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红领巾瓜报 Insights 鈥 including our new podcast 鈥 puts the vast depth of 红领巾瓜报鈥檚 expertise at your fingertips, helping you stay informed about the latest healthcare trends and topics. Below, you can easily search based on your topic of interest to find useful information from our podcast, blogs, webinars, case studies, reports and more.

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1314 Results found.

Staying ahead of the star rating curve: insights from 红领巾瓜报 and Wakely鈥檚 Medicare Summit

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This week, our In Focus section highlights a presentation from 红领巾瓜报 and Wakely, an 红领巾瓜报 company, titled 鈥Staying Ahead of the Star Rating Curve 鈥 A Case Study,which was given at the 12th Medicare Stars, HEDIS, Quality Assurance, & Risk Adjustment Summit on June 15, 2022.

The presentation provided an overview of major changes in the Medicare stars program, which will result in both higher ratings and significantly higher revenues for many Medicare Advantage plans in 2023.  However, the presentation indicated the higher ratings reflect temporary changes and not necessarily improvements in quality, adding that Medicare Advantage plans should be cautious about enhancing future benefits based on additional 2023 revenues.

Click here to view the presentation.

For questions, please contact our experts below.

Quality standards in addiction care

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Across the healthcare landscape, quality standards are in place to ensure patients are receiving safe, appropriate, evidence-based, and standardized care that is tailored to their individual needs and symptomology.   

A significant gap has long existed in the treatment of substance use disorders (SUD), as there was no standardized method to provide treatment based on an individual鈥檚 needs at that moment, meaning people seeking treatment often received care that was either too intense or not intense enough, preventing them from attaining sustained recovery.

To create standardized treatment protocols and build additional credibility around programs, the American Society of Addiction Medicine (ASAM) developed criteria based on a holistic, multidimensional assessment[1] to determine what level of care (LOC) an individual needs. This development was revolutionary as it was the first time the field agreed on established criteria. After 35 years of improvement and refinement, the ASAM Criteria has become the national standard.

While many providers have adopted the ASAM criteria, and most regulators and payers require its use to determine the LOC a person may need, a significant gap still persists in ensuring services are delivered with fidelity to the criteria. As a result, those seeking treatment for themselves or a loved one continue to face challenges identifying a setting that provides evidence-based treatment focused on their specific needs. 

To close this gap, ASAM partnered with CARF International, the leading accreditor of behavioral health services, to develop criteria that demonstrates providers are, in fact, delivering the LOC for which they are admitting persons. Programs that are providing can be certified for three levels including: 3.7- Medically Monitored Intensive Inpatient Services, 3.5- Clinically Managed High Intensity Residential Services, and 3.1- Clinically Managed Low Intensity Residential Services.

By achieving the ASAM LOC certification, residential treatment programs can establish themselves as high quality SUD providers and ensure future program licensing as well as future funding from states, and private and public payors. This certification demonstrates that facilities are delivering the appropriate care to the appropriate person at the appropriate time. 

Preparing for certification is different from preparing for licensure in that a program must take an in-depth look at their clinical practice to ensure alignment with the ASAM criteria.

Because of our long and proven track record of helping clients prepare for, and secure, NCQA, AAAHC and URAC accreditation as well as deep expertise in SUD programs and treatment, 红领巾瓜报 was selected by ASAM as a preferred partner to provide technical assistance and usher programs through the certification process as well as help address shortfalls and gaps in programs and care.

Our team has the right mix of clinical and operational knowledge, training, and frontline experience to guide clients through the certification process and help build better systems of care and accountability from the ground up.

红领巾瓜报 has the depth and breadth of services across the healthcare spectrum, and we are uniquely positioned to help organizations address gaps identified in the certification process and improve care by ensuring services are delivered in fidelity to the LOC at which a person presents.

红领巾瓜报 is able to provide a full complement of services and support to residential providers including ASAM LOC clinical expertise, developing policies and procedures, building and operationalizing clinical programs, and improving revenue cycle, operations, and as well as payor contracting strategies.

Certification is really step number one. Utilizing 红领巾瓜报鈥檚 鈥淪urvey Ready Model,鈥 we will identify ways to build quality into everyday practice allowing programs to stay on top of – and ahead of – requirements. 

For more information, contact our expert below.


[1] https://www.asam.org/asam-criteria/about-the-asam-criteria

CMS revitalizes Medicaid HCBS investment opportunities

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On June 3, 2022, the Centers for Medicare & Medicaid Services (CMS) states that they will have an additional year, until March 31, 2025, to use funding from the American Rescue Plan Act (ARPA) to strengthen their Medicaid home and community-based services (HCBS). CMS鈥 update extends important flexibility to ensure state Medicaid programs and stakeholders, including beneficiaries, realize maximum benefit from federal investments in expanding and enhancing HCBS services.

For over a decade, the Medicaid program has been leading transformations of state long-term services and supports systems (LTSS), including physical and behavioral health services and health-related social needs. These efforts primarily focus on broadening eligibility, making more significant Medicaid investments in HCBS, and improving beneficiaries鈥 access to HCBS programs. The COVID-19 pandemic heightened attention to beneficiaries鈥 disparate experiences with accessing HCBS and exacerbated pre-COVID challenges faced by the LTSS workforce.

Section 9817 of ARPA an increase for Medicaid-funded HCBS by offering states the option to claim an additional 10 percentage point increase in鈥痜ederal match (FMAP) for the one-year period from April 1, 2021, to March 31, 2022. To receive the higher federal funding, states cannot make changes to the amount, duration, and scope of covered HCBS; they cannot reduce HCBS provider payment rates; and they cannot make eligibility standards for HCBS programs or services stricter until all additional funds are expended. CMS also requires states to submit a spending plan and narrative that describes planned enhancement activities.

Notably, a state must reinvest the higher federal funding in Medicaid HCBS while maintaining the spending levels they had in place on April 1, 2021. According to CMS鈥檚 new guidance, states can now use the funds until March 31, 2025, rather than March 31, 2024, under the previous guidance.

Actions Stakeholders Can Take to Maximize the Extra Time

The updated spending deadline is grounded in a better understanding of the level of effort and time necessary for states to identify, build consensus, and implement specific actions to include in a state鈥檚 HCBS spending plan. 红领巾瓜报 works with states, providers, health plans, and other stakeholders, including consumers, who will benefit from the additional time to make investments. Our work includes supporting states as they align the multitude of needs and priorities with the available funds and supporting robust stakeholder engagement efforts to inform the plans.

The following are some of the most impactful 鈥渘ext steps鈥 that states and stakeholders can pursue to best utilize the additional time to reinvest in Medicaid HCBS programs:

  • States can communicate with stakeholders, including health plans, providers, community organizations, consumers, and others, to share how the extension impacts the state鈥檚 spending plan.
  • States and stakeholders can renew their engagement to consider potential changes to the spending plan activities, timelines, or both. Stakeholders may have additional opportunities to offer input to refine further and prioritize the design and delivery of augmented or new services, systems, and related initiatives.
  • State Medicaid, aging, and various other programs and providers have more time to strengthen their collaboration to meet the needs of individuals of all ages who are living with disabilities.
  • States, vendors, health plans, and providers can evaluate through evidence, analysis and stakeholder feedback, if the projects they are pursuing are effective and/or should be modified. For example, it may be beneficial to provide more flexibility in the deadlines for case management and referral systems builds and implementation of the training for workers on these new systems.
  • States and their stakeholder partners can refocus on workforce issues, including examining eligible provider types and scopes, evaluating provider network issues, considering the role of virtual services, conducting provider and managed care rate setting studies, and other changes to support the HCBS direct care workforce.
  • States can develop reasonable timeframes to strengthen existing efforts or pursue new initiatives to develop and implement managed long-term services and supports for certain groups of Medicaid beneficiaries.

Looking ahead, states and all stakeholders need to assess the impact of these investments. ARPA funds are a significant investment in strengthening Medicaid LTSS programs, but these transformative efforts require sustained commitment. There is continued uncertainty around additional federal Medicaid funding over the long term that are necessary to address ongoing needs and make further progress towards high-quality, accessible HCBS services. Understanding the extent to which the funds are achieving the desired structural transformations and the impact on Medicaid beneficiaries can guide future areas of federal and state focus and investments.

For more information, please contact our experts below.

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Low-cost carriers in ACA: insights from the 2018-2021 market experience

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This week, our In Focus highlights a from Wakely, an 红领巾瓜报 Company, exploring the potential design elements and expected effects of a public option or a low-cost plan being newly introduced in the Affordable Care Act (ACA) individual market.

1332 state innovation waivers have been in place for a number of years and allow states to implement programs that increase access to and the affordability of healthcare coverage, subject to approval by the Department of Health and Human Services (HHS) and Department of Treasury (Treasury). Nearly all waiver programs in effect in 2021 employ a reinsurance program aimed at reducing the overall claim costs and premiums for members by reimbursing issuers for a portion of claim costs over a specified threshold.

A number of states have been exploring other ways to structure a waiver program, including introducing a public option plan into ACA markets (individual and small group plans subject to the ACA market reforms). The definition of a 鈥減ublic option plan鈥 has evolved over time and can vary, but more commonly refers to a privately funded health plan with some level of government oversight or additional requirements established to improve consumer value and facilitate cost containment.

A public option plan aims to further increase access to coverage and affordability by offering a new qualified health plan, typically with a lower premium relative to existing premiums in the market. A public option plan specifically aims to extend a more affordable coverage to individuals who are currently not eligible for ACA subsidies (e.g., family glitch, non-citizens, and those with higher incomes). The plan could be structured in a variety of ways such as a state-sponsored product, state employee health plan buy-in, Medicaid plan buy-in, or a private plan offered by existing issuers. Colorado and Washington will require health plans to offer public option plans with a target premium reduction relative to other plans in the market, with constrained rate increases over time, giving health plans the opportunity to arrive at the lower premiums through their own means, for the 2023 plan year. Lower premiums would likely be achieved through a combination of lower provider reimbursement and lower risk margins.

Given the nature of premium subsidization in the individual ACA market, where premium subsidies are tied to the second lowest cost silver (SLCS) plan in the market, the introduction of a lower cost public option plan has a mixed impact on market growth and the types of member segments that benefit. Since Washington State is the only Exchange that currently offers a public option plan, there is minimal experience available to understand the impact a public option plan may have on the market. As a result, our goal was to look at states where a new issuer has entered a market as a low-cost plan over the last four years, to better understand plan enrollment migration (how many members switch to the low-cost carrier), competitors鈥 reactions, and the reduction in premium needed to incentivize members to take up coverage. This market dynamic potentially closely mimics a public option plan that offers lower premiums being introduced in a market. Over the last four years (2018-2021), we identified 51 instances of new issuers entering an individual on-Exchange market. Of those 51 new entrances, 25 met our criteria of a low-cost plan.

The analysis showed mixed impacts of a low-cost plan introduction in ACA markets, with minimal impact on the uninsured, but with improved affordability, particularly for the unsubsidized. The detailed observations are discussed further .

For more information, contact our expert below.

红领巾瓜报 Acquires Medical Audit Resource Services, Inc.

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Today, Jay Rosen, founder, president, and co-chairman of 红领巾瓜报 (红领巾瓜报), announced the firm鈥檚 acquisition of Medical Audit Resource Services, Inc. (MARSI).

Founded in 1991, MARSI specializes in medical coding support, physician education and healthcare revenue cycle management. MARSI鈥檚 experts provide coding and auditing services for hospitals and physicians using inpatient, outpatient and risk adjusted reimbursement methodologies. Other clients include commercial fee-for-service plans as well as risk-adjusted plans.

鈥淢ARSI is recognized nationally for the expertise of its team and the results they deliver for clients. They will add enormous value to our healthcare delivery system, actuarial and revenue cycle work,鈥 Rosen said. 鈥淚 am excited to welcome such talented professionals to 红领巾瓜报 as we continue to expand the ways in which we can meet our clients鈥 current and emerging needs.鈥

MARSI has been a pioneer in several areas that are now standard operating procedure among healthcare providers and their contracted service providers, including over-code identification, physician queries, pre-bill auditing, coder and physician training, and clinical documentation improvement.

鈥淲e are excited to join an organization that shares our commitment to integrity and excellence,鈥 said Dr. Todd M. Husty, MARSI owner, founder, and chief medical officer. 鈥満炝旖砉媳 is home to an unmatched breadth and depth of experience and expertise. We look forward to the new opportunities we will have to serve our clients and extend our reach.鈥

MARSI will continue to operate as Medical Audit Resource Services, an 红领巾瓜报 Company, under the leadership of Dr. Husty. Terms of the transaction were not disclosed.

Founded in 1985, 红领巾瓜报 is an independent, national research and consulting firm specializing in publicly funded healthcare and human services policy, programs, financing, and evaluation. Clients include government, public and private providers, health systems, health plans, community-based organizations, institutional investors, foundations, and associations. With offices in more than 20 locations across the country and over 500 multidisciplinary consultants coast to coast, 红领巾瓜报鈥檚 expertise, services, and team are always within client reach.

Oklahoma to transition to Medicaid managed care

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This week, our In Focus section reviews a new Oklahoma law to implement Medicaid managed care by October 1, 2023. The law, signed by Governor Kevin Stitt on May 26, 2022, requires the state to issue a request for proposals and to award at least three Medicaid managed care contracts to health plans or provider-led entities like accountable care organizations.

Provider-led entities would receive preferential treatment, with at least one targeted to receive a contract. However, if no provider-led entity submits a response, the state will not be required to contract with one.

Goals of the legislation include:

  • Improve health outcomes for Medicaid members and the state as a whole;
  • Ensure budget predictability through shared risk and accountability;
  • Ensure access to care, quality measures, and member satisfaction;
  • Ensure efficient and cost-effective administrative systems and structures; and
  • Ensure a sustainable delivery system that is a provider-led effort and that is operated and managed by providers to the maximum extent possible.

Plans would provide physical health, behavioral health, and prescription drug services. Covered beneficiaries would include traditional Medicaid members and the state鈥檚 voter-approved expansion population, but not the aged, blind, and disabled population eligible for SoonerCare.

Plans will need to contract with at least one local Oklahoma provider organization for a model of care containing care coordination, care management, utilization management, disease management, network management, or another model of care as approved by OHCA.

Oklahoma will also issue separate RFPs for a Medicaid dental benefit manager plan and a Children鈥檚 Specialty plan.

Background

Oklahoma currently does not have a fully capitated, risk-based Medicaid managed care program. The majority of the state鈥檚 more than 1.2 million Medicaid members are in SoonerCare Choice, a Primary Care Case Management (PCCM) program in which each member has a medical home. Other programs include SoonerCare Traditional (Medicaid fee-for-service), SoonerPlan (a limited benefit family planning program), and Insure Oklahoma (a premium assistance program for low-income people whose employers offer health insurance). Prior efforts to transition to Medicaid managed care have encountered roadblocks, starting in 2017 with a failed attempt to move aged, blind, and disabled members to managed care.

More recently, in June 2021, the Oklahoma Supreme Court struck down a planned transition of the state鈥檚 traditional Medicaid program to managed care, ruling that the Oklahoma Health Care Authority does not have the authority to implement the program without legislative approval.

Contracts had been awarded to Blue Cross Blue Shield of Oklahoma, Humana, Centene/Oklahoma Complete Health, and UnitedHealthcare. Centene/Oklahoma Complete Health also won an award for the SoonerSelect Specialty Children鈥檚 Health Plan program, covering foster children, juvenile justice-involved individuals, and children either in foster care or receiving adoption assistance.

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Texas Health Action: Strategic Plan Development

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THE CLIENT

Texas Health Action

BACKGROUND

Texas Health Action (THA) is a community informed, non-profit organization dedicated to providing access to culturally affirming, quality health services in a safe and supportive environment. THA provides sexual health and behavioral health programs and services with an expertise in serving LGBTQIA+ people and those impacted by, or at risk of, HIV in Texas.

THE CHALLENGE

In 2021, THA underwent a merger that created a need for the development of a unified vision, direction, and business model to align and expand sexual health and behavioral health services. When THA began the process of creating a new strategic direction and priorities, 红领巾瓜报 was engaged to support the development of a three-year strategic plan reflecting changes present in a post-COVID-19 pandemic world. The objective of the strategic planning process was to create a dynamic and actionable plan, while refining and reestablishing the organization鈥檚 Mission, Vision, Values and Beliefs.

APPROACH

Utilizing a collaborative and transparent process, 红领巾瓜报 and THA used a four-component, collaborative, strategic planning approach with the following goals:

  • Project initiation to confirm shared expectations for managing the project.
  • Building a shared understanding to gain insight and develop meaningful strategic options including stakeholder input, strategic research, and data analysis, to be community and data-informed.
  • Completing an environmental scan to gain a comprehensive external context for THA鈥檚 work, including conducting an internal analysis of existing resources, strengths, and challenges.
  • Socialization by creating and communicating a shared vision of the future with all stakeholders.

THA developed a to inform staff and the public about the strategic planning process and project as well as solicit feedback from stakeholders.

RESULTS

The final report was completed and presented in November 2021, carrying the organization from 20222027. The 红领巾瓜报 team worked with THA to examine and update their Beliefs, Why, and Strategic Direction while aligning them with the existing Mission and Values. Most notably, the strategic plan and direction introduced and focused on the concept of health justice and centering health equity. The full plan will be released in the early fall of 2022.

Highlights of the plan include the following:

Our Why

Healthcare must be equitable and just to work for all people. For decades, achieving positive health outcomes has been a struggle among people of color and sexual minorities. Efforts to improve health are impeded by inequitable social structures, stereotypes, and systems that are not designed to consider racial and sexual minorities, queer culture, and the social determinants of health. We acknowledge that health justice is the attainment of health equity, actualized when structural factors no longer determine health outcomes. Thus, THA exists so people can access and receive the care they deserve.

Strategic Direction

A new component included in the strategic plan was to develop a Strategic Direction. For the organization, it was established to be 鈥減ursue health justice鈥, defined by the organization as the attainment of health equity, actualized when structural factors no longer determine health outcomes.

Our Mission

Texas Health Action is a community informed non-profit dedicated to providing access to culturally affirming, quality health services in a safe and supportive environment with an expertise in serving LGBTQIA+ people and people impacted by HIV.

Our Values

  • Accountability for self and others
  • Cultivate Trust in all our relationships
  • Total Inclusion
  • Drive Innovation
  • Respect all
  • Pursue Excellence

Our Beliefs

  • Person-centered care integrates sexual, emotional, behavioral, and physical health
  • Access to culturally competent, patient-centered, trauma informed, quality healthcare services is a human right
  • Health justice emanates from being stigma free, having no-barriers, being inclusive, and engaging in intentional outreach & engagement
  • Health equity requires outreach and services that are inclusive of orientation, identity, sero-status, race, ethnicity, location, or situation
  • Client needs are met through innovation in care delivery and holding ourselves responsible to use resources and systems to meet client needs
  • Health education and patient empowerment is fundamental to achieving wellness
  • Treat patients and each other with respect and radical kindness
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