量子资源

Insights

HMA Insights - Reports

Show All | Podcast | Blogs | Webinars | Weekly Roundup | Videos | Case Studies | Reports | News | Spotlight

Filter by topic:

Receive timely 量子资源 insights on topics you care about.

Select Topics

108 Results found.

Brief & Report

HMA helps navigate dQM to improve health outcomes

Download

The healthcare industry is undergoing a seismic shift in how quality data are collected and reported, creating opportunities to use digital quality measures (dQM) to significantly improve health outcomes and efficiency. Starting in January 2027, new federal interoperability and prior authorization rules will promote widespread data exchange, enabling full digital quality measurement. Payers and providers must invest early to be well-positioned to undergo major strategic and operational changes to optimize healthcare data and transform their business processes.

This issue brief explains the federal policies and national changes that make digital quality measurement possible, explores challenges facing the health insurance industry, and highlights opportunities for payers and providers.

Our HMA dQM team helps health plans, providers, health & hospital systems, federal, state and local payers such as Medicare and Medicaid navigate the transformation to dQM and broader interoperability鈥攆rom early planning through strategy development, implementation, and impact evaluation.

Brief & Report

340B Duplicate Discounts: Enforcement Inconsistent and Weak Due to Lack of Data Transparency and Despite Federal Prohibition

Download

At the intersection of the federal 340B Drug Pricing program and the federal Medicaid Drug Rebate Program (MDRP), a potentially large set of Medicaid claims are generating duplicate discounts, which pharmaceutical manufacturers provide to eligible entities such as hospitals and health centers. These two complex federal programs were designed to reduce the costs of prescription drugs for providers that serve low-income patients, but both state Medicaid agencies and federal policymakers have been actively working to eliminate the unintended overlap of these two programs. To gain deeper insights into why duplicate discounts continue to occur, the scope of this concern, and to identify considerations of future policymaking, HMA conducted interviews with Medicaid officials and drug policy 量子资源s across several states.

Duplicate discounts occur when for a single sale a manufacturer is required to: (1) prospectively reduce the price of the product (a discount) they sell to a 340B covered entity in advance of the delivery of care to the patient; and (2) provide a retrospective payment (a rebate) to a state Medicaid program or managed care plan under the MDRP after care is delivered to a Medicaid enrollee. When duplicate discounts occur the manufacturer鈥檚 product is discounted twice for the same sale, contravening federal law, which prohibits duplicate discounts.

Despite the statutory prohibition, duplicate discounts remain a concern. Both state and federal policymakers have been actively addressing duplicate discounts but have been unable to identify clear and consistent policy solutions that neutralize this inefficiency. On the state level, Medicaid agencies and state legislatures have implemented policies to address duplicate discounts. On the federal level, the Health Resources and Services Administration (HRSA) and the Centers for Medicare & Medicaid Services (CMS) have conducted audits and published best practices for states to eliminate duplicate discounts. Nonetheless, duplicate discounts persist. 

To gain deeper insights into how Medicaid agencies navigate duplicate discounts, 量子资源 (HMA) conducted semi-structured interviews with former and current Medicaid directors and pharmaceutical policy 量子资源s in 14 states. Interviewees were asked about the frequency of duplicate discounts, the extent to which Medicaid agencies devote resources to tracking them, the policies states have implemented to address them, and the extent to which state or federal authorities are working to eliminate duplicate discounts.

Based on interviews, four key themes emerged:

  • Duplicate discounts remain a problem, the scope of the problem is unclear, and better data collection from covered entities is necessary.
  • The opacity and complexity of duplicate discounts create a burden for state Medicaid agencies, influencing the policies they implement, resulting in variable state policy strategies.
  • Contract pharmacies add an additional layer of complexity, exacerbating the burden that duplicate discounts create.
  • State and federal authorities could take more decisive action to address duplicate discounts.

Policymakers should consider that the environment for addressing duplicate discounts may become more complex in the future, which may increase the need for a federally coordinated policy solution. The complexity of the environment may deepen due to the increasing presence of contract pharmacies, the increasing presence of managed care in Medicaid programs, and the implementation of the drug pricing policies of the Inflation Reduction Act of 2022. Policy action coordinated across the various stakeholders (e.g., HRSA, CMS, state Medicaid agencies, covered entities, and manufacturers) may represent the best opportunity for success in eliminating duplicate discounts.

Brief & Report

Los Angeles County State of Children鈥檚 Health Report: Policy Briefs

Download

Informed by research and exploration of the on some of the most complex challenges facing children in a post-pandemic world, 量子资源s from L.A. Care Health Plan, the nation鈥檚 largest publicly operated plan, and Children鈥檚 Hospital Los Angeles (CHLA), one of the nation鈥檚 leading pediatric hospitals, unveiled their first-ever Los Angeles County State of Children鈥檚 Health report. The report, made up of four policy briefs, identified core issues impacting kids and teens and key recommendations to proactively address them.  

The report originated from roundtables held in November of 2023 that convened 量子资源 stakeholders resulting in four distinct policy briefs and action plans. Recommendation highlights include establishing new school-based programs to improve mental health services within educational settings, launching an effort to dispel vaccine myths to improve children鈥檚 health, and addressing resource challenges that children and youth with complex chronic conditions and in social welfare system experience in Los Angeles County and beyond.

量子资源 量子资源s in child welfare and behavioral health worked with the team of outside children’s health 量子资源s to prepare these four policy briefs with actionable solutions:

  • Vaccine Catch-Up and Misinformation: How can we improve access to and the provision of immunizations to promote children鈥檚 health?
  • Children and Families鈥� Resiliency: How can we improve the systems of care to improve well-being and address children鈥檚 mental health needs?
  • Supporting Children and Youth Involved in the Child Welfare System聽: How can we improve the quality, appropriateness of supports, and ease of access to care to address the unique needs of children involved in the child welfare system?
  • Children and Youth with Complex Medical Needs Transition to Adulthood: How can we facilitate the continuation of critical support as children with complex medical needs age out of care eligibility?

You can access the comprehensive reports and video series .

Brief & Report

Substance Use Disorder in California – A Focused Landscape Analysis

Download

HMA found that the substance use disorder treatment system, which sits outside of specialty mental health and mild-to-moderate mental health services, results in an inconsistent and siloed system. The delivery of programs and services across the state vary because of differences in geography (rural, suburban, and urban densities) as well as county participation in the Drug Medi-Cal Organized Delivery System (DMC-ODS). This landscape analysis provides a deeper exploration into the challenges and opportunities specific to addressing substance use disorder.

The analysis was produced with support from the California Health Care Foundation.

Brief & Report

State Approaches to Managing the Medicaid Pharmacy Benefit

Download

Millions of Americans rely on Medicaid drug coverage to treat acute illnesses and manage chronic and disabling conditions. Though optional, all states provide pharmacy benefits under Medicaid but administer the benefit in different ways in accordance with federal guidelines. To better understand how states across the country administer the Medicaid pharmacy benefit, as well as states鈥� planned priorities and anticipated future challenges, HMA surveyed all 50 states and the District of Columbia in early 2024. A total of 46 states and the District of Columbia participated.

The report includes survey findings addressing a variety of topics including how states administer the pharmacy benefit and use of pharmacy benefit managers, state containment and utilization management strategies, payment and rebate approaches, value-based arrangements, planned policy changes, priorities and challenges in managing the pharmacy benefit in FY 2025 and beyond, and more. The HMA authors are Kathy Gifford, Aimee Lashbrook, and Constance Payne.

The report authors will also be discussing this paper and presenting their findings at a pre-conference workshop “Paying for Innovative Pharmaceuticals: State and Federal Trends Shaping Public Programs” at HMA’s Unlocking Solutions in Medicaid, Medicare, and Marketplace conference, October 7-9.

Brief & Report

Economic Analysis of Opioid Use Disorder in the Medicare Fee-for Service Program

Download

This report quantifies the economic impact of opioid use disorder (OUD) specific to the Medicare fee-for-service (FFS) program, which covers approximately 51.6 percent of Medicare beneficiaries. We find that the cost to Medicare for managing these newly diagnosed patients was $29,669 more per patient than the propensity-matched control patients without OUD in 2022. We thus estimate that newly diagnosed OUD patients cost the Medicare program $4.3 billion in 2022. If these incident patient results were extrapolated into a 10-year budgetary impact analysis and if we assume constant rates of OUD incidence in the Medicare population, we estimate that the 10-year impact of OUD to the Medicare program would be $62.56 billion.

Our analysis demonstrates that OUD results in significant Medicare spending, including rising costs to beneficiaries through copayments and increased premiums. Additional work may be needed to determine whether the cost differential for incident patients with OUD generalizes to prevalent OUD patients as well. Though the 10-year budgetary impact figures require extrapolation and assumptions about future OUD use, they illustrate for policymakers the size of the fiscal challenge created by OUD in the Medicare population.

Brief & Report

HMA paper examines federal funding streams supporting crisis pregnancy centers

Download

Crisis pregnancy centers (CPCs) are organizations that represent themselves as reproductive healthcare clinics offering services for pregnant people and appear similar to clinics offering a full range of reproductive health services. Federal funding to CPCs may constitute non-allowable uses of such support based on the legislative intent and grant requirements of these programs. In this paper, HMA provides a comprehensive analysis of federal funding streams and state allocations of that funding to CPCs and CPC networks. HMA found that more than 650 CPCs in 49 states and Washington, DC, received federal funding between 2017 and 2023, totaling more than $400 million.

Brief & Report

HMA report evaluates needs of Nevada’s Medical Assistance for the Aged, Blind, and Disabled program

Download

The Nevada Division of Health Care Financing and Policy (DHCFP) engaged HMA to evaluate Nevada鈥檚 Medical Assistance for the Aged, Blind, and Disabled (MAABD) program and the needs of its participants. A targeted focus of the evaluation was on home and community-based services (HCBS) within the Nevada MAABD population, including Nevada鈥檚 Frail Elderly (FE) and Physically Disabled (PD) waiver.

The project included:

  • Data analyses of Nevada鈥檚 population and long term services and supports (LTSS) landscape, the state鈥檚 ongoing efforts to rebalance LTSS dollars from institutional to HCBS services and demographic and other information about the MAABD population
  • Stakeholder engagement, including three focus groups that engaged 55 stakeholders and individual interviews, to provide stakeholders a greater voice in the MAABD improvement process
  • Evaluation of the MAABD structure and administration
  • Program recommendations to help inform and guide DHCFP鈥檚 considerations for better serving the FE and PD MAABD populations throughout the state

The report made recommendations to enroll the MAABD population aged 65 and older into a combination MLTSS/FIDE-SNP (managed long-term services and supports/fully integrated dual eligible special needs plan) program, implement Program of All-Inclusive Care for the Elderly (PACE) as a targeted nursing home diversion strategy and strengthen Nevada鈥檚 Medicaid quality framework to better deliver and ensure improved quality of care for the MAABD population.

Brief & Report

New HMA report using VRDC data analyzes hip fracture outcomes in Dual Eligible population

Download

In this new report, “Answering Questions Using Virtual Research Data Center (VRDC): How using Home and Community-Based Services (HCBS) Impacts Hip Fracture Outcomes“, HMA is now using Centers for Medicare & Medicaid Services (CMS) Virtual Research Data Center (VRDC) to answer important healthcare questions. One contractual obligation for use of CMS data is the release of a publicly available research paper using the dataset, which contains all Medicare fee for service (FFS) and Medicaid FFS and managed care organization (MCO) claims. HMA used the VRDC data to examine the relationship between Long-Term Services and Supports (LTSS) and Home and Community-Based Services (HCBS) on hip fracture outcomes for people who are dually eligible for Medicare and Medicaid benefits. The analysis found that patients who receive HCBS were less likely to incur a future inpatient stay. The report and data analysis are detailed below.

VRDC Medicare and Medicaid claims data can be used to develop best practices for the healthcare system, looking at patient demographics, including eligibility/enrollment types (including dual-eligibles), race/ethnicity, age, and other critical subgroups to inform equity analyses. These data can be used longitudinally to measure the effect of interventions as well as to inform population health strategies. HMA鈥檚 nationally renowned subject matter 量子资源s can now incorporate VRDC data analysis and analytics into their recommendations to help your organization solve your toughest challenges.

Brief & Report

Medicare Physician Fee Schedule Reform: Structural Topics and Recommendations to Strengthen the System for the Future

Download

Recent years have witnessed a growing bipartisan call to reform how Medicare reimburses for physician and other health professional services. Stakeholders assert that the current system鈥攖he Medicare Physician Fee Schedule (PFS)鈥攊s misaligned to today鈥檚 practice patterns and market dynamics. Many constituencies maintain that the current approach is insufficiently updated, embeds known pricing distortions, and does not appropriately effectuate value-based care principles, such as providing cost-conscious, high-quality care that prioritizes performance measurement and patient experience. Calls for reform are further prompted by increasing concern about the viability of independent physician practices, including the implications of consolidation and private equity acquisition of physician offices. Finding a workable comprehensive solution to updating physician payments is an uphill battle stymied by the significant cost of doing so, competing stakeholder positions, and the complexities of restructuring payment.

The original design of the Medicare PFS, still in use today, is based on the resources typically needed to provide services to patients. First implemented in 1992, the PFS is a fee-for-service (FFS) system of payment premised on the idea that services should be separately valued in relation to each other. This requires information on the effort and costs incurred to perform those services and how those variables change over time. The Centers for Medicare & Medicaid Services鈥� (CMS鈥檚) efforts to update data used to set rates in the required budget neutral manner often result in system instability and may take years to fully implement due to concerns about redistribution. These innate vulnerabilities have been compounded by three decades of policy decisions, statutory changes, and advancements in care delivery.

While established metrics suggest that physicians鈥� participation in the Medicare program and beneficiary access is currently adequate, the Medicare Payment Advisory Commission (MedPAC) raises concerns that beneficiaries may experience more access to care barriers moving forward. For the past two years, MedPAC has recommended physician payment updates based on changing economic conditions, as well as additional 鈥渟afety net鈥� payments to physicians treating low-income beneficiaries. Reducing health disparities and improving the foundation of care is a top priority for many in this country, and payment reform within the PFS and more broadly that expands technology while also investing in person-centered, community-oriented care (especially for populations that are underserved and/or living with multiple chronic conditions) is central to that cause.

As robust policy discussions are taking place to explore these issues and identify solutions, Arnold Ventures engaged HMA to provide accessible background and context on the PFS for people who may be unfamiliar with the payment system, including a review of how the stakeholder community got to the point of needing to 鈥渇ix鈥� the fee schedule. Through a thorough assessment of the most pressing policy and payment concerns, we identified several key structural issues within the physician fee schedule that should be considered and balanced when making policy changes to the payment system.

Brief & Report

Compassionate Overdose Response: Summit Highlights and Key Takeaways

Download

HMA鈥檚 Compassionate Overdose Response Summit suggests 鈥渉igh dose鈥� naloxone isn鈥檛 necessary.

More than 100,000 people in the United States die every year from drug overdoses, driven by the availability of illicitly manufactured fentanyl. On March 19, 2024, HMA held the Compassionate Overdose Response Summit to discuss overdose response and reversal drugs like naloxone in the context of a fluctuating drug supply. Forty 量子资源s participated in consensus-building discussion on a standard of care opioid overdose response protocol. Throughout four panel presentations, a critical message emerged: those responding to an overdose should aim to restore breathing without causing withdrawal by supporting the person鈥檚 breathing, giving low or standard doses of naloxone (0.4 mg intramuscular injection and <4 mg intranasal spray) until spontaneous breathing is restored, and creating a calm environment. Despite fluctuations in the drug supply, standard dose naloxone is effective.

The standard dose of naloxone is considered 0.4 mg intramuscular injection and <4 mg intranasal spray. It is extremely effective and preferred by people who experience overdose. Reports at the Summit from four states (Missouri, Kentucky, Pennsylvania, and New York) made clear that an increase in naloxone dose is not a necessary response to the presence of fentanyl in the drug supply. Negative reactions following naloxone administration may be avoided, and anger can potentially be managed via low-dose naloxone titration and a calm, compassionate, and considerate communication style between the person who overdosed, the person who administered an opioid antagonist, and bystanders, including EMS.

Another key takeaway from the Summit, and shared in the report released today, was the acute and long-term adverse outcomes of withdrawal on people who experience overdose. The way a person is treated during an overdose, i.e., the communication style of the responder, likelihood of withdrawal, and the care they are offered after, affects their risk behavior such as using more opioids to feel better. In a study from New York State, those who received 8 mg nasal spray were more likely to experience withdrawal than those who received 4 mg nasal spray. People who experience withdrawal after an overdose may be discouraged from seeking help in the future.

鈥淎 compassionate overdose response is looking at the entire person. It鈥檚 not that moment of reviving them. It鈥檚 [also] what happens afterward.鈥� 鈥� Joy Rucker, Summit Panelist

The findings shared at the Summit are timely given the availability of high-dose and long-acting overdose reversal products in the US. The FDA continues to ignore the life-threatening side-effects of high-dose products and recently approved a . This trend has drawn concern from addiction medicine providers, emergency medical services, toxicologists, harm reductionists and people who experience overdose alike. Standard dose products are available at the lowest cost for bulk purchase and decades of research show their use in the community reduces overdose mortality. A chart with currently available opioid overdose reversal products is available at

What鈥檚 Next

To learn more about compassionate overdose response and the significance of overdose reversal product selection, listen to the event proceedings and read the report below. View the webinar replay with links to download PDFs of speakers鈥� presentations.

Contact Erin Russell to discuss the policy and program implications of the Summit鈥檚 findings.

Contributions

The Compassionate Overdose Summit was presented with support from HMA, Harm Reduction Therapeutics, Vital Strategies, the Bloomberg American Health Initiative, and the University of Pittsburgh Graduate School of Public Health. Funds were used to secure event space and speaker stipends to cover their time and travel needs, hotels, meals, AV equipment, and event staffing.

Brief & Report

HMA white paper examines expanding home care value through innovative client and caregiving supports

Download

As the U.S. population ages, non-medical personal care services are increasingly important for supporting Americans to remain in homes, as the vast majority of them prefer. But in-home personal care services will remain in short supply throughout the country unless home care agencies have greater success recruiting and retaining caregivers. In this HMA white paper, we describe the programs developed by Help at Home, the nation鈥檚 largest personal care services providers with 53,000 in 11 states, to use technological solutions to increase ease of caregiver recruitment and to provide its caregivers with a greater sense of purpose and meaning in their work.

The latter accomplishment has been achieved through Help at Home鈥檚 innovative care management program, 鈥淐are Coordination at Help at Home,鈥� in which its caregivers receive a weekly text asking them to complete a brief survey about their personal care client鈥檚 physical and behavioral health symptoms and any health-related social needs. This information is transmitted to the agency鈥檚 Clinical Support 量子资源, composed of nurses, social workers, and community health workers, who review the caregivers鈥� observations and, if needed, conduct further evaluations of the clients and/or alert the appropriate primary care or specialty providers about their escalating health and social needs. The program鈥檚 outcomes: Decreased client utilization of Emergency Department visits and hospitalizations since brewing health concerns are addressed earlier on. Increased caregiver retention because caregivers feel like they are making a significant difference in the health and well-being of their clients.

Ready to talk?