 2020 the number of Medicare claims for any type of virtual care service exceeded 9 million, while 2019 the number of these 杏吧视频 provided monthly never exceeded 100,000 (Figure 1). On an annual basis, from 2019 to 2021 the number of virtual care visits jumped from roughly 1 million to 39 million and the number of unique beneficiaries receiving these 杏吧视频 increased from 300,000 to nearly 12 million.
Figure 1: Number of Virtual Care Service Visits, Number of Unique Medicare Fee-For-Service Beneficiaries, and Number of visits per Utilizer by Month, December 2019 to December 2021.
Source: HMA analysis of CMS鈥檚 100 percent Medicare Fee-For-Service Claims data for 2019, 2020, and 2021.
The growth of virtual care 杏吧视频 has largely been driven by an increase in telehealth visits, but we observe important trends in the use of CTBSs, as well. In late 2021, more than 90 percent of visits were associated with telehealth, while 10 percent were associated with CTBSs. Early in the PHE, all of these service types experienced an initial, abrupt increase in use (Figure 2). By contrast, the growth in the use of remote patient monitoring (RPM) has been continuous since 2020. The growth in use of RPM reflects the general movement of 杏吧视频 into patients鈥� homes and has been accelerated by specialist such as cardiologists and endocrinologists beginning to leverage the power of RPM. We expect greater diffusion and use of RPM and other CTBSs in the next five years.
Figure 2: Number of Virtual Care Service Visits for Remote Patient Monitoring, Virtual Check-ins, E-visits, and E-Consultations by Month, December 2019 to December 2021.
Source: HMA analysis of CMS鈥檚 100 percent Medicare Fee-For-Service Claims data for 2019, 2020, and 2021.
Policies temporarily in place until the end of 2024
During the PHE, Congress made critical long-term changes to Medicare鈥檚 coverage of virtual care 杏吧视频 that continued to spur the use of these 杏吧视频 and offer access to care for beneficiaries. In 2021, Congress changed the law to permanently allow Medicare beneficiaries to receive behavioral/mental telehealth 杏吧视频 regardless of location (urban or rural) and for this care to be available to patients in their own homes.
In 2022, Congress severed the link between the PHE declaration and Medicare coverage policies for virtual care 杏吧视频, extending those benefits through the end of calendar year 2024. We expect that coverage for all telehealth 杏吧视频 will receive considerable attention from federal policymakers and stakeholders towards the end of 2024.
Immediate impact of expiring policies
Certain aspects of Medicare鈥檚 virtual care policies will, however, terminate May 11, 2023, when the PHE declaration comes to an end. Several of the expiring policies have a broader impact beyond the Medicare program, affecting patients insured by private payers and State Medicaid programs.
Specifically, when the PHE ends, policymakers will need to address the following anticipated changes:
The Office for Civil Rights (OCR) will return to imposing penalties on providers who violate the provisions of the Health Insurance Portability and Accountability Act (HIPAA) by using public-facing remote communication technologies which are not HIPAA-compliant. This may prohibit the use of some of the most common smartphone-based video conferencing tools for health care visits.
Medicare beneficiaries without an existing relationship with a clinician will be unable to receive CTBSs such as RPM, virtual check-ins, and e-visits.
Providers will no longer be allowed to provide virtual care 杏吧视频 across state lines, because most state medical licensure boards will return to pre-PHE policy.
Federal rules from the Drug Enforcement Agency (DEA) may revert to the pre-PHE requirement that clinicians establish a patient-provider relationship in-person before being permitted to prescribe controlled substances for substance use disorder treatment.
Potential policy changes occurring before 2025 As explained earlier, Medicare coverage for many virtual care 杏吧视频 will remain in place for the next 19 months. Before the end of 2024, Congress will need to address several policy questions, and among the most widely debated are whether to:
Restore Medicare鈥檚 statutory prohibition on telehealth 杏吧视频 being delivered in urban areas or in home settings;
Allow Federally Qualified Health Centers and Rural Health Clinics to provide telehealth 杏吧视频 to Medicare beneficiaries; or
Continue to cover audio-only telehealth visits under Medicare.
Lawmakers will look to payers, patients, and providers for feedback before making these policy decisions. Among the most critical pieces of information they will also consider will be the results of the study Congress has required of HHS regarding trends in the use of virtual care. This study鈥檚 final report is due in 2026, which has led some to speculate that Congress will delay action on virtual care coverage policy until then. In the meanwhile, we expect HHS will be assessing the overall volume of virtual care use, who is using which types of 杏吧视频, and the levels of related fraud and abuse.
Looking Ahead
In the United States, our experience during the acute phase of the pandemic demonstrated that patients and providers are more receptive than previously thought to utilizing digital technologies for the delivery of care. This experience may also influence policymakers鈥� decisions about reimbursement and coverage of wearable devices, as well as other cutting-edge tools that rely on artificial intelligence or machine learning.
HMA believes payers and providers alike can take steps now to strategically prepare for the still evolving and growing landscape of digital health care.
Based on the various changes that have occurred in the virtual care environment over the last 3 years, we are intently watching several areas of potential change in the practice of medicine and the ways payers set coverage policy. Below are some of the trends we anticipate in the years ahead:
Continued use of virtual care 杏吧视频 at levels observed in 2021.
An expansion of CMS’s programs to protect against fraud and abuse related to virtual care.
Notable growth in the use of RPM, and related 杏吧视频 for physical and occupational therapy 杏吧视频.
The proliferation of innovative home-based screening and testing technologies. We anticipate payers will encourage the use of these at-home tests for things like kidney function, liver function, and colorectal cancer screening in order to limit care delivery in higher cost settings.
Growth in 鈥渧irtual-first鈥� insurance plans, where patients are encouraged to use virtual care first – prior to being seen in person. As these plan options expand, we anticipate virtual care use will rise, and reimbursement rates will begin to change.
Virtual care 杏吧视频 are primed for additional growth and HMA is working with a wide variety of payers, providers, and foundations to develop strategies for adapting to state and federal rules and regulations related to virtual care. Changes in this landscape will hinge on research CMS will complete by the end of 2026, and coverage decisions made by states and commercial payers. HMA is well positioned to assist stakeholders with work in this area and can leverage access to Medicare and Medicaid claims data to conduct health 杏吧视频 research to illustrate geographic variations in the use of virtual care.
If you have questions on how HMA can support your agency before or after the end of the PHE, please contact our experts below.
[2] Centers for Medicare & Medicaid Services. Medicare telemedicine health care provider fact sheet. March 17, 2020. https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet
[3] HHS Administration for Strategic Preparedness & Response (ASPR). https://aspr.hhs.gov/legal/PHE/Pages/default.aspx
This week, our In Focus section reviews CMS鈥檚 proposed changes to the federal (CMS-2439-P). A future In Focus will take a closer look at the proposed changes to the federal regulation (CMS-2442-P), which also has significant implications for state Medicaid programs.
On April 28, 2023, the Centers for Medicare & Medicaid Services (CMS) unveiled two significant and related proposed rules addressing Medicaid managed care access, finance, and quality requirements. Together these proposed rules signal a new era of accountability and transparency in the Medicaid program. They also strengthen beneficiaries鈥� role in influencing the policies and administration of state Medicaid programs.
Table 1 identifies a few of the key themes and issues addressed in the Medicaid managed care proposed rule. The deadline for submitting comments to CMS is July 3, 2023.
Table 1. Medicaid Managed Care Proposed Rule: Snapshot of Proposed Changes
Key Themes and Considerations
Payment Ceilings May Accelerate Value-Based Payment Arrangements. Current federal regulations allow states to direct managed care organizations (MCOs) to pay providers according to specific rates or methods. States have used these directed payment arrangements to set minimum payment rates for certain types of providers or to require participation in value-based payment (VBP) initiatives.
In the proposed rule, CMS calls for establishing an upper limit for these payments. Specifically, the agency plans to limit the projected total payment rates to the average commercial rate (ACR) for inpatient and outpatient hospital 杏吧视频, nursing facility 杏吧视频, and qualified practitioner 杏吧视频 at academic medical centers that states include in state-directed payment (SDP) arrangements. The ACR limit, in concert with the proposed SDP documentation and reporting, is among the most significant and complex proposed changes in the rule.
Considerations: The proposed changes represent a strong federal regulatory push to accelerate movement to VBP in Medicaid, which provides states with new levers to drive value in their Medicaid delivery systems. It also means that MCOs, providers, and other stakeholders will need to navigate and help inform the policies and contractual arrangements that will flow from the pending changes. For example, states may need to reflect on the following considerations:
Whether the proposals will require them to reduce reimbursement
Whether they will need to develop new value-based arrangements through SDPs and how these policies will be structured
What outcomes they might need to prioritize
How transparency in reporting provider-level payments could affect non-federal funding and SDP initiatives
Updated Approach to in Lieu of Services (ILOS) Facilitates Whole-Person Care. In January 2023, CMS issued a Letter (SMDL#23-001) advising states of the option to use the ILOS authority in Medicaid managed care programs to reduce healthcare inequities and address unmet health-related social needs (HRSNs), such as housing, food insecurity, and intimate partner violence. The proposed Medicaid managed care rule would expand upon and codify in regulation that guidance.
Considerations: Although the ILOS proposal adds reporting requirements and guardrails to address fiscal accountability, overall, the updated policy signals CMS鈥檚 willingness to support innovative state approaches to meet a continuum of beneficiary needs, including HRSNs that affect the social drivers of health. Notably, CMS advises that the substitution of an ILOS for a state plan service or setting should be cost-effective but does not need to be budget-neutral. States also can specify that an ILOS can be an immediate or longer-term substitute for a state plan service or setting.
States could pursue a variety of options under CMS鈥檚 revised ILOS framework. State Medicaid agencies and their partners can collaborate on ILOS strategies that will allow them to make further progress toward reducing healthcare inequities, as well as fulfill their quality strategy goals and objectives.
New Standards for Medical Loss Ratio Strengthen Link to Performance Improvement. Existing federal regulations require Medicaid managed care plans to report their medical loss ratio (MLR) to states annually, and, in turn, states must submit a summary of those reports to CMS. Many state MCO contracts require plans to comply with provider incentive and bonus policies; however, MCOs infrequently make incentive payments contingent on the provider meeting quantitative clinical or quality improvement standards.
Consistent with the healthcare sector鈥檚 transition toward value-based care, CMS proposes to strengthen the link between an MCOs incentive payment to a provider and the provider meeting defined quality improvement or performance metrics. Additionally, contractual language between MCOs and providers will need to more explicitly identify the dollar amounts tied to successful completion of these metrics. Only incentive payments based on quality improvement will be considered incurred claims when plans calculate their MLR; administrative costs cannot be included in quality improvement activity reporting.
Considerations. The proposed requirements are expected to add more transparency to negotiations between Medicaid MCOs and providers. MCOs will retain flexibility to determine the quality improvement or quantitative performance metrics, which carry more weight and accountability in CMS鈥檚 revised regulatory framework.
Network Adequacy Requirements Strengthen Link to Access and Rates. CMS also proposes policies that the agency believes will help strengthen Medicaid enrollees鈥� access to 杏吧视频. For example, the rule would require states to develop wait-time standards for adult and pediatric primary care and outpatient mental health, substance use disorder (SUD), and OB/GYN 杏吧视频, with CMS establishing federal minimum appointment wait times. States also will need to develop a quantitative network adequacy standard, beyond wait times, for certain providers.
Notably, CMS also plans to require states to submit an MCO-level analysis of MCO-to-provider payments. This analysis may provide more insights about the relationship between rates and access to certain types of providers and 杏吧视频. It may also improve alignment in access policies across delivery systems.
Considerations: States and MCOs should expect to need more sophisticated analysis of provider capacity at state and local market levels. This information will be critical in developing network adequacy standards and determining where additional provider support may be necessary. Expanded and new strategies may be needed to ensure compliance with the federal rules and resulting changes to state policies.
What鈥檚 Next
Many of CMS鈥檚 proposals track closely with many recent recommendations from federal commissions and oversight entities, including the Medicaid and CHIP Payment and Access Commission (MACPAC) and Government Accountability Office (GAO), which may indicate a greater likelihood that CMS will finalize those policies. If they are finalized largely as proposed, the rule will further the Biden Administration鈥檚 directional imprint on the Medicaid program.
Within the proposed rules described above, CMS identifies numerous areas where stakeholder input would be beneficial. States, MCOs, providers, and other interested stakeholders should analyze the proposals and consider submitting comments to CMS on the feasibility, potential impact, and, where applicable, alternatives to the proposed changes. Stakeholders also may use this time to begin planning for 2024 and determining what resources and tools they may need to prepare for implementation of the final regulations, as well as how their approach may vary based on state-specific factors.
For questions about the rule and how HMA鈥檚 team of experts can support your organization鈥檚 response, please contact聽our experts below.
This week our In Focus section reviews guidance from the Centers for Medicare & Medicaid Services (CMS), released on April 17, 2023, encouraging states to apply for the new Medicaid Reentry Section 1115 Demonstration Opportunity. The demonstration is aimed at helping improve care for individuals in carceral settings prior to their release.
Background
The United States has approximately 1.9 million individuals incarcerated nationwide. Studies have shown higher rates of mental illness and physical health care needs in incarcerated populations compared to the general population, as well as associations between jail incarceration and increases in premature death rates from infectious diseases, chronic lower respiratory disease, drug use, and suicide.
CMS states that formerly incarcerated individuals with physical and mental health conditions and substance-use disorders (SUDs) typically have difficulty succeeding upon reentry due to obstacles present immediately at release, such as high rates of poverty and high risk of poor health outcomes. These individuals tend to face barriers in obtaining housing, education, employment, and health care access upon release. They often do not seek outpatient medical care and are at significantly increased risk for emergency department (ED) use and hospitalization.
Purpose and Goals
After collecting feedback from stakeholders, including managed care organizations, Medicaid beneficiaries, health care providers, the National Association of Medicaid Directors, and other representatives from local, state, and federal jail and prison systems, CMS designed the Reentry Section 1115 Demonstration Opportunity. The 杏吧视频 covered under this demonstration opportunity should aim to improve access to community resources that address the health care and health-related social needs of the carceral population, with the aims of improving health outcomes, reducing emergency department visits, and inpatient hospital admissions for both physical and behavioral health issues once they are released and return to the community.
The purpose of this demonstration opportunity is to provide short-term Medicaid enrollment assistance and pre-release coverage for certain 杏吧视频 to facilitate successful care transitions. The full goals, as quoted from CMS, are as follows:
鈥淚ncrease coverage, continuity of coverage, and appropriate service uptake through assessment of eligibility and availability of coverage for benefits in carceral settings just prior to release
Improve access to 杏吧视频 prior to release and improve transitions and continuity of care into the community upon release and during reentry
Improve coordination and communication between correctional systems, Medicaid systems, managed care plans, and community-based providers
Increase additional investments in health care and related 杏吧视频, aimed at improving the quality of care for beneficiaries in carceral settings and in the community to maximize successful reentry post-release
Improve connections between carceral settings and community 杏吧视频 upon release to address physical health, behavioral health, and health-related social needs
Reduce all-cause deaths in the near-term post-release
Reduce number of ED visits and inpatient hospitalizations among recently incarcerated Medicaid beneficiaries through increased receipt of preventive and routine physical and behavioral health care鈥�
CMS encourages states to engage with individuals who were formerly incarcerated when contemplating the design and implementation of their proposal. CMS also encourages states to design a broadly defined demonstration population that includes otherwise eligible, soon-to-be former incarcerated individuals. States have the flexibility to target population, such as individuals with specific conditions, but are encouraged to be mindful of undiagnosed conditions. States should have a plan to ensure incarcerated individuals will be enrolled in Medicaid upon their release, applying for Medicaid no later than 45 days before the day of release.
Reentry Section 1115 Demonstration Opportunity
To receive approval for the demonstration, the state proposal must include in the pre-release benefit backage:
Case management to assess and address physical and behavioral health needs and health-related social needs;
Medication-assisted treatment (MAT) 杏吧视频 for all types of SUD as clinically appropriate, with accompanying counseling; and
A 30-day supply of all prescription medications that have been prescribed for the beneficiary at the time of release, provided to the beneficiary immediately upon release from the correctional facility.
In addition to these three 杏吧视频 states may include other important physical and behavioral health 杏吧视频 to cover on a pre-release basis, such as family planning 杏吧视频 and supplies, behavioral health or preventive 杏吧视频, including those provided by peer supporters/community health workers, or treatment for Hepatitis C. CMS is also open to states requesting Section 1115 expenditure authority to provide medical supplies, equipment, and appliances.
The Reentry Section 1115 Demonstration opportunity is not intended to shift current carceral health care costs to the Medicaid program. CMS will not approve state proposals to receive federal Medicaid matching funds for any existing carceral health care 杏吧视频 funded with state or local dollars unless the state agrees to reinvest the total amount of new federal matching funds received into activities or initiatives that increase access to or improve the quality of health care 杏吧视频 for individuals who are incarcerated.
CMS also expects states to refrain from including federal prisons as a setting in which demonstration-covered prerelease 杏吧视频 are provided under the opportunity.
States with approved demonstrations will need to submit an implementation plan, a monitoring protocol, quarterly/annual monitoring reports, a mid-point assessment report, an evaluation design, and interim/summative evaluation reports.
California
California became the first state to for a Section 1115 waiver amendment earlier this year to provide limited Medicaid 杏吧视频 to incarcerated individuals for up to 90 days immediately prior to release. The approval period runs through December 31, 2026, timed with the expiration of the CalAIM Medi-Cal waiver demonstration. California鈥檚 reentry demonstration initiative aims to provide health care interventions at earlier opportunities for incarcerated individuals to reduce acute 杏吧视频 utilization and adverse health outcomes. The state anticipates it will increase coverage and continuity of coverage for eligible beneficiaries, improve care transitions for beneficiaries as they reenter the community, and reduce morbidity and mortality in the near-term post-release.
Pre-release 杏吧视频 include comprehensive care management, physical and behavioral clinical consultation, lab and radiology, MAT, community health worker 杏吧视频, and medications and durable medical equipment. A care manager will be assigned to eligible individuals to establish a relationship, understand their health needs, coordinate vital 杏吧视频, and make a plan for community transition, including connecting the individual to a community-based care manager they can work with upon their release. Additionally, all counties implementing Medi-Cal application processes in jails and youth correctional facilities will 鈥渟uspend鈥� the Medicaid status while an individual is in jail or prison, so that it can be easily 鈥渢urned on鈥� when they enter the community.
On April 6, 2023, HMA held a webinar titled, 鈥淢edicaid authority and opportunity to build new programs for justice-involved individuals.鈥� The webinar replay is now available. HMA will announce additional webinars on the topic.
Since the inception of the Certified Community Behavioral Health Clinics (CCBHC) model, we鈥檝e been working across the country with designated CCBHCs, to help implement the model in ways that maximize the value of the designation.
We鈥檝e worked with a diverse range of behavioral health providers and other stakeholders in planning for and implementing the CCBHC model both within the demonstration program framework, as well as through federally funded CCBHC-expansion grants. Our team of experts supports providers to leverage the CCBHC model to support their overall agency mission and growth goals.
APPROACH
HMA鈥檚 CCBHC-related support spans a spectrum from strategic planning through grant securing, grant implementation, organizational change management, to demonstration program participation. HMA offers implementation support that is customized to each organization and its unique circumstances, while leveraging our unmatched breadth of experience with Substance Abuse and Mental Health Services Administration (SAMHSA), CCBHCs, behavioral health treatment and support 杏吧视频, state Medicaid systems, clinical integration, health information technology, quality improvement, healthcare finance, and strategy.
Strategic planning to see how CCBHCs can support each agency to meet its goals
Readiness assessment to best position the agency for CCBHC certification in a competitive landscape
Write SAMHSA proposals to secure CCBHC grant funding
Implementation support in alignment with CCBHC criteria, as well as SAMHSA and state requirements
Ongoing quality improvement to support improvement and advancement of CCBHC programming
Help agencies transition from CCBHC grant funding to a sustainable reimbursement model
In addition, HMA can support a CCBHC implementation with any or all of the following 杏吧视频: financing, workforce recruitment/retention strategies, project management, technical assistance, and health information technology and exchange.
RESULTS
In 2022 alone, we supported behavioral health providers to attain more than $110 million in expansion grant funding they will use in their communities, including over $46 million in CCBHC-planning, development, and implementation grant funding and more than $63 million in CCBHC-improvement and advancement grant funding.
In addition, we have supported more than 20 states to write their CCBHC planning grant applications to initiate a state-run CCBHC model. Most recently, we had 100% success rate for our FY23 planning grant applications, resulting in four states receiving one year planning grants to build a state-run CCBHC model.
