1312 Results found.
Financial impact summary of the 2024 Medicare Advantage advance notice
This week, our In Focus section highlights a Wakely, an 量子资源网 Company, summary and analysis of the 2024 Medicare Advantage Advance Notice, prepared for America鈥檚 Health Insurance Plans (AHIP). The Centers for Medicare & Medicaid Services (CMS) released the contract year (CY) 2024 Advance Notice with an accompanying fact sheet on February 1, 2023. AHIP has retained Wakely Consulting Group to provide a financial impact summary report of the information presented in the notice. Specifically, Wakely was asked to analyze changes to Medicare Advantage (MA) revenue, risk adjustment models, and fee-for-service (FFS) normalization.
Key highlights of the analysis are:
- The CY 2024 FFS growth rate is lower than projections from the 2023 Final Announcement. A portion of the downward restatement is driven by a technical change. CMS has not commented on the additional drivers.
- Based on a large sample of plans, Wakely estimated that the proposed Part C risk adjustment model is expected to decrease plan risk adjusted payment by 3.7 percent overall, which represents a bigger headwind than the CMS estimated decrease of 3.12 percent. The impacts vary significantly by model segment and geographic region, and for individual plans.
- The proposed FFS normalization factor excludes PY 2021 risk scores in the calculation of the underlying trend. The exclusion of PY 2021 increases the FFS normalization factor which decreases PY 2024 risk scores.
The report, released March 6, 2023, provides additional detail and discussion of these issues. For questions, please contact our experts below.
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Evaluating the delivery of virtual child welfare services
This week, our In Focus reviews a new 量子资源网 (量子资源网) report, highlighting hybrid (in-person & virtual visits) as the future of child welfare service delivery. During the COVID-19 public health emergency (PHE), the federal government waived the requirement for 鈥渙nce every 30 days鈥� in-person visits by caseworkers for children in foster care, allowing these visits to occur virtually. In 2021, commissioned 量子资源网 to evaluate the delivery of virtual child welfare services and outline the implications of the COVID-19 PHE on the child welfare system.
The report 鈥�Evaluating the Delivery of Virtual Child Welfare Services鈥� is now available. It summarizes 量子资源网鈥檚 findings and elevates the voices of staff in public and private child welfare agencies, and of youth and families with lived experiences, and examines their perspectives on how well virtual services have worked. It also details the implications of the COVID-19 PHE, the response from public child welfare agencies, and offers guidance on a hybrid (part in-person, part virtual) service model, which we believe will continue to be a factor in the future delivery of child welfare services.
As the COVID-19 PHE accelerated the spread and scale of telehealth adoption in health care, we surmised that the experience offered valuable opportunities to learn more about how the health care sector鈥檚 adoption of telehealth services could be applied in the child welfare community. While cognizant of the unique considerations for child welfare, this disruption also represents a substantial opportunity to rethink the child welfare system and advance both the use of technology as well as a more prevention- and strengths-based approach to child welfare.
The report highlights innovative approaches in the field, offers questions to frame a jurisdiction鈥檚 decision-making process, and provides a tool to facilitate an informed decision on the hybrid model. The report also offers a broader value proposition that outlines policy, practice, workforce, and technology imperatives to develop a hybrid approach to the delivery of child welfare services.
For questions, please contact our experts below.
New report highlights hybrid (in-person & virtual visits) as the future of child welfare service delivery
During the COVID-19 public health emergency (PHE), the federal government waived the requirement for 鈥渙nce every 30 days鈥� in-person visits by caseworkers for children in foster care, allowing these visits to occur virtually. In 2021, commissioned 量子资源网 (量子资源网) to evaluate the delivery of virtual child welfare services and outline the implications of the COVID-19 PHE on the child welfare system.聽 The report 鈥淓valuating the Delivery of Virtual Child Welfare Services鈥� is now available. It summarizes 量子资源网鈥檚 findings and elevates the voices of staff in public and private child welfare agencies, and of youth and families with lived experiences, and examines their perspectives on how well virtual services have worked. It also details the implications of the COVID-19 PHE, the response from public child welfare agencies, and offers guidance on a hybrid (part in-person, part virtual) service model, which we believe will continue to be a factor in the future delivery of child welfare services.
As the COVID-19 PHE accelerated the spread and scale of telehealth adoption in health care, we surmised that the experience offered valuable opportunities to learn more about how the health care sector鈥檚 adoption of telehealth services could be applied in the child welfare community. While cognizant of the unique considerations for child welfare, this disruption also represents a substantial opportunity to rethink the child welfare system and advance both the use of technology as well as a more prevention- and strengths-based approach to child welfare.
The report highlights innovative approaches in the field, offers questions to frame a jurisdiction鈥檚 decision-making process, and provides a tool to facilitate an informed decision on the hybrid model. The report also offers a broader value proposition that outlines policy, practice, workforce, and technology imperatives to develop a hybrid approach to the delivery of child welfare services.
Please complete the form in this link to access a copy of the report and the tools and recommendations offered.
CMS announces plans to pursue new Medicare and Medicaid drug payment models
This week our In Focus section reviews the Centers for Medicare and Medicaid Services鈥� (CMS) that the agency will explore three new prescription drug payment models in the Medicare and Medicaid programs:
- Medicare High-Value Drug List Model
- Cell and Gene Therapy (CGT) Access Model
- Accelerating Clinical Evidence Model
The announcement 鈥� and accompanying 鈥� responds to President Biden鈥檚 October 2022 directing CMS鈥� Center for Medicare and Medicaid Innovation (the Innovation Center) to identify models that could lower cost sharing for commonly used drugs and include value-based payment for drugs.
Notably, the Innovation Center offered varying levels of specificity about the models, leaving unanswered many questions about the structures and timelines for the potential models. The Innovation Center will need to conduct more robust analysis to determine the design specifications for each model, stakeholder interest, and practical and political feasibility for each. In addition, each model will need to have its own application or rulemaking process to identify participants and other key model parameters. While this makes it difficult for the Innovation Center to specify timelines, it provides stakeholders some flexibility to analyze and develop recommendations for the potential models over the next several months.
量子资源网鈥檚 experts are also closely tracking CMS鈥� work on additional areas identified for the agency to research. For example, CMS could consider other regulatory pathways, partnerships, or campaigns to promote the following changes:
- Opportunities to encourage price transparency for prescription drugs
- Options to improve biosimilar adoption
- Medicare fee-for-service options to support CGT access and affordability
The drug payment models build on other federal and state-level efforts to address prescription drug costs and total cost of care initiatives. For example, CMS鈥� drug payment model announcement comes just a week after the agency its implementation approach for the drug payment policies approved as part of the inflation Reduction Act of 2022 (IRA) (P.L. 117-169). CMS is balancing the extensive implementation needs for the IRA while also acknowledging the new law may not directly address other value-based considerations impacting cost and access for certain prescription medications.
Below are some of the highlights of the Innovation Center鈥檚 drug payment models.
Medicare High Value Drug List Model
The Medicare High Value Drug List model would provide standardized approach to cost sharing for specified Part D medications. CMS suggests a standardized list with consistent cost-sharing to allow providers to easily identify and prescribe appropriate medications. Part D Sponsors could offer a Medicare-defined standard set of approximately 150 high-value generic drugs with a maximum co-payment of $2 for a month鈥檚 supply. Under this model, generic drugs included in the standardized list would not be subject to step therapy, prior authorization, quantity limits, or pharmacy network restrictions.
According to the report, CMS could explore leveraging existing systems, which would allow for a streamlined implementation. CMS also plans to seek input from beneficiaries, Part D Sponsors, manufacturers, and providers, but the agency did not provide a more specific timeline for announcing the Model specifications and start date.
Cell and Gene Therapy (CGT) Access
The Cell and Gene Therapy (CGT) Access model would be a voluntary opportunity for states and manufacturers. The model builds on existing state Medicaid initiatives to develop outcomes-based agreements (OBAs) with certain manufacturers of high-cost and breakthrough medications. CMS suggests the multistate test could inform a more permanent framework for evaluating, financing, and delivering CGTs on a broader scale. This model may also help address complexities with the federal drug rebate requirements in states that wish to pursue value-based contracting arrangements. Under this model a state Medicaid agency could choose to adopt the CMS structure for multi-state OBAs with participating manufacturers. CMS would be responsible for implementing, monitoring, reconciling, and evaluating financial and clinical outcomes. Initially the model would focus on CGTs for illnesses like sickle cell disease and cancer. This approach could remove some of the barriers that have slowed state uptake of OBAs.
CMS plans to begin model development in 2023, announce the model sometime in 2024-25, and test it as early as 2026.
Accelerating Clinical Evidence Model
The Innovation Center is considering mandatory participation for Medicare Part B providers in the Accelerating Clinical Evidence Model. Under this potential model, the agency would adjust Medicare Part B payment amounts for Accelerated Approval Program (AAP) drugs to determine if adjustments incentivize manufacturers to timely complete trials, which in turn may facilitate earlier availability of clinical evidence.
The Innovation Center identified some challenging aspects for this model and stated the agency will need to consult with the U.S. Food and Drug Administration (FDA) in 2023 to consider approaches for this model. Statements from agency officials about the model also indicate the need for consultation with the Medicare Payment Advisory Commission (MedPAC) and other stakeholders, including through an Advance Notice of Proposed Rulemaking.
If the Innovation Center determines this model is feasible, the agency will provide more details about a targeted launch. The Innovation Center has previously attempted to implement mandatory Part B drug payment models but never implemented them due to legal challenges and stakeholder opposition.
量子资源网 and 量子资源网 companies will continue to analyze these potential models and initiatives developing in parallel with the Innovation Center鈥檚 work. We have the depth and breadth of expertise to assist with tailored analysis, to model policy impacts of the potential models, and to support the drafting of feedback to CMS as it considers these options.
If you have questions about the Innovation Center鈥檚 proposed models and how it will affect manufacturers, Medicare providers, Medicaid programs and patients, contact our experts below.
February 22, 2023
CMS Announces Plans to Pursue New Medicare and Medicaid Drug Payment Models
Mental health and addiction crises top the federal policy agenda in 2023
This week our In Focus section reviews President Joseph R. Biden鈥檚 2023 (SOTU) to Congress. The President highlighted specific actions that Congress, and the Administration have taken over the last two years to advance his health care priorities.
During his first SOTU address in 2022, President Biden announced the creation of a 鈥淯nity Agenda鈥�, which included priority policy areas with potential for bi-partisan support. The President highlighted several steps the Administration has taken to advance the 鈥淯nity Agenda鈥� including:
- The bipartisan effort to enact the Mainstreaming Addiction Treatment (MAT) Act, which removed the federal requirement for practitioners to have a waiver (known as the X-waiver) to prescribe medications, like buprenorphine, for the treatment of opioid use disorder
- The Cancer Moonshot announcements for almost 30 new programs, policies, and resources to close the screening gap, tackle environmental exposure, decrease preventable cancers, advance cutting-edge research, support patients and caregivers, and more.
- Addressing mental health needs through the expansion of Certified Community Behavioral Health Clinics and launch of the 988-suicide prevention hotline.
In his SOTU and accompanying White House , the President also proposed new policies and initiatives to further advance his health care agenda. These actions include a combination of issues that would require Congressional approval as well as actions regulatory agencies can already advance. Congress and the Administration are expected to build on previous bipartisan achievements to tackle the nation鈥檚 dual crises with addiction and mental health.
Notably, the policies outlined in the SOTU foreshadow an active regulatory agenda over the next 18 months as the Administration seeks to solidify key aspects of the President鈥檚 health care agenda ahead of the next Presidential election.
The Administration鈥檚 planned actions include the following:
Opioids
- Calling on Congress to pass legislation to permanently schedule all illicitly produced fentanyl-related substances into Schedule I.
- SAMHSA will provide enhanced technical assistance to states who have existing State Opioid Response funds, and will host peer learning forums, national policy academies, and convenings with organizations distributing naloxone beginning this spring.
- By this summer, the Federal Bureau of Prisons will ensure that each of their 122 facilities are equipped and trained to provide in-house medication-assisted treatment (MAT).
- This spring CMS will provide guidance to states on the use of federal Medicaid funding to provide health care services鈥攊ncluding treatment for people with substance use disorder鈥攖o individuals in state and local jails and prisons prior to their release. California is the first state to receive approval for a similar initiative.
Mental Health
- CDC plans to launch a new campaign to provide a hub of mental health and resiliency resources to health care organizations in better supporting their workforce.
- The Department of Education (ED) will announce more than $280 million in grants to increase the number of mental health care professionals in high-need districts and strengthen the school-based mental health profession pipeline.
- HHS and ED will issue guidance and propose a rule to make it easier for schools to provide health care to students and more easily bill Medicaid for these services.
- The Administration is scheduled to propose new mental health parity rules this spring.
- HHS will improve the capacity of the 988 Lifeline by investing in an expansion of the crisis care workforce; scaling mobile crisis intervention services; and developing additional guidance on best practices in crisis response.
- HHS also plans to promote interstate license reciprocity for delivery of mental health services across state lines.
- HHS intends to increase funding to recruit future mental health professionals from Historically Black Colleges and Universities and to expand the Minority Fellowship Program.
- The Department of Veterans Affairs (VA), working with HHS and Defense, will launch a program for states, territories, Tribes and Tribal organizations to develop and implement proposals to reduce suicides in the military and among veterans.
- VA will also increase the number of peer specialists working across VA medical centers to meet mental health needs
Cancer Moonshot
- The President called on Congress to reauthorize the National Cancer Act to overhaul cancer research and to extend the funding for biomedical research established in the 21st Century Cures Act.
- The Administration will take steps to ensure that patient navigation services are covered by insurance. This could require legislation depending on which type on insurance an individual has.
Health care costs
- Urging Congress to pass legislation to cap insulin prices in all health care markets. Expanding the $35 insulin cap to commercial markets will require the 60 votes in the Senate.
Home and community services
- Working with Congress to approve legislation to ensure seniors and people with disabilities can access home care services and to provide support to caregivers.
量子资源网 and 量子资源网 companies are closely monitoring these federal policy developments. We can assist healthcare stakeholders in responding to the immediate opportunities and challenges that arise and contextualize these actions for longer-term strategic business and operational decisions.
If you have questions about these or other federal policy issues and how they will impact your organization, please contact our experts below.
February 15, 2023
Mental Health and Addiction Crises Top the Federal Policy Agenda in 2023
How will changes to Medicare Part C and D Star Ratings impact your plan?
What are your plans to minimize your risk to avoid dropping in your Star Rating or to plan a head to maintain or improve your Star Rating?
On February 1, 2023, the Center for Medicare and Medicaid Services (CMS) released the and included some key specifics on the upcoming changes to the Medicare Star Rating program. CMS is proposing changes that will align with the recently announced 鈥淯niversal Foundation鈥� of quality measures, a core set of measures that are aligned across CMS quality rating and value-based care programs. The Advance Notice also included information on substantive measure specification updates, new measure concepts, and the addition of measures to align with other CMS programs.
You can learn more about these proposed changes along with a blueprint for improving your Medicare Advantage Star Ratings at the 量子资源网 quality conference on March 6 in Chicago. The working session 鈥淢oving the Needle on Medicare Stars Ratings鈥� will feature speakers ; John Myers, BS, M.Eng., VP of Health Quality & Stars, Humana; ; and Dr. Kate Koplan, MD, MPH, FACP, CPPS, Chief Quality Officer & Associate Medical Director Quality and Safety, Kaiser Permanente of Georgia
Moderators of this session are Mary Walter, Managing Director of Quality and Accreditation, and David Wedemeyer, Principal. Both have health plan legacy experience in Stars strategy, execution and getting results.
Objectives of this session:
- Overview of the CMS proposed changes and their impact on the Stars program
- Attendees will obtain a blueprint for improving Medicare Advantage Star Ratings, including the importance of ensuring executive management buy-in
- Discussion of how the use of data analytics can help plans to identify quality gaps, target interventions, and track improvement
- Strategies to avoid the type of siloed initiatives that often fail to achieve lasting results
- Speakers will also address the importance of quality in achieving market viability and financial
sustainability
Stay in the know about the upcoming proposed changes and develop your organization鈥檚 strategy in this interactive impactful working session. This session will allow attendees to integrate any learnings and take-aways into your Stars program to meet your overall Star Rating strategic goal.
Follow #量子资源网talksQuality on and for more updates on Stars and quality initiative efforts throughout the year. View the full agenda and register for 量子资源网鈥檚 first annual quality conference on March 6 in Chicago. Registration closes on February 21, 2023.
What is 鈥渁dequate鈥� behavioral health provider capacity?
At 量子资源网, our subject matter experts get questions every day from people working in state agencies, counties, health plans and provider groups about how to 鈥渞ight size鈥� the behavioral health continuum to obtain equitable access for growing behavioral health demand. From legislatures to providers, improving access to mental health services is critical to improving overall health outcomes. It is time for behavioral health to create a specific definition of network adequacy that accounts for the complexity and nuance of access to mental health and substance use care. It is time to identify and define the factors that lead to 鈥渁dequate鈥� provider capacity, to ensure that the right level of care is available to individuals when they need care. Network adequacy in behavioral health needs an overhaul to meet the complexity that is driving access challenges.
Together let鈥檚 re-define what 鈥渁dequate鈥� means in behavioral health to ensure we build systems that meet the needs of communities. At 量子资源网鈥檚 quality conference on March 6 in Chicago, the 鈥淒eveloping a Behavioral Health Quality Strategy鈥� working session will engage participants in an in-depth discussion on identifying factors to inform a more accurate definition of behavioral health network adequacy. Speakers will outline some of the core challenges in network adequacy and innovations they have used.聽 Attendees will work collaboratively in a structured exercise on three knotty challenges within network adequacy to identify factors that could improve measurement for states, plans and providers. The goal is for participants to walk away with tangible actions they can implement in their work on behavioral health access.
Please join our 量子资源网 experts and our featured panelists:
And follow #量子资源网talksQuality on and for more updates on behavioral health quality efforts throughout the year. View the full agenda and register for 量子资源网鈥檚 first annual quality conference on March 6 in Chicago. Registration closes on February 21, 2023.