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Future Of Health Care Beyond 2020 Series: Interview With Dwayne Mayes

In this interview, Dwayne Mayes, PsychU Patient and Caregiver Section Co-Advisor, discusses the future of health care beyond the COVID-19 pandemic with Heather Davidson, PhD, Medical Science Liaison, of Otsuka Medical Affairs. Listen in to hear Mayes’ perspective on the opportunities and challenges that lie ahead.

Dwayne Mayes is the PsychU Patient and Caregiver Section Co-Advisor, as well as the Program Director of the Recovery Network and Peer Training Program at the Mental Health Association of Westchester, New York.

Heather Davidson, PhD, is a Medical Science Liaison for Otsuka Pharmaceutical Development and Commercialization, Inc.

In this presentation, the objectives are to:

  • To understand the burden of behavioral health disorders on all stakeholders
  • To define behavioral health quality measures, and how they’re used
  • To describe the growing importance of value-based care in behavioral health care
  • To discuss payer and provider roles in quality improvement including challenges and strategies for success
Request this program for your region or organization today! This live (online or in-person) presentation, and others like it, are available for free for PsychU members. View our complete listing of presentations and programs by visiting our Request A Presentation page.

In this presentation, the objectives are to:

  • Provide a brief overview of Major Depressive Disorder (MDD) and measurement-based care (MBC)
  • Understand the benefits of MBC and commonly used MBC tools
  • Understand why measurement-based tools are underutilized
  • Discuss possible strategies for implementing MBC tools into clinical practice

Request this program for your region or organization today! This live (online or in-person) presentation, and others like it, are available for free for PsychU members. View our complete listing of presentations and programs by visiting our Request A Presentation page.

In this presentation, the objectives are to:

  • Discuss current developments in digital health for psychiatry and consider the advantages and challenges of using digital tools
  • Examine the use of technology in promoting treatment adherence
  • Review shared decision making in psychiatry and the contribution that digital tools can make to its implementation

Request this program for your region or organization today! This live (online or in-person) presentation, and others like it, are available for free for PsychU members. View our complete listing of presentations and programs by visiting our Request A Presentation page.

The U.S. Department of Health and Human Services has extended the coronavirus disease 2019 (COVID-19) public health emergency declaration for an additional 90 days. Secretary Alex Azar endorsed the renewal on July 23, 2020, ahead of its expiration on July 25. With it comes several policy implications for physicians that would have disappeared over the weekend.

Mr. Azar said the administration will continue its whole-of-America response to ensure Americans can get the care they need. A number of organizations have advocated for the extension, citing several ramifications of the renewal, including continuing requirements that payers cover COVID-19 testing without cost-sharing, telehealth waivers, and the 20% add-on Medicare payment for treating coronavirus inpatients.

The mission of the U.S. Department of Health & Human Services is to enhance and protect the health and well-being of all Americans. The department seeks to fulfill that mission by providing for effective health and human services and fostering advances in medicine, public health, and social services.

For more information, please contact:

  • ASPR Press Office, U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Washington, District of Columbia 20201; 202-205-8117; Email:; Website:

About 67% of adults ages 18 to 64 enrolled in a high deductible health plan (HDHP) have a health savings account, but 55% do not contribute. About one-third of HDHP enrollees do not have a health savings account. Among HDHP enrollees with a health savings account who contributed money to it in the past 12 months, the most frequent level of contribution was $2,000 or more. People with less education and/or low health literacy were less likely to make HSA contributions. As of 2016, about 40% of privately insured adults were enrolled in an HDHP.

An HDHP is defined as a private insurance plan with a deductible of at least $1,300 for an individual or $2,600 for a family in which the plan does not pay out until the deductible is met. HSAs are special savings accounts that allow HDHP enrollees to contribute pre-tax dollars to the HSAs to save for future health care expenses.

Additional findings about the intersection of HDHP enrollment and HSAs were as follows:

  • About 70% of HDHP members who enrolled through a health insurance exchange and 36% of people whose employer offered only one option lacked an HSA.
  • 55% of HDHP members with an HSA had not contributed money to it in the past 12 months.
  • Nearly 32% of those with an HSA said they were unable to afford saving for health care.

These findings were reported in “Use of Health Savings Accounts Among US Adults Enrolled in High-Deductible Health Plans” by Jeffrey T. Kullgren, M.D., MS, MPH; Elizabeth Q. Cliff, Ph.D.; Christopher Krenz, BA; et al. The researchers analyzed survey responses from 1,637 working-age, English-speaking adults enrolled in an HDHP for at least 12 months. The survey was conducted in August and September 2016. The respondents were asked if they had an HSA, defined in the National Health Interview Survey as “a special account or fund that can be used to pay for medical expenses” that are “sometimes referred to as health savings accounts (HSAs), health reimbursement accounts (HRAs), personal care accounts, personal medical funds, or choice funds, and are different from flexible spending accounts.” The respondents were also asked if they saved for health care expenses in the last 12 months and, if so, which savings vehicles they used and how much they saved. Those who had not saved were asked to state why. Other survey questions health status and source of insurance coverage, as well as factors that could potentially influence health care savings, such as consumer engagement, financial literacy, and health insurance literacy.

The full text of “Use of Health Savings Accounts Among US Adults Enrolled in High-Deductible Health Plans” was published July 17, 2020, by JAMA Network Open. An abstract is available online at

For more information, contact:

  • Jeffrey T. Kullgren, M.D., MS, MPH, Assistant Professor, Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Post Office Box 130170, Ann Arbor, Michigan 48113; Email:; Website:

The U.S. has historically “separated” the health of an individual from their social circumstances. “Clinically appropriate” was added to the payment criteria to address level of care—the least restrictive level of care only. But social issues or supports were never in the equation.

That perspective has changed for a couple reasons. Over a decade ago, the fundamentals of health insurance underwriting changed with the Patient Protection and Affordable Care Act. The end of preexisting condition exclusions, the end of annual and lifetime care limits, parity for behavioral health services, and the requirements to accept all applicants eliminated the practice of shifting people with more expensive and complicated health conditions from private health plans to public programs. This situation prompted more investigation about the drivers of use of health care resources. What the research found—health care utilization is driven by a number of factors related to the environment (e.g., poverty), demographics (e.g., gender, insurance status), and mental and physical health (e.g., chronic conditions, serious mental illness, addiction). And the pandemic has and will continue to exacerbate the social needs of the U.S. population—more anxiety and depression, loss of housing, loss of income, interrupted education, and food insecurity.

The social supports/health connection was the focus of a recent web briefing, Population Health: Clinical & Administrative Implications, featuring OPEN MINDS Senior Associates, Sharon Hicks, Paul Duck, and OPEN MINDS Vice President, Richard Louis, III. They discussed how health plan managers have acted on this emerging body of data and are investing in social support services as a tactic for reducing member spend. A just-published survey of social service investments by Medicaid health plans in Texas and California, Comparison Of SDOH-Related Investments By Texas And California Medicaid Health Plans, confirmed this trend, finding that all of the Texas plans addressed food insecurity and transportation, while 71% of plans addressed housing issues. In California, housing instability was addressed by 84% of plans, while lack of transportation and food insecurity were addressed by 79% and 74% of plans, respectively. There are many examples of these health plan initiatives in our recent coverage:

  • Humana has a number of initiatives focused on social supports. They launched a value-based program that pays provider organizations for social determinants of health (SDOH) screenings; documentation of assessment findings; and connecting the member to appropriate resources. They have also continued their “Bold Goal” initiative, launched in 2015, with two additional cities (Cincinnati, Ohio and Detroit, Michigan) announced in May 2020.
  • CVS Health/Aetna launched a collaboration with Unite Us to develop a social determinants of health platform and connect Aetna Medicaid members with a coordinated network of local social service provider organizations.
  • Kaiser Permanente created a three-year initiative with Community Solutions to end chronic homelessness in 15 communities.
  • Horizon Blue Cross Blue Shield of New Jersey announced a demonstration project to assist community health workers in addressing SDOH through an online platform, NowPow.
  • Optum has a new partnership with Wider Circle and Helping Hands Community Partner—“Community Food Circle”—providing Optum beneficiaries in Los Angeles with healthy food amid the COVID-19 pandemic.

And, at a broader level, The Centers for Medicare & Medicaid Services (CMS) has recently allowed payment for services for “social needs” out of Medicare Advantage health plan savings. This is the first time that CMS has broadened the definition of services that can be paid with Medicare funds.

Many traditional specialty provider organizations have a long history of, and great expertise in, addressing the social needs of consumers. How do those organizations meet the emerging market need for connected health and social services and improve their market positioning? My colleagues offered some advice.

Include this expertise in your market positioning—If your organization has expertise in addressing the social support needs of consumers, do health plans managers and other payers know about that expertise? This is a matter of market positioning—understanding whether or not that expertise is a real market differentiator. And, if it is “repositioning,” how you present your organization and your brand—focusing on that expertise and attracting new referrals.

Provide linkages to social support services to all consumers—whether in fee-for-service or value-based initiatives—In your current services, providing referrals and supports for consumers to meet their social support needs is just good business. It results in better consumer outcomes and is a differentiator for health plans. As Ms. Hicks noted, a clinical social worker may not be able to find housing for a consumer, but they can easily arrange a contact with staff at a community-based organization that can. Social needs assessment and social services referrals can be built into standard clinical practices.

Develop targeted approaches to social services for value-based contracts and measure their impact—If your organization has value-based contracts, your management team (like the management teams of health plans) should be thinking about what social support services could improve performance and improve profitability. And any initiative needs a financial analysis of costs and likely returns—and a return-on-investment analysis of whether the predicted financial gains are achieved.

Evaluate the creation of new social support service lines focused on the needs of health plans and other payers—It’s clear health plans and other payers are investing in social services, but what exactly are they looking for? In the OPEN MINDS 2019 survey of health plans, Trends in Behavioral Health: A Population Health Manager’s Reference Guide on the U.S. Behavioral Health Financing and Delivery System, found that 27% of health plans are investing in initiatives to improve access to affordable housing and 21% are investing in transportation initiatives. Thirteen percent are investing in food insecurity. To decide whether your organization should invest in a new service line focused on social supports requires the same process as developing any other service line- market research to determine specific needs, assessment of the competition, operational and financial feasibility analysis, and a marketing launch plan. The key, as Mr. Louis underscored, is to first understand your organization’s current ability to provide social support programs—then come together with the community to better understand the needs of consumers while aligning the strategic initiative with the goals of the health plan or payer.

An estimated 550 additional veterans in the United States are projected to die by suicide annually for every five-percentage point rise in unemployment, compared to veteran suicide levels prior to the onset of the coronavirus disease 2019 (COVID-19) pandemic. Due to the extended duration of the COVID-19 pandemic, unemployment rates in the general population have increased by nearly 10 percentage points since January 2020, rising from about 3% to more than 13%. According to models based on U.S. state-level data, each additional percentage point increase in the rate of unemployment will result in more than one hundred additional veteran suicide deaths.

At the 13% unemployment rate as of May 2020, an increase of six more percentage points is projected to result in nearly 700 additional veteran suicides due to increases in unemployment. If the unemployment rate were to increase by 20 percentage points, more than 2,500 more veterans could die from suicide annually.

Addiction rates are also projected to rise with the unemployment rate. A five-percentage point increase in the unemployment rate is projected to result in more than 20,000 additional cases of addiction disorder per year in the U.S.

The analysts recommended proactive efforts be implemented to address short-term and long-term needs related to mental health and addiction for veterans before they reach crisis levels. Health systems should enable veterans to employ coping skills learned while in service of the country to mitigate suicidal urges and the threat of developing addiction.

These findings were presented in “Projected COVID-19 MHSUD Impacts, Volume 2: Effects of COVID-Induced Economic Recession (COVID Recession) on Veteran Suicide and Substance Use Disorder (SUD) – June 15, 2020,” by the Meadows Mental Health Policy Institute. Researchers for the Institute partnered with the Cohen Veterans Network (CVN) to analyze U.S. state-level data from 1997 to 2010, which includes the 2007 to 2009 recession, data from the National Survey on Drug Use and Health, and data available from the U.S. Department of Veteran’s Affairs. This data was used in models that applied logarithmic (log) transformation of the suicide rate to permit reporting change in suicide rates as a percentage. An exact percentage change formula was used that is associated with log dependent variables when estimating the effect of a 20-percentage point increase in the unemployment rate on suicide. The goal was to determine how a COVID-19 induced economic recession increases rates of suicide and addiction disorders, with a specific focus on military veterans.

The full text of “Projected COVID-19 MHSUD Impacts, Volume 2: Effects of COVID-Induced Economic Recession (COVID Recession) on Veteran Suicide and Substance Use Disorder (SUD) – June 15, 2020,” was published on June 18, 2020 by the Meadows Mental Health Policy Institute. A copy can be found at:

For more information, contact:

  • Anthony Guido, Vice President, Communications & Marketing, Cohen Veterans Network, 72 Cummings Point Road, Stamford, Connecticut 06902; 203-569-0284; Email:; Website:

If you or someone you know is in crisis, please contact the Suicide Prevention Hotline / Lifeline at 1-800-273-TALK (8255), or text the Crisis Text Line at 741-741.

The nation’s largest private funder of suicide prevention research, the American Foundation for Suicide Prevention (AFSP) announced the research priority areas for the 2020-2022 grant funding cycles. The new research priorities are suicide prevention within underrepresented racial and ethnic communities and the evaluation of technological tools for suicide prevention. Applications in these areas will be reviewed along with the general pool of grant applications, with priority given to strong grants in the designated fields.

This year’s focus on diversity is a part of AFSP’s larger commitment to addressing the disparity in mental health care access. With the vast array of technological tools for suicide prevention, the second priority area is on evaluation of technology for suicide prevention. The two-year priority period allows for resubmission of unsuccessful applications in the second year. Each application is reviewed multiple times by the top suicide prevention researchers in the world. The research grants are funded mainly through individual donors who attend the AFSP Out of the Darkness Walks and other public education events. Many of the AFSP grantees then go on to receive further funding from the National Institute of Mental Health and other large funding agencies. Last year, AFSP awarded over $5M in research grants for nearly 40 new studies.

The American Foundation for Suicide Prevention is dedicated to saving lives and bringing hope to those affected by suicide. AFSP creates a culture that’s smart about mental health through education and community programs, develops suicide prevention through research and advocacy, and provides support for those affected by suicide. Led by CEO Robert Gebbia and headquartered in New York, AFSP has local chapters in all 50 states with programs and events nationwide.

For more information, please contact:

  • American Foundation for Suicide Prevention, 120 Wall Street, 29th Floor, New York, New York 10005; 212-363-3500; Email:; Website:

If you or someone you know is in crisis, please contact the Suicide Prevention Hotline / Lifeline at 1-800-273-TALK (8255), or text the Crisis Text Line at 741-741.

Since the start of the pandemic, 53 million Americans have filed for unemployment, close to 16% of the adult population. For many of these people, the loss of their job also means a loss of health insurance.

Exactly how many Americans will lose their health insurance is not clear. Before the COVID-19 pandemic, 27.9 million non-elderly Americans—8.5% of the adult population—were uninsured. A third of the workers experiencing job loss have insurance through another family member’s job and a quarter have coverage through a Medicaid program prior to the pandemic. Of the estimated 10 million people who will lose employer-sponsored health insurance between April and December 2020, a third will regain employer-sponsored insurance by being added to a family member’s policy, nearly half will be eligible for Medicaid, and 10% will be eligible for marketplace subsidies. The balance will likely be uninsured and faced with either buying individual health insurance policies or remaining uninsured and paying cash for services.

This means an increase in enrollment in Medicaid health plans and commercial health plans. There will also be a likely bump in Medicare beneficiaries, with a group of consumers who will apply for coverage based on disability. And there will be an increase in uninsured, cash-paying consumers. Executive teams of provider organizations should be planning for all of the above.

Regarding Medicaid, it is likely that plans will shift a bit in the months ahead. States with stressed budgets will be looking to trim Medicaid. One way is to enroll more consumers in managed care plans and link more payments (to both health plans and provider organizations) to performance. There is financial assistance to state Medicaid plans through the Families First Coronavirus Response Act (FFCRA), with a temporary increase of Federal Medical Assistance Percentage (FMAP) by 6.2 percentage points, which will last through the end of the federal emergency period. In accepting these funds, states cannot decrease enrollment/eligibility, but can change some benefits and provider organization payments.

Now is the time to assess these likely changes in coverage and their potential impact on organizational competitiveness and sustainability in the “new normal.” It takes planning, time, and money to build a direct-to-consumer practice. And on the health plan front, it takes 18 months to go from health plan outreach to new health plan revenue. Now is the time to get started.

People who have been confirmed with mild to moderate COVID-19 can leave their isolation without receiving a negative test, according to recently revised guidance from the Centers for Disease Control and Prevention. Increasing evidence shows that most people are no longer infectious 10 days after they begin having symptoms of COVID-19. As a result, the CDC is discouraging people from getting tested a second time after they recover.

For people who have tested positive but don’t have symptoms, isolation and other precautions can be discontinued 10 days after the date of their first positive test. There are exceptions for the 10-day guidance, including people with compromised immune systems who may be infectious for a longer period of time.

The Centers for Disease Control and Prevention is the leading national public health institute of the United States. It is a United States federal agency, under the Department of Health and Human Services, and is headquartered in Atlanta, Georgia.

For more information, please contact:

  • Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, Georgia, 30329-4027; 800-232-4636; Website:

The National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health (NIH), has established a new clinical trials network that aims to enroll thousands of volunteers in large-scale clinical trials. They will be testing a variety of investigational vaccines and monoclonal antibodies intended to protect people from COVID-19.

The COVID-19 Prevention Network (CoVPN) was established by merging four existing NIAID-funded clinical trials networks: the HIV Vaccine Trials Network (HVTN), based in Seattle; the HIV Prevention Trials Network (HPTN), based in Durham, North Carolina.; the Infectious Diseases Clinical Research Consortium (IDCRC) based in Atlanta; and the AIDS Clinical Trials Group based in Los Angeles. Those individual networks will continue to perform clinical trials for HIV vaccine and prevention and other infectious diseases in addition to their new COVID roles.

The network’s vaccine testing will be led by Larry Corey, M.D., of the Fred Hutchinson Cancer Research Center in Seattle, and Kathleen M. Neuzil, M.D., MPH, of the University of Maryland School of Medicine. The network’s monoclonal antibody clinical testing efforts will be led by Myron S. Cohen, M.D., of the University of North Carolina, Chapel Hill, and David S. Stephens, M.D., of Emory University in Atlanta. The HVTN, which is based at the Fred Hutchinson Cancer Research Center, will serve as the CoVPN’s operational center.

NIAID continues to pursue progress in understanding, treating, and preventing infectious and immunologic diseases, it recognizes that new challenges to public health continue to emerge. NIAID will continue its tradition of supporting innovative scientific approaches to address the causes of these diseases and find better ways to prevent, diagnose, and treat them.

For more information, please contact:

  • NIAID Office of Communications, 5601 Fishers Lane, MSC 9806, Bethesda, Maryland 20892-9806; 301-402-1663; Email:; Website:

Based on an assessment of coronavirus disease 2019 (COVID-19)-related job loss, it is estimated that approximately 10.1 million non-elderly adults in the United States will lose employer-sponsored health insurance as a result of job loss in their household by the end of December 2020. This equals approximately 21% of the estimated 48 million non-elderly people in the United States will be part of a household in which someone loses a job due to COVID-19, overall.

Projections show that approximately 3.3 million individuals who lose employer-related health insurance will regain employer-sponsored insurance by being added to a family member’s policy. About 2.8 million will enroll in Medicaid, and 600,000 people will enroll in the individual market, mainly via the Affordable Care Act’s marketplace. However, this still leaves approximately 3.5 million individuals who will be uninsured after December 2020, due to loss of employer-sponsored health insurance.

The researchers concluded that COVID-19 will widely affect the health insurance status of non-elderly adults in the U.S. This includes 10.1 million who will lose employer-sponsored health insurance, 16.3 million who will lose insurance through a family member’s employment, and almost 12.7 million who will lose health insurance the received through Medicaid or CHIP.

These findings were reported in “Changes in Health Insurance Coverage Due to the COVID-19 Recession: Preliminary Estimates Using Microsimulation,” by J. Banthin, M. Simpson, M Buettgens, L.J. Blumberg, and R. Wang for the Urban Institute. The researchers used projections data from the U.S. Department of Labor’s Health Insurance Policy Simulation Model, a detailed microsimulation model of the health insurance system designed to estimate the cost and coverage effects of proposed health care policy options. This model offers projections data on employment losses by industry, state, and demographic characteristics. The goal was to determine potential job loss related to the COVID-19 pandemic, and subsequent loss of employer-sponsored health insurance.

The full text of “Changes in Health Insurance Coverage Due to the COVID-19 Recession: Preliminary Estimates Using Microsimulation,” was published on July 13, 2020 by the Robert Wood Johnson Foundation. An abstract can be found at–preliminary-estimates-using-microsimulation.html.

PsychU last reported on this topic in “Nearly 27 Million Americans May Have Lost Job-Based Health Insurance Due To COVID-19; 42% Likely Eligible For Medicaid,” which published on May 26, 2020. The article can be found at

For more information, contact: 

  • Melissa Blair, Media Contact, Robert Wood Johnson Foundation, 50 College Road East, Princeton, New Jersey 8540-6614; 609-627-5937; Email:; Website:

“If we think what we are doing today will serve us tomorrow, then we will not be here tomorrow.” This comment, made at The OPEN MINDS 2020 Strategy & Innovation Institute keynote address, Innovation By Design: Capturing Value In Health Care, by Carl Clark, M.D., Chief Executive Officer, Mental Health Center of Denver (MHCD), are words of wisdom for every executive team member of a specialty provider organization. Innovation is no longer a luxury; it is a strategic survival skill.

The pandemic has sped the need for innovation in service delivery. On one hand, it has changed “customer preference” (both consumers and health plans) for services—more virtual, more home-based, and more data-driven. On the other hand, many organizations have been busy introducing new services designed for these changing times. There are four announcements below, each an example of a game changer for specialty provider organization market positioning:

  • Optum’s purchase of AbleTo. An online behavioral health service delivery system now owned by a major health insuring organization, UnitedHealth Group.
  • Heal’s launch of “Heal Pass.” A program that offers physician house calls and next day shipping of medications for a monthly fee of $49 dollars.
  • Mayo Clinic’s expansion of nationwide acute care services at home. Through a partnership with Medically Home and a new “hospital-at-home” advanced care platform, Mayo Clinic’s physicians can deliver high-intensity services to and remotely monitor consumers at home.
  • Quartet’s arrangement with health plans to support mental health and primary care integration through its virtual care platform and coordinated network of mental health professionals, and to use its technology platform to provide virtual tele-psychiatry and tele-therapy to members.

Certainly, these new service offerings aren’t appropriate for all consumers—many consumers with chronic conditions and complex needs will need another approach. But many will prefer these new options—and will embrace the convenience and value they offer. And more importantly, it is these competitive forces that will reshape the service delivery system and force provider organization managers to change their service line portfolio to remain sustainable. Innovation is the solution to this strategic dilemma. As Dr. Clark says, “Innovation is about figuring out how to get people what they need in a new way, when you can’t do the things the way you usually would.”

But how do you nurture a mindset of innovation? How do you embed it in the way you do business? And how do you scale for success? Dr. Clark described five fundamentals that provider organization executives should think about—strategy, culture, resources, partnerships, and agility.

Innovation is strategic. Innovation must be baked into your strategic planning. Dr. Clark advises that you start by asking the key questions. What is the problem you want to solve? What value does it bring (to the organization, to the community, to the consumers you serve)? Does the innovative solution align with your strategic plan? What resources do you need, and do you have the means to obtain them? What is the tolerance for risk within your organization?

At MHCD, innovation is driven by one key question—how to expand access to care. Only two in five people who need care for mental illness and addictions can access that care, says Dr. Clark. Therefore, they are solving so the three in five can also get care. They are thinking about how to expand the capacity of clinical professionals to see more people through technology supports that act as “force multipliers.”

“We look for conflict and complaints, which are opportunities to do something new and different,” explained Dr. Clark.

Innovation is a culture. A culture of innovation must start from the top but cascade down to every level of staff and those served. Executives at MHCD describe it as human-centered design engaging the people served to develop the solutions, cutting through the red tape to solve at the line level where possible, or escalating the issues quickly to the level where they can be solved. When the pandemic enforced remote work, managers at MHCD found a way to “skip the meetings and solve the problems” through daily huddles where quick decisions could be made.

Innovation also leverages input from consumers and the community. MHCD partnered with one of its local neighborhoods to create the Dahlia Campus for Health & Well-Being to support high risk youth in the community and bought four acres of land with the idea of establishing a 20,000 square foot clinic. But when they asked the community what it needed to thrive; more urgent problems became evident. There was a food desert and food swamps, with mostly junk food. MHCD could not solve for behavioral health issues without addressing the social determinants of health. So, they transformed the area into an urban farm with community gardens, a greenhouse, a teaching kitchen, a pre-school, and a pediatrics clinic. And when the kitchens had to close during the pandemic, they still found ways to get the food out. “Getting in with the community created something we never imagined,” said Dr. Clark.

Innovation needs resources. Initially, MHCD had a whole portfolio of ideas but did not dedicate the resources to nurturing them. “We had our core business and innovation was ‘other duties as assigned.’ It was like oil and water,” said Dr. Clark. It wasn’t until they created an Innovation Lab and dedicated funding and staff that they were able to make innovation happen. Today, MHCD invests 15% of its resources in innovation initiatives.

While not every provider organization might have the ability to scale innovation at the same level, a mindset of innovation will help executives get creative about funding. From talking to payers who are eager to support innovation to “crowdfunding,” the options are many when the solutions are evident.

Innovation thrives on partnerships. The resources to support innovation can come from strategic partnerships. Public-private partnerships have proved beneficial for MHCD and the communities it serves.

In 2016, MHCD set out on an ambitious project to help address the housing crisis in Denver (approximately 400 chronically homeless individuals were costing the city $11 million each year). The city issued social impact bonds to raise funds to build a 60-unit apartment building to house the homeless. And MHCD applied the “Housing First” model principles and offered trauma-informed approach to help design the apartments with personal safety in mind. Today, previously homeless consumers are staying in the apartments and either working or attending school.

Another innovative program that thrives on a public-private partnership is MHCD’s “co-responder” program where licensed clinical social workers (LCSWs) accompany police on a first visit when there are issues involving consumers with behavioral health challenges. This intervention at the first responder level helps get people into care quickly. MHCD piloted the program with six LCSWs and was able to reduce the number of people going to jail from 97% to 7% of encounters.

“Innovation enables us to get people what they need right at the moment they need it,” said Dr. Clark and informed us that once the pilot proved successful, they added 24 LCSWs to scale up the program for impact.

Innovation demands agility. For organizations just getting started on innovation, Dr. Clark recommended a rapid-fire process, “Come up with the idea, prototype it, test it, and figure out what worked well and what didn’t.”

There are two ways of thinking when it comes to innovation. The first is exploitative; taking something you already do and improving it. The second is exploratory; starting from scratch and making broad jumps. Exploration, while it can have a big pay off in the end, is risky. So, start small and leverage the resources you already have. As Dr. Clark suggested, “The innovative solution doesn’t have to be completely thought out before you start. Being agile is key—you can modify based on feedback as you go.” He also advised focusing on “the how” rather than “the what” and developing evidence-based practices right from the get-go.

Executives who support innovation must accept that failure is often part of the process. “In health care, we don’t want to make mistakes. But for an innovative culture to work, we must challenge people to take risks and make it okay if things don’t work out.

On July 6, 2020, the Internal Revenue Service (IRS) clarified that for-profit health care provider organizations must pay taxes on payments from the Provider Relief Fund created by the Coronavirus Aid, Relief, and Economic Security (CARES) Act. Non-profit health care provider organizations that receive Provider Relief Fund payments are generally exempt from paying taxes on the payment, according to the IRS. However, a non-profit provider organization may be subject to taxes on the payment if the provider organization used the payment to cover expenses or lost revenue attributable to an unrelated trade or business.

The IRS clarified the taxability of Provider Relief Fund payments in responses to frequently asked questions. The IRS also noted that health care provider organizations cannot exclude the payments from gross income as a qualified disaster relief payment, even if the business is a sole proprietorship. The payment must be included in gross income.

The Provider Relief Fund allocations are intended to help health care provider organizations cover lost revenue and increase costs during the public health emergency due to coronavirus disease 2019 (COVID-19). The federal Department of Health and Human Services has been distributing the funds since April 10, 2020. The most recent funding tranche, $15 billion for Medicaid and Children’s Health Insurance Program (CHIP) provider organizations, opened in late June 2020.

The data set of CARES Act Provider Relief Fund payments can be viewed online at

PsychU last reported on this topic in the following articles:

  • “HHS Begins Releasing $100 Billion CARES Act Funding To Provider Organizations For Relief Assistance & Treating The Uninsured,” which published on May 4, 2020, at
  • “24 Provider Organizations Receive Over $100 Million In CARES Act Provider Relief; New York & Presbyterian Hospital Tops The List,” which published on July 27, 2020, at
  • “$15 Billion HHS Relief Fund For Medicaid & CHIP Provider Organizations Is Open For Applications,” which published on August 10, 2020, at

For more information, contact:

  • Media Relations Office, Internal Revenue Service, 1111 Constitution Avenue Northwest, Washington, District of Columbia 20224; 202-317-4000; Website:

Shatterproof, a non-profit organization dedicated to reversing the addiction crisis in the United States, announced a free, first-of-its-kind tool to connect those in need with high-quality and appropriate addiction treatment.  ATLAS™, an Addiction Treatment Locator, Assessment, and Standards Platform, will launch in six states.

ATLAS evaluates addiction treatment facilities’ use of evidence-based best practices, allows consumers to see and provide feedback on their experience, and offers an easy-to-use online interface to allow those in need and their loved ones to search for and compare facilities using criteria such as location, services offered, and insurer so they can connect with appropriate treatment. ATLAS is currently available in Delaware, Louisiana, Massachusetts, New York, North Carolina, and West Virginia. The platform lists all of the state’s addiction treatment facilities for any addiction, including opioid use disorder, with more than half voluntarily providing information on services and practices they utilize.

Shatterproof worked with RTI International, an independent research institute with expertise in quality measure development, data collection, and quality reporting, to build ATLAS using a combination of rigorous analytic approaches and data collection innovations. ATLAS was funded by Arnold Ventures, the Robert Wood Johnson Foundation, and a coalition of national health care companies: Aetna, a CVS Health Company, Anthem, Inc., Beacon Health Options, Blue Cross Blue Shield of North Carolina, Cigna, Magellan Health, and UnitedHealth Group.

Shatterproof is a national non-profit organization dedicated to reversing the course of the addiction crisis in America. Shatterproof is focused on ensuring that addiction treatment is based upon proven research and ending the stigma of addiction. The organization advocates for changes to federal and state policy, payer reform, treatment quality assessment, and provides public education through online programs.

For more information, please contact:

  • Shatterproof, 135 West 41st Street, 6th Floor, New York, New York 10036; 800-597-2557; Email:; Website:

Following the 2016 rollout of self-scheduling of video and phone visits at Kaiser Permanente Northern California, 14% of appointments took place via phone or video telemedicine visits during 2016, 2017, and 2018. During these years, an average of 14% of appointments were selected as phone or video visits instead of office visits by health care consumers, and 7% of the telemedicine visits were by video.

Health care consumers were most likely to choose telemedicine or telephonic care if they were aged 18 to 44 years of age: about 49.4% of this demographic scheduled video visits, and 39.8% scheduled telephone visits. Those with an office visit copayment of $35 or more were 1.5 times more likely to choose a video or telephone visit than those with a $0 to $10 copayment. Consumers who were required to pay for parking in a garage structure for their visit were about 1.7 times more likely to choose a video or telephone visit than those who did not. Those who had prior experience with a video visit within the past year were about 11.4 times more likely to choose a video or telephone visit than those who had no prior experience.

The researchers concluded that health care consumers usually chose an in-person visit when scheduling an appointment through the online portal. However, telemedicine may allow health care professionals to reach vulnerable consumer groups, and may improve access for those with transportation, parking, or cost barriers when receiving on-site care.

These findings were reported in “Patient Characteristics Associated With Choosing a Telemedicine Visit vs Office Visit With the Same Primary Care Clinicians” by Mary E. Reed, DrPH; Jie Huang, Ph.D.; Ilana Graetz, Ph.D.; et al. The researchers analyzed 2,178,440 primary care appointments scheduled by 1,131,722 health care consumers after the 2016 rollout of self-scheduling for video and phone visits at Kaiser Permanente Northern California. The goal was to determine characteristics associated with those choosing between telemedicine or office visits.

The full text of “Patient Characteristics Associated With Choosing a Telemedicine Visit vs Office Visit With the Same Primary Care Clinicians” was published June 17, 2020, by JAMA Network Open. An abstract is available online at

PsychU last reported on telemedicine in “14% Of Physicians Used Telemedicine Video Visits Weekly Pre-COVID-19,” which published on June 29, 2020. The article is available at

For more information, contact: 

  • Mary E. Reed, DrPH, Research Scientist, Division of Research, Kaiser Permanente, 2000 Broadway, Oakland, California 94612; Email:; Website:

Unemployment is projected to increase homelessness by up to 45%, from 568,000 as of January 2020 to more than 800,000 people by the end of 2020, due to the coronavirus disease 2019 (COVID-19) public health emergency. The projection is based on the historic data trend indicating that for every percentage point increase in the unemployment rate, the rate of homelessness per 10,000 people increases by 0.65%.

Before the COVID-19 public health emergency began in mid-March 2020, the national unemployment rate in February was 3.5%. The Bureau of Labor Statistics reported that the unemployment rate rose to 14.6% in April. As of June, the unemployment rate had dropped to 11.1%.

These estimates were reported in “Analysis On Unemployment Projects 40-45% Increase In Homelessness This Year” by Brendan O’Flaherty, Ph.D., for Community Solutions, a non-profit organization focused on reducing homelessness. It leads Built for Zero, a movement of more than 80 cities and counties using data to radically change how they work and the impact they can achieve to reduce homelessness to “functional zero.” Dr. O’Flaherty analyzed data from the Annual Homeless Assessment Report to Congress (AHAR) from January 2019, which provides an annual estimate of people experiencing homelessness in the United States, nationally and by state. That number was used as the baseline for the model projecting the impact of unemployment. The model drew on projections of unemployment published by the Economic Policy Institute, which in early April projected 15.6% unemployment in July 2020 due to the effects of COVID-19. The EPI estimate was similar to the 16% unemployment projected by the Congressional Budget Office for July 2020.

Dr. O’Flaherty used the AHAR homelessness baseline and the Economic Policy Institute unemployment projections as inputs in a calculation of the relationship between unemployment and homelessness. The formula was developed by Kevin Corinth, Ph.D., and published in 2017 in “The impact of permanent supportive housing on homeless populations,” by the Journal of Housing Economics.

The full text of “Analysis On Unemployment Projects 40-45% Increase In Homelessness This Year” was published in May 2020 by Community Solutions. A copy is available online at

For more information, contact:

  • Brendan O’Flaherty, Ph.D., Professor, Urban Economics, Columbia University, 420 West 118th Street, 1022 International Affairs Building, Mail Code 3308, New York, New York 10027; 212-854-2449; Email:; Website:
  • Maya Acharya, Social And Press Coordinator, Community Solutions, 60 Broad Street, Suite 2510A, New York, New York 10004; 646-797-4370; Email:; Website:

As a result of the coronavirus disease 2019 (COVID-19) pandemic, Sigma Mental Health Urgent Care is expanding access to mental health care across the state of Texas through their proprietary, HIPAA complaint platform. Sigma’s platform allows a psychiatrist to conduct an appointment virtually with the same quality and efficiency as a face-to-face appointment.

Sigma will also handle prescriptions remotely through the virtual platform. According to Melissa Deuter, M.D., board-certified psychiatrist and founder of Sigma Mental Health Urgent Care, the response to the new methodology has been exceptionally well received and the transition has been seamless, as the telehealth model allows Sigma clinical professionals to obtain a full view of an individual’s mental health and well-being (e.g., weight loss or gain) for the most effective treatment.

Sigma Mental Health Urgent Care provides mental health evaluations, short-term counseling, psychopharmacological services, and referrals for longer-term care when necessary. The mission of Sigma Mental Health Urgent Care Center is to improve the lives of people living with mental health disorders by providing immediate psychiatric and therapeutic services during moments of crisis as well as creating a continuity of care between our staff members and other mental health provider organizations in the community.

For more information, please contact:

  • Sigma Mental Health Urgent Care, 18587 Sigma Road, Suite 260, San Antonio, Texas 78258; 210-314-4564; ​Email:; Website:

Kroger Health, the health care division of The Kroger Co., announced the U.S. Food and Drug Administration (FDA) has granted Emergency Use Authorization for the COVID-19 Test Home Collection Kit. The testing solution combines the safety and convenience of at-home sample collection with the expert guidance of a telehealth consultation to help improve the quality of the collection process.

Kroger Health’s COVID-19 Test Home Collection Kit is available to frontline associates across Kroger’s Family of Companies, based on medical need. In partnership with Gravity Diagnostics, a full-service clinical laboratory located in Covington, Kentucky, Kroger Health plans to rapidly expand the availability of the home collection kits to other companies and organizations in the coming weeks, with a goal of processing up to 60,000 tests per week by the end of July. The Kroger Health COVID-19 Test Home Collection Kit will initially be available in Arizona, Colorado, Georgia, Indiana, Kansas, Kentucky, Michigan, Montana, Nevada, New Mexico, Ohio, Tennessee, Utah, and Virginia. Additional states will be added in the coming weeks. Kroger Health launched public drive-thru and walk-up COVID-19 testing sites in April. Since then, Kroger Health has administered more than 100,000 tests across 19 states.

Kroger Health, the health care division of The Kroger Co., is a retail health care organization with over 2,000 pharmacies and 200 clinics in 35 states serving more than 14 million customers. Kroger Health is comprised of a team of 22,000 health care practitioners including pharmacists, nurse practitioners, dietitians, and technicians.

For more information, please contact:

  • The Kroger Co., 1014 Vine Street, Cincinnati, Ohio 45202-1100; 513-762-4000; Website:

Center on Addiction has changed its name to Partnership to End Addiction. In tandem, it has launched a new brand identity and redesigned website at The changes are part of an evolution following the 2019 merger of two distinguished leaders in the addiction space. They also align with the organization’s ongoing efforts to address community needs at a time of increased national uncertainty exacerbating the addiction crisis.

The new website provides critical information for families impacted by addiction, as well as policymakers, researchers, and health care professionals in the addiction space. Family members seeking guidance and information can access the organization’s educational content on treatment, recovery, and prevention in addition to one-on-one support from trained helpline specialists. They can also learn about advocating for policy changes, leading efforts in their own communities, and volunteering with the organization. Professionals in government, research, and health care can engage with the organization’s state- and federal-level policy and advocacy work, professional services, partnership opportunities, and addiction research and science.

Partnership to End Addiction’s updated logo, a combined heart and check, reflects its unique approach to ending addiction with a mix of heart and science, compassion, and expertise. Its new brand design demonstrates the broad spectrum of the non-profit’s activities and its evolution as a combined organization now working on all fronts to solve our nation’s addiction crisis.

Partnership to End Addiction is a national non-profit providing personalized support and resources for families impacted by addiction. With decades of experience in direct services, communications and partnership-building, the organization mobilize families, policymakers, researchers, and health care professionals to more effectively address addiction systemically on a national scale.

For more information, please contact:

  • Partnership to End Addiction, 485 Lexington Avenue, 3rd Floor, New York, New York 10017-6706; 212-841-5200; Email:; Website:

On June 18, 2020, Humana announced that its “Bold Goal” initiative focused on social determinants of health continues to show improvement in population health five years after its introduction. The program works to improve the average number of “Healthy Days” by screening for and addressing members’ upstream social needs like food insecurity (inability to obtain proper nutrition), transportation problems, and loneliness (a discrepancy between an individual’s desired and actual social relationships, whether in their quality or quantity). Under the Bold Goal initiative, Humana has provided more than 2.6 million social determinant screenings. Each member screened had an average of 3.5 health-related social needs.

Humana Medicare Advantage members across all markets improved on the Healthy Days measure between 2015 and 2019. In the seven original Bold Goal communities, Medicare Advantage members reported 2.3% fewer unhealthy days, from an average of 13.58 days per month in 2015 to an average of 13.27 days per month in 2019. In non-Bold Goal communities, the average number of unhealthy days rose by 0.2%, from 13.42 days to 13.45 days. In five of the seven original Bold Goal communities (San Antonio, Texas; Baton Rouge and New Orleans, Louisiana; Tampa, Florida; and Knoxville, Tennessee), Humana Medicare Advantage members experienced fewer unhealthy days in 2019 than in 2015. In two Bold Goal communities (Louisville, Kentucky and Broward County, Florida), the average number of unhealthy days rose, which Humana attributed in part to growth of new membership in higher-risk populations in those markets.

Humana Medicare Advantage Improvement On Healthy Days Metric, 2015 To 2019, In Bold Goal Communities
Area 2015 Average Number Of Unhealthy Days In The Past 30 Days 2019 Average Number Of Unhealthy Days In The Past 30 Days Percent Change
Non-Bold Goal Communities 13.42 13.45 +0.2%
Seven Original Bold Goal Communities 13.58 13.27 -2.3%
San Antonio, Texas 14.69 13.43 -8.6%
Baton Rouge, Louisiana 13.72 13.10 -4.5%
New Orleans, Louisiana 13.38 13.09 -2.2%
Tampa, Florida 12.93 12.44 -3.7%
Knoxville, Tennessee 14.14 13.83 -2.2%
Louisville, Kentucky 12.66 13.60 +7.4%
Broward County, Florida 14.13 14.21 +0.6%

In some Bold Goal communities, Humana monitored the effects on Medicare Advantage members with specific chronic health conditions. Members with chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD), depression, congestive heart failure (CHF), and hypertension are experiencing a decrease in unhealthy days compared to the prior year. Humana believes that the decrease is due to integration of procedures to identify and address health-related social needs along with health conditions, both physical and mental, in care management. Between 2015 and 2019, the number of unhealthy days declined as follows:

  • COPD: 1.2% fewer unhealthy days
  • CAD: 1.8% fewer unhealthy days
  • Depression: 2.9% fewer unhealthy days
  • CHF: 3.1% fewer unhealthy days
  • Hypertension: 3.2% fewer unhealthy days

The Bold Goal initiative uses the Centers for Disease Control and Prevention’s (CDC’s) Healthy Days tool to measure population health-related quality of life. The method for estimating unhealthy days is supported by the actual pattern of survey responses to questions regarding self-reported physical health (physical illness and injury) and mental health (stress, depression, and problems with emotions) during the 30 days prior to the survey.

Humana Inc. is a for-profit health insurance company with more than 13 million covered lives in the United States. The “Bold Goal” initiative, which began in 2015, tracks individuals’ unhealthy days for individuals and populations. The goal of the initiative was to target these social determinants of health and, community behavioral health, to help the communities Humana serves become 20% healthier by 2020 and beyond. Having reached that goal for its associates, Humana set a further goal to achieve 500,000 more “healthy days” by the end of 2022.

Since launching the Bold Goal initiative in the seven original communities, Humana has expanded the initiative to 16 total markets. In 2018, it expanded to Chicago, Illinois; Kansas City, Missouri and Kansas; Jacksonville, Florida; and Richmond, Virginia. In 2019, it expanded to Detroit, Michigan; Cincinnati, Ohio; Charlotte, North Carolina; Atlanta, Georgia; and Houston, Texas.

The full text of “2020 Bold Goal Progress Report, Data Trends” was published in June 2020 by Humana. A copy is available online at  An interactive version is posted online at

PsychU last reported on this topic in “Screening Humana Medicare Advantage Members For Social Determinants Of Health Reduced ‘Unhealthy Days’ By 2.7%,” which published on June 10, 2019. The article is available at

For more information, contact:

  • Alex J. Kepnes, Corporate Media Relations, Humana, 500 West Main Street, Louisville, Kentucky 40202; Email:; Website:

The Centers for Medicare and Medicaid Services (CMS) made big news once again. On June 17, CMS issued a proposed rule to grant state Medicaid programs and other payers flexibility to enter value-based payment (VBP) arrangements with drug manufacturers. The rule’s definition of VBP is an arrangement intended to align payments to therapeutic or clinical value in a population, such as evidence-based measures. The cost should be linked to existing evidence of the effectiveness and/or outcomes-based measures. Or payment should be linked to the drug’s actual performance in a consumer or a population—such as reduction in medical expenses.

A significant change is that the proposed rule allows medication manufacturers to report multiple “Best Prices” for a medication. The current Federal reporting requirements for medication prices are byzantine in my view and an impediment to rational pricing. In short, under the current Federal reporting requirements, manufacturers must report to CMS their drug’s “Best Price”—the lowest net price a manufacturer offers for the medication in the U.S. after factoring in all rebates and discounts. Manufacturers then pay Medicaid programs a rebate equal to 23.1% of a drug’s “Average Manufacturer Price” if that amount of rebate results in a net price lower than or equal to the Best Price. This is intended to assure that the post-rebate price to Medicaid programs is no more than the Best Price available on the commercial market.

This pricing situation makes manufacturers hesitant to participate in VBP. Under the proposed rule, instead of reporting a Best Price depending on a single outcome, manufactures will be allowed to use “bundled sale” price reporting. This would permit reporting of Best Price as the average net price across all sales prices. This would change Best Price to be the lowest average price that any payer actually pays per unit, including both failures and successes. And CMS is planning an alternative to the bundled sale pricing reporting. The proposed rule would allow commercial health insurers to pay different prices for a medication based on outcomes. The manufacturer would then report the lowest price that any payer negotiates for each outcome as a Best Price, as well as the lowest available price absent a VBP arrangement.

CMS Administrator Seema Verma, in her Health Affairs blog post, CMS’s Proposed Rule On Value-Based Purchasing For Prescription Drugs: New Tools For Negotiating Prices For The Next Generation of Therapies, explained the goals of the proposed rule changes: “Value-based payment in health care involves basing payment on improvements in patient outcomes….However, value-based payment for prescription drugs is still in its infancy….Today, payment for much of health care including pharmaceuticals is based primarily on volume. Volume drives negotiations; the greater the quantity of a manufacturer’s product that a payer sells, the larger the rebate that the payer usually receives from the manufacturer….Today’s proposal would empower commercial plans to negotiate based on value while extending these discounts to Medicaid programs….All Medicaid programs in the country would immediately benefit from these private market deals without having to design the arrangements themselves, as Medicaid programs would only have to pay the lowest price offered for each outcome if they chose to participate.”

With so much happening, this is probably not a top-of-mind issue for most provider organization executives. Some would argue, however, if adopted at scale, there are many implications. Generally, there are concerns that this model of VBP will limit consumer medication choices. There is also the chance that the selected performance measures will “bend” treatment patterns, with preference for certain types of programs.

But most would still add this to the list of new opportunities. For most of these arrangements, “value” will be demonstrated through reduced emergency department use, reduced use of inpatient care, fewer inpatient admissions, cutting inpatient length of stay, and improving (or achieving) particular health status measures—all achieved through the use of the “best” medications, used in the “best” way.

Put it this way—to achieve those performance measures, consumers need to take the medication, take the medication correctly, and integrate the medication into their overall disease management plan. To make that happen, pharmaceutical companies will need provider organization partners with expertise in those disease states, consumer treatment planning and care coordination, and outreach and engagement. As these regulatory changes roll out, VBP for medications will likely open the door to a variety of solutions to achieve these best practices, such as packaging digital technologies, professional services, and support services into programmatic solutions for consumers. The key will be to find these new opportunities—likely through partnerships—to operate in yet another health care market focused on value.

Icertis, an enterprise contract management platform in the cloud, announced Humana selected Icertis as its contract management platform to increase visibility and enterprise-wide efficiency, while reducing cycle time. To meet the demands of the fast-moving, highly-regulated health insurance industry, Humana needed to modernize its manual contract processes with an intelligent, easy-to-use contract management solution that could help it manage intercompany agreements between its insurance group and its health care services, wellness, and care delivery organization business units. Humana will use the Icertis Contract Management (ICM) platform to standardize contract management processes, perform amendments to legacy contracts and create a single source of truth for all intercompany agreements while ensuring compliance with the company’s strict security and data privacy policies.

Health care payers rely on intercompany agreements to manage transfers of assets, liabilities, and risk between subsidiaries and must maintain strict records of these transactions to meet legal audit requirements. Humana selected Icertis due to the contract management leader’s prior experience with leading health care brands like AbbVie, Australian Unity, Johnson & Johnson, Merck and Sanofi and ability to manage all contract types from across its diverse business groups in a central repository.

Icertis is an enterprise contract management platform in the cloud that helps companies unlock the full business value of their contracts to increase revenue, reduce cost, accelerate cash flow, and minimize risk. The adaptable, AI-infused Icertis Contract Management platform quickly turns contracts from static documents into strategic assets.

Humana Inc. is a for-profit American health insurance company based in Louisville, Kentucky. As of 2014, Humana had over 13 million members in the U.S.

For more information, please contact:

  • Haley Flanagan, Manager of Corporate Communications, Icertis; 14711 NE 29thPlace, Suite 100, Bellevue, Washington 98007; 425-869-7649; Email:; Website:
  • Contact information: Kelley Murphy, Humana Corporate Communications, Humana, Inc., 500 W Main Street, Louisville, Kentucky 40202; 502-224-1755; Email:; Website:

Following the 2016 rollout of self-scheduling of video and phone visits at Kaiser Permanente Northern California, 14% of appointments took place via phone or video telemedicine visits during 2016, 2017, and 2018. During these years, an average of 14% of appointments were selected as phone or video visits instead of office visits by health care consumers, and 7% of the telemedicine visits were by video.

Health care consumers were most likely to choose telemedicine or telephonic care if they were aged 18 to 44 years of age: about 49.4% of this demographic scheduled video visits, and 39.8% scheduled telephone visits. Those with an office visit copayment of $35 or more were 1.5 times more likely to choose a video or telephone visit than those with a $0 to $10 copayment. Consumers who were required to pay for parking in a garage structure for their visit were about 1.7 times more likely to choose a video or telephone visit than those who did not. Those who had prior experience with a video visit within the past year were about 11.4 times more likely to choose a video or telephone visit than those who had no prior experience.

The researchers concluded that health care consumers usually chose an in-person visit when scheduling an appointment through the online portal. However, telemedicine may allow health care professionals to reach vulnerable consumer groups, and may improve access for those with transportation, parking, or cost barriers when receiving on-site care.

These findings were reported in “Patient Characteristics Associated With Choosing a Telemedicine Visit vs Office Visit With the Same Primary Care Clinicians” by Mary E. Reed, DrPH; Jie Huang, Ph.D.; Ilana Graetz, Ph.D.; et al. The researchers analyzed 2,178,440 primary care appointments scheduled by 1,131,722 health care consumers after the 2016 rollout of self-scheduling for video and phone visits at Kaiser Permanente Northern California. The goal was to determine characteristics associated with those choosing between telemedicine or office visits.

The full text of “Patient Characteristics Associated With Choosing a Telemedicine Visit vs Office Visit With the Same Primary Care Clinicians” was published June 17, 2020, by JAMA Network Open. An abstract is available online at

PsychU last reported on telemedicine in “14% Of Physicians Used Telemedicine Video Visits Weekly Pre-COVID-19,” which published on June 29, 2020. The article is available at

For more information, contact: 

  • Mary E. Reed, DrPH, Research Scientist, Division of Research, Kaiser Permanente, 2000 Broadway, Oakland, California 94612; Email:; Website:

On June 24, 2020, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) launched Accelerate to Value, a comprehensive program to help independent primary care practices deal with financial challenges related to coronavirus disease 2019 (COVID-19). The program provides financial stabilization payments starting in September 2020 based on the primary care practice’s 2019 revenue. In exchange for receiving the payments, the practice must commit to transitioning to value-based care by the end of 2020. Starting in 2022, the participating practices will be eligible to receive monthly population-based capitated payments, rather than fee-for-service reimbursement.

To participate in the Accelerate to Value program, applications must be submitted by July 31, 2020. Participating practices will have two options:

  • Join an existing accountable care organization through a Blue Premier clinically integrated network.
  • Join Aledade, a company that helps primary care practices move to value-based care.

Accelerate to Value is intended for independently owned and operated primary care practices, including internal medicine, family medicine, pediatrics, geriatrics, multispecialty, and/or OB-GYN. Practices owned by hospitals and health systems are not eligible. Through the duration of the program, participating practices will take steps to improve clinical quality for Blue Cross NC members, including ensuring access to care, adopting and expanding telehealth, using electronic health records, and delivering preventive care and care coordination activities responsive to the COVID-19 pandemic. Practices that meet program requirements will receive a new contract amendment from Blue Cross NC.

Blue Cross NC serves more than 3.8 million covered lives. The organization is an independent licensee of the Blue Cross and Blue Shield Association.

For more information, contact: 

  • Accelerate to Value, Blue Cross and Blue Shield of North Carolina, 1965 Ivy Creek Boulevard, Durham, North Carolina 27707; Email:; Website:

There is a lot of telehealth going on. Medicare has temporarily increased access through the Medicare 1135 waiver, which covers all office visits provided via telehealth in any setting throughout the country, for any physical or mental health service; has suspended enforcement of the “established-relationship” requirement; and added 85 more physician procedure codes. All provider organizations that are eligible to bill Medicare for their professional services can now deliver telehealth.

In Medicaid, most state regulations have been relaxed to provide more telehealth services for beneficiaries, including: the health care professional’s home can serve as a distance site; new consumers (i.e., those not previously receiving telehealth) are able to receive telehealth services; new HIPAA procedures for smart phones and previously non-compliant applications are allowed for telehealth services; verbal consent can be given in lieu of written consent; and telephone-only encounters. In total, 44 states have modified their Medicaid state plans to authorize the coverage of telehealth services for Medicaid beneficiaries.

In a new OPEN MINDS survey, they looked at what has been happening in health plans. What did they find? Approximately 95% of health plans report waiving cost-sharing requirements for beneficiaries. 42% of health plans have contracted with out-of-state or out-of-network provider organizations to deliver telehealth services. They also identified that approximately 22% of health plans are reimbursing provider organizations for telehealth services at the same rate as face-to-face interactions, and 45% of health plans have modified their benefits during the COVID-19 outbreak, including eliminating co-pays, reimbursing the same as in-person, and making treatment related to COVID-19 free.

They also looked at the specialty managed behavioral health organizations (MBHOs)—approximately 46% of MBHOs have reported policy or provision changes since the COVID-19 outbreak. 21% of MBHOs have modified their service delivery to waive cost-sharing requirements and approximately 18% have contracted out-of-state or out-of-network provider organizations to deliver telehealth services. And 18% are reimbursing provider organization for telehealth services at the same rate as face-to-face interactions.

But the big planning question for provider organization management teams is what will happen after the crisis period ends? We have seen health plans set expiration dates on the expanded telehealth benefits, but those dates have been repeatedly moved—for example, Blue Cross Blue Shield of Texas has moved their cut-off date three times. Some states like Colorado and Idaho have made the telehealth expansion permanent. At the federal level, there is still no concrete plan on how long the current benefits will last, but earlier this month, 38 senators released an open letter asking U.S. Secretary of Health and Human Services Alex Azar and Centers for Medicare and Medicaid Services Administrator Seema Verma to provide a plan to make the expanded telehealth access permanent. And as Ms. Verma said earlier in the crisis, “the genie is out of the bottle” and there is no going back.

Yesterday, OPEN MINDS hosted a private roundtable briefing, Telehealth – What Will The Payers Change Post-COVID-19? Let’s Ask Them: An OPEN MINDS Executive Roundtable, for their Elite members of OPEN MINDS Circle on this topic. The faculty—Deborah Adler, Senior Associate at OPEN MINDS; Kathleen Mahieu, Director of Digital Product Innovation and Strategic Partnerships at Aetna Mental Wellbeing; Sean Schreiber, Executive Vice President of Network and Community Health at Alliance Health; Amy Pearlman, Vice President of Clinical Provider Strategy at Beacon Health Options; and Roberta Montemayor, Director of Telemental Health Innovation for Network Strategy Optum Behavioral Health—provided a few key takeaways about what managers can expect in the future.

Payers will continue to offer provisions to encourage telehealth but need to see the value. They need performance measures that demonstrate clinical effectiveness and engagement. They need to know if telehealth services are delivering the same quality and clinical outcomes that face-to-face services can. They need to see if consumers are staying engaged. For example, Mr. Schreiber explained, “We are seeing increased engagement for individuals already involved in care grow over time, but we aren’t seeing as much growth of new members coming into care. The focus needs to be on what the barriers are and how providers are handling bringing new members into care via telehealth, as we see a decrease in new member access and fewer new assessments.”

Payers also noted that the focus on quality and performance will likely expand from the individual-level to a programmatic level, Ms. Pearlman noted that Anthem/Beacon has been asking questions like “How are you being thoughtful in terms of standard operating procedures? How do you handle a crisis?” She noted, “These are the types of programmatic questions that will look different over telehealth than when someone is in the room with you.”

A Coalition of leading addiction and mental health advocacy groups and stakeholder organizations announced the launch of the Recovery Access Coalition to address the barriers to accessing potentially life-saving digital therapeutics authorized by the U.S. Food and Drug Administration (FDA) to treat addiction disorder, like prescription digital therapeutics (PDTs). Members of the Coalition include Advocates for Opioid Recovery, Global Recovery Initiatives Foundation, the Kennedy Forum, the National Council for Behavioral Health, Shatterproof, and Young People in Recovery. Pear Therapeutics, Inc. is a member and sponsor of the initiative.

Digital therapeutics, including PDTs, have a critical role to play for people in recovery. Under current circumstances, the advantages of digital therapeutics to people with addiction treatment needs, and their clinicians, are significant. Digital therapeutics can treat people without physical proximity, extend care over distances, promote deeper connection between people and their care team, and empower people to strengthen their self-assessment skills and better navigate their care. The Recovery Access Coalition is advocating for Medicare coverage of FDA authorized digital therapeutics at the federal level, for Medicaid coverage at the state level, and for broad coverage across the commercial health insurance market. According to the Coalition, policymakers have the rare opportunity to embrace a clinically validated, FDA-authorized therapeutic solution that already exists and is made for the challenges and demands of the moment.

The Recovery Access Coalition aims to eliminate barriers to access for FDA authorized digital therapeutics for addiction disorder. Specifically, the Coalition is seeking policy changes in Medicare, Medicaid, and the commercial insurance market to authorize coverage for digital therapies, including prescription digital therapeutics, for addiction treatment. The goal of the Coalition is to increase policymakers’ awareness of the dire need for digital therapy for substance use disorder, educate policymakers about the value, safety, and efficacy of digital therapeutics in providing needed treatment digitally and promote greater consumer access to and adoption of FDA authorized digital therapeutics for addiction.

For more information, please visit:

  • The Recovery Access Coalition, Website:

On July 17, 2020, the North Carolina Department of Health and Human Services (NCDHHS) announced it has selected 39 vendors, among them health and human service provider organizations, to conduct testing and contact tracing for coronavirus disease 2019 (COVID-19). These organizations represent the state’s initial pool of qualified vendors to support the state’s response to COVID-19. NCDHHS selected the first group of 26 organizations on June 19 and selected 13 more on July 17, 2020.

The state is using a rolling qualification process and vendors will be able to submit a response by the first of every month through December 2020. The goal is to help NCDHHS surge resources such as testing, lab capacity, and contact tracing to respond to the COVID-19 pandemic. Organizations could apply to be qualified for individual or multiple components.

The first areas of work focus on testing all residents and staff of nursing homes and significantly increasing testing for African American/Black, LatinX/Hispanic, Native American, and refugee populations in ZIP codes that lack access to testing sites. Historically marginalized populations are being disproportionately impacted by COVID-19 due to long standing health inequities that NCDHHS is addressing proactively as it responds to the pandemic.

Testing and lab capacity: The state is focusing on supporting historically marginalized populations, testing in congregate living facilities, testing in areas with outbreaks, addressing low-tested counties or communities, and supporting businesses and their workforce. Qualified vendors for testing and laboratory reserve capacity include:

  1. CW Williams Community Health Care Center
  2. EGL Genetic Diagnostics
  3. Laboratory Corporation of America Holding
  4. Omnicare, a CVS Health Company
  5. Orig3n, Inc
  6. United Providers of Health LLC
  7. University Health System of East Carolina

Qualified vendors for testing only include:

  1. Cone Health
  2. Groundwater Solutions
  3. Mako Medical
  4. North Carolina Community Health Center Association
  5. Piedmont Health Services and Sickle Cell Agency
  6. Substance Abuse Treatment Labs
  7. Visit Healthcare

Qualified vendors for lab capacity only include:

  1. Kashi Clinical Laboratories
  2. Mako Medical
  3. Substance Abuse Treatment Labs

Contact tracing: NCDHHS sought vendors who represent the communities and people impacted by COVID-19 to build on the work of local health departments. Contact tracing identifies people who have recently been in close contact with someone who has tested positive for COVID-19. Qualified vendors for contact tracing include:

  1. 22nd Century Technologies
  2. Agile Government Services, Inc.
  3. AM LLC
  4. Arbor/Res-care
  5. Atrium Staffing
  6. Automated Health Systems
  7. BizTechPeople LLC
  8. CW Williams Community Health Care Center
  9. Computer Aid Inc (CAI)
  10. Conduent State Healthcare LLC
  11. Global Contact Services
  12. Grace Federal Solutions LLC
  13. Groundwater Solutions
  14. Intellect Resources
  15. Jennifer Temps, Inc
  16. K4 Solutions Inc
  17. Keystone Peer Review
  18. Maximus Health Services
  19. Medical Edge Recruitment LLC
  20. Piedmont Health Services and Sickle Cell Agency
  21. PRC
  22. Public Consulting Group Inc
  23. ResponsePoint
  24. SouthEastern Healthcare of NC
  25. Spanish Speaking LLC
  26. SWC Group LLP dba Healthcare Solutions
  27. WellSky

From March 1, 2020 through July 20, more than 100,000 North Carolina residents have been diagnosed with COVID-19. There have been 1,642 deaths due to COVID-19. Of the more than 1.4 million tests conducted through July 20, about 7% have been positive for COVID-19.

For more information, contact:

  • Mandy Cohen, Secretary, North Carolina Department of Health and Human Services, 101 Blair Drive, Adams Building, 2001 Mail Service Center, Raleigh, North Carolina 27699-2001; 919-855-4840;  Email:; Website:

The Centers for Medicare & Medicaid Services (CMS) is preparing to allow Medicare home health provider organizations to continue using telehealth to provide home health services as they have been under relaxed regulations due to the coronavirus disease 2019 (COVID-19) public health emergency. The goal is to give home health provider organizations predictability in their service delivery options, and to ensure that Medicare beneficiaries continue to have access to the latest treatment technologies.

These proposed changes are among the first flexibilities provided during the COVID-19 public health emergency that CMS is proposing to make a permanent part of the Medicare program. After the public health emergency ends, home health provider organizations will be able to continue to report the costs of telecommunications technology as allowable administrative costs on the home health provider organization cost report.

The telehealth services must be related to the skilled services being furnished, must be outlined in the beneficiary plan of care, and must be tied to a specific goal indicating how such use would facilitate treatment outcomes. Telehealth cannot be used as a substitute for an in-person home visit that is ordered in the plan of care and cannot be considered a visit for the purpose of determining eligibility or payment.

The proposed rule was issued on June 30, 2020, “Medicare and Medicaid Programs; CY 2021 Home Health Prospective Payment System Rate Update; Home Health Quality Reporting Requirements; and Home Infusion Therapy Services Requirements.” Comments will be accepted through August 31, 2020. Additional topics in the proposed rule include the following:

  • Routine, statutorily required updates to the home health payment rates for calendar year 2021. CMS estimates a 2.6% aggregate increase in Medicare payments to home health provider organizations, totaling about $540 million.
  • Updates to the home health wage index including the adoption of revised Office of Management and Budget (OMB) statistical area delineations and limiting any decreases in a geographic area’s wage index value to no more than 5% in calendar year 2021.
  • Implement Medicare enrollment policies for qualified home infusion therapy suppliers and proposes updates to the calendar year 2021 home infusion therapy services payment rates using the calendar year 2021 Physician Fee Schedule amounts.

A link to the full text of “Medicare & Medicaid Programs; CY 2021 Home Health Prospective Payment System Rate Update; Home Health Quality Reporting Requirements; and Home Infusion Therapy Services Requirements” may be found at

A link to the full text of “Home Health Agencies: CMS Flexibilities To Fight COVID-19” may be found at

PsychU last reported on this topic in the following articles in “Medicare Further Expands Telehealth Access For Long-Term Care, Hospice & Home Health Benefits,” which published on May 18, 2020, at

For general information about the Home Health PPS, contact:

  • Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; Email:; Website:; or Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145;  Fax: 202-260-1462; Website:

About 17% of accountable care organizations (ACOs) are developing new home visit programs, according to topline results of a recent survey of 163 ACOs. About 26% of ACOs already have a home visit program. Another 25% conduct home visits, but do not have a formal program. About 32% said they had no plans to start a home visit program.

The majority of ACOs that have or that are developing a home visit program use it to deliver primary care. According to survey responses, other reasons for home visit programs are part of a hospital-at-home model, to support care coordination, or to support transitions from inpatient or residential settings to home care. A minority of programs are intended to address social determinants of health.

The survey was conducted from September 2019 through the start of January 2020 by the Institute for Accountable Care (IAC) and West Health Institute with members of the National Association of ACOs (NAACOS). Responses were received from 163 ACOs. The majority are participating in the Medicare Shared Savings Program; a few are participating in the Next Generation ACO program.

The survey results are being submitted to a peer-reviewed journal. Summary results were reported on July 5, 2020, in “Nearly 70% of ACOs Will Soon Offer Some Type of Home Visits” by Bailey Bryant for Home Health Care News. The article is posted at

For more information, contact:

  • David Pittman, Health Policy and Communications Advisor, National Association of Accountable Care Organizations, 601 13th Street Northwest, Suite 900 South, Washington, District of Columbia 20005; 202-640-2689; Email:; Website: 

On June 2, 2020, Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) announced it had expanded its Horizon Neighbors in Health (HNIH) demonstration project that addresses social determinants of health (SDOH). Horizon BCBSNJ partnered with six health systems to expand the program to members in 70 ZIP Codes across 11 counties (Bergen, Essex, Hudson, Mercer, Monmouth, Morris, Ocean, Passaic, Sussex, Union, and Warren). The health systems are Atlantic Health Systems, Hackensack Meridian Health, RWJ Barnabas Health, the Trenton Health Team, University Hospital, and St. Joseph’s Health. Each health system received grants to hire and train local community health workers; in total 60 will be hired. Over three years, Horizon BCBSNJ anticipates that the health systems will enroll 24,000 members covered by its commercial, Medicaid, or Medicare Advantage plans.

The community health workers use an online platform called NowPow to connect Horizon BCBSNJ members with an array of non-medical services such as food, housing, mental health support, education, or employment opportunities. The program is intended to help Horizon BCBSNJ members connect to services and resources, obtain what they need to improve their health, and maintain the connections independently. Through this program, Horizon BCBSNJ seeks to demonstrate and quantify the impact of using community health workers to help members connect to SDOH on member health and on the total cost of care.

Horizon BCBSNJ is providing $25 million to over three years to fund HNIH. The funding pays for 50% of the community health worker salaries, and half of the salaries for their managers and directors. It will cover 100% of the cost for training and certification for the community health workers, and 100% of the cost of the NowPow data platform. Horizon BCBSNJ makes quarterly payments to its partners based on the number of community health workers and management staff that are predetermined to be hired. The HNIH staffing level varies by partner depending on the number of members the partner seeks to enroll in the program.

Since April 2017, Horizon BCBSNJ has piloted a version of HNIH with Robert Wood Johnson Barnabas Health’s Newark Beth Israel Medical Center. In total, the pilot reached out to assist 1,000 Horizon members living in four ZIP Codes within the medical center’s service area. In early 2019, Horizon BCBSNJ reported that for the participating members, the pilot cut their aggregate total cost of care by 25% as of October 2018. The participants had 20% fewer hospital inpatient admissions and 24% fewer emergency department visits. Their visits to behavioral health professionals increased by 35%. In 2019, Horizon began inviting other health systems across the state to participate to expand HNIH statewide.

To identify potential HNIH participants, Horizon BCBSNJ uses advanced analytics and predictive modeling that consider individual and community factors gleaned from census data, claims data, and other data sources that provide a comprehensive profile on the target population. Using grant funds from Horizon BCBSNJ, the participating health systems hire community health workers from the same communities as the potential participants. Each community health worker is trained by the Penn Center for Community Health Works and, over two weeks, completes the Penn Health IMPaCT Training and Certification Program. After training, the community health workers engage directly with high and at-risk consumers identified by Horizon BCBSNJ. Horizon monitors the progress being made by its partners to ensure that they are achieving enrollment goals.

Due to the coronavirus disease 2019 (COVID-19) pandemic, the HNIH program has been adapted from face-to-face engagement during in-home visits by a community health worker to telephonic engagement. Since the pandemic began, the HNIH community health workers have been helping connect members to SDOH resources and helping the members manage stresses created by the pandemic. In both the face-to-face and telephonic engagement visits, the community health workers use the NowPow online platform to connect HNIH participants to services, track utilization, and document outcomes to ensure that participants are connecting with needed assistance. The NowPow platform maintains an up-to-date inventory of services available from local social, non-profit, and community service organizations.

PsychU last reported on the HNIH pilot outcomes in “New Jersey Horizon Blues Social Determinants Pilot Cut Total Cost Of Care By 25%,” which published on April 25, 2019. The article is available at

For more information, contact:

  • Valerie Harr, Director, Community Health, Horizon Blue Cross Blue Shield of New Jersey, 1700 American Boulevard, Pennington, New Jersey 08534;  Email:; Website:; and

In this presentation, Becky Wong, PharmD, MBA, provides an overview of measurement-based care, how measurement-based care may be used to improve quality in psychiatry, shares a fictional case example of measurement-based care in psychiatry, as well as provides additional mental health screening resources.

Becky Wong, PharmD, MBA, is a Senior Medical Science Liaison for Otsuka Pharmaceutical Development & Commercialization, Inc.

Between March and May 2020, an estimated 1.64 million people employed by non-profit organizations lost their jobs due to the coronavirus disease 2019 (COVID-19) pandemic public health emergency. This equates to more than 13% of those employed by a non-profit organization, and about 8.8% of all job losses during this period. Of the non-profit jobs lost, approximately 35% have been in the health care field.

Across economic sectors, the share of non-profit jobs lost varied. Overall, non-profit job losses accounted for about 71% of all private educational service job losses, about 43% of all private health care job losses, and about 41% of private job losses in the social assistance sector.

Estimated Non-Profit Job Losses By Field, April Thru May 2020, Based On Bureau Of Labor Statistics Overall Private Employment Situation Data
Industry Sector Total Jobs Lost Non-Profit Jobs Lost Non-Profit Share Of Private Jobs Lost
All Private Non-Farm Employment -18.7 million -1.6 million 8.8%
Professional, Scientific & Technical Services -489,200 -14,689 3.0%
Educational Services -455,600 -323,201 70.9%
Health Care -1,322,600 -574,530 43.4%
Ambulatory Health Care Services -1,041,150 -200,942 19.3%
–Offices Of Physicians -229,650 -58,345 25.4%
–Offices Of Dentists -398,100 -4,189 1.1%
–Offices Of Other Health Care Professionals -175,150 -8,552 4.9%
–Outpatient Care Centers -83,600 -37,276 44.6%
Hospitals -26,700 -22,381 83.8%
Nursing & Residential Care Facilities -36,600 -12,883 35.2%
Social Assistance Individual & Family Services -630,150 -259,007 41.1%
Child Day Care Centers -223,900 -79,316 35.4%
Community Food & Housing, Other Relief Services -332,600 -97,568 29.3%
Vocational Rehabilitation Services -8,100 -7,389 91.2%
Arts, Entertainment & Recreation -1.3 million -205,964 15.5%
Performing Arts, Spectator Sports & Similar -226,200 -48,723 21.5%
–Performing Arts Companies -49,100 -42,492 57.0%
Other Services (Except Public Administration) -1.2 million -218,167 18.9%
Religious, Grantmaking, Civic, Professional & Similar -246,050 -147,061 59.8%
Other Fields (Includes: Construction; Manufacturing; Wholesale Trade; Retail Trade; Transportation & Warehousing; Information; Finance & Insurance; And Accommodation & Food Services) -11.4 million -47,570 0.4%

The non-profit sector in 2017 was the third largest employment sector in the United States, with 12.5 million workers. Only the retail sector with 15.8 million workers and the accommodation/food service sector, with 13.6 million workers were larger. The non-profit sector in the United States accounted for more than $670 billion in total annual wages

These findings were presented in the “2020 Nonprofit Employment Report,” by Lester M. Salamon and Chelsea L. Newhouse. The researchers analyzed the latest-available data on non-profit employment and wages generated by the U.S. Bureau of Labor Statistics from the Quarterly Census of Employment and Wages (QCEW), which encompass approximately 97% of non-farm employment. The goal was to determine the current status of non-profit employment, and to estimate the impacts that COVID-19 has had on non-profit employment. They concluded that the U.S. non-profit sector is a larger and more robust economic force than is widely recognized. The significant job losses in the non-profit sector have resulted in increased pressure on the services these organizations have historically provided.

The full text of “2020 Nonprofit Employment Report” was published on June 24, 2020 by the Johns Hopkins Center for Civil Society Studies. A copy of the report can be accessed at

For more information, contact:

  • Chelsea Newhouse, Communications Associate, Johns Hopkins Center for Civil Society Studies, Department of Political Science, Johns Hopkins University, 3100 North Charles Street, Merganthaller Hall 3rd Floor, Baltimore, Maryland, 20218; Email:; Website:

Over the 2020 operating year, primary care practices in the United States could lose a total of $15.1 billion in revenue due to coronavirus disease 2019 (COVID-19). This equals a loss of $67,774 in gross revenue per full time physician, from an anticipated base gross revenue of $542,190 per physician had COVID-19 not happened.

The researchers concluded that COVID-19 will cause large, meaningful revenue reductions for primary care practices during 2020. If practices are unable to collect sufficient funding through either fee-for-service or capitated payment mechanisms, these results may threaten practice viability.

These findings were presented in “Primary Care Practice Finances In The United States Amid The COVID-19 Pandemic,” by Sanjay Basu, Russell S. Phillips, Robert Phillips, et. al. The researchers used a microsimulation model incorporating national data on primary care. The goal was to estimate the potential impact of COVID-19 on primary care practice operating expenses and revenues.

The full text of “Primary Care Practice Finances In The United States Amid The COVID-19 Pandemic” was published on June 25, 2020, by Health Affairs. A copy can be found at

For more information, contact:

  • Sanjay Basu, M.D., Ph.D., Director of Research and Population Health at Collective Health, and Director of Research at Center for Primary Care, Harvard Medical School, 635 Huntington Avenue, Second Floor, Boston, Massachusetts 02115; 617-432-2222; Email:; Website:
  • Sue Ducat, Senior Director of Communications, Health Affairs, 7500 Old Georgetown Road, Suite 600, Bethesda, Maryland 20814; 301-841-9962; Email:; Website:

The National Committee for Quality Assurance (NCQA) collects information on the performance of health care service delivery from health plans covering more than 191 million people using its proprietary Healthcare Effectiveness Data and Information Set, or HEDIS. One of health care’s most widely used performance improvement tools, HEDIS consists of more than 90 measures over six domains of care. In the behavioral health realm, HEDIS assesses depression screening and follow-up, medication adherence, access, care coordination, opioid overuse, and more. Join NCQA speakers, Junqing Liu, PhD, MSW, and Lyndsey Nguyen, MS, BA, as they provide an update on HEDIS behavioral health measures, the expansion of telehealth inclusion in HEDIS measures, the progress of and learnings from quality improvement projects, and relevant behavioral health programs.

Junqing Liu, PhD, MSW, is a Research Scientist for NCQA. As the measure lead of NCQA’s behavioral health measures, Dr. Liu guides the re-evaluation and updates of HEDIS® behavioral health measures. Dr. Liu’s research focuses on access to mental health services, evidence-based treatment for behavioral health problems, and child welfare services. Dr. Liu was previously a Research Assistant Professor at the University of Maryland School of Social Work and conducted the evaluation of a federally funded research project on the implementation of evidence-based practices in child welfare systems in six states.

Lyndsey Nguyen, MS, BA, currently serves as a Senior Health Care Analyst in the NCQA’s Performance Measurement Department at NCQA. She manages, leads, and coordinates activities related to the development of quality metrics for U.S. health care. Her areas of focus include mental health, substance use, and pain management. Ms. Nguyen holds an MS degree in physiology (complementary and alternative medicine) from Georgetown University and a BA in cognitive science from the University of Virginia.

Hiten Patadia, PharmD, RPh, is a Managed Market Liaison for Otsuka Pharmaceutical Development & Commercialization, Inc.

“You can’t cut your way to prosperity.”

One of the challenges for executive teams in managing to the end of a crisis—especially an extended crisis like this one—is addressing the loss of revenue. In more normal times, the need to replace service line revenue is a gradual one. As service lines age, demand and revenue decrease with new competition. Over time, contracts are lost to competitors. The need to create new sources of revenue is gradual.

But in this pandemic crisis, we’ve seen service lines shuttered with little notice, cost increases that have changed programs from profitable to losing propositions, and a host of new competitors. The economic forecast for the U.S. is not great—and health and human services (at 17% of the country’s gross domestic product) will inevitably be affected by the downturn. The need to find “new revenue” is more pressing.

So where to look? Right now (this could change in a month), we see a few key areas of opportunity for provider organizations serving consumers with chronic conditions and complex needs—each of which we have covered over the past two months.

  1. Expansion of telehealth—Many organizations have (whether willing or not) taken the plunge and are providing virtual care services. But, for many executive teams, the perspective is to serve “current consumers.” This is an area for expansion—new payers, new consumers, new services, and new geographies.
  2. Hybrid service models—Not all services will remain “totally virtual” in the “new normal.” The market advantage will go to the organization offering service lines that combine the depth of face-to-face services with the convenience and cost reductions of virtual care. Think of services that fit into integrated care models with reimbursement based on performance.
  3. Specialty primary care—The pandemic has had a big impact on primary care. Practice revenues are down, and it is likely that many private practices will close. Physician salaries are also down. At the same time, the demand for primary care services for consumers with complex needs has never been greater and health plans are starting to move primary care payments to capitated models.
  4. Intensive home-based services—For good reason, consumers are hesitant to consider any type of residential facility unless necessary. Nursing homes, assisted living facilities, and residential treatment facilities are experiencing falling census and revenue declines as consumers and payers look for alternatives.

5. Housing alternatives—Housing has always been an issue but expect more housing dislocation as the economic outlook sinks and rental support programs decline. Creative approaches to meet the need for stable housing will be in demand.

OPEN MINDS Senior Associate, Paul Duck pointed out that “While most provider organizations are addressing the pandemic by cutting costs, the more progressive organizations are innovating and reinventing their service delivery system and are well positioned for post-pandemic opportunities.” Mr. Duck provided a few tried-and-true tips on increasing revenue in his recent web briefing, Aggressive Business Development Strategies – Adding To The Top Line With Breakthrough Services. The first is to assess whether any of these emerging market opportunities “fit” with your organization’s longer-term vision and recovery plan. The second is to do the vetting work and “due diligence” required to evaluate specific opportunities. The third is to think creatively about expanding a revenue base in a new area. Identify at-risk competitors to form a strategic partnership or enter into new markets.

Despite the significant upset to the health and human service system caused by the pandemic crisis, the move to value-based reimbursement (VBR) seems to be moving along. On June 3, The Centers for Medicare and Medicaid Services (CMS) announced adjustments to 16 value-based care (VBC) models, with goals of accounting for COVID-19-related changes in health care delivery (and the uptick in costs), as well as allowing more time for participating provider organizations to transition to VBC. And, on June 19, CMS issued a proposed rule to grant state Medicaid programs and other payers flexibility to enter value-based payment (VBP) arrangements with drug manufacturers.

At the health plan level, most recent was the launch of Blue Cross and Blue Shield of North Carolina’s “Accelerate to Value” program to help primary care practices deal with COVID-19-related financial challenges. The program, which requires primary care practices to commit to transitioning to VBC by the end of 2020, provides financial stabilization payments based on the practice’s 2019 revenue.

Over the past few months, we’ve seen similar initiatives emerge from BlueCross BlueShield of Western New York (BCBSWNY), the Pennsylvania Clinical Network with Geisinger Health Plan, and Aetna.

What this means for provider organization recovery strategy depends on the organization’s current market positioning. The likely impact of the impending payer budget crunch (both government and employer) is more managed care and more value-based reimbursement arrangements. But that will vary by specialty, by consumer type, and by geography. Many provider organization executive teams are not waiting to see what comes their way. They are using changing reimbursement as a market positioning advantage for their post-recovery strategy.

For example, Heal announced the launch of a new “health assurance” offering called “Heal Pass”—a monthly subscription of $49 dollars where enrollees receive eight physician house calls, annual physicals, and next-day shipping on medications prescribed by a Heal clinical professional. And, Talkspace has a number of subscription options that consist of unlimited texting, live sessions, or therapy options geared toward specific populations including couples and adolescents—ranging from a rate of $260 per month to $396 per month.

The question for executive teams is to evaluate whether a proposed non-fee-for-service reimbursement model would be better for market positioning—with more revenue and/or greater profitability. To evaluate that question, executive teams need an external perspective—good customer perspectives on what they need and how they prefer to pay for those services. But equally as important, executive teams need to understand the costs of their services, not only by unit of service but by type of consumer over time.

OPEN MINDS Senior Associate, Ken Carr, believes that our traditional view of VBR—reduced costs, focus on value, and consumer outcomes—needs to take on an additional dimension with the advent of models like Heal and Talkspace. Their approach to value is to identify what is important to the consumer—immediate access, price transparency, and consistent payment, with good service and outcomes implied. For provider organization managers, fee-for-service reimbursement has driven business models—filling the schedules of clinical professionals, ensuring required levels of productivity, and shaping consumer access around available office hours. And consumers have no idea how much the service costs until they receive a statement in the mail a month later. In contrast, as Mr. Carr explained, “The new approach to value must focus on ease of access—house calls, phone calls, and virtual services.” The consumer (or the health plan) doesn’t need to worry about the cost—the subscription can be worked into a monthly spending budget like a gym fee or even a Netflix subscription.

Moving to using VBR as a proactive market strategy requires setting aside past structures and creating entirely new approaches. But how do provider organization managers begin to deal with the costs of a consumer-driven access model and set prices for these new models? Identifying the unit cost of a service and the related utilization is a starting point. But building a sustainable model will also require data on how consumers access the service, how often they use the service, and the intensity of their needs. “Provider organizations must create a structure to manage a new payment method that will lower their financial risks while better meeting consumer needs. For that, having timely data, and adjusting resource capacity is critical,” said Mr. Carr.

Mr. Carr had some more pointers for provider organizations gearing up for the shift to value in his seminar, Succeeding With Value-Based Reimbursement: An OPEN MINDS Executive Seminar On Organizational Competencies & Management Best Practices For Value-Based Contracting, at The 2020 OPEN MINDS Strategy & Innovation Institute:

  • Establish yourself as the “preferred provider” with a payer or operate exclusively within a payer system. This means demonstrating outcomes above and beyond what other provider organizations are doing (and having the data to prove it) to gain and maintain a stronger market position.
  • Realign internal operations to manage payer requirements in terms of revenue cycle—an essential process to revisit in an environment where getting paid for the services you provide is critical.
  • Deliver services that are actually valued by payers—using an integrated and holistic approach to care (behavioral health and primary care), care coordination for complex consumer populations, social supports, and medication management.

At the end of the day, VBR is here to stay. As Mr. Carr explained, “Now is the time to start the transition. VBR isn’t going to be set aside or delayed as a result of the pandemic. If anything, it’s going to be adopted as a strategy to keep costs down during a time where budgets are increasingly strained.”

The increased use of virtual therapies during this pandemic crisis will likely make a permanent change in how consumers receive services in the future. But another form of technology, also driven by the staffing challenges presented by the pandemic crisis, is gaining ground in health and human services—the robot.

Before you go to that mental place that says this is too far in the future to worry about, remember that cost pressures, fear of virus transmissions, staffing shortages, and more value-based reimbursement are going to provide market opportunities for organizations with “high value” services. And many “robotic” solutions are available now and can provide unique cost and staffing advantages.

To think about using robots, it is important to remember their simple definition—a mechanical device that can perform a variety of tasks either on command or according to instructions programmed in advance. These devices can be designed in human form (an android) or simply machines designed to perform a task with no regard to their aesthetics. And one note, robots are part of most Americans’ daily lives—Amazon has more than 200,000 mobile robots working in its warehouses, alongside thousands of human workers.

Analysts are predicting an annual growth rate of 12% of health care robots. Of the many types of robots, there are five types that executive teams serving consumers with complex needs should be considering right now.

Companion robots— We’ve covered companion robots before, but the big news, however, is that there is now a window for them to be reimbursed by Medicare. In her session, Emerging Models & New Benefits For Individuals Dually Eligible For Medicare & Medicaid, at last month’s 2020 OPEN MINDS Strategy & Innovation Institute, Allison Rizer, former Vice President of Strategy and Health Policy at UnitedHealthcare, remarked that new flexibility in the definition of services that can be purchased by Medicare D-SNP plans is now allowing the purchase of services that meet the social needs of dual eligible consumers who often suffer from isolation and diminishing emotional and cognitive function, including companion robots.

Disinfection and cleaning robots—Whether operating a residential or inpatient facility, or reopening outpatient offices, provider organization management teams need more focus on disinfecting workspaces. And there are robots for that! One of these robots is the THOR UVC robot by Finsen Technologies, used for cleaning and disinfection of consumer rooms, emergency departments, perioperative, intensive care units, progressive care units, and transitional care units.

Diagnostic temperature-taking robots—Wondering what staff person is going to take temperatures at the door of your office and who wants that job? There is a robot for that! Zorabots, developed by a Belgian software company, check people’s temperatures and if face masks are worn properly…and all in 53 different languages.

Telepresence treatment robots—Taking virtual care one step further is a whole group of telepresence treatment robots. One example is Ava Robotics’ autonomous telepresence robots, which are allowing health care professionals to treat those with COVID-19 while avoiding infection. Another example comes from OhmniLabs, which announced last month ongoing investments to offer telepresence robots to health care organizations. And in Boston, a dog-like robot named Spot is being used at Brigham and Women’s Hospital and allowing physicians to interact with individuals with COVID-19 via telemedicine. The clinical professionals managing the visit may be remote or avoid contact with the consumer and participate by video but the consumers are onsite and the telepresence robots are performing essential procedures and tests.

Siri, Alexa, and other chatbots—The use of specially programmed voice-enabled tools like Alexa or Siri offer yet another way to leverage the power of “robots” (in this case, artificial intelligence). Last year, Amazon announced the launch of a new Alexa feature that allows consumers to set medication reminders by using their pharmacy prescription information, and to request prescription refills. Another interesting application is “The Patient Is In,” a suite of apps based on Siri and the Apple Watch. With the app, consumers and clinical professionals can stream data both ways, connect in real time, and manage practice logistics and scheduling.

Staffing issues alone may drive the adoption of robotic technologies. We are reminded of the notion of “force multiplier” presented by Carl Clark, M.D., President and Chief Executive Officer of the Mental Health Center of Denver. During his keynote address, Innovation By Design: Capturing Value In Health Care, at our 2020 OPEN MINDS Strategy & Innovation Institute, Dr. Clark suggested that technology can be used as a “force multiplier” to supplement the work of clinical professionals—and the early adopters are making the case.

Imagine the possibilities, Dr. Clark pointed out—one clinical professional on a crisis line can talk to one person on the phone but could text four people at once. And scaling that up, one clinical professional can see 70 consumers a year for depression and provide cognitive behavioral therapy (CBT). But what if we use artificial intelligence to provide the mechanics of CBT—the writing, the assignments, the reviews, and the clinical professional was to talk to the consumers for higher-level interventions. Then one clinical professional can see 700 consumers a year— that’s a 10-times force multiplier! Technology is all about “how we change the way we deliver services to give more people access to care,” said Dr. Clark. Because three out of five people who need care for mental illness or addictions are not receiving that care and we just don’t have an adequate workforce to meet the need.

Passport Health Plan (Passport) announced that Molina Healthcare (Molina), Evolent Health, and Passport have entered into a definitive agreement for Molina to acquire certain assets of Passport Health Plan. Molina agreed to buy certain business lines from Passport Health Plan of Louisville, Kentucky, for $20 million. The agreement helps to provide continuity of care and coverage for Passport members while also preserving hundreds of Kentucky jobs.

The agreement calls for Molina to pay an additional amount beyond the $20 million contingent upon the results of the 2020 open-enrollment period in Kentucky. Molina will also acquire the rights to the Passport Health name. Under the terms of the agreement, which is subject to regulatory approval, Molina intends to acquire the Passport brand, operational and clinical infrastructure, and certain provider organization and vendor agreements. Molina will also offer Passport employees the opportunity to continue employment with Molina. Under a separate agreement, Molina has also agreed to purchase Passport’s real estate in west Louisville.

Passport Health Plan is a community-based health plan administering Medicaid benefits to approximately 315,000 members, as of June 30, 2020. Passport has been contracted with the Commonwealth of Kentucky to administer Medicaid benefits since 1997.

Molina Healthcare, Inc., a FORTUNE 500 company, provides managed health care services under the Medicaid and Medicare programs and through the state insurance marketplaces. Through its locally operated health plans, Molina Healthcare served approximately 3.4 million members as of March 31, 2020.

For more information, please contact:

  • Ben Jackey, Communications Director, Passport Health Plan, 5100 Commerce Crossings Drive, Louisville, Kentucky 40229; 502-457-0381; Email:; Website:
  • Caroline Zubieta, Director of Public Relations, Molina Healthcare, Inc., 200 Oceangate, Suite 100, Long Beach, California 90802​​; 562-951-1588; Email:; Website:

The Substance Abuse and Mental Health Services Administration (SAMHSA) announced the adoption of the revised Confidentiality of Substance Use Disorder Patient Records regulation, 42 CFR Part 2. The adoption of this revised rule represents a historic step in expanding care coordination and quality through the Deputy Secretary’s Regulatory Sprint to Coordinated Care.

The new rule advances the integration of health care for individuals with addiction while maintaining critical privacy and confidentiality protections. Under Part 2, a federally assisted substance use disorder program may only disclose consumer identifying information with the individual’s written consent, as part of a court order, or under a few limited exceptions. Health care provider organizations, with an individuals’ consent, will be able to more easily conduct such activities as quality improvement, claims management, individual safety, training, and program integrity efforts.

The ease of sharing information, with consent, among provider organizations will enable better, higher-quality care for those with addiction. This serves as an important milestone in further aligning 42 CFR Part 2 and the Health Insurance Portability and Accountability Act of 1996 (or HIPAA) regulations.

The Substance Abuse and Mental Health Services Administration is the agency within the U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the nation. Their mission is to reduce the impact of addiction and mental illness on America’s communities.

For more information, please contact:

  • Substance Abuse and Mental Health Services Administration, 5600 Fishers Lane, Rockville, Maryland 20857; 800-487-4889; Website:

Federal officials are partnering with several health systems and telehealth companies to develop a nationwide telecritical care network, including a separate telemedicine platform for the Department of Veterans Affairs (VA). The U.S. Defense Department’s Telemedicine & Advanced Technology Research Center (TATRC) and Medical Technology Enterprise Consortium (MTEC) recently launched Phase 1 of National Emergency Telecritical Care Network (NETCCN) Project, aimed at creating a network of “virtual critical care wards” to address the coronavirus pandemic.

TATRC and METC are partnering with Avera Health, the Oregon Health and Science University (OHSU), the Medical University of South Carolina (MUSC), UPMC, Philips, Deloitte Consulting, the Expressions Network, Unissant and the Geneva Foundation on the massive project. Among the projects being developed by this consortium is MUSC’s Portable Remote Operational Wireless Enabled Surge Specialist (PROWESS) ICU, a mobile telehealth platform aimed at offering remote consumer monitoring solutions for individuals who are quarantined and an in-patient telemedicine unit for provider organizations.

In a separate announcement, Philips and the VA announced a 10-year, $100 million contract to create what they’re calling the world’s largest telecritical care program. The partnership between the two longtime collaborators will build upon one of the nation’s largest connected health network, serving close to 9 million veterans a year through mHealth and telehealth platforms and more than 1,700 health care sites.

The United States Department of Veterans Affairs is a federal Cabinet-level agency that provides near-comprehensive health care services to eligible military veterans at medical centers and outpatient clinics located throughout the country. The agency also provides non-health care benefits including disability compensation, vocational rehabilitation, education assistance, home loans, and life insurance.

For more information, please contact:

  • U.S. Department of Veterans Affairs, 810 Vermont Ave NW, Washington, District of Columbia 20420; Website:

Centene Corporation and Quartet Health announced a nationwide expansion of their existing partnership to help members quickly and easily access the behavioral health care they need. The nationwide expansion will enable members to seamlessly access quality behavioral health care from providers located in their areas who serve their unique clinical needs. To support members who want access to care from their homes during the COVID-19 pandemic, all scheduled appointments will be with provider organizations who support virtual care. Centene and Quartet first began their partnership in June 2019, launching in Illinois and Louisiana.

Quartet’s HIPAA-compliant technology platform will integrate with Centene’s population health software, allowing Care Managers and Utilization Managers to refer members to Quartet for behavioral health care, track member progress, and collaborate with the referred behavioral health provider organizations within their existing workflows. Quartet’s national network of care options includes virtual tele-psychiatry and tele-therapy, enabling members to access the care they need safely from their homes during the COVID-19 pandemic.

Centene Corporation, a Fortune 50 company, is a leading multi-national health care enterprise that is committed to helping people live healthier lives. The Company provides fully integrated and cost-effective services to government-sponsored and commercial healthcare programs, focusing on under-insured and uninsured individuals. Centene offers affordable and high-quality products to nearly 1 in 15 individuals across the nation, including Medicaid and Medicare members, as well as individuals and families served by the Health Insurance Marketplace, the TRICARE program, and individuals in correctional facilities.

Quartet Health is a health care technology and services company on a mission to improve the lives of people with mental health conditions. The collaborative technology and range of services bring together physicians, mental health providers, and insurance companies to effectively improve consumer health and drive down health care costs. Quartet is headquartered in New York City and is currently operating in several markets across the United States, including Pennsylvania, Washington, Northern California, New Jersey, North Carolina, Louisiana, and Illinois.

For more information, please contact:

  • Marcela Manjarrez-Hawn, Media Contact, Centene, 7700 Forsyth Boulevard, St. Louis, Missouri 63105; 314-445-0790; Email:; Website:
  • Contact information: Quartet Health, Bryant Park, New York, New York 10018; 877-258-4010; Website:

Ridesharing company Uber has rolled out a service to give public health officials quick access to user data to track coronavirus cases. The contact tracing service will be provided for free and is being introduced to public health officials in all countries where Uber operates.

The service provides health departments with data about who used Uber’s services and when and allows health agencies to urge affected drivers and users to quarantine. Uber has a protocol in place that it can disclose user information to public health agencies in an emergency involving danger of death or serious physical injury. Since COVID-19 can be transmitted through close proximity to affected individuals, public health officials have identified contact tracing as a valuable tool to help contain its spread. Uber has seen an increase in contact tracing requests from countries credited for their initial success in containing the virus, such as Australia and New Zealand.

Uber Technologies, Inc. develops, markets, and operates a ridesharing mobile app that allows consumers to submit a trip request, which is routed to crowd-sourced taxi drivers. Its smartphone application connects drivers with consumers who need a ride.

For more information, please contact:

  • Uber Technologies, Inc., 1455 Market Street, Suite 400, San Francisco, California 94103; 415-986-2715; Website:

Most executives are big fans of metrics-based service line analysis and the portfolio management framework that it provides for executive teams. It is one of the best ways for provider organizations to manage their present financial performance and their future market positioning.

However, portfolio management in a crisis is an essential, but completely different exercise. Service line metrics are needed to make crucial decisions. In crisis planning, there are four service line questions. First, given the newly changed environment, what service lines have a positive margin or are at least break even? Second, what service lines have a negative margin and will draw down on available cash? Third, what service lines are critical to success after the crisis and need stabilization and investment? Lastly, when you put these service lines together and look at the entirety of organizational financial performance, if no changes are made, does the organization have enough cash to make it through the crisis period?

If the answer to the last question is “no,” service line portfolio management is the key to crisis recovery strategy. Howard Snyder, Director of Business Development at ActiveDay, a provider organization offering adult day services through more than 115 centers in 12 states, explained their dilemma. As they reopen centers, they find that adhering to social distancing in the facilities and in vehicles providing transportation has limited maximum capacity to approximately 50%. While this may be close to breakeven in larger centers, programs serving 30 or fewer members are unsustainable. Mr. Snyder lamented, “We have already made the terrible decision to permanently close a number of such smaller centers. It’s crushing to walk away from these smaller communities where there are often few alternatives for members.” And he pointed out that most states have provided minimal, if any, support in the form of retainer payments, grants, or fees for remote wellness services. “Allowing vocational rehabilitation provider organizations to suddenly offer in-home care is not a viable pivot, the rates do not support a facility-based infrastructure and a transportation fleet of vehicles,” he noted.

And there is a bigger issue in portfolio management in a crisis. A crisis is the time to invest in the service lines that are key to an organization’s recovery strategy, even if this means increasing the losses in those particular service lines. Executive teams need to assure that their organization is ready to perform in the “new normal” when the crisis period is over (we’re currently using February 2021 as that likely date, based on vaccination availability information). For many organizations, that means new investments. The pain in making this decision is that it may require taking resources from other programs. As we look ahead to the continuing pandemic crisis and (hopefully) an end in the new year, executive teams can use service line analysis and portfolio management to guide their recovery plan.

The American Red Cross is launching a Virtual Family Assistance Center to support families struggling with loss and grief due to the ongoing coronavirus pandemic. People can visit to access a support hub with virtual programs, information, referrals, and services to support families in need. The hub will also connect people to community resources provided by partners in their area.

The Red Cross has set up a virtual team of specially trained mental health, spiritual care, and health services volunteers who are connecting with families over the phone to offer condolences, support, and access to resources that may be available. They are also providing support for virtual memorial services for families, including connecting with local faith-based community partners. Volunteers are also hosting online classes to foster resilience and facilitate coping skills. They are also sharing information and referrals to state and local agencies as well as other community organizations including legal resources for estate, custody, immigration or other issues. All Family Assistance Center support will be provided virtually and is completely confidential and free.

The American Red Cross shelters, feeds, and provides emotional support to victims of disasters; supplies about 40% of the nation’s blood; teaches skills that save lives; provides international humanitarian aid; and supports military members and their families. The Red Cross is a non-profit organization that depends on volunteers and the generosity of the American public to perform its mission.

For more information, please contact:

  • American Red Cross; 431 18th Street, NW, Washington, District of Columbia 20006; 202-303-4498; Email:; Website:

Torchlight, an employee-caregiver support solutions provider organization, announced the release of the first installment of its “Caregiving in Times of Crisis Toolkit.” The Toolkit is designed for organizations, businesses, individuals, parents, and caregivers in need of assistance and information during the Coronavirus/COVID-19 pandemic. With the vast majority of Americans staying at home during the pandemic, many are not only struggling with health concerns and high stress, they are also grappling with eldercare concerns, distance learning, working at home, sudden job losses/furloughs, and the death of loved ones.

The “Caregiving in Times Crisis Toolkit” contains nearly two dozen guides and tools, including articles, podcasts and webinars for eldercare and parent/child resources. Torchlight will continue to add and update resources to the Tool-kit to support individuals and families as the pandemic evolves.

Torchlight’s decision-support tools, caregiving knowledge base, and human expertise combine to reduce stress and enhance outcomes for both families and their sponsoring organizations more cost-effectively than call center or concierge-only solutions. Torchlight’s approach includes a user-friendly digital platform and a team of expert advisors.

For more information, please contact:

  • Torchlight, 25 Corporate Drive, Suite 100, Burlington, Massachusetts 01803; Website:

Headspace Inc. has added another nearly $48 million to its offerings during the coronavirus disease 2019 (COVID-19) public health crisis. The new financing was disclosed in a filing with the Securities and Exchange Commission in June 2020 under the issuer name OrangeDot Inc.

With May 27 noted as the date of first sale, Headspace raised the additional funds in the midst of the coronavirus crisis and closed quickly, selling the entire offering amount of $47.7 million and filing the documentation by June 10. Ten investors participated in the new financing. The new funding is an extension of the company’s Series C announced in February, bringing Headspace’s total funding to nearly $216 million.

Founded in 2010, Headspace is a digital meditation app for mindfulness and mental training. Headspace is headquartered in California with offices in San Francisco and London.

For more information, please contact:

  • Headspace Headquarters, 2415 Michigan Avenue, Santa Monica, Los Angeles, California 90404; Email:; Website:

The Illinois COVID-19 Response Fund (ICRF) has awarded Chestnut Health Systems $100,000 in its most recent round of funding. In all, ICRF awarded $6.95 million to 42 non-profit organizations around the state to help populations most burdened by the outbreak. The most vulnerable populations in downstate Illinois will be able to get help as a result of the grant award.

Chestnut will use the funding to provide mental health treatment and addiction treatment for people in Illinois impacted by the pandemic. Chestnut operates in Central Illinois, in the St. Louis Metro East area, and in Jefferson County, Missouri.

ICRF is a fund held and processed by The Chicago Community Foundation. It was created to quickly help people all over the state who are in economic, social, and health crisis due to the pandemic.

Chestnut Health Systems is a non-profit organization that has cared since 1973 for persons needing behavioral health services. Chestnut provides addiction treatment, mental health counseling, primary health care, credit counseling, and housing and supportive services. It is a leader in addiction-related research.

For more information, please contact:

  • Lori Laughlin, Director of Marketing and Communications, Chestnut Health Systems, 1003 Martin Luther King Drive, Bloomington, Illinois 61701; 309-820-3814; Email:; Website:

On July 8, 2020, Walgreens Boots Alliance, Inc. (WBA) and VillageMD entered a $1 billion investment agreement that will result in opening 500 to 700 in-store full-service primary care clinics in more than 30 Walgreens markets over the next five years. Walgreens and VillageMD will open “Village Medical at Walgreens” in Houston and Phoenix markets first. VillageMD will use 80% of the investment to fund the opening of the clinics and build the partnership, including integration with Walgreens digital assets. The investment gives WBA a 30% ownership stake in VillageMD.

WBA and VillageMD tested the concept in a Houston, Texas pilot with five in-store clinics, beginning in November 2019. WBA said the clinics had high consumer satisfaction, with Net Promoter Scores over 90. Tim Barry, chairman and chief executive officer (CEO) for VillageMD said the partnership will allow primary care physicians and pharmacists to work in a coordinated way to enhance the consumer experience.

The new clinics will be staffed with VillageMD primary care professionals and will integrate the Walgreens pharmacist as a key member of a multi-disciplinary team. The clinics will provide a comprehensive range of outpatient services, at-home visits, and 24/7 telehealth services. Clinic size will vary with existing store space. Most of the clinics will be about 3,300 square feet, although some may be as large as 9,000 square feet. The stores will continue to stock a broad range of retail products.

More than half of the new clinics will be located in Health Professional Shortage Areas and Medically Underserved Areas/Populations, as designated by the U.S. Department of Health and Human Services. VillageMD is in the process of recruiting more than 3,600 primary care professionals to staff the clinics. The clinics will accept a wide range of health insurance options and offer comprehensive primary care across a broad range of physician services.

VillageMD and Walgreens also recently announced the availability of Village Medical telehealth provider organizations on Walgreens Find Care™, which is an online platform that connects consumers with a wide range of health services. The rollout advances the WBA strategic priority of “Creating Neighborhood Health Destinations.” WBA runs more than 9,200 stores in the United States.

VillageMD, through its subsidiary Village Medical, provides value-based primary care services to about 600,000 people in nine markets. It partners with more than 2,800 physicians to provide tools, technology, operations, staffing support, and industry relationships. VillageMD manages $4 billion in total medical spend via value-based contracts. The Village Medical brand provides primary care for consumers at traditional free-standing clinics, Village Medical at Walgreens clinics, at home and via virtual visits.

For more information, contact:

  • Walgreens Boots Alliance Inc., 200 Wilmot Road, Deerfield, Illinois 60015; (877) 250-5823; Website:; or VillageMD, 125 South Clark Street, Suite 900, Chicago, Illinois 60603; (312) 465-7900; Website:

Mindstrong, a healthcare company dedicated to transforming mental health through innovations in virtual care models and digital measurement, today announced it has secured $100 million in Series C fundraising. Mindstrong’s Series C raise included participation from new and existing investors, including General Catalyst, ARCH Venture Partners, Foresite Capital, 8VC, Optum Ventures, and What If Ventures, among others.

Mindstrong is unlocking an entirely new virtual care model to deliver healthcare to people living with a serious mental illness (SMI). They’re also developing technology for remote patient monitoring and mental health symptom measurement. Their in-house clinical team of therapists, psychiatrists and care coordinators use their technology platform to deliver flexible, efficient, and seamless virtual care to members through a smartphone app. Clinical services are provided by their own team of full-time clinicians on an unlimited basis and at no cost to members, thanks to Mindstrong’s value-based partnerships with national private and public insurance payers.

In addition to Mindstrong’s virtual care model, the member-facing smartphone app allows members to monitor their own mental health symptoms through AI-powered digital biomarker technology that can track changes in mental health symptoms. More importantly, the technology can also trigger alerts to a member’s clinical team when these markers indicate their mental health may be at risk or deteriorating, outside of a therapy or psychiatry session. Therapists use in-app messaging, video, and phone conversations to deliver cognitive-based therapy with members and help coordinate what is oftentimes a complex care plan for an individual living with a serious mental illness. Members can also receive telehealth medication management with a psychiatrist through the Mindstrong app.

Mindstrong is a health care innovation company, dedicated to transforming mental health through innovations in digital measurement, data science, and virtual care models. Mindstrong’s solution and health services help deliver preemptive care and improve outcomes. The company is based in Mountain View, California, and has an office in San Francisco. They are backed by ARCH Venture Partners, General Catalyst, Foresite Capital, Optum Ventures, 8VC, and others

For more information, please contact:

  • Mindstrong, 303 Bryant Street, Mountain View, California 94041; 855-944-0909; Email:; Website:

Capital District Physicians’ Health Plan, Inc. (CDPHP) announced the expansion of its provider organization network to include tele-mental health services provided by Valera Health. Members can receive care in their homes through Valera’s secure telehealth platform by connecting directly through Valera’s website, or by contacting a representative at the CDPHP Behavioral Health Access Center.

The partnership expansion also addresses the need for better access to mental health services for the 370,000 plus members in the CDPHP service area. CDPHP remains committed to bringing on innovative models that focus on quality, access, and high-performing team-based care.

Established in 1984, Capital District Physicians’ Health Plan, Inc. is a physician-founded, member-focused and community-based non-profit health plan. The company offers high-quality affordable health insurance plans to members in 26 counties throughout New York.

Valera Health is a tele-mental health service company that offers team-based care across the entire spectrum of mental health needs, from behavioral health coaching and therapy, to medication management and psychiatry. Valera also offers a behavioral health engagement platform to payers, provider organizations, and health systems.

For more information, please contact:

  • Ali Skinner, Vice President, Communications Strategy, Capital District Physicians’ Health Plan, Inc., 500 Patroon Creek Boulevard, Albany, New York 12206; 518-641-5035; Email:; Website:
  • Emma Smith, Program Manager, Valera Health, 134 North 4th Street, Brooklyn, New York 11249; Email:; Website:

The volume of health care services is down. Since the start of the pandemic, in many states, non-emergency health care services other than virtual care have not been available to consumers. And it is likely that the return to a “typical” health care practice model will be slow. Health care provider organization management teams are struggling with how to reopen. Consumers are trying to weigh the risks of going outside their homes for services of any type. This drop is reflected in the financial performance of both physician practices and hospitals.

A recent Kaiser Family Foundation poll found that almost half of consumers (48%) report that they or their family members have skipped medical care, and only 11% report that the health conditions in question have worsened. PwC’s Health Research Institute (HRI) recently reported that many consumers plan to change their health care habits for medications (11%) and health care visits (16%), with 78% planning to skip at least one visit for care. Many emergency rooms have seen a dramatic drop in use—often 40% or more, and there has been a 50% to 73% drop in vaccinations for measles, mumps, rubella, diphtheria, whooping cough, and HPV. And one interesting note, on a web meeting yesterday, I listened to a health plan manager talk about how consumers were delaying even their virtual visits to primary care professionals, but that virtual visits to mental health professionals have surpassed previous face-to-face volume.

The likely effect of these delays in health services raises big strategic questions that our team considers almost daily. Will there be “pent up demand” for face-to-face services once there is a coronavirus vaccine? Will we see increases in certain conditions at some point in the future? For that reason, a recent op-ed by Sandeep Jauhar, M.D., in The New York Times caught everyone’s attention, “People Have Stopped Going To the Doctor. Most Seem Just Fine.” In his article, he said, “Perhaps Americans don’t require the volume of care that their doctors are used to providing. Most patients, on the other hand, at least those with stable chronic conditions, seem to have done OK. In a recent survey [note: the Kaiser Family Foundation poll], only one in 10 respondents said their health or a family member’s health had worsened as a result of delayed care. Eighty-six percent said their health had stayed about the same.”

One could argue that it is a little too soon to tell if the self-assessment of “health” is accurate. And the early data show that the pandemic crisis is causing excess deaths for conditions other than COVID-19. An analysis of death certificates shows that a fifth of the 24,000 excess deaths that occurred in New York City between March 11th and May 2nd were caused by factors other than COVID-19. Hospitals saw a 38% drop in serious heart-attack cases in March alone, suggesting that even people with acute, life-threatening illnesses have been avoiding medical visits. A nationwide survey conducted in April found that a quarter of individuals with cancer receiving active treatment had delays in care. The effects of delayed health screenings and the postponed management of chronic conditions are not going to be noticed by consumers—or health care professionals—in the short term.

There is a lot of inappropriate use of health care resources. We don’t use health care professionals to the top of their capabilities. We have duplication of testing because of lack of electronic health record interoperability and financial incentives to test too much. Productivity rates of health care professionals are hampered by operational process design and consumer incentives. Emergency rooms are used too often for non-urgent situations. And, our system uses highly trained professionals to do work that could be done by technology.

In the same article, Dr. Jauhar makes the point, “If beneficial routine care dropped during the past few months of the pandemic lockdown, so perhaps did its malignant counterpart, unnecessary care. If so, this has implications for how we should reopen our health care system. Doctors and hospitals will want to ramp up care to make up for lost revenue. But this will not serve our patients’ needs. The start-up should begin with a renewed commitment to promoting beneficial care and eliminating unnecessary care.”

So, what is the big takeaway from this issue for provider organizations serving consumers with chronic conditions? As we look ahead to continued rocky economic times, this pandemic-era period of health care utilization is going to be used to justify reductions in health care spending. Provider organization management teams need to go “long” on developing the ability to demonstrate value using customer-facing metrics—payers and the health plans will be asking.

Addus HomeCare Corporation (Addus), comprehensive home care provider organization, announced the acquisition of A Plus Health Care, Inc. Based in Kalispell, Montana, A Plus Health Care provides home care services, including personal care, private duty nursing, care management, and medical staffing, to approximately 1,200 clients through over 650 employees in seven office locations.

Addus closed the transaction on July 1, 2020, with funding provided by cash on hand. Financial terms of the acquisition were not disclosed. According to Dirk Allison, President and Chief Executive Officer of Addus, the acquisition represents another significant step forward in their strategy to acquire providers that strengthen their presence in their current markets.

Addus HomeCare is a home care services provider organization that primarily includes personal care services that assist with activities of daily living, as well as hospice and home health services for individuals who are at risk of hospitalization or institutionalization. Addus HomeCare’s payor clients include federal, state, and local governmental agencies, managed care organizations, commercial insurers, and private individuals. Addus HomeCare currently provides home care services to approximately 43,000 consumers through 180 locations across 25 states.

A Plus Health Care is a statewide home care and medical staffing agency for Montana with seven regional offices and over 650 employees. With almost 30 years in home care, the company is listed in the top 100 largest companies in Montana.

For more information, please contact:

  • Dru Anderson, Corporate Communications, Addus Homecare, 6801 Gaylord Parkway, Suite 110, Frisco, Texas 75034 ; 615-324-7346, Email:; Website:
  • A Plus Health Care, 926 Main Street #16, Billings, Montana 59105; 406-752-3697; Website:

The National Institutes of Health (NIH) is facilitating a national rapid innovation initiative to speed delivery of accurate, easy-to-use, scalable home or point-of-care tests for coronavirus disease 2019 (COVID-19) before the fall of 2020. The goal is that millions of tests will be available by September 2020, and a pipeline of more COVID-19 tests to be available in advance of the 2020 flu season. Funding of $1.5 billion for this effort was provided by the Coronavirus Aid, Relief, and Economic Security (CARES) Act. NIH launched the Rapid Acceleration of Diagnostics (RADx) initiative on April 29, 2020.

RADx is using a competitive three-phase selection process to identify the most promising at-home or point-of-care tests for COVID-19. The finalists will share $500 million over all phases of development. Each finalist will be matched with technical, business, and manufacturing experts to increase the odds of success. If the selected technologies are relatively far along in development, they will be put into a separate track and immediately advanced to the appropriate step in the commercialization process. Projects will be assessed at each milestone and must demonstrate significant progress to receive continued support.

The NIH National Institute of Biomedical Imaging and Bioengineering (NIBIB) expanded the Point-of-Care Technologies Research Network (POCTRN) to facilitate RADx. The network will use a flexible, rapid process to infuse funding and enhance technology designs at key stages of development, with expertise from technology innovators, entrepreneurs, and business leaders across the country. The network has assembled expert review boards covering scientific, clinical, regulatory, and business domains that will rapidly evaluate technology proposals. To roll-out new products by the end of summer 2020, RADx will use a rapid, parallel process to allow quick project throughput.

Project proposals are being accepted through the online RADx portal on a rolling basis and are reviewed within a week of receipt. Each is reviewed for technical, clinical, regulatory, and commercialization feasibility. Final determinations for advancement to Phase 0 work package development are based on potential for rapid development and commercialization. For proposals advanced to Phase 0, the process is as follows:

  • Phase 0: Work Package Development. Project teams will initiate Phase 0, a “deep dive” with content and commercialization experts that produces a customized one- or two-phase work package. Awards of up to $25,000 will be provided to cover the approximately one-week participation in the RADx deep dive. Based on the results of this deep dive, a subset of projects will be selected for progression to Phase 1. More advanced approaches with higher technology readiness levels will be selected for acceleration directly to Phase 2.
  • Phase 1: Work Package #1. After NIH approves a project for entry into phase 1, funding will be provided immediately to allow work to begin. Depending on the structure of the work package, some funding may be dependent on successful achievement of interim milestones. The awarded budget will be sufficient to address barriers and risks identified in Phase 0 on a maximally accelerated timetable. In-kind support may be provided in technical, clinical, manufacturing, and regulatory domains. Depending on the milestones that must be met, project budgets are expected to range from $500,000 to millions of dollars.
  • Phase 2: Work Package #2. The awarded milestone-driven budget will be sufficient to enable full product deployment on an accelerated timeline. Additional resources will be made available through partnerships established by NIH and in-kind support provided by NIH and RADx. For projects that meet all milestones toward product distribution, budgets of tens of millions of dollars are anticipated. NIH will negotiate cost sharing with for-profit institutions as appropriate.

Project proposals for RADx can be submitted online at

For more information, contact:

  • John T. Burklow, Director, Office of Communications and Public Liaison, National Institutes of Health, 1 Center Drive, MSC 0188, Building 1, Room 344, Bethesda, Maryland 20892-0188; 301-496-5787; Email:; Website:

Health care has always been a stressful profession. Even before the pandemic, we knew that over half of physicians had at least one sign of burnout, including 59% of emergency physicians, 56% of obstetricians, and 55% of family and internal physicians. And burnout hasn’t been limited to physicians. Child welfare workers, nursing home aides, and many other occupational groups in health care suffer from burnout in their increasingly stressful roles.

Then comes the pandemic. The crisis has greatly exacerbated the stress of essential health care workers—the stress from fear of contracting the coronavirus or spreading it to family members; the shortage of essential health care workers during this period; and the stress of high mortality rates in emergency rooms, nursing homes, group homes, and prisons.

A report on health care workers in New York City, conducted by Columbia University Irving Medical Center and New York-Presbyterian, found that right now, half of workers have high levels of acute stress and screened positive for depressive symptoms, while one-third have anxiety. A recent survey of frontline health care workers in China treating individuals with COVID-19 found that 71% were distressed, 50% were depressed, 44% were anxious, and 34% had insomnia. Another study from Italy, currently under review, found 49.38% of health care workers reported symptoms of post-traumatic stress disorder (PTSD).

Add to this the financial instability of provider organizations—something we have reported on over the past three months. The health care sector lost 1.4 million jobs in April. And that is just the tip of the iceberg. Between May and June, dozens of large health systems announced salary reductions and layoffs. Trinity Health announced 1,000 layoffs, in addition to the 2,500 furloughs previously announced. Tower Health has announced layoffs, and Signature HealthCARE has reported layoffs at its corporate headquarters.

What should leaders do to address the growing stress levels in the health care workforce? An initiative with learning sessions with health care professionals found five common concerns—feedback, protection, preparation, support, and additional care. Health care professionals reported that, in this time of crisis, they are looking for clear communication channels and sessions with leadership; personal protection; enhanced and specific training; physical and emotional support services, and care for individuals living apart from their families.

The Royal Ottawa Hospital, in conjunction with the Phoenix Australia Centre for Posttraumatic Mental Health, has developed materials for provider organizations to reduce the impact on those susceptible to so-called moral injury, a type of PTSD. Some of the suggested measures include rotating staff between high- and low-stress roles, establishing policies to guide them through ethically tough decisions, and promoting a supportive culture. It also urges workers, including physicians, nurses, lab technicians, and social workers, to practice self-care through proper nutrition, exercise, and social connection, and to seek professional help when needed.

These issues and potential solutions were discussed by Carl E. Clark II, Chief Executive Officer of Devereux Advanced Behavioral Health, in the session The Crisis Has Changed The Key Staffing Issues For Specialty Services at The 2020 OPEN MINDS Strategy & Innovation Institute. The featured speakers, experienced managers of health care professionals, had some interesting perspectives. Their take is that there are three primary actions that leaders should take—declare crisis leadership; empower first level, direct line supervisors; and practice regular stress debriefing.

Declare crisis leadership—This strategy, like all strategies, must be a top-down endeavor with clear plans, consistent messaging, and regular reinforcement of the plan. The key is to eliminate as many stressors as possible, including any lack of clarity on process and responsibilities, inequitable workloads, or reduced staffing concerns. OPEN MINDS, Senior Associate, Ray Wolfe explained, “Increased visibility of the executive team and the verbal and nonverbal messages they convey will be critical. The leadership should speak clearly, directly, and with one voice about stress in the workplace and assure that it is defined as a community problem so that it can be discussed freely.”

OPEN MINDS, Senior Associate, Sharon Hicks, expanded on this approach, pointing out how important it is for leadership to acknowledge and remove the stigma from the “need” that staff have for support and help. Leadership must normalize the process of asking for help and help reshape how “staff vulnerability” is viewed at their organizations. She explained, “It is important to both SAY that staff should practice self-care while at the same time DOING things, like putting policies in place, that don’t oppose the need for self-care. Understanding your unspoken culture may be the first, and most important thing, that leadership can do to keep frontline staff healthy and productive.”

Empower first level, direct line supervisors—This level of leadership must understand the new strategy, their importance in implementing this strategy, and “carry the ball” when it’s time to roll it out. This will require some level of new training that at the very least requires supervisors to do weekly check-ins with staff on their emotional state and provide more consistent positive reinforcement. It might even, in some situations, require using trauma-informed principles for the benefit of staff. Mr. Wolfe noted, “We empower and provide resources to the supervisors for dealing with these concerns. They are the most trusted leader in an organization and the key to both change efforts and cultural development.”

Practice stress debriefing—The most effective response to stress is regular opportunities to talk, and realistic feedback that empowers a person to take charge of how they respond to stress. The key is to build this around a well-crafted assessment and intervention that creates opportunities for staff group sessions to discuss their concerns. OPEN MINDS, Senior Associate, George Braunstein, advised, “Wherever possible, provide staff a way to take charge of their work environment, such as designing how to maintain safety within the standards for reopening or how to ensure that any lingering organizational racism is addressed. These cannot be one-time events, but ongoing for at least the time where the stressors are still acutely active.”

Ms. Hicks summed up the situation noting, “The level of stress that direct care providers and ancillary staff who are working in hospitals is extraordinary. The stress on clinical staff in ambulatory settings has also been great. And the worst is yet to come. As the overall crisis begins to abate, staff and administrative personnel, outpatient clinics, specialty providers, and direct care staff are going to be vulnerable to experiencing significant psychological issues, including, anxiety, depression, and post-traumatic stress disorder.”

She concluded by emphasizing the importance of ongoing communication and culture building and building an approach that extends true empathy to the stresses staff face. She summarized, “Leaders and culture setters must ask employees what they need and then work to provide that for them. This is about your culture and how you express to your staff that you value them. The key to supporting staff during this unprecedented time is true empathy.”

Cedar Gate Technologies (Cedar Gate), a leading value-based care performance management company, announced its acquisition of Citra Health Solutions (Citra), a capitation management software solutions provider organization. By acquiring Citra, Cedar Gate expands its software and services capabilities across the full spectrum of value-based care. The financial terms of the acquisition were not disclosed.

By combining Cedar Gate’s existing capabilities in risk-based contract performance management, high-performance analytics, bundled payment solutions, and advisory services, the acquisition now adds capitation through Citra’s market-leading EZ-Suite platform. Citra’s EZ-Suite is a comprehensive claims, benefits, and care management software solution that delivers a highly-configurable, scalable, and flexible platform supporting multiple lines of business, including Medicare Advantage, Medicaid, Medi-Cal, carve-out and commercial populations for health plans, Independent Practice Associations (IPAs), and Management Services Organization (MSOs) accepting risk.

Cedar Gate’s enterprise platform includes the ISAAC SaaS performance management system, which enables payers, provider organizations, and self-insured employers to optimize any risk-based contract by identifying improvements in medical loss ratios, capturing lost revenues and enhancing provider network and clinical performance. Cedar Gate’s bundles and capitation administration systems also deliver high-performing, value-based centers-of-excellence programs.

Cedar Gate Technologies is a leading value-based care performance management company founded in 2014. In 2018, Ascension Ventures, a strategic healthcare venture firm, became part of the ownership group.

Citra Health Solutions provides integrated software solutions solving for the administrative, financial and clinical needs of health care payer organizations, with a highly configurable membership, authorization, capitation, claims, payment, and analytics platform. Citra Health Solutions has over 10 million members served by more than 100 Independent Practice Associations, Management Services Organization, health plans, and provider groups managing Medicare, Medicaid/Medi-Cal, specialty care, and commercial populations,

For more information, contact:

  • Julie Callahan, Cedar Gate, One Sound Shore Drive, Suite 300, Greenwich, Connecticut 06830; 469-579-8045; Email:; Website:
  • Citrahealth, 430 Davis Drive, Suite 180, Morrisville, North Carolina 27560; 888-674-7662; Website:

The Paul G. Allen Family Foundation announced the opening of a new housing and homeless services facility in Seattle, Washington. The Gardner House is a community center with 95 family-sized apartments, about half of which are designated as permanent supportive housing for families that need ongoing resources. The other half are rented as affordable housing to tenants experiencing or at risk of homelessness. Two units provide a third function as in-home daycare facilities designed custom for residents who wished to become childcare professionals. Gardner House has already filled 94 of the 95 units.

The Paul G. Allen Family Foundation partnered with Mercy Housing Northwest and the City of Seattle on what they call a “first of its kind” facility. The ground floor houses the Allen Family Center, an 8,000-square-foot community hub offering housing and employment assistance, childcare, other services, and events. The Paul G. Allen Family Foundation provided $30 million to develop and build the Gardner House. The facility received an additional $5 million from the City of Seattle and $10.7 million through a tax credit. Day-to-day operating funds for the resource center will come from Seattle’s Human Services Department. The Gardner House is hosting a virtual tour for its grand opening; the facility worked with local public health officials to establish safety protocols for residents and service professionals.

Founded by philanthropists Jody Allen and the late Paul G. Allen, co-founder of Microsoft, the foundation initially invested in community needs across the Pacific Northwest with a focus on regional arts, under-served populations, and the environment. The foundation supports a global portfolio of frontline partners working to preserve ocean health, protect wildlife, combat climate change, and strengthen communities. The foundation invests in grantees to leverage technology, fill data and science gaps, and drive positive public policy to advance knowledge and enable lasting change.

For more information, please contact:

  • The Paul G. Allen Family Foundation, 505 5th Avenue South, Suite 900, Seattle, WA 98104; 206-342-2000; Email:; Website:

The Pennsylvania Department of Health and Department Human Services issued updated guidance to ensure a safe return to activities, visitation, and other events for residents in nursing homes, personal care homes, assisted living residences, and private intermediate care facilities. In order to cautiously lift restrictions in long-term care facilities (LTCFs), the departments will now require all LTCFs to meet several prerequisites before proceeding into the official three-step process of reopening.

LTCFs must develop an implementation plan and post that plan to the facility’s website, if the facility has a website that specifies how the reopening and visitation requirements will be met. LTCFs must also administer tests within 24 hours of a resident showing COVID-19 symptoms and complete baseline testing as required in the Secretary’s Orders for skilled nursing facilities issued on June 8 and for personal care homes, assisted living residences, and private intermediate care facilities issued on June 26. They must also develop a plan to allow visitation that includes scheduling and other safety measures and a plan for cohorting or isolating residents diagnosed with COVID-19 in accordance with PA-HAN 509. LTCFs need to establish and adhere to written screening protocols for all staff during each shift, each resident daily, and all persons entering the facility. They must also have adequate staffing and supply of personal protective equipment for all staff and be located in a county that is either in the yellow or green phase of the Governor’s Reopening Plan. Once a facility meets the required prerequisites, the facility can proceed with the three-step process of reopening.

From the date the facility enters step one, a facility must maintain no new COVID-19 cases among staff or residents and have no spread in the facility for 14 consecutive days in order to enter step two. While in step two, facilities are required to maintain no new cases of COVID-19 among staff or residents and have no spread in the facility for 14 consecutive days to progress into the final step. The final step allows LTCFs to operate as outlined for the remainder of the Governor’s COVID-19 Disaster Declaration as long as there are no new COVID-19 cases among staff and residents for 14 consecutive days.

Governor Tom Wolf was sworn in as Pennsylvania’s 47th governor on January 20, 2015. Governor Wolf has been focused on three simple goals since taking office: jobs that pay, schools that teach, and government that works.

For more information, please contact:

  • Office of the Governor, 508 Main Capitol Building, Harrisburg, Pennsylvania 17120; 717-787-2500;

The PA Clinical Network and Geisinger Health Plan (GHP) announced a new, value-based contract to achieve better health outcomes and lower costs for GHP members. According to Jaan Sidorov, MD, President and Chief Executive Officer of PA Clinical Network, Geisinger Health Plan shares their interest in measurable improvements in quality with lower costs and a better member experience supported by a high performing network.

GHP is excited to partner with the PA Clinical Network to build on the success of their consumer-centered focus on their members’ health. The PA Clinical Network consists of physician-led practices seeking to increase prevention, achieve wellness and reduce avoidable complications from chronic conditions. The network uses information technology and care delivery expertise to drive measurable improvements in care delivery. It is a subsidiary of the Pennsylvania Medical Society, Pennsylvania’s largest physician advocacy organization.

The PA Clinical Network is Pennsylvania’s first and only clinically integrated network (CIN) for independent practices, led by over 150 community-based physicians. The CIN is supported by the Pennsylvania Medical Society and its Care Centered Collaborative.

Geisinger is comprised of 13 hospital campuses, two research centers, a college of medicine, and a nearly 600,000-member health plan serving more than three million residents in central, south-central and northeast Pennsylvania and beyond. Geisinger has approximately 26,500 employees, including over 1,700 employed physicians, all of whom share a commitment to quality healthcare.

For more information, please contact:

  • PA Clinical Network, 777 East Park Drive, Harrisburg, Pennsylvania 17111; 866-441-2392; Website:
  • Mark Gilger, Media Relations Specialist Marketing and Public Relations, Giesinger Health Plan, 100 North Academy Avenue, Danville, Pennsylvania 17822; 570-214-9026; Email:; Website:

Health and well-being company Humana Inc. announced a pilot home-testing program that will enable at-home COVID-19 test collection for members, making Humana the first insurer to offer LabCorp’s at-home test-collection kits. Humana also announced an innovative new collaboration with Walmart and Quest Diagnostics to help members more easily get tested, becoming the first health care company to offer its members drive-thru testing at hundreds of Walmart Neighborhood Market drive-thru pharmacy locations across the country. Humana will continue to waive member costs related to COVID-19 diagnostic tests.

To create a seamless experience for members, Humana has developed a coronavirus risk-assessment tool. Members who have symptoms consistent with COVID-19 infection, or those without symptoms who may be been exposed to the virus qualify for testing and will be given the option to request an in-home test or drive-thru testing. This is part of Humana’s ongoing effort to meet members where they are and ensure that they have a wide range of options and choices for COVID-19 diagnostic testing. Humana members with Medicare Advantage, Medicare Supplement, Medicaid, or Employer Group plans through Humana are eligible for the tests, with Humana waiving member costs for the tests.

Humana Inc. is committed to helping their medical and specialty members achieve their best health. Humana’s efforts seek to lead to a better quality of life for people with Medicare, families, individuals, military service personnel, and communities at large.

For more information, please contact:

  • Jim Turner, Corporate Communications, Humana, 500 West Main Street, Louisville, Kentucky 40202; 502-608-2897; Email:; Website:

Kindred Healthcare, LLC (Kindred) announced it has completed its acquisition of the WellBridge Greater Dallas and WellBridge Fort Worth behavioral health hospitals. WellBridge Greater Dallas and WellBridge Fort Worth provide a full continuum of inpatient and outpatient behavioral health services to senior and adult populations in the Dallas-Fort Worth metropolitan area and the greater North Texas region.

Each hospital has 48 licensed beds and both are leaders in behavioral health care, with proven records of providing exceptional behavioral health services and superior clinical outcomes. Kindred plans to continue using the WellBridge name. Through Kindred Behavioral Health (KBH), Kindred is focused on addressing the unmet need for high-quality, specialized and compassionate behavioral health services, including crisis stabilization for acute mental health and addiction disorders; detoxification from alcohol, opiates, cocaine and other drugs; suicidal thoughts or actions, anxiety, depression and post-traumatic stress disorder; and many other behavioral health illnesses. Kindred also recently announced it is now managing Riverside Medical Center’s 64-bed behavioral health unit in Kankakee, Illinois.

Kindred Healthcare, LLC is a health care services company based in Louisville, Kentucky with annual revenues of approximately $3.2 billion. Kindred through its subsidiaries has approximately 31,800 employees providing health care services in 1,731 locations in 46 states, including 64 long-term acute care hospitals, 21 inpatient rehabilitation hospitals, 10 sub-acute units, 95 inpatient rehabilitation units (hospital-based), contract rehabilitation service businesses which served 1,541 non-affiliated sites of service, and behavioral health services.

For more information, contact:

  • Susan E. Moss, Kindred Healthcare, Senior Vice President, Marketing and Communications, Kindred Healthcare, 680 South Fourth Street, Louisville, Kentucky 40202; 502-596-7296; Email:; Website:

Summit BHC, an addiction treatment and behavioral health service provider organization, announced the acquisition of Highland Hospital, a 131-bed psychiatric facility in Charleston, West Virginia. This is Summit’s second acquisition in 2020 and its first facility in West Virginia.

According to Jon O’Shaughnessy, chief executive officer of Summit, the addition of Highland Hospital to the Summit family allows them to continue providing quality psychiatric care to their growing population of clients. Mr. O’Shaughnessy also stated Highland Hospital has a history of treating individuals in a state-of-the-art facility for all ages, and also providing specific treatment options for people with drug and alcohol addiction. Highland Hospital has 24 beds dedicated for psychiatric residential treatment with an additional 91 beds for inpatient acute psychiatric needs. Also, part of the acquisition, the Highland Health Center is a 16-bed crisis residential/detox addiction disorder facility licensed as a behavioral health center.

Headquartered in Franklin, Tennessee, and founded in June 2013, Summit was established to develop and operate a network of leading addiction treatment and behavioral health centers throughout the country. The company’s sole focus is on the provision and management of specialty Substance Use Disorder and Mental Health services within a flexible and dynamic continuum of care. The leadership team at Summit is composed of senior executives with decades of combined experience in the behavioral healthcare industry at the national level. The company currently owns and operates 20 freestanding behavioral health and addiction treatment centers in 15 states across the country.

Highland Hospital has been serving the West Virginia community for over sixty years providing quality mental health care, an educated staff, and a safe environment. Highland Hospital’s mission is to provide quality behavioral health care services to children, adolescents, and adults in a caring environment.

For more information, please contact:

  • Daniel Krasner, Executive Vice President of Business Development, Summit BHC, 389 Nichol Mill Lane, Suite 100 & 160, Franklin, Tennessee 37067; 601-906-9024; Email:; Website:
  • Highland Hospital, 300 56th Street SE, Charleston, West Virginia 25304; 304-926-1600; Website:

Three Medicare Advantage insurers—Highmark, Kaiser, and Humana—received member satisfaction scores higher than the industry average, as ranked by J.D. Power. Across 10 Medicare Advantage plan sponsors, member satisfaction scores averaged 800 of 1,000 possible points; the scores ranged from 773 to 830. WellCare had the lowest score. The three top-ranked plan sponsors received the following scores: Highmark received 830 points; Kaiser Foundation Health Plans received 829; and Humana received 806. Member satisfaction is based on three information and communication performance indicators (clear, helpful, and proactive communication).

Health plans included in the ranking, and their member satisfaction scores, were as follows:

  1. Highmark received a score of 830.
  2. Kaiser Foundation received a score of 829.
  3. Humana received a score of 806.
  4. UnitedHealthcare received a score of 800.
  5. Aetna received a score of 789.
  6. Cigna HealthSpring received a score of 781.
  7. Anthem received a score of 779.
  8. BlueCross BlueShield of Michigan received a score of 779.
  9. Centene received a score of 775.
  10. Wellcare received a score of 773.

More than 40% of Medicare Advantage members utilize digital means when gathering information regarding their health coverage. Overall, information gathering in general is significantly more likely among Medicare Advantage members (87%) than among those who are commercially insured (82%). Interest in telehealth has also increased since the onset of the coronavirus disease 2019 (COVID-19) pandemic, from about 5% of members who had used telehelath prior to March 2020, to 20% of Medicare plan members who say they are interested in receiving information about telehealth after March 2020.

These findings were presented in “J.D. Power 2020 Medicare Advantage Study,” by J.D. Power. The study examined satisfaction among 3,314 members of Medicare Advantage plans across the United States from January 2020 through March 2020. The study measures member satisfaction with Medicare Advantage plans (also called Medicare Part C or Part D) based on six factors: coverage and benefits; provider choice; cost; customer service; information and communication; and billing and payment. Rankings were based on a 1,000-point scale. The average of the satisfaction scores was 800 out of 1,000.

The full text of the top line findings of the 2020 Medicare Advantage Study was published on June 18, 2020, by JD Power. A copy is available online at

For more information, contact: 

  • Geno Effler, Director, Corporate Communications, J.D. Power, 3200 Park Center Drive, Floor 13, Costa Mesa, California 92626; 714-621-6224; Email:; Website:

On May 29, 2020, the Hawaii Department of Human Services (DHS) announced that it intended to rescind the Medicaid Med-QUEST managed care organization (MCO) contracts awarded in January 2020, and the request for proposal (RFP) released August 2019. The new RFP is slated for release in the fall of 2020. Before it is released, DHS intends to issue a request for information (RFI) to better understand the evolving needs of communities and provider organizations due to the coronavirus disease 2019 (COVID-19) public health crisis. Existing contracts with the five incumbent health plans—AlohaCare, Hawaii Medical Service Association (HMSA), UnitedHealthCare Community Plan, Ohana Health Plan/WellCare, and Kaiser—will be extended until the new contract awards are made.

The state’s action is in response to a 7.5% rise in Medicaid enrollment due to unemployment caused by the COVID-19 public health emergency. Since March 4, 2020, Med-QUEST has enrolled over 24,000 additional beneficiaries. As of June 22, 2020, Medicaid enrollment was 358,488, up from 333,321 a year ago. DHS anticipates that the number of Med-QUEST applicants will continue to climb, and that Medicaid enrollment will remain high until the state’s economic recovery begins and there is a return to pre-pandemic employment levels.

Before the pandemic, Hawaii’s unemployment rate was less than 3%. To control the spread of COVID-19, in March, Hawaii had imposed a mandatory 14-day quarantine on arriving visitors to any of the islands. The flow of visitors slowed from about 30,000 arriving per day to a few hundred. About 25% of jobs in the state are connected to tourism. In April, the state’s unemployment rate rose to 23.8%; and dipped in May to 22.6%.

DHS had awarded the QUEST Integration (QI) MCO contracts on January 22, 2020. The contracts, valued at $17 billion, were awarded to four of the five incumbents: AlohaCare, HMSA, UnitedHealthCare Community Plan, and Ohana Health Plan/WellCare. AlohaCare and WellCare were to serve Oahu, while HMSA and United was to serve statewide. Kaiser did not submit a bid. The contracts were slated to begin July 1, 2020, and run through December 31, 2025, with four optional renewal years. The contract called for the MCOs to offer a dual-eligible special needs plan for Medicare and Medicaid members in Hawaii no later than January 1, 2021.

A link to the full text of “Hawaii Med-QUEST/Medicaid Data By County, Weekly Application & Enrollment Data Update” may be found at

For more information, contact:

  • Public Information & Communications Officer, Hawaii Department of Human Services, Post Office Box 339, Honolulu, Hawaii 96809-0339; 808-586-4892; Fax: 808-586-4890; Email:; Website:

eHome Counseling Group announced the expansion of the virtual eHome post-traumatic stress disorder (PTSD) treatment program. The program combines mental health counselors with 24/7 technology to treat those impacted by post-traumatic stress completely virtually. The eHome PTSD treatment program removes the barriers many people face when seeking treatment, with minimal impact on work or family time, and the ability to have counseling sessions conveniently and confidentially on a smartphone, tablet, or computer.

The program includes an artificial intelligence app that can connect consumers to a counselor 24/7 if help is required between counseling sessions. It also has assessments and online educational resources for comprehensive care. eHome uses metrics-based treatment to rapidly diagnose mental health issues and track improvement. Through the Deep Mind Insight™ program, clients receive an online assessment that quantitatively measures anxiety, depression, PTSD, addiction disorder, and other conditions. The client gets a written report that is discussed with their therapist at the first session. The assessment is then repeated periodically to show progress and final outcomes.

eHome Counseling Group is a nationwide virtual counseling network based in Orlando, Florida that provides anytime, anywhere mental health treatment by computer, tablet or smartphone. The organization provides a convenient, confidential, highly effective alternative to traditional office-based counseling programs using a HIPAA-compliant, customer friendly, integrated platform.

Priority Health and Cigna announced they have formed a strategic alliance and will partner to make comprehensive health care coverage more affordable and accessible to Michigan employers, their employees and families. This new strategic alliance will offer a competitive network solution for employer groups in the state, leveraging the best capabilities of each organization and the strength of their provider organization relationships.

Starting January 1, 2021, Cigna clients and customers will have access to Priority Health’s comprehensive network of high-quality provider organizations, which includes 97% of primary care physicians in Michigan, a wide variety of specialists and access to the vast majority of hospitals, labs and ancillary care services in the state. Priority Health members who live, work, or travel outside of Priority Health’s service area will have access to Cigna’s national network of quality physicians, specialists, hospitals, labs and facilities around the country. The strategic alliance will make it simpler for customers to find in-network provider organizations and navigate their health care experience in Michigan and around the country. Priority Health and Cigna have worked together since 2018 to provide competitive network solutions for Michigan employers that have a national footprint, which continues to be an area of growth for Priority Health.

With over 30 years in business, Priority Health is the second largest health plan in Michigan offering a broad portfolio of health benefits options for employer groups and individuals, including Medicare and Medicaid plans. Serving more than one million members each year and offering a network that includes 97% of primary care physicians in Michigan, Priority Health focuses on quality, customer service, transparency, and product innovation.

Cigna Corporation is a global health service company. All products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Cigna Life Insurance Company of New York, Connecticut General Life Insurance Company, Express Scripts companies or their affiliates, and Life Insurance Company of North America.

Contact information

  • Emily Potts, Senior Marketing Specialist, Priority Health, 1231 East Beltline Avenue, NE, Grand Rapids, Michigan 49525-4501; 616-885-6253; Email:; Website:
  • Holly Fussell, Business Communications Lead, Cigna, 900 Cottage Grove Road, Bloomfield, Connecticut 06002; 423-304-9128; Email:; Website:

Optum, a leading health services company, and Wider Circle, a tech-enabled community-based health care services company that drives better health for older adults and other vulnerable communities, have partnered with Helping Hands Community (HHC) to launch the “Community Food Circle” initiative to bring food to thousands of Optum consumers in Los Angeles County during the COVID-19 pandemic. The initiative supports Optum’s goal of helping people reach their health and well-being goals, including addressing social determinants of health.

Optum volunteered from its AppleCare and HealthCare Partners physician groups, Wider Circle staff, volunteered from HHC and other community partners, packed and loaded food supplies into Uber vehicles. Uber drivers then delivered the food to consumers across Los Angeles County. Since the beginning of California’s shelter-in-place order, Optum and Wider Circle have offered social support and meal delivery services free of charge to more than 20,000 Optum consumers in Los Angeles County. The recent partnerships with HHC expands the meal delivery service by offering it to an additional 60,000 individuals. Each food package provides an individual 10 days of food.

Optum California is an integrated health system that serves more than 1.4 million individuals across Southern California through its family of medical groups and provider organization networks. Optum California’s network includes OptumCare Medical Group, HealthCare Partners, AppleCare Medical Group, Monarch HealthCare, and North American Medical Management of California.

Wider Circle works with health plans nationally to deliver unique community care programs that connect neighbors for better health. Centered on trusted relationships, Wider Circle connects health plan members with familiar neighbors to inform, support and motivate one another, empowering them to be more proactive about their health. Wider Circle’s trusted delivery network has been proven to drive resilience, improve member experience and engagement, and reduce hospitalizations.

Helping Hands Community is a non-profit organization dedicated to serving those most vulnerable to COVID-19: senior citizens, the immunocompromised, and people with pre-existing medical conditions which put them at additional risk. The community of volunteers deliver groceries, medicine, and other necessary supplies, and local and national partners help the organization identify and reach those in need wherever they may be.

Contact information:

  • Brad Lotterman, Communications, Optum, 11000 Optum Circle, Eden Prairie, MN 55344; 714-445-0453; Email:; Website:
  • Jessy Green, Media Contact, Wider Circle, 711 Nevada St, Suite 20, Redwood City, CA 94061; 917-689-9295; Email:; Website:
  • Lauren Volkmann, Public Relations & Corporate Communications, Helping Hands Community, 831-331-3307; Email:; Website:

In an unfamiliar environment, the leader with the best data has a distinct advantage. That is a frequently heard adage, but I was really struck by the concept at one of The OPEN MINDS Executive Leadership Retreats. The historian talked about how Robert E. Lee’s strategy at Gettysburg was compromised when his cavalry (the advanced surveillance unit of its time) was waylaid.

While leaders know that the right information allows better decision making, in a recent survey, 67% of U.S. corporate executives say they are not comfortable accessing or using data from their tools and resources. And shockingly, the number of companies that say they are data-driven actually declined from 37% in 2017 to 31% in 2019.

So where is your organization on the journey to a data-driven culture? One way to assess that is to look at the OPEN MINDS process for becoming a data-driven organization. Where is your team on this path?

  1. Identify a market-driven strategy

The first step on the path to becoming data-driven requires the executive team to get on the same page as to what metrics are considered important for monitoring strategy in terms of growth, quality, and finance. Specifically, what are the key actionable drivers that will give a clear indication that the strategy is working?

  1. Begin the participatory process through c-suite technical assistance

The second step in the process is to engage in a participatory discussion to start identifying the metrics desired by each member of the executive team to manage strategy. In this step of the process, you may walk away with a 10-person wish list totaling 600 measures but it will get you on the road to narrowing the list down to those metrics that matter most.

  1. Create the “wish list”

After each executive team members’ desired metrics are identified, the next step in the process is to create an inventory of potential metrics, prioritizing each by what data is available, what is actually feasible to measure, and what is the anticipated cost of measuring each.

  1. Select the C-suite base metrics set

Once the C-suite metrics are identified and prioritized, the key is to start small. Creating a very limited data set with key metrics is critical to the implementation process and to avoiding ‘data overload’.

  1. Operationalize and automate

Going from vision to production is not necessarily complicated, but it can be time consuming. In this step of the process, ensuring that the metrics are clearly defined and operationalized is critical, along with how the data will be displayed. Once defined, the reporting must be automated to ensure timeliness and limit work on the backend (if it’s not automated, put it back on the wish list to revisit in the future).

  1. Practice at the C-suite level

The next step in the process is to actually practice using the data at the C-suite level. But, it’s important to remember, initial disbelief is common particularly when turnover is reporting as especially high or productivity is especially low. Make sure the data is valid and reliable—and then turn to problem solving. Pick out the major pain points and hone in on those to guide executive team meetings rather than taking a deep dive into every data point.

  1. Add high-value metrics that require investment

As executive teams begin to master the basics, additional metrics can be added in terms of their return on investment (ROI). Whether the team desires to merge two electronic health records, pull data in from the financial system, or highlight claims data, this all comes at an increased cost and should show a clear ROI. The point to remember here is, no performance dashboard is ever static. The metrics that are important now may be overshadowed by other metrics over time as your business model or payer contracts change.

  1. Extend within the organization

The next step to becoming a data driven organization—once the executive team and board are “on board”—is to extend and distribute the data across the organization (billing department, web team, clinical staff and programs, contract managers). Consider the data that each team needs to successfully manage their own performance. While transparency in this regard is important, focus is key, because what gets measured is what gets done.

  1. Educate

While every organization may educate team members differently, it’s critical for supervisors and clinical staff to not only understand the data, but also understand why it matters—whether it’s to the consumer or payer or for financial sustainability. The more meaningful the data is, the more likely the team will learn to embrace it.

  1. Implement performance-based team compensation

Once the executive team has laid out clear, data-driven performance expectations to staff members, they can be integrated into both performance evaluations and compensation planning.

  1. Share with external stakeholders

As you begin to “know” your data (and the equivalent benchmarking data of competitors), there is a new opportunity to use performance data as a marketing advantage. As provider organizations conduct outreach to consumers or engage in discussions with health plans, knowing your performance is superior (and having the data to quantify and prove it) is essential to become an advanced data-driven organization.

  1. Share (real-time) with partners

The final (and hardest) step is data transparency. Sharing data in real-time with key stakeholders, affiliation partners, or health plans is a characteristic of a mature, strong partnership and one that will likely be more successful with shared performance metrics.

The executive teams that have the best data—and the best insights based on that data—are those that have been able to pivot quickly in our current crisis. But they will likely need to pivot again. As we enter the post-crisis normal, demonstrating your value, and having the data to back it up, will be key not only for future strategy development but also for long-term sustainability.

After the successful opening of three Walmart Health centers in Georgia, Walmart is opening the newest location in Northwest Arkansas at the Supercenter. With the new Walmart Health located at 4870 Elm Springs Road in Springdale adjacent to the Supercenter, the community will have access to transparent pricing for key health center services, regardless of insurance status.

This facility provides quality, affordable and accessible health care. In addition, Walmart Health is partnering with several on-the-ground health provider organizations to be a first-of-its-kind health center to deliver primary and urgent care, labs, x-ray and diagnostics, counseling, optical and hearing services all in one facility at affordable, transparent pricing regardless of an individual’s insurance status. Additionally, Walmart Health plans to add dental services starting in July.

Walmart Health Elm Springs is the fourth such location the retailer has opened. The first opened in September 2019 in Dallas, Georgia. Each location is unique and serves as a prototype to test and learn the right mix of health and wellness services for individual communities. Walmart Health is operated by qualified medical professionals, including physicians, nurse practitioners, dentists, behavioral health providers and optometrists. Onsite Walmart Care Hosts and Community Health Workers will help customers navigate their visit, understand resources and be a familiar presence for regular visits.

Walmart operates approximately 11,500 stores under 56 banners in 27 countries and eCommerce websites in 10 countries. They employ approximately 2.2 million associates around the world with 1.5 million in the U.S. alone.

Contact information:

  • Walmart, 702 SW 8th Street, Bentonville, Arkansas 72712; 800-925-6278; Website:

Centerstone, a national leader in behavioral health care, is introducing a zero-suicide initiative at its locations in Illinois. While Centerstone has long had a focus on crisis and suicide prevention services, the goal of this new initiative is to add further resources around the issue of suicide.

According to Jenna Farmer-Brackett, clinical manager at Centerstone, zero lives lost due to suicide has always been the goal and the Zero Suicide initiative will further support that goal. The Zero Suicide initiative will additionally help clients by providing a safe place for them to talk about suicide, help erase the stigma of talking about this issue, and will educate people to have conversations and take steps to get help. Educational training and professional development opportunities will be provided to staff to further increase comfort and knowledge around suicide, suicide screenings, and supporting clients when safety may be a concern.

Centerstone is a non-profit health system providing mental health and addiction treatment. Services are available nationally through the operation of outpatient clinics, residential programs, the use of telehealth, and an inpatient hospital. Centerstone serves over 170,000 people and families in Florida, Illinois, Indiana, Kentucky, and Tennessee.

If you or someone you know is in crisis, please contact the National Suicide Prevention Lifeline at 1-800-273-TALK (8255).

Contact information

  • Centerstone of America, 44 Vantage Way, Nashville, Tennessee 37228; 615-460-4020; Email:; Website:

On June 9, 2020, the federal Department of Health and Human Services (HHS) announced a $15 billion Provider Relief Fund allocation for provider organizations that participate in state Medicaid and Children’s Health Insurance Program (CHIP) programs, but that have not received a payment from earlier relief allocations. The Provider Relief Fund was created by the Coronavirus Aid, Relief, and Economic Security (CARES) Act. The initial General Distribution provided payments to approximately 62% of all provider organizations participating in state Medicaid and CHIP programs. The Medicaid and CHIP targeted distribution will make the Provider Relief Fund available to the remaining 38%. As of June 29, 2020, HHS was still determining the recipients that would receive allocations from the fund.

To be eligible for this new funding allocation, health care provider organizations must not have received payments from the $50 billion Provider Relief Fund General Distribution and must either have directly billed their state Medicaid/CHIP programs or Medicaid managed care plans for health care-related services between January 1, 2018 and May 31, 2020. HHS estimates this will provide relief to several hundred thousand more provider organizations with many considered safety net organizations.

According to the “HHS Instructions For The Medicaid Provider Distribution” released on June 26, 2020, to apply for the funds, organizations must meet all of the following six eligibility criteria:

  1. Must not have received payment from the $50 billion General Distribution
  2. Must have either directly billed their state Medicaid/CHIP programs or Medicaid managed care plans for health care-related services during the period of January 1, 2018, to December 31, 2019, or own (on the application date) an included subsidiary that has either directly billed their state Medicaid/CHIP programs or Medicaid managed care plans for health care-related services during the period of January 1, 2018, to December 31, 2019
  3. Must have either filed a federal income tax return for fiscal years 2017, 2018, or 2019 or be an entity exempt from the requirement to file a federal income tax return and have no beneficial owner that is required to file a federal income tax return (e.g., a state-owned hospital or health care clinic)
  4. Must have provided consumer care after January 31, 2020
  5. Must not have permanently ceased providing consumer care directly, or indirectly through included subsidiaries
  6. If the applicant is an individual, have gross receipts or sales from providing consumer care reported on Form 1040, Schedule C, Line 1, excluding income reported on a W-2 as a (statutory) employee

HHS will accept applications from eligible provider organizations through July 20, 2020; tardy applications submitted after that date will not be considered. The application must include gross revenue from consumer care for calendar years 2017, 2018, or 2019; the most recent federal income tax returns for 2017, 2018 or 2019; the applicant’s Employer’s Quarterly Federal Tax Return on IRS Form 941 for Q1 2020, Employer’s Annual Federal Unemployment Tax Return on IRS Form 940; and the applicant’s Full-Time Equivalent Worksheet. Some applicants may be required to submit the Gross Revenue Worksheet.

HHS partnered with UnitedHealth Group (UHG) to provide rapid payment of the Medicaid and CHIP distribution to provider organizations eligible for the distribution of the initial $30 billion in funds. The provider organizations will be paid via Automated Clearing House account information on file with UHG or the Centers for Medicare & Medicaid Services (CMS). Automatic payments will come to provider organizations via Optum Bank with “HHSPAYMENT” as the payment description. Provider organizations who normally receive a paper check for reimbursement from CMS will receive a paper check in the mail for this payment as well. Within 45 days after receiving the payment, the provider organization must attest to confirm receipt of the funds and agree to the terms and conditions. If the payment is not returned within 45 days of receipt, HHS will count the non-return as acceptance of the terms and conditions.

On June 10, 2020, HHS launched an enhanced Provider Relief Fund Payment Portal that will allow eligible Medicaid and CHIP provider organizations to report their annual consumer revenue, which will be used as a factor in determining their Provider Relief Fund payment. The payment to each provider organization will be at least 2% of reported gross revenue from consumer care. The final amount each organization receives will be determined after the data is submitted, including information about the number of Medicaid beneficiaries the organizations serve.

A link to the full text of “Medicaid Provider Distribution Application Form” may be found at

A link to the full text of “HHS Instructions For The Medicaid Provider Distribution” may be found at

A link to the full text of “HHS Terms & Conditions For The Medicaid Provider Distribution” may be found at

The National Council letter issued on June 18, 2020, is posted at

PsychU last reported on the CARES Act Provider Relief Fund in the following articles:

For more information, contact: 

  • S. Department of Health and Human Services, 200 Independence Avenue SW, Washington, District of Columbia 20201; 202-690-6343; Email:; Website:

“No one wants to give a significant contribution to an organization that is circling the drain.” This comment was made by a board member of a community foundation in a recent meeting. The discussion was whether they were going to provide funding for a local provider organization that has been hard hit by the pandemic crisis. The board member said there were many organizations (more than they could fund) asking for financial relief and that this particular organization didn’t appear to be sustainable going forward, even with the financial relief. As the conversation continued, the suggestion was made that the organization’s board consider a merger with another similar organization to stabilize its financial future.

This conversation illustrates the problem faced by many organizations right now (whether non-profit or for-profit, by the way). It’s not that they are going to run out of cash over the next couple months, but they don’t have a recovery plan and sustainable business model for the next year or two. And they have an urgent need for cash and capital. Using collaborations to address this very situation was the focus of the recent web briefing, Using Mergers, Acquisitions & Affiliations To Address ‘Urgent’ Cashflow Needs, by OPEN MINDS, Senior Associate, Ken Carr. His advice—recognize that it’s not enough to find cash to run the business for a couple more months. What recovery really requires is building a sustainability plan for the next 12 to 18 months.

In his briefing, Mr. Carr addressed the big questions every health and human service executive team and board member needs to answer in the recovery planning process:

  • Are we financially sustainable right now, during the crisis?
  • As the economy moves from crisis to post-crisis normal, will we be financially sustainable?
  • If yes, what are the market scenarios that would potentially harm our sustainability?
  • If no, what growth strategy do we need to become financially sustainable? And is size alone enough?

While size is an element in sustainability, size alone is not enough. Mr. Carr said, “For your specific market, in your state, you need to look where you are going and utilize this as a strategy, not to just get larger but to prepare for the future. You will need to review and assess your diversity of revenue sources, service lines, profitability, debt ratio, and cash on hand, all so that whether you are an acquiring organization or want to be acquired, you have more information to put out there with which to create a better relationship with someone who is looking to partner.”

And now is not the time for the wishful thinking that many board members engage in. The “Recovery Tracker” from Harvard University, Brown, and the Bill and Melinda Gates Foundation, presents a grim picture—consumer spending across the U.S. has decreased by 8.5% from January to June 2020. And two-thirds of the total reduction in spending came from households in the top 25 percent of the income distribution, causing businesses in the most affluent neighborhoods in America to lose more than 70% of their revenue and lay off people. As a result, household names like Virgin Airlines, General Nutrition, Chuck E. Cheese, Hertz, and Cirque de Soleil are filing for bankruptcy and likely going out of business. And health care organizations are feeling the pinch. Trinity Health announced an expected $2 billion in losses and another 1,000 layoffs, in addition to the 2,500 furloughs previously announced. Tower Health is down $212 million and cutting more jobs, and Signature HealthCARE has reported 100 layoffs at its corporate headquarters.

At the same time, there is a stream of new competitors entering the space. Walmart is planning to launch what it calls “healthcare supercenters,” tech-enabled in-home health care provider organization, DispatchHealth, announced $135.8 million in growth capital financing, and virtual mental health services provider organization, AbleTo, expanded its suite of mental health services.

This is the time to be clear-eyed about the need for affiliations and the opportunities in those affiliations. Mr. Carr noted, “As you move forward, how big you are can determine goals. Ask some questions. Why do you want to move forward? What collaboration model would work best? How do you get engagement from the board and executive team for both considering and escalating this strategy? All are critical questions.”

And maybe answers will lead us to reprise the famous lines from the Joseph Stein musical, Fiddler on the Roof, “Matchmaker, Matchmaker/make me a match/find me a find/catch me a catch.”

While the natural tendency is for every organization to “find the catch” or be the acquirer, it is important to be realistic about the limits of any organization’s cash and management talent—often assets that come from being acquired by a larger organization.

In this fluid market, executive teams need to speed up their processes for developing a recovery strategy, determining whether/how affiliations fit in that strategy, and executing the process. To do this, they must determine their goals, build a plan based on organizational needs, and maximize the return on investment in terms of finances as well as leadership time spent. Then they must review and assess their organizational potential through a “market positioning” lens that spells out exactly what their efficiencies and prospects are or are not. Next, they need to assess the current market and build a “go forward plan” to identify the structure for the ideal collaboration. Finally, they can start identifying potential collaboration partners, and due diligence beforehand will reveal if the goals, resources, and market potential of the potential partners line up or not.

Mergers are not a popular option, particularly for non-profit organizations where boards and executive team members fear loss of their positions, changing the mission, or altering the brand. Mr. Carr shared that in a recent study of non-profit mergers, 88% of participating organizations reported that they were better off after the merger.

The right affiliation executed at the right time can be like a healthy dose of vitamins for the overall health of a provider organization and can bring in an infusion of funding, staffing, services, reach, and consumers to keep the doors from closing for good.

Martin Luther King Jr. once said, “Every crisis has both its dangers and its opportunities. Each can spell either salvation or doom.” This is exactly how it has been for health and human service provider organizations of all hues during the coronavirus pandemic. And the outlook could be grim, or exciting, as we crawl back to “the new normal.” Right now, most health care provider organizations are struggling to see their way through the crisis and find a path to sustainability in the post-crisis period.

To provide a framework for executive action in the face of this crisis, The OPEN MINDS team developed the OPEN MINDS Executive Blueprint For Crisis Management. Its goal is to help executive teams optimize their performance and financial viability during and after the crisis. The framework consists of seven components—crisis management, cash management, virtual service delivery and operations, virtual revenue generation, short-term revenue maximization, short-term business development, and post-disruption sustainability.

AbleTo, Inc., a leading virtual mental health provider organization, announced an integrated suite of solutions for payers to address the growing mental health needs across their populations with AbleTo’s care model. AbleTo’s evidence-based care is found to significantly reduce mental health symptoms and improve overall health. The solution allows payers to meet the increasingly high demand for mental health services, especially teletherapy.

With the expanded product suite, AbleTo’s clinically rigorous care is available to treat mental health needs across broad populations. Each solution offers structured cognitive behavioral therapy (CBT) programs that are tailored to the participant’s unique needs for a personalized treatment experience. AbleTo uses a data-driven approach to assess needs and goals to guide individuals to a customized experience across the suite of solutions. Each participant receives up to eight weeks of treatment with a blend of human and technology support according to the severity of need and personal preference. The entire suite of solutions is integrated across a data-driven care management platform to ensure quality across programs and enable measurement-based care.

AbleTo, Inc. provides technology-enabled behavioral health care. AbleTo’s proprietary platform connects individuals and their care teams with AbleTo licensed clinical professionals who deliver weekly sessions by phone or video supported by an integrated digital experience.

Contact information:

  • Mary Mooney, Marketing Director, AbleTo, Inc., 320 West 37th Street, 7th floor, New York, New York 10018; 312-593-4280; Email:; Website:

Martin Luther King Jr. once said, “Every crisis has both its dangers and its opportunities. Each can spell either salvation or doom.” This is exactly how it has been for health and human service provider organizations of all hues during the coronavirus pandemic. And the outlook could be grim, or exciting, as we crawl back to “the new normal.” Right now, most health care provider organizations are struggling to see their way through the crisis and find a path to sustainability in the post-crisis period.

To provide a framework for executive action in the face of this crisis, The OPEN MINDS team developed the OPEN MINDS Executive Blueprint For Crisis Management. Its goal is to help executive teams optimize their performance and financial viability during and after the crisis. The framework consists of seven components—crisis management, cash management, virtual service delivery and operations, virtual revenue generation, short-term revenue maximization, short-term business development, and post-disruption sustainability.

Crisis Management

At this point, most provider organizations have a crisis management plan in place. But remember, it’s important to continuously update and refresh that plan to address evolving safety threats to staff and consumers, ensure continued operations of your organization, and communicate across stakeholders. A robust crisis management plan must outline possible crisis scenarios and your likely responses. It must designate a clear chain of command—the crisis SWAT team—and the communication responsibilities of each team member. You’ll need a plan to analyze financial impact and build stability. And you must put into place new policies and procedures for conducting all business activities.

Cash Management

Cash flow has been the single biggest challenge for provider organizations in the pandemic crisis with declining volume of services and increasing expenses. And we know that 90% of small businesses that close do so because of cash problems. So, it is critical to manage cash aggressively and improve your financial strength and resilience by looking at both the revenue and expense sides. On the revenue side, you could explore how to improve the speed of billing and collections, request prepayment for services, secure additional short-term financing in the form of emergency relief funds and loans and look for quick collaboration opportunities. On the expense side, consider renegotiating payment terms with your vendors and developing financial thresholds to discontinue non-optimal service lines. You’ll also need to aggressively manage costs, streamline operations through activity-based costing, eliminate unnecessary expenses, optimize the performance of revenue-producing team members, improve the efficiency of administrative staff, and outsource non-core services.

Virtual Service Delivery & Operations

It has become clear that virtual is the new norm and here to stay, beyond the crisis. It’s time to shore up your telehealth platform, policies, and operating procedures for the long-term, factoring in regulation and reimbursement changes that will start to take effect as pandemic-related allowances are retracted. Virtual service delivery must be synced to your electronic health record, scheduling, documentation, and billing systems. And you need to determine how to measure treatment efficacy and modify performance measures, as payers will look for demonstration of value. Behind the scenes, you need to think about remote operations and what “work from home” looks like as a permanent option, even as you deal with the challenges of reopening your physical locations. You may need to re-channel investments from brick and mortar facility upgrades and maintenance to new training, equipment, and connectivity tools for staff.

Virtual Revenue Generation

The proliferation of virtual services means your current and future customers will be looking for you online. Your digital brand and reach will have a significant impact on your sustainability. You need to assess how to enhance your online presence to drive volume in virtual services. Improving the content, design, and performance of your website and social media channels must be a priority. You must optimize your website for search—so you rank at the top of the listings when consumers Google the services you provide—and then consider how to convert visitors to customers by offering quick and convenient access to appointments, information, reviews, and recommendations.

Short-Term Revenue Maximization

Despite decreases in service volume, there are ways to stabilize revenue by streamlining your processes, so you get paid for all services provided and track net collections. You can put your referral generation plan on steroids to bring in new business and address the growing need for mental health and addiction treatment that has escalated during the crisis. This is also a good time to have conversations with payers and negotiate rates and contracts— they are open if you can establish value and approach them with a concrete plan for how you will keep your doors open for the vulnerable populations you serve. And ask your payers about new reimbursement models for emergency/high-demand services.

Short-Term Business Development

While survival may seem like the only priority during a crisis and in its immediate aftermath, you don’t want to miss the opportunities for diversification and growth that any market disruption yields. Assess the urgent needs in your markets and create a rapid response model with creative and nimble service planning, pricing, staff deployment, and outreach to funders. Explore how you can maximize the revenue of current services and assets through re-purposing and repositioning in an increasingly virtual market. For example, virtual services may prime the pump for geographic expansion, and it would pay to identify replicable services and target markets.

Identify services and programs you provide today that could be repurposed for other consumer and payer markets. Look out for any competitor contracts at risk and monitor local organization “failures” that may open opportunities for you to fill the service gaps. It’s also important to develop a strategic short-term fundraising plan—identify your “critical services” to public agencies and health plans and request financial support; consider targeted appeals for specific programs; and make time for personal outreach to key donors and local charities.

Post-Disruption Sustainability

Market disruption demands fresh thinking about many things that were once untenable for most non-profits. It requires losing the “we serve; therefore, we will get paid” complacency and acknowledging the new competitors in the market. Think about how you would redesign your organization if you were starting from scratch and recalibrate frequently to keep up with market changes and needs. Strategic planning for long-term sustainability in the post-crisis market must be based on a growth mindset and include some essential elements focused on marketing, service line portfolio analysis, leverage of technology and organization-wide performance measurement.

Improving overall cost management and organizational efficiencies must be a continuous endeavor. Consider how you can become the provider organization of choice by delivering superior customer experiences. And above all, foster a culture of continuous innovation—planning, developing, and launching new service lines (while you let go of unprofitable “sacred cows”) to meet evolving needs and expectations of a market that will be in flux for a long time.


There is a lot we don’t know about coronavirus disease 2019 (COVID-19). The death rates, the incidence in the population, and the effect of antibodies are still big questions. But there are conclusions about one issue that seem to be emerging in almost every study—hospitalization and death rates are being driven by underlying chronic medical conditions.

Among people diagnosed with COVID-19, the most common underlying health conditions linked to hospitalization and death were cardiovascular disease (32%), diabetes (30%), and chronic lung disease (18%). And last week, the Centers for Disease Control and Prevention (CDC) expanded its list of populations at highest risk, including those with chronic kidney disease, chronic lung diseases, weak immune systems from transplants, obesity, heart conditions, sickle cell disease, and diabetes.

This data is consistent with earlier findings in China and Italy. The March 2020 Italian epidemiological study found that more than 99% of Italians who died of COVID-19 had a chronic illness, including hypertension, diabetes, heart disease, cancer, dementia, or history of stroke. Of that group, 48.5% had three or more chronic illnesses, 25.6% had two chronic illnesses, and 25.1% had one chronic illness. Another study from Wuhan found that 48% of consumers who were hospitalized had a comorbidity, including hypertension (30%), diabetes (19%), and coronary heart disease (8%).

Unfortunately, almost half (45%, or 133 million) of all Americans suffer from at least one of these conditions. We also know that approximately 75% of individuals with a serious mental illness have at least one chronic health problem and half have a diagnosis of two or more chronic health problems. Chronic pulmonary illness was the most prevalent at 31%. Among consumers with an intellectual and developmental disability (I/DD), 45% have three or more chronic conditions; and among people in prison, this percentage rises to 50%.

For provider organizations serving these populations, there is an opportunity to both “do the right thing” and gain market differentiation needed for building a sustainable market position. These vulnerable populations need care management approaches that fully embrace chronic disease management and the “whole person” care approach—and that is exactly what health plan managers have been saying they want as well.

Many times, when this idea is raised, the common push back is that we are too far into the pandemic crisis for wellness and prevention programs to make a difference. But some interesting researchers have dissuaded me of that. David Katz, M.D., founding director of the Yale-Griffin Prevention Research Center, makes a great case for creating a national health promotion campaign for those at highest risk. His point is that the pandemic has turned America’s chronic health liabilities into an acute threat. As he says, “The very things we tell people to do to improve their long-term health actually do fortify your immunity. Those healthy practices can affect how your immune system functions in hours, certainly in days, and a whole lot in a span of weeks….”  In his article, he continues this train of thought, “This…is what we in Preventive Medicine call a ‘teachable moment’… The immunologic responses of generally healthy bodies are an obviously high-potency defense against the ravages of SARS-CoV-2. Why race for the extrinsic salvation of a vaccine while neglecting the rarefied, intrinsic defenses of our native immune system….?”

For provider organization executive teams looking to the future, this wellness-oriented support for our most vulnerable and high-risk consumers is also exactly what health plans are looking for. This is one of those moments in time when organizations can do well by doing good.

“The most important factor in survival is neither intelligence nor strength but adaptability”—Charles Darwin

What can we say about leadership during this pandemic crisis? We have a health crisis that is changing the health and human service field in very fundamental ways. We have an economic crisis that is just beginning with recession and likely to slide into a depression in the fourth quarter. Over 47 million Americans have already filed for unemployment and more are likely to follow in the third quarter.

But what we know about the future as leaders is limited. There will be more virtual services and there is high risk to essential workers. Unemployment will continue to increase. An estimated 25,000 retail stores are going to close this year. Government agencies will be strapped for funds.

More problematic for leaders—whose job is to assure organizational survival and recovery to continue their mission—are the big unknowns. When will the most severe part of the health crisis be over? What is the likely shape of the economic recovery—a sharp “V” or a long “L”? What is the likely timing of an economic recovery? What industry sectors, what organizations, and what individuals will have access to government financial aid? For various health and human service lines, what is a sustainable service model and business model when moving to recovery? What will be the sustainable service model and business models when recovery happens?

To manage during the crisis, we have developed a framework for executive action. And when your team gets to developing a recovery strategy, my advice to leaders is to try to let go of the anchors of the past and think creatively about your organization’s assets and opportunities. My suggestion is to ask yourself and your team a few essential questions:

  1. Why does your organization exist? What is its role in the community and in the field?
  2. If you continue at your current rate of revenue and expenses, is your organizational sustainable? And if not, how long can your organization continue to operate? And how can you reduce expenses while continuing to serve your mission?
  3. What is it that your organization does that “pays the bills?” Look at your service lines individually and in the aggregate—revenue, payers, consumers, and margins. What makes money and what does not?
  4. Based on your assessment of the most likely future, what is your vision for your organization’s role in the community and its mission a few years in the future?
  5. What are the key objectives that your organization needs to achieve over the next year?
  6. What is the best-case future scenario for your organization?
  7. What are the future scenarios that would severely damage your organization’s sustainability?
  8. What service lines have the potential for short-term revenue growth? For long-term revenue growth?
  9. What should your team do in the next month to achieve those future objectives?

These are the tough questions that shape future strategy. And with this assessment (which needs to be repeated with any shift in the market), you can develop a recovery strategy and mobilize your team to move ahead.

But, having the framework for crisis management and plan for crisis recovery is not enough. Leaders need to bring their teams with them on this new and surreal journey. There are essential executive actions that are needed, regardless of the plan, in order to assure success.

There are some specific leadership competencies that are required for success at that time. The ability to use data and the ability to manage in a virtual environment are two of many. But to be creative and develop innovative solutions requires distance. So, once you’ve thought and planned and organized and communicated, step away. No matter where you find mindfulness (whether gardening or video gaming or needlepoint or music or hiking), take a break and let it all percolate. You will likely need to do it all over again soon.

In its latest move to address mental health in the workplace, Starbucks is making mental health training available for all U.S. assistant store managers, store managers, and above, in addition to all non-retail employees. The coffee chain announced that training will be available through July and is intended to provide employees with a resource that can help them listen for, recognize and respond to signs of mental health and addiction issues and provide resources available to their teams.

The training—dubbed Starbucks Mental Health Fundamentals—is inspired by the National Council for Behavioral Health’s Mental Health First Aid and includes four 30-minute modules: effective listening; providing encouragement and reassurance; providing resources and information; and the importance of self-care. The training is the latest offering the employer has added to its roster of mental health benefits, which Starbucks leaders started examining last year. In April, Starbucks added a new therapy benefit through provider Lyra Health to provide all U.S. employees—and their eligible family members—access to 20 sessions a year with a mental health therapist or coach. Sessions can be in-person or via video-chat.

In January, the coffee chain introduced Headspace, a daily meditation and mindfulness app, as a benefit for employees. Employees can sign up for a free subscription and access hundreds of sessions and guided meditations on topics ranging from stress to anxiety to sleeplessness. Last month, Starbucks said more than 68,000 employees in the U.S. and Canada are now using Headspace.

Founded in 1971, Starbucks Coffee Company is an American coffee company that currently operates more than 30,000 stores worldwide. Starbucks was founded and is headquartered in Seattle, Washington.

Contact information

  • Starbucks, Post Office Box 34067, Seattle, Washington 98124-1067; 206-318-7100; Email:; Website:

As executive teams look to diversify, there is one challenge that comes with every new service—identifying and managing new performance measures. The range of performance measures—and how to set up a system that can adapt to a wide range of measures, was the focus of a new white paper, Maximize Success With Performance And Quality Measures, that Monica E. Oss, Chief Executive Officer, OPEN MINDS wrote with Scott Green, Senior Vice President and General Manager of Human Services at Netsmart.

How different are the performance measures? It depends on your service lines. A recent analysis of performance measures found there were 558 unique mental health performance measures. This includes the “alphabet soup” of measurement systems like the Merit-Based Inventive Payment System (MIPS), Meaningful Use (MU), Certified Community Behavioral Health Clinic (CCBHC), Inpatient Psychiatric Facility Quality Reporting (IPFQR), and the Treatment Episode Data Set (TEDS) initiatives.

At the service line level, what do performance reporting requirements look like? Take just these three examples—health homes, CCBHCs, and long-term services and supports (LTSS). Medicaid health homes are required to report on eight quality measures and three utilization measures to receive payment. Some measures on the table include initiation and engagement of alcohol and other drug abuse or dependence treatment, controlling high blood pressure, screening for depression and follow-up plan, follow-up after hospitalization for mental illness, all-cause readmissions, adult Body Mass Index assessment, and the Prevention Quality Indication (PQI) 92: for chronic conditions. CCBHCs are tracking follow-up after hospitalization for mental illness, adherence to antipsychotics for individuals with schizophrenia, initiation and engagement of alcohol and other drug dependence treatment, and suicide risk assessment for major depressive disorder.

In contrast, LTSS provider organizations need to measure metrics related to assessment, care planning, and care coordination through comprehensive assessments and care plans. Some of the specifics include shared care planning with the primary care professional; reassessment/care plan update after inpatient discharge; and screening, risk assessment, and plan of care to prevent future falls.

The constant comment from provider organization executive teams is that there are too many different performance measures—with different requirements depending on the service, the consumer type, and the health plan. I don’t see that changing any time soon. Rather, management teams need to build a technology infrastructure with flexible reporting capabilities. There are six key elements to a “best practice” infrastructure: a shareable electronic health record (EHR); integrated workflows; customizable measures for each type of contract; identified gaps in care; visual dashboards; and the ability to calculate everything in real-time.

A shareable EHR—On-demand data interoperability is essential to care coordination and managing transitions of care, and for a provider organization to truly be high-functioning, it needs everyone on the care team to have access to the metrics that can build and support a whole-person approach to care. Developing a shared platform across all users equips the team to identify behavioral health concerns exposed by the data, and then to align the treatment plans.

Integrated workflows—Feeding data into the daily workflows across all clinical, financial, and operational decision making is at the heart of increasing efficiency and leveraging the potential to meet metrics requirements, increase quality, and capture the requisite outcome measurement scores. Building this “new” workflow approach should focus on clinical form consolidation, point-of-service access to health records, increased record compliance, and enhanced health record reviews and audits.

Customizable measures for each type of contract—When it comes to measures, not all contracts are created the same, and many executives will have to embrace and remain diligent in the face of “measurement fatigue.” But it’s an inescapable reality that every contract will have its own requirements and quality measures. Investing in collection methods and tools that can flexibly allow executives to target and report different data is a must.

Proactively identify gaps in care—There is no competitive advantage if provider organizations don’t have the ability to put performance measures to good use in improving consumer care. That is the key competitive advantage in a data-rich, performance-based world. Shared data and integrated workflows alone are good but run the risk of being reactive instead of proactive. A targeted investment in predictive analytics allows executives to look ahead and identify the gaps in care that threaten to keep the care team from achieving its goals.

Reporting and visual dashboards—The key to the effective use of any data is automating the data collection and analysis, and then delivering actionable information through customized reporting and dashboards for end users. These are the hands-on tools that can take large chunks of unwieldy and dense data and deliver them in a “digestible” way.

Calculate everything in real-time—Real-time data is far more valuable than lagging indicator data because it supports a proactive approach to outcomes management. It allows managers to change performance rather than just discussing why poor performance happened.

On June 12, 2020, the federal Department of Health and Human Services (HHS) finalized changes to a section of the Patient Protection and Affordable Care Act (PPACA) to eliminate protections from discrimination based on gender identity. The change affects Section 1557 referring to sex discrimination. The HHS Office of Civil Rights said it will enforce Section 1557 by returning to the government’s interpretation of “sex” discrimination based on the presence of male or female genes. HHS said this was the plain meaning of the word “sex.” The rule is effective August 18, 2020.

Section 1557 of the PPACA is a civil rights provision that prohibits discrimination on the basis of race, color, national origin, sex, age, or disability in certain health programs or activities. Congress prohibited covered health programs or activities from discriminating on any of the grounds protected by four federal civil rights statutes:

  • Title VI of the Civil Rights Act of 1964 (Title VI) (prohibiting discrimination on the basis of race, color, or national origin).
  • Title IX of the Education Amendments of 1972 (Title IX) (prohibiting discrimination on the basis of sex).
  • Section 504 of the Rehabilitation Act of 1973 (Section 504) (prohibiting discrimination on the basis of disability).
  • Age Discrimination Act of 1975 (Age Act) (prohibiting discrimination on the basis of age).

It is unknown how the HHS changes in definition regarding “sex” to enforce PPACA Section 1557 will be affected by the June 15, 2020, ruling by the United States Supreme Court in Bostock v. Clayton County, which held that federal employment discrimination law protects gay and transgender employees. The ruling means that an employer who fires an individual solely for being gay or transgender violates Title VII of the Civil Rights Act of 1964. The court said that gender identity—being gay or transgender—is “inextricably bound up with sex.”

A link to the full text of “HHS Office Of Civil Rights Final Rule: Nondiscrimination In Health & Health Education Programs Or Activities, Delegation Of Authority” may be found at

A link to the full text of “Fact Sheet: HHS Finalizes ACA Section 1557 Rule” may be found at

A link to the full text of “Supreme Court Of The United States Opinion In Bostock v. Clayton County” may at

For more information, contact:

  • Luben Montoya, Supervisory Civil Rights Analyst, Office for Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, District of Columbia 20201; 800-368-1019; Email:; Website:

The Madonna hit from the ‘80s, “I am a material girl living in a material world” crept into my subconscious when I was thinking about how we are each called upon to be a digital leader because you know that “we are living in a digital world.” The pandemic sent health and human services headlong into a “digital first” world and most executives learned to adapt quickly, along with their staff, consumers, payers, and other stakeholders. And of course, we all know that lockdowns or not, digital is the way most health care—and in fact most of life—will be in the foreseeable future. Connecting with a clinical professional will be akin to ordering paper towels on Amazon, getting food delivered through GrubHub, or even watching a Broadway show on YouTube. Are we ready to deliver?

The answer is no, according to a survey of 1,200-plus executives, in which more than half (53%) of respondents said they believe the management or senior leadership at their company is unprepared to implement a successful digital strategy. Steven Nilsen, a partner at Boyden—the firm that conducted the survey—notes that for the new generation of leaders who are poised to capture the digital transformation, “…digital is not a task to be done. It is how a task gets done. It is a culture and a mindset.”

A digitally savvy leader is more than one who knows how to use their smartphone, weigh in on social media, and look cool on Zoom meetings —although those are all good skills to cultivate.

The culture and mindset for leadership in a digital world requires different approaches than it did in our previously nondigital (but evolving) world. An MITSloan Management Review research report, cautions that “time is running out for leaders who are holding on to old ways of working and leading.” This report reiterates that only 48% of executives agree that their organizations are prepared to compete in digitally driven markets and economies. While 82% believe that leaders in the new economy will need to be digitally savvy, less than 10% of respondents feel that their organizations have leaders with the right skills to thrive in the digital economy.

The authors of the MITSloan report also present emerging behaviors of digitally savvy leaders— purpose-driven, nurturing passion, making data-driven decisions, demonstrating authenticity, demonstrating empathy, employing an inclusive approach, showing humility, and working across boundaries. These would seem like enduring behaviors for all times. In addition, I would say that digitally savvy leaders in the health care world must assimilate seven truths to prepare for success in a digital world.

Digital is not a substitute for nondigital—it’s a new way of doing business.
Back in early March of 2020, most provider organizations started to provide—or ramped up capacity to provide—virtual services only because brick and mortar facilities began to close. But before long, most organizations realized that while digital can’t replicate the in-person visit, it offers other advantages. Leaders who embrace digital will recognize opportunities for new value propositions to new markets. It’s not just about telehealth. Think artificial intelligence to improve the accuracy and efficiency of routine tasks. Think telework to expand your talent pool and improve staff productivity. Think online scheduling. Think late evening appointments and even 24/7 care if clinical professionals can work shifts from home. And think about new consumers who are looking online for online services.

Digital first is not tech first, it’s people first.
Yes, today’s leaders must be tech savvy, web savvy, and social media savvy. But remember technology is only an enabler to help meet consumers wherever they are. Think about what consumers want, what they can and cannot do, and how they are willing to access and pay for care. Whether you provide services through a virtual or in-person model—or some combination of the two—the people who use your services want the same experience that they have on Amazon, Facebook, or TripAdvisor. Ease of access, instant gratification, intuitive to use, ability to connect with others who use the same services, and ability to provide feedback and have a dialogue. Digitally savvy leaders are those who can walk a mile in their customers’ shoes every day and recognize that shoe styles and sizes are changing as lifestyles and preferences evolve rapidly in a digital world.

Digital can empower deeper relationships.
Digital can empower strong face-to-face connections with consumers and stakeholders, while enabling two-way communication and the ability to obtain continuous feedback for continuous improvement. Technology also makes it easier to stay in touch with stakeholders and to engage with them often. Digitally savvy leaders use technology to listen to their audience and not just to talk at them. Digital also expands the possibilities when it comes to marketing and advertising, allowing for personalization and customization in a way that traditional channels would not allow. Just think about how Netflix, Hulu, and HBO can hold you captive with “Watch Next” or “Because you watched Tiger King, we think you’ll like…” popups, text alerts, emails, and customized home pages.

Digital demands a data-driven culture.
Google and the iPhone and social media have turned every human into a walking data cache. The “If you don’t measure it, you can’t improve it” adage in health care has been underscored by all the tools and capabilities that technology bestows on us. Digital savvy leaders are focused on data but not just for data’s sake. They seek the insights that data can provide and create a culture that “starts with why” (the phrase made legendary by Simon Sinek) and that asks the right questions before determining what data will be collected and analyzed. And digital leaders in a digital world must be prepared to deal with the skeptics who are likely to decry the data if it means they must change the way they do things.

Digital requires connecting the dots.
Leaders who “get” digital will nurture a culture where all managers will see how their work is connected to the work of others in the organization. Digital can serve as the great connector and eliminate silos by enabling transparency, faster and broader communication, and platforms for sharing information and results. Clinical professionals can’t remain oblivious to the challenges in accounting and vice versa; IT can’t live in an ivory tower; and HR is not the only problem solver. Technology can bring people together in meaningful ways and enable goals to be aligned and the big picture to remain in the spotlight.

Digital expands the competition, but also the possibilities.
Smart leaders recognize that digital ushers in more competition. A growing number of apps, e-counseling platforms, and virtual employee assistance programs are competing with traditional behavioral health organizations for consumer attention and even payer contracts. Primary care practices might consider embedding their own behavioral health services through telehealth. Assessing the competitive landscape and planning and refining the strategy to gain an edge over competitors is more critical than ever before in the digital domain. But savvy leaders also recognize that digital opens new opportunities for collaboration and partnerships. Behavioral health provider organizations may be able to embed medical care through telehealth or accept warm handoffs virtually. Digital also provides new channels for community education and engagement.

Digital divides and leaves gaps.
Discerning leaders who serve vulnerable populations recognize that the “digital divide” or the gap between the haves and the have nots in terms of tech devices and Internet bandwidth is real and growing. Even as they think about expanding services through digital channels, health care leaders must think about how to address the needs of those who cannot access such care. Digital access is increasingly being listed as a social determinant of health and is an issue that payers and policymakers know they must address.

At the end of the day, digitally savvy leaders are those who leverage the opportunities yielded by the digital world while keeping the human element front and center. “‘Cause everybody’s living in a digital world” as Madonna might say in a reprise of “Material World.”

Aegis Treatment Centers, a California-based outpatient treatment provider organization owned by Pinnacle Treatment Centers, has opened an opioid treatment program in Ceres, California. The facility is the 36th Aegis location in the state.

Aegis Ceres is providing medication assisted treatment services, including methadone and buprenorphine, as well as individual and group counseling for the treatment of opioid addiction. The facility will also incorporate cognitive behavioral therapy, motivational interviewing, relapse prevention, life skills training, contingency management, mindfulness, and stress and relaxation techniques. According to Joe Pritchard, chief executive officer of Pinnacle, the new location supports the organizations’ overarching commitment to drive affordable services into underserved communities.

Aegis Treatment Centers is a large outpatient addiction treatment center in California. The organization serves over 9,200 people through the support of over 600 staff members.

Contact information:

  • Aegis Treatment Centers, LLC., 7246 Remmet Avenue, Canoga Park, California 91303; 818-206-0360; Email:; Website:

Toledo, Ohio-based ProMedica has made a bid to assume the day-to-day operations of University of Toledo Medical Center (UTMC). Under the proposal, the University of Toledo would maintain ownership of UTMC. ProMedica would provide management and other services.

University of Toledo stated it was considering a sale of its hospital after the medical center reported more than $12 million in operating losses through the first half of fiscal year 2020, a loss of $7 million in fiscal 2019 and a $3.6 million loss in fiscal 2018. ProMedica said in its proposal it believes it can provide a unique local solution that will enable UTMC to become financially stable. ProMedica said if it wins the bid, it would work to stabilize UTMC’s finances, replace its outdated EMR and continue to offer academic and research opportunities at UTMC. A third-party advisor will review the submissions and make recommendations to the university’s board. Shortly after ProMedica announced its bid, community members voiced concerns about the potential partnership.

ProMedica is a health system serving communities in 28 states. ​The health system includes 13 hospitals, four ambulatory surgery centers, and more than 400 post-acute facilities. ProMedica has nearly 56,000 employees and more than 2,100 physicians with privileges system wide. In collaboration with educational institutions locally and regionally, ProMedica offers research, grants, and residency programs, as well as fellowship, clerkship, nursing, pharmacy, allied health, and continuing education opportunities.

Contact information:

  • ProMedica,100 Madison Avenue, Toledo, Ohio 43604; 800-774-3627; Website:

The Center for Medicare and Medicaid Innovation (CMMI) will accept Letters of Intent from hospices and other provider organizations that seek to participate in the professional or global Primary Care First Direct Contracting models until July 6. The direct contracting options include three voluntary payment models that are designed to help the U.S. Centers for Medicare & Medicaid Services (CMS) and health care provider organizations reduce the cost of care and improve quality within Medicare fee-for-service programs.

The three models include the professional, global, and geographic options. The models adapt and integrate concepts from other programs such as Accountable Care Organizations, the Medicare Shared Savings Program, and Medicare Advantage, as well as strategies used in the private sector. The direct contracting program is associated with the agency’s Primary Care First Initiative, which also consists of a general payment option and a Serious Illness Population (SIP) option. All of these programs were slated to launch January 1, 2021, but CMS has pushed back the SIP and direct contracting implementation dates to April 1 of that year.

Under direct contracting professional model, provider organizations would accept the risk for 50% of shared savings or losses for all Medicare Part A or Part B services for individuals that fit the Primary Care First eligibility requirements. Organizations working in this model would receive a risk-adjusted monthly payment for primary care services equivalent to 7% of the total cost of care. Within the global model, provider organizations would also bear 100% of the risk associated with eligible individuals.

The Centers for Medicare & Medicaid Services is the agency within the U.S. Department of Health and Human Services that administers the nation’s major health care programs. The CMS oversees programs including Medicare, Medicaid, the Children’s Health Insurance Program, and the state and federal health insurance marketplaces.

Contact information:

  • Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 877-267-2323; Website:

AAC Holdings Inc., the publicly traded parent of American Addiction Centers (AAC), filed for Chapter 11 bankruptcy protection. The Brentwood, Tennessee-based company listed debt of $517.4 million and assets of $449.3 million in its filing in U.S. Bankruptcy Court in Delaware.

The company stated it expects to emerge from bankruptcy in 125 days after executing on a recapitalization plan that will slash its debt. AAC lined up $62.5 million of initial financing that will allow it to maintain operations during the restructuring, according to a separate statement. The company, which operates rehab centers in seven states, has struggled with its debt load, including borrowings it took on from its acquisition of AdCare in 2018. The company defaulted on its debt obligations in 2019 and entered into a forbearance agreement with lenders. AAC operates rehab facilities in California, Florida, Texas, Nevada, Mississippi, New Jersey, and Rhode Island. The case is AAC Holdings Inc., 20-11648, U.S. Bankruptcy Court for the District of Delaware.

American Addiction Centers’ mission is to provide quality, compassionate, and innovative care to adults struggling with addiction and co-occurring mental health disorders. Through comprehensive and customized treatment plans, we instill hope that long-term recovery is possible. Their purpose and passion is to empower you, your family, and your community by helping you achieve recovery and optimal wellness of the mind, body, and spirit.

Contact information:

  • American Addiction Centers, 200 Powell PIace, Brentwood, Tennessee 37027; 888-987-1784; Website:

While the adage “The best defense is a good offense” is typically associated with military combat and sports (and is often attributed to Michael Jordan), it was first said by George Washington in 1799, “…offensive operations, often times, is the surest, if not the only means of defense.” In the midst of the current crisis, it may appear that defense is the best choice—hunkering down and waiting it out seems safe. But defense is not the only option. Crises often present opportunities but executive teams need to plan their offense. They need a plan for how to “grow” in the midst of turbulence.

A structured approach to growth in a time of crisis was the focus of The 2020 OPEN MINDS Strategy & Innovation Institute session, Proven Methodology For Identifying Strategic Opportunities: Cultivating, Negotiating & Decision Making. The presenter, Matthew M. Dorman, Chief Executive Officer of Credible Behavioral Health, Inc. discussed his structured approach to evaluating growth choices by considering both the current and future customer base and service offerings. His three-step process—understand the market position of your current service line portfolio, set your growth targets and strategy, and use growth tools to make that strategy a reality.

Understanding market position

Traditionally, serving long-time customers with long-time products has been the “safe” thing to do for health and human service organizations. But maintaining status quo could sound the death knell in this highly disrupted market. At best, “you may be left behind” given the aggressive and growing competition in the market, Mr. Dorman warns.

It’s time to evaluate your TAM (the total demand for your product), SAM (the market based on your current business model in the context of geographic location, employee base, and internal infrastructure), and SOM (what you can do based on the practical limits of your current strategy and model).

And it’s time to take a hard look at your numbers—reimbursement rates, current market share and demand for your services, your organization’s capacity and cost to market and provide the services, and the return-on-investment.

Turning those numbers into key metrics that are tangible, understandable, and relevant is critical. As Mr. Dorman emphasized, “Make sure you are graphing numbers that are relevant to your end goal—otherwise you will get lost in the data and you’ll burn a lot of time.”

Setting growth targets and strategy

With knowledge of the market and the position of the organization’s portfolio, executive teams can set growth targets and strategy.

A low risk option is to leverage current relationships to sell new products to old customers. That’s not without challenges, especially if the new products don’t fit into the long-standing brand your old audiences are familiar with. Selling new products to new customers is the most exciting strategy—but comes with the highest risk and lowest return. The optimal growth strategy is to leverage what you already do well with current products and expand it to new consumers.

Interestingly, we’re seeing these growth strategies in play right now. The pandemic crisis has pushed us over the tipping point in terms of telehealth and we know it’s here to stay. And that has two implications—telehealth could pave the way toward better outcomes from increased consumer and family engagement and convenience. On the flip side, it could help us define our niche for service delivery that demands an in-person or blended model for efficacy. The pandemic also underscores the urgent need for integrated care so we can deliver holistic care for vulnerable populations with co-occurring, complex, and chronic conditions.

And what about new markets? Will we see increased demand for services and increased spending? Are there opportunities for more home-based services? What does the rising rate of nursing home closures mean for home and community-based services? Growth strategies that involve entering these new markets will require a keen eye on the landscape and moving in quickly where competitors fail or where gaps in care start to surface.

Making strategy a reality  

But strategy alone isn’t enough. Making the growth strategy a reality is what matters—and leveraging tools to make that happen is key.

Being transparent about your growth strategy is critical to obtaining organizational and board buy-in and ensuring long-term success. To sell the broader team on any new strategic initiatives and prepare for smooth execution, executives must clearly explain the choice of the growth strategy, communicate the roles and expectations of each team member in the process, and be clear about deadlines and timelines.

Making strategy happen also requires negotiating—whether it’s negotiating the cost of services, the ability to add employees, expand internal capacity, or expand geographically through new locations and facilities. Executive teams must know what they are bringing to the table and figure out their breakeven point in terms of costs. Mr. Dorman explained, “When you know your goals and your numbers, you also know your threshold for failure,” ultimately giving you more leverage in the negotiation process.

It’s important to realize there is more than one path to growth—and sometimes that path means being prepared to walk away for a new opportunity. Mr. Dorman discussed, “We can get so focused on a particular outcome that we don’t realize when we try to go from A to B to C, there’s another path that gets us to that same outcome. The best alternative is always a solution that gets you to your end goal with as little sacrifice as possible—you have more power than you realize.”

A sustainable strategy doesn’t have to be all-or-nothing, there are many paths to growth—the key is to make sure it’s the right path for you.

On June 3, 2020, the Centers for Medicare & Medicaid Services (CMS) announced risk adjustments to the Medicare accountable care organization (ACO) Track 1+ and the Next Generation ACO models to account for the coronavirus disease 2019 (COVID-19) pandemic public health emergency (PHE). The goal is to account for changes in health care delivery and related additional costs due to the pandemic and ensure that provider organizations are not at risk for costs due to the pandemic. The adjustments make changes to the financial methodology, quality reporting requirements, and the model timelines.

CMS Innovation Center Changes To ACO Track 1+ & Next Generation ACOs To Account For COVID-19 Public Health Emergency
Innovation Center Model Financial Methodology Changes Quality Reporting Changes Model Timeline Changes
Medicare ACO Track 1+ Model Remove episodes of care for treatment of COVID-19

Medicare Shared Savings Program Extreme and Uncontrollable Circumstances policy applies to 2020 financial reconciliation

2019 Web Interface quality measure reporting deadline extended from March 31, 2020 to April 30, 2020

Medicare Shared Savings Program Extreme and Uncontrollable Circumstances policy applies to 2019 and 2020 reporting


Continue to monitor impact on 2020 quality reporting


Voluntary election to extend agreement for one year through December 2021


Next Generation ACO Model (NGACO) Reduce 2020 downside risk by reducing shared losses by proportion of months during the PHE.

Cap NGACOs’ gross savings upside potential at 5% gross savings

Remove episodes of care for treatment of COVID-19

Use retrospective regional trend, rather than prospective, for 2020

Remove 2020 financial guarantee requirement

2019 Web Interface quality measure reporting deadline extended from March 31, 2020 to April 30, 2020

2019 quality audit canceled

Continue to monitor impact on 2020 qua


The adjustments to the ACO models were done as CMS was making changes to all of its value-based care (VBC) models to account for the impact of the COVID-19 pandemic. CMS used the following principles to determine which changes were appropriate:

  • Use flexibilities that already exist in current model design.
  • Continue sufficient financial incentives that encourage higher-quality outcomes.
  • Ensure equity and consistency across models.
  • Align as much as possible with national value-based and quality payment programs.
  • Minimize risk to model participants, the Medicaid program, and the Medicare Trust Funds.
  • Limit delays in new model implementation, while providing additional opportunities for participation in new models.
  • Minimize reporting burden.
  • Complement and build off the new CMS COVID-19 Public Health Emergency flexibilities as outlined in regulation and waivers.

A link to the full text of “CMS Innovation Center Models COVID-19 Related Adjustments” may be found at

For more information, contact:

  • Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Website:

St. Luke’s University Health Network (SLUHN) will acquire Easton Hospital on July 1, 2020, including affiliated physician practices and two physician residency programs with 36 physician residents. This acquisition will preserve the 125-year-old hospital for future generations, ensuring future jobs and bringing St. Luke’s world class health care to the citizens of the greater Easton-area community. St. Luke’s and Steward Health Care of Dallas, the current owner of Easton Hospital since May 2017, recently signed an asset purchase agreement that will allow for the transfer of ownership to SLUHN effective on July 1.

The acquisition, which was approved by the St. Luke’s Board of Trustees, is subject to certain conditions, including review and approval by various regulatory agencies. Financial terms of the acquisition were not disclosed

Steward Health Care is a large private, tax-paying physician-led health care network in the United States. Headquartered in Dallas, Texas, Steward operates 35 hospitals in the United States and the country of Malta that regularly receive top awards for quality and safety. The Steward network includes multiple urgent care centers and skilled nursing facilities, substantial behavioral health services, over 7,200 beds under management, with more than six million annual consumer encounters.

Founded in 1872, St. Luke’s University Health Network is a fully integrated, regional, non-profit network of more than 15,000 employees providing services at 11 hospitals and 300 outpatient sites. With annual net revenue greater than $2 billion, the Network’s service area includes 11 counties: Lehigh, Northampton, Berks, Bucks, Carbon, Montgomery, Monroe, Schuylkill, and Luzerne counties in Pennsylvania and Warren and Hunterdon counties in New Jersey.

For more information, please contact:

  • Sam Kennedy, Corporate Communications Director, St. Luke’s University Health Network, 1736 Hamilton Street, Allentown, Pennsylvania 18104; 484-526-4134; Email:; Website:
  • Darren Grubb, Vice President Communications, Steward Health Care System Corporate Headquarters, 1900 North Pearl Street, Suite 2400, Dallas, Texas 75201; 469-341-8901; Email:; Website:

Health care costs for people with treatment-resistant depression (TRD) are much higher than costs for people whose depression responds to antidepressants within 12 months of starting medication. Higher costs for the TRD population were observed for commercial insurers, Medicare, and Medicaid. For those who responded to treatment, their all-cause monthly per-person costs dropped by 21% to 32% from baseline to month 12, and their per-person monthly mental health related costs dropped by 33% to 61%. However, for those with TRD, the change in their all-cause monthly per-person costs ranged from an increase of 1% to a decrease of 13% from baseline to month 12; the change in their mental health-related costs was 0% to -37%. Those with TRD had higher utilization and costs at baseline, and higher costs persisted for each month during the 12 months after starting depression treatment.

Comparison Of Per-Person Annual Baseline Total Health Care Costs By Payer Based On Antidepressant Response
Type Of Cost Treatment Responsive Treatment Resistant
Commercially Insured
All Cause $6,491.85 $9,111.29
Mental Health-Related $1,100.86 $1,507.58
All Cause $5,631.69 $6,736.44
Mental Health-Related $2,009.95 $2,279.44
All Cause $16,726.87 $17,362.93
Mental Health-Related $1,382.08 $2,622.60

Among those with TRD the odds of hospitalization were 32% to 76% higher; the odds of an emergency department visit were 38% to 45% higher and the odds of outpatient visits were 29% to 54% higher compared to those who responded to antidepressants. Costs for people with TRD were from $4,093 to $8,054 higher than people who responded to antidepressants.

Incremental Annual Per-Person Cost Of Treatment-Resistant Depression By Payer
Payer All Cause Mental Health-Related
Commercial $6,742.29 $3,428.10
Medicaid $4,093.37 $2,122.87
Medicare $8,054.41 $3,316.14


These findings were reported in “Incremental Health Care Burden of Treatment-Resistant Depression Among Commercial, Medicaid, and Medicare Payers” by Anshu Shrestha, M.P.H., Ph.D.; Meaghan Roach, M.P.H.; Kruti Joshi, M.P.H.; John J. Sheehan, Ph.D., M.B.A.; Prodyumna Goutam, Ph.D.; Katie Everson, M.S.; Kristin Heerlein, M.D.; and Anupam B. Jena, M.D., Ph.D. The researchers conducted a multi-payer retrospective cohort study of claims for adults diagnosed with major depressive disorder who had received one or more antidepressant treatments. They analyzed the Truven Health Analytics commercial, Medicaid, and Medicare supplemental claims databases for 2006/2007 through 2017. The analysis included 111,544 commercial claims, 24,036 Medicaid claims, and 8,889 Medicare supplemental claims. For each payer, the researchers compared annual use (hospitalization, outpatient, and emergency department) and costs for people with TRD and people without TRD. The researchers concluded that TRD may exist and affect health care utilization before a person with depression is identified as being non-responsive to antidepressants.

The full text of “Incremental Health Care Burden of Treatment-Resistant Depression Among Commercial, Medicaid, and Medicare Payers” was published April 2, 2020, by Psychiatric Services. An abstract is available online at

For more information, contact:

  • Anshu Shrestha, MPH Ph.D., Senior Epidemiologist, Public Health Institute, 555 12thStreet, 10th Floor, Oakland, California 94607; 510-285-5500; Fax: 510-285-5501 Email:; Website:

For provider organization executives looking at recovery planning, “top of the list” is different relationships with payers. In most discussions, higher rates, less administrative costs, standardized performance measurement, and sharing in savings are the key talking points. The question—how do you get to that new kind of relationship? The health plan executives in the session, Health Plan-Provider Partnerships: Improving Care Through Collaboration, at The 2020 OPEN MINDS Strategy & Innovation Institute, had an answer—reach out to health plan managers and let them know both what you can do and what you want.

Alexsis Desrochers, Vice President, Value-Based Programs at Magellan Complete Care; and Neha Patel, Director of Care Delivery Transformation, Southeast Region, Anthem, Inc., provided some very useful perspectives on what health plans are looking for, and how they evaluate provider organization partnerships. Magellan Complete Care is focused on whole person care (physical, behavioral, and social needs), and is present in six markets—Arizona, Florida, Massachusetts, New York, Virginia, and Wisconsin. They have a range of value-based reimbursement (VBR) arrangements with their network provider organizations on the physical health side, and their behavioral health-centered VBR programs are still in negotiation.

Ms. Desrochers explained, “We have a lot of programs along the continuum, from basic administrative tasks, to shared risk. A lot depends on the sophistication of the provider organization, their staff, and their capabilities. Usually our VBR sits on top of our normal fee-for-service (FFS) contracts, although we can go further to do some wrap around type contracts.”

Anthem’s approach to VBR is exemplified through its Enhanced Personal Health Care (EPHC) program. Launched in 2013, it’s a consumer-centered, value-based care program focused on collaborating with provider organizations by providing the necessary tools, resources, and consulting to achieve VBR success. They have a continuum of VBR programs dependent on the capabilities and willingness of provider organizations. It is also Anthem’s largest value-based initiative. Ms. Patel noted, “This is not an easy conversation to have because the stigma of the payer as the enemy is hard to combat. One of the ways we have tried to do this is to bring in the tools and resources, and to support them from a PMPM rate perspective as a part of our program. We also provide people power to really bring this all to life.”

As provider organization management teams think about telling health plans about “what they do,” it is important to think about your presentation (in a document and in person) from the perspective of the health plan managers. Ms. Desrochers and Ms. Patel recommended that the discussion include three key issues—readiness and experience with VBR, current performance and outcome measures, and the ability to participate in integrated care initiatives.

VBR competency is an issue—While many provider organization executive teams may say they are ready to assume some type of financial risk, health plan managers are hesitant to accept those assurances at face value. Sharing data is the key to convincing the payer. Ms. Patel explained, “It’s hard getting provider organizations to sit at the table with us, to look at their own data, and to see what their practice looks like from a data perspective. They say they are doing things, but is it showing up in the data?”

Health plans look for provider organizations with an integrated technology platform with all-inclusive clinical data, performance management analytics, and care coordination functionality. They look for experience with data-informed decision making in real-time, as well as a thorough understanding of service delivery cost variables and the risk-based contracting process. Mastery over administrative functions can help land contracts reimbursing an administrative fee for services or offering quality incentives that reimburse for individual metrics and targets.

Ms. Desrochers noted, “No matter where you come out in an assessment, there is an opportunity, but you need to understand where you are along the continuum. Are you just activity based, or are you ready to move into the outcomes-based programs? You need to come into the negotiation understanding what you are ready for, and what you are not.”

Current measures of success—Every executive believes their organization has good outcomes and solid performance. But that needs to be demonstrated in metrics. What are your current performance stats? How do they compare to competition? To answer those questions, provider organizations need to be strategic about what data to collect and analyze, ­and the story that data is telling payers. The key is not to silo what is reported to payers from what is used to make internal decisions about clinical efficacy, productivity, and growth.

Creativity and dialogue about what to measure are also encouraged. Payers are willing to admit they don’t have all the answers and to factor in perspectives from the frontlines.

Ms. Desrochers suggested going through all of the Healthcare Effectiveness Data and Information Set (HEDIS) measures, but not being limited to those. She said, “In general, there is no set game plan or cemented playbook for what measures VBR must include. Come to the table with your own suggestions. For example, daily living activities that can measure consumer functionality, or any social determinants of health.”

Be sure to provide feedback to payers on what’s working and what’s not. Ms. Patel explained, “Whatever your current relationship is, be willing to share your thoughts, experiences, and barriers. We gather that feedback. We don’t have answers to everything, but we must make decisions on the short, medium, and long-term impacts. Hearing provider organization feedback helps us understand the impacts and engage.”

And provider organizations should seek benchmarks, set goals, and not hesitate to ask payers how they compare against their peers and competitors.

Ability to participate in integrated care initiatives—The key to improving consumer care and reducing use of unnecessary resources is coordination, which drives health plan interest in integrated care models. Provider organizations must be prepared to outline how their organization would “fit” into those initiatives. They must demonstrate how they can support interoperability; drive referrals; and expand the scope of services delivered, geography covered, or consumers served.

Health plans also look for experience in whole person care and population health management. This is where the specialty provider organization takes on a role more akin to primary care to “quarterback” consumer care, and take total responsibility for physical health, medication, and other costs, while ensuring better outcomes. In addition, provider organizations must be ready to openly discuss how they can manage social determinants of health, pharmacy, or social services. Executives need to be prepared to show that their organization can cover every element of consumer care. Ms. Patel explained, “We are firm believers in looking at populations and looking at the trends in the data to improve care. But we need to decide who should be the quarterback, such as community mental health care or primary care. The ability to transition back and forth is the evolution and success is about who is on my care team.”

If the future of health and human services is value-based, then the future requires a different relationship between health plans and the provider organizations—one based on the ability to come to the negotiating table with confidence. The most confident organizations will be able to step up and push for integrated care with value-based strategies.

Follow-up mental health visits, within 14 days after emergency department contact, are lower among those with substance addiction than those with other mental health diagnoses. Approximately 40.2% of 57,797 individuals who visited the emergency room for a mental health issue had a follow-up mental health visit within 14 days: just 25.2% were those with initial substance use visits.

Of those with follow-up visits that were not related to substance use, about 56.1% initially presented with bipolar disorder, 51.1% initially presented with major depressive disorder, and 46.4% initially presented with schizophrenia. Psychiatrist follow-up visits accounted for about 33.1% of those who initially presented with bipolar disorder, 26.0% for those with schizophrenia, and 21.4% for those with major depressive disorder. Primary-care follow-up visits accounted for about 29.7% of those with major depressive disorder, had primary care follow-up only (N=5,243), 23.0% for those with bipolar disorder, and 20.4% for those with schizophrenia.

The researchers concluded that successfully transitioning individuals to outpatient care following an emergency department visit for mental health reasons will require system-wide and coordinated solutions. Physicians alone are unlikely to be able to adequately care for those with complex mental health conditions without coordinated and well-resourced interprofessional teams with case management support. This is especially true in the case of those presenting with substance addiction, where time is limited to seek care before potentially rapid deterioration occurs.

These findings were presented in “Urgent Outpatient Care Following Mental Health ED Visits,” by Lucy C. Barker, M.D.; Nadiya Sunderji, M.D., M.P.H.; Paul Kurdyak, M.D.; The researchers analyzed Ontario health administrative data at ICES (was the Institute for Clinical Evaluative Sciences), an independent nonprofit health research institute. The population-level data was from Ontario, Canada’s most populated province (approximately 14 million individuals), between 2010 and 2012. The cohort was comprised of 143,662 Ontario residents ages 19 and over with an psychiatric emergency department visit, (including 31,592 presenting with substance use disorders and 112,070 whose primary presentation was not a substance use disorder). The goal was to determine the likelihood of receiving outpatient mental health care after psychiatric emergency department visits in a population-level sample.

The full text of “Urgent Outpatient Care Following Mental Health ED Visits” was published February 24, 2020, by Psychiatry Online. An abstract is available online at

PsychU last reported on this topic in “Following A Positive Suicide Screen In ER Visit, 42% Of Older Adults Receive A Follow-Up Mental Health Evaluation,” which published on October 16, 2017. The article can be found at

For more information, contact:

  • Lucy Barker, M.D., Psychiatry Resident, Department of Psychiatry, University of Toronto, 250 College Street, 8thFloor, Toronto, Ontario M5T 1R8; 416-979-6948; Email:; Website:

“Hybrid” is a word that is no longer associated with just cars, and plants. The pandemic crisis has changed all of that. We couldn’t dine in our favorite restaurants, but takeout meals ordered online saved the day. Farmer markets have created portals for online orders that are picked up at the market. Grocery stores and drugstores are offering home delivery and curbside pickup that can be initiated with a telephone call or email. But as we move into the post-crisis period, hybrid will take on a new meaning in the delivery of health and human services. The models that will likely win the race for competitive advantage are not the traditional face-to-face models or the all-telehealth-all-the time models. The winning service model is one that blends the best of both for maximum convenience and value for both consumers and payers.

We got a close look at what these new hybrid models look like in the addiction treatment field last week in the exclusive OPEN MINDS Circle web briefing, Blended Virtual & Onsite Services For Continuity Of Care, led by OPEN MINDS, Senior Associate, Deb Adler. Executives from two addiction treatment provider organizations—Lakeview Health and Hazelden Betty Ford Foundation, and from two health insurance organizations—Cigna and Optum, discussed the promising practices for blended addiction treatment models that combine the onsite and the online for intensive outpatient (IOP) and partial hospitalization programs (PHP). Both provider organizations are providing addiction treatment services using proprietary hybrid service models. Their executives stressed two important factors in program design—balancing consumer convenience and safety with the solid value proposition.

The Emerging Models  

Lakeview Health runs multi-site adult addiction treatment programs in Florida and Texas and treats consumers with alcohol and substance use disorders simultaneously with any co-occurring mental health or physical health issues. The organization has a value-based contract with Aetna and is the preferred provider organization for NFL Trust, Mayo Clinic, and Cleveland Clinic. Lakeview switched to virtual services for consumers in IOP and PHP programs where feasible and permitted by state regulations. Family workshops and visitations went entirely virtual.

However, the organization kept its facilities open for those who needed in-person care, especially for consumers with co-occurring disorders and complex medical conditions. To do this, Lakeview sanitized all facilities and practiced social distancing according to guidelines from the Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO). Consumers who came in and exhibited symptoms were sent home to quarantine but received daily check-ins through telehealth. As an integrated care facility with physicians and nurses onsite, Lakeview was able to offer nursing assessments seven days a week for all consumers—those with a temperature were isolated, tested, and sent to the emergency room. Screening and two levels of testing (point of contact testing for antibodies and nasopharyngeal swabs) were instituted—at first for staff and symptomatic consumers but eventually for all. As Lakeview has a 3-building campus, one of the buildings was designated as a quarantine facility through which all new residential consumers were admitted before being transitioned to other facilities. This facility also allowed for isolation of residential consumers who tested positive for COVID-19. With the blended care model, they saw readmission rates for IOP and PHP consumers drop to an all-time low of 2.3% while PHQ-9 and GAD-7 scores between admission and discharge dropped significantly.

The Hazelden Betty Ford Foundation provides comprehensive inpatient and outpatient treatment for adults and youth affected by alcohol and drug addiction, as well as co-occurring mental health conditions. The organization has 17 locations nationwide and collaborates with an expansive network throughout health care. Hazelden’s Butler Center for Research advances knowledge about addiction treatment and recovery and helps to integrate addiction treatment research into practice. Hazelden Betty Ford started to offer telehealth about a year before the COVID-19 crisis started and learned many lessons on the go about how to improve virtual service delivery. This was valuable as they ramped up telehealth during the crisis. But they also modified programs to work better virtually—for example, family groups that were done over three days in-person transitioned to one-day virtual events.

Starting May 1, 2020, Hazelden is following more than 1,000 IOP consumers and monitoring how they are doing one, three, six, nine, and 12 months after discharge. They’ve had continuous interaction with payers to determine what performance measures they want to see. “Why do some patients do better?” asked Quyen Ngo, Ph.D., executive director of the Butler Center for Research at Hazelden Betty Ford Foundation. The Butler Center is tracking data for four groups of consumers—those in in-person IOP for the three months prior to the virtual transition, those who stepped in to virtual IOP following the virtual transition, those who started in in-person and transitioned to virtual, and those who started in virtual treatment and transitioned to in-person treatment.

The Payer Perspective

Ms. Adler pointed out that pre-COVID-19 key performance indicators have not changed—length of stay in IOP and PHP; readmission rates within 30, 90, and 180 days; 90-day episode costs; medical costs (emergency room, labs, or pharmacy); outpatient follow-up within seven days; consumer-reported outcomes; migration to lower levels of care; Consumer Assessment of Healthcare Providers and Systems surveys; and net promoter score.

Deb Nussbaum, senior director of behavioral product at Optum, and Erin Boyd, solutions and program director at Cigna, both emphasized that payers want to know what provider organizations are measuring and want to have a dialogue to ensure better outcomes with virtual and hybrid care. They want to monitor treatment outcomes over time to understand who needs to be seen in person and who needs to be seen virtually. Cigna is working with Hazelden Betty Ford to help shape what is measured in their longer-term research but in the meantime, the payer will compare the standard performance indicators for in-person vs. telehealth visits to gauge variations in efficacy.

Payers are pleased to see a significant uptick in the use of virtual services. Pre-COVID, Optum mainly offered reimbursement for virtual therapy sessions and medication management visits while Cigna also offered virtual IOP reimbursement. But few provider organizations used any of these options before the crisis. However, payers added reimbursement of virtual services for more complex IOP, PHP, and medication assisted treatment (MAT) during the pandemic crisis to respond to consumer needs and maintain continuity of care.

While the number of consumers seeking PHP and IOP services dropped by nearly 30% during the crisis, those who did get services largely opted for telehealth. Cigna contracted with digital provider organizations (such as Talkspace, Meru Health, and nocd) to expand virtual services. Optum also noted a 125% increase in registrations for its free wellness app, Sanvello, during the crisis.

Business Model Considerations

In the future, Cigna intends to contract with virtual-only IOP provider organization platforms that embed peer support. “There’s no turning back,” said Ms. Boyd, but treatment efficacy must continue to be monitored closely to determine the long-term viability of blended care, beyond the crisis. Ms. Boyd also suggests embedding virtual services into discharge plans for consumers who receive IOP and PHP services, to demonstrate continuity of care to payers.

“A hybrid model is a win-win for all,” said Ms. Adler. Consumers like the advantages of virtual and can stay engaged. Provider organizations can meet consumer preferences with a smaller footprint and have fewer no-shows to contend with. And payers appreciate the increased utilization and increased efficiency, with regulatory compliance.

So what does this mean for traditional provider organizations with addiction treatment programs? From the comments of our panel, it appears that the payers think they will get the addiction treatment outcomes they are looking for in treatment services that are largely virtual. A return to pre-crisis levels of residential or even facility-based outpatient addiction treatment is unlikely. For crisis recovery planning, executive teams of addiction treatment provider organizations need to plan on the majority of services remaining virtual. This means creating treatment program packages that are funded with a business model that is sustainable—at a price point that is set largely by virtual behavioral health organizations. And it means looking at how to get payers to contract with traditional provider organizations for expanded virtual care, in preference to digital-only provider organizations. In short, how can provider organizations become the virtual platform of choice for health plans?

Any level of onsite and residential services can likely be sustained only if integrated care for co-occurring medical and behavioral health disorders is a key element of the model. So think about which integrated model is feasible for rapid implementation.

And, referral generation and marketing planning must change as well. The traditional models for addiction treatment referral generation will need to be enhanced with a stronger virtual marketing plan.

It appears that the hybrid model is the future of addiction treatment. Finding the business model for that future is the challenge.

Uplift Family Services announced the receipt of a two-year $4,000,000 grant from the Substance Abuse and Mental Health Services Administration (SAMHSA), a federal agency with a mission to reduce the impact of addiction and mental illness in the United States. As part of the grant, Uplift Family Services, in partnership with School Health Clinics of Santa Clara County and Pacific Clinics, will form a consortium to become a Certified Community Behavioral Health Clinic (CCBHC).

The CCBHC will serve 2,000 low-income individuals in Santa Clara County by offering access to and improving the quality of mental and addiction treatment in the community by integrating physical health services. The consortium is among 200 behavioral health organizations and health centers in the nation, and one of five in California, to become a CCBHC.

Uplift Family Services is one of the largest, most comprehensive mental and behavioral health treatment programs in California. Uplift Family Services takes a state-of-the-art approach to children and adolescents with complex behavioral health challenges and helps them recover from trauma such as abuse, severe neglect, addiction, and poverty.

School Health Clinics of Santa Clara County improves the health and well-being of more than 5,400 low income, medically underserved adults and children each year by providing comprehensive, easily accessible primary health care. The organizations’ six clinics are Patient Centered Medical Home certified and located on public school campuses in San José and Gilroy in the low income neighborhoods where families live and work.

Founded in 1926, Pacific Clinics is a community-based behavioral health agency that provides outpatient services to individuals of all ages at over 50 locations and 325 schools across Los Angeles, Orange, San Bernardino, and Ventura counties. Each year over 22,200 individuals benefit from comprehensive and supportive services, including case management, health navigation, early education, school-based services, housing support and employment assistance.

For more information, please contact:

  • Rachel Lepold, Editorial Contact, Uplift Family Services, 251 Llewellyn Avenue, Campbell, California 95008; 408-628-5579; Email:; Website:
  • Stephanie Kleinheinz, Chief Executive Officer, School Health Clinics of Santa Clara County, 6840 Vía Del Oro #210, San Jose, California 95119; 408-284-2288; Email:; Website:
  • Myeisha Peguero Gamiño, Editorial Contact, Pacific Clinics, 800 South Santa Anita Avenue, Arcadia, California 91006; 626-254-5054; Email:; Website:

Landmark Health and its affiliated medical groups in 46 U.S. communities announced the launch of its proprietary telemedicine app. The Landmark Health app was developed to securely connect individuals with their Landmark medical provider organizations via smartphone. The app is available to Android users as of April 27, 2020 and will soon be available to iOS users.

Telemedicine helps extend Landmark provider organizations and clinical teams into the homes of individual with higher frequency, especially those living in more rural areas. Landmark’s typical consumer is in their mid-80’s with six or more chronic conditions. The company opted to build a telemedicine app to fully customize the user experience for simplicity, while being HIPAA-compliant.

Individuals can download the Landmark Health app and go through a one-time-password (OTP) authentication registration. From there, they are brought to a home screen where they can call their local 24/7 Landmark clinical line and view their upcoming Landmark appointments. During a video call, the individual sees their provider on-screen, with a small corner video of themselves. They can flip the camera front/back if they need to show the provider a rash, swollen ankle, medication bottle, etc. The Landmark provider can call an individual directly through the app as well. The individual sees the Landmark logo and words “Incoming Call” and taps “Accept” to connect to their provider. This simplicity is critical for an older adult – it removes the need for them to remember the appointment time or find the dedicated link to connect with the provider. They simply answer a call.

Founded in 2014, Landmark Health and its affiliated medical groups deliver comprehensive in-home medical care to older adults. Specialized in complex chronic care, more than 100,000 people across 14 states and 46 metropolitan communities can access Landmark’s care at no cost.

For more information, please contact:

  • Landmark Health, 7755 Center Avenue, Suite #630, Huntington Beach, California 92647; 657-237-2450; Website:

Homelessness in Los Angeles County, California increased approximately 12.7%, from 58,936 in January 2019 to 66,433 in January 2020. This increase happened despite a sustained increase in the number of people who have been rehoused after homelessness. The estimated inflow over 2019 was 82,955 individuals, with 22,769 housing placements, and an estimated 52,689 individuals finding other housing.

Figures show that 18,395 individuals experiencing homelessness in Los Angeles County were sheltered in 2019: this is a 25% increase from 14,722 during 2018. While there was a 36.8% increase in sheltered families during the year, Los Angeles County saw an 82.8% increase in unsheltered families (resulting in an overall 45.7% increase in homeless families).

According to experts, Los Angeles County needs approximately 509,000 new affordable housing units to meet the current demand. The average monthly rent is $2,182; this means that renters in Los Angeles County need to earn 2.8 times the City’s minimum wage to make rent (renters need to earn $41.96 per hour).

These statistics were reported in “2020 Greater Los Angeles Homeless Count” by the Los Angeles Homeless Services Authority. The annual report captures a picture of homelessness in Los Angeles County as it was in January 2020, the time of this year’s Homeless Count.

A link to the full text of “2020 Greater Los Angeles Homeless Count” may be found at

For more information, contact:

  • Chris Yee, Communications Specialist, Los Angeles Homeless Services Authority, 811 Wilshire Boulevard, #600, Los Angeles, California 90017; 213-219-1417; Email:; Website:

United Us announced that Staple Health will join its growing data analytics team through the recent acquisition of the company. Founded in 2017, Staple Health combines in-house predictive analytics and comprehensive integrated care in the community. The organization was founded during a time when health care provider organizations were becoming more interested in social determinants of health (SDoH) data in the move towards value-based care. Staple Health specifically provided detailed and predictive analytics about the impact of social factors on acute care, behavioral health, addiction, and other health outcomes.

In preparation, Unite Us has worked to strengthen its data team to better analyze outcomes data and its use in communities to address and prevent the factors that negatively impact health, according to Kelly Binder, chief of staff for Unite Us. In addition, Unite Us is introducing Unite Us Insights and social risk analysis to clients nationally.

Unite Us is a technology company that builds coordinated care networks of health and social service provider organizations. With Unite Us, provider organizations across sectors can send and receive secure electronic referrals, track every person’s total health journey, and report on tangible outcomes across a full range of services in a centralized, cohesive, and collaborative ecosystem.

For more information, please contact:

  • Emily Rogan, Communications Manager, Unite Us, 217 Broadway, 8th Floor, New York, New York 10007, US; 516-381-4781; Email:; Website:

Spero Health has announced plans to open a new addiction treatment clinic in Warren, Ohio as part of the organization’s quick response to the growing need for expanded services as communities continue to adjust to the COVID-19 outbreak. CARF-accredited and community based, Spero Health is a national leader in providing care for individuals struggling with addiction and will bring affordable, high quality addiction treatment services through a combination of telehealth and in-person visit options at this new clinic.

The new Warren clinic opened on June 23, joining a network of more than 35 Spero Health locations throughout Kentucky, Ohio, Tennessee, and Indiana, providing care for more than 7,200 consumers each month. To ensure access to care is not a barrier to treatment, Spero Health accepts Ohio Medicaid and most commercial insurance plans. The Warren Spero Health clinic is one of several new clinics the organization is opening over the next few months to meet the high demand for access to addiction treatment services close to home.

Spero Health, Inc., is an integrated health care services organization specializing in local and affordable outpatient care for individuals with addiction. Spero Health utilizes an innovative evidenced-based integrated care model that combines both physical and behavioral health care services to provide whole person health care.

For more information, please contact:

  • Spero Health, Inc., 2529 Maple Ave, Zanesville, Ohio 43701, 740-297-8859; Email:; Website:

WellCare of New Jersey, a subsidiary of Centene Corporation, announced a plan to provide additional mental health resources to New Jersey residents impacted by the COVID-19 pandemic. Through a series of local partnerships across the state, WellCare will enable provider organizations to better support communities experiencing elevated levels of stress and mental strain caused by an increase in grief, loss, economic pressure, unemployment, and social isolation.

As part of this effort WellCare, in partnership with its parent company Centene, is announcing investments to support various programs. They will support training for clinical professionals and support for frontline health care workers dealing with the COVID-19 crisis and the increase in mental health-related challenges in their practices. WellCare will support ‘Warmline’ call centers by making a donation to a local organization in New Jersey coping with an increase in demand for their ‘warmline’ services, which provide early interventions to potential mental health crises. WellCare will make an investment to help the National Council for Behavioral Health transition part of their training program to a virtual program, which will make Mental Health First Aid (MHFA) training more accessible for people in New Jersey and nationwide. WellCare will also support those impacted by domestic violence by making a $500,000 donation to the National Domestic Violence Hotline, a national service provider organization which offers service via call, chats, and texts providing support for those impacted by domestic violence in times of crisis.

WellCare of New Jersey provides government-sponsored managed care services to families, children, seniors and individuals with complex needs primarily through Medicaid, Medicare Advantage, and Medicare Prescription Drug Plans across the state. WellCare is a wholly subsidiary of Centene Corporation, a leading multi-national health care enterprise committed to helping people live healthier lives.

For more information, contact:

  • WellCare, 8725 Henderson Road Tampa, Florida 33634; 800-960-2530; Website:

Kindred Healthcare, LLC (Kindred) and Landmark Medical Center, a subsidiary of Prime Healthcare, announced a definitive agreement to create a partnership that will own and operate the Rehabilitation Hospital of Rhode Island in North Smithfield, Rhode Island. Kindred will have a 60% ownership interest in the joint venture and Landmark will own 40%. The hospital is licensed for 82 rehabilitation beds.

Under the agreement, Kindred will bring its proven rehabilitation management and services expertise to the existing hospital, which serves patients from across Rhode Island and neighboring Massachusetts. Each year, Kindred Rehabilitation Services treats nearly 50,000 consumers at its joint venture inpatient rehabilitation hospitals across the country. Kindred’s inpatient rehabilitation hospitals serve patients who are recovering from a variety of conditions, including stroke, brain injury, spinal cord injury, orthopedic injury, neurological conditions, amputation and trauma. Kindred and Prime expect to complete the transaction by the third quarter of 2020, subject to the completion of due diligence, regulatory and licensing approvals.

Kindred Healthcare, LLC is a health care services company based in Louisville, Kentucky with annual revenues of approximately $3.2 billion. At March 31, 2020, Kindred through its subsidiaries had approximately 31,800 employees providing healthcare services in 1,731 locations in 46 states, including 64 long-term acute care hospitals, 21 inpatient rehabilitation hospitals, 10 sub-acute units, 95 inpatient rehabilitation units (hospital-based) and contract rehabilitation service businesses which served 1,541 non-affiliated sites of service.

The Rehabilitation Hospital of Rhode Island is a stand-alone rehabilitation hospital with a capacity of 82-beds. Prime Healthcare Services acquired the Rehabilitation Hospital of Rhode Island in North Smithfield, Rhode Island in January 2014.

For more information, please contact:

  • Susan E. Moss, Kindred Healthcare, Senior Vice President, Marketing and Communications, 680 South Fourth Street, Louisville, Kentucky 40202; 502-596-7296; Email:; Website:

During the coronavirus disease 2019 (COVID-19) pandemic emergency, Massachusetts emergency departments and outpatient settings conducted fewer psychiatric assessments per week in late March compared to January and February. The share of emergency department visit notes with mentions of depression dropped by 44%, from a mean of 1,446 visits per week in January and February to 886 visits the week of March 19 to 25. The share of outpatient visit notes with mentions of depression dropped by 81%, from 49,312 visits in January and February to 9,315 visits the week of March 19 to 25. Similar patterns were observed for other symptoms.

In emergency department settings, the odds of COVID-19 testing increased by nearly 50% in visits during which violence was referenced in the record. In outpatient settings, notes with the presence of psychiatric terms were associated with a 20% reduction in the likelihood of COVID-19 testing for anxiety, 36% reduction for depression, 37% reduction for psychosis, 27% reduction for suicide, and 60% reduction for violence.

These findings were reported in “Electronic Health Record Documentation of Psychiatric Assessments in Massachusetts Emergency Department and Outpatient Settings During the Coronavirus Disease 2019 (COVID-19) Pandemic” by Victor M. Castro, MS; Roy H. Perlis, M.D., MSc. They sought to determine the trend in documentation of psychiatric symptoms in narrative clinical notes as COVID-19 activity increased in eastern Massachusetts. They analyzed electronic health records for all individuals seen in outpatient or emergency department visits between January 2 and March 25, 2020, from two large academic medical centers and three affiliated community hospitals in Massachusetts.

The presence of depression, anxiety, suicide, psychosis, and violence was identified by the presence of terms related to these conditions. These terms included depressed, depressive, dysphoric, dysthymic, sad, and tearful for depression; anxiety, anxious, fearful, frighten, hypervigilant, nervous, panic, phobia, phobic, scared, stress, tense, and worried for anxiety; suicide, suicidal, and suicidality for suicide; psychotic, psychosis, hallucination, delusion, paranoid, paranoia, hallucinate, hallucinated, and delusional for psychosis; and violence and violent for violence.

The full text of “Electronic Health Record Documentation of Psychiatric Assessments in Massachusetts Emergency Department and Outpatient Settings During the Coronavirus Disease 2019 (COVID-19)” was published June 8, 2020, by JAMA Network Open. An abstract is available online at

For more information, contact:

  • Roy H. Perlia, M.D., MSc, Division of Clinical Research, Center for Quantitative Health, Massachusetts General Hospital, 185 Cambridge Street, 6thFloor, Boston, Massachusetts 02114; Email:

Addcounsel Chief Executive Officer Paul Flynn announced a new service, Orchestrate Health, to treat clients with complex mental health needs from the comfort of their home. Mr. Flynn designed the at-home alternative for people who need mental health care but do not need or want to go into psychiatric units.

The goal of the home treatment option is to enable clients to live their lives in the least restrictive way possible, allowing them the best quality of life despite the mental health difficulties they face. Orchestrate Health offers an alternative to the mainstream and is also able to act as the continuum of care for people who may have been through treatment, and although no longer in need of complex inpatient care, require a level of support at home or for individuals who would prefer to be treated at home.

Orchestrate Health provides anonymous, private mental health services and care across the United Kingdom and internationally in the comfort of the client’s home. The services offered at Orchestrate Health are exclusive mental and behavioral health care treatment from the privacy of the client’s home and round the clock rapid response home mental health care.

For more information, please contact:

  • Addcounsel Ltd, LG, 28 Grosvenor Street Mayfair, London, United Kingdom W1K 4QR; +44 (0)203 709 3968; Email:; Website:

On June 3, 2020, the Centers for Medicare & Medicaid Services (CMS) announced adjustments to 16 value-based care (VBC) models to account for the coronavirus disease 2019 (COVID-19) pandemic public health emergency (PHE) that began in March 2020. The goal is to account for changes in health care delivery and related additional costs, and to give the participating provider organizations more time to transition VBC. As much as possible, the participating provider organizations will not be at-risk for costs due to the pandemic.

CMS Innovation Center Changes To Value-Based Care Models To Account For COVID-19 Public Health Emergency
Innovation Center Model Financial Methodology Changes Quality Reporting Changes Model Timeline Changes
Bundled Payments for Care Improvement Advanced Yes No No
Comprehensive ESRD Care Model (CEC) Yes Yes Yes
Comprehensive Care for Joint Replacement (CJR) Model Yes No Yes
Direct Contracting (Global and Professional) Yes Yes Yes
Emergency Triage, Treat, and Transport (ET3) No No Yes
Home Health Value-Based Purchasing Model (HHVBP) No Yes No
Independence at Home (Section 3024 of the ACA) No Yes No
Integrated Care for Kids (InCK) Model No No Yes
Kidney Care Choices Yes Yes Yes
Maternal Opioid Misuse Model (MOM) No No Yes
Medicare Care Choices Model No No No
Medicare Diabetes Prevention Program Expanded Model (MDPP) No Yes No
Medicare ACO Track 1+ Model Yes Yes Yes
Next Generation ACO (NGACO) Yes Yes Yes
Oncology Care Model (OCM) Yes Yes Yes
Primary Care First—Serious Illness Component No No Yes

CMS seeks to make the changes consistently across models and programs to provide stability and predictability for the model participants. For some models, reporting requirements and timelines have been delayed. For other models, the payment methodology has been changed to mitigate risk during the emergency, or cost targets and benchmarks have been modified. CMS used the following principles to determine which changes were appropriate:

  • Use flexibilities that already exist in current model design.
  • Continue sufficient financial incentives that encourage higher-quality outcomes.
  • Ensure equity and consistency across models.
  • Align as much as possible with national value-based and quality payment programs.
  • Minimize risk to model participants, the Medicaid program, and the Medicare Trust Funds.
  • Limit delays in new model implementation, while providing additional opportunities for participation in new models.
  • Minimize reporting burden.
  • Complement and build off the new CMS COVID-19 Public Health Emergency flexibilities as outlined in regulation and waivers.

A link to the full text of “CMS Innovation Center Models COVID-19 Related Adjustments,” which includes summaries of the changes to each model may be found at

For more information, contact:

  • Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Website: 

Miami’s Monte Nido & Affiliates, an eating disorder treatment provider organization, has selected Kipu as Mydecine Innovations Group Inc. (Mydecine) announced that it has signed a definitive share exchange agreement with Mindleap Health Inc. (Mindleap) for the acquisition of a 100% interest in MindLeap’s Digital Telehealth Platform focused on the emerging psychedelics industry. Mydecine will acquire 100% of the issued and outstanding shares of Mindleap in exchange for: (i) 6,363,636 common shares in the capital of the Company, and (ii) the binding commitment to advance CAD $500,000 in working capital to Mindleap upon closing of the transaction and an additional CAD $500,000 on or before September 1, 2020.

Certain principals of Mindleap will be subject to resale restrictions on the sale of the Mydecine shares for the periods ending 4, 12, 18, and 24 months from closing. Closing of the acquisition is subject to the receipt by Mindleap of the signatures of all of its shareholders on the share exchange agreement.

Mydecine Innovation’s Group is a life sciences company focused on the development and commercialization of products and services that contribute to improving overall health and well-being. The company’s mission is to create a healthier world through advanced technologies, natural products, and psychedelic derived medicines.

Mindleap Health is developing an advanced digital telehealth platform that will provide support for people that are looking to achieve personal transformations and overcome mental health challenges. MindLeap’s telehealth platform combines telemedicine with mood, emotion, and habit tracking.

For more information, please contact:

  • Mydecine Innovation’s Group, 789 West Pender Street Suite 810 Vancouver, British Columbia V6C 1H2 Canada; 888-871-3936
  • Mindleap Health, The King George Building, 905 W Pender St, Vancouver, British Columbia V6C 1L6; 800-972-5194; Email:; Website:

There are a few interesting observations about ‘reopening’ of health care service operations after the pandemic crisis closures, based on discussions during last week’s virtual 2020 OPEN MINDS Strategy & Innovation Institute. Executives are conflicted—for many reasons—about reopening their office-based operations. And, there is a real lack of clarity about the mandates and availability of testing.

The Centers for Disease Control and Prevention (CDC) guidelines for the reopening of operations of any type are ambiguous at best. I’ve read most of them. They are a combination of vague, seemingly off base, and impractical. And there is no mention of testing in any of them.

There are also variations in state and county regulations. For example, in Pennsylvania, you can hold a meeting of up to 250 people for counties in the ‘green’ phase. But, in Orange County, California, the limit is 100 people. In North Carolina, gatherings are still limited to no more than 10 people indoors, and no more than 25 people in outdoor spaces. During the Institute discussion, one executive of a multi-location provider organization discussed the complexity and cost of tracking what the requirements are—and putting them in place.

Another issue is employee perceptions of safety. During the session, Navigating The New Normal With COVID-19 Part 2: An Update On Sustainable Strategies For The Disrupted Market, David Klements, Chief Executive Officer of Qualifacts, talked about forming a cross functional team of employees to develop the guidelines that Qualifacts will use for reopening. Every team member wants to think their work environment is as safe as possible.

There are also questions about whether the delivery of many therapies will ever return to office-based practice. Not only do the majority of consumers prefer the convenience of virtual services, every executive at the 2020 OPEN MINDS Strategy & Innovation Institute who discussed their move to virtual services talked about the decrease in no-show rates, the increase in clinical professional productivity, and the elimination of the costs of office space. Therapy services weren’t profitable before the pandemic crisis occurred—and those rates are not likely to go up in the future. Many executive teams may make the decision to keep much of their therapy capacity—and those services—in a virtual delivery model. The executive commented, “We’re not going to open our offices any time soon. We’re focused on expanding our home-based services instead.”

Finally, there is the testing issue. First, none of the CDC guidelines mention testing. Yet there is a broad consensus that employee and consumer testing is a key to reopening. In testimony to Congress on June 4, Georges Benjamin, M.D., Executive Director of the American Public Health Association, told members of the U.S. Senate committee on Health, Education, Labor and Pensions that without adequate testing, universities “can’t function at all.”

There are admittedly variabilities in the accuracy of different tests. But there is widespread agreement that rapid testing—combined with sanitation measures, contact tracing, and quarantines—is an important tool for moving ahead.

One key tool for executive teams planning for recovery after this crisis period is having the metrics to make the right decisions – think of this data in three domains. There is financial data for short-term cash management strategy. There is strategic market information for planning long-term post-recovery strategy (this includes both external and internal data). And there is service performance data to optimize value.

We got a great example of service performance data in the presentation, Measurable Client Outcomes – A Provider’s Journey Continues, by Scott Zeiter, executive vice president and chief operating officer, and Jeremy Ulderich, director of educational consulting at Grafton Integrated Health Network, at The 2020 OPEN MINDS Strategy & Innovation Institute. Grafton has implemented a sophisticated approach to providing measurement-based care (MBC) in their programming for consumers with complex behavioral challenges. The program started over a year ago. Their presentation focused on what they have learned after fully implementing the MBC service model.

The model is based on a five-step process—identify the consumer behaviors that are problematic and need to change; develop a goal for behavior change; select an “intervention”;  develop a plan for integrating the intervention into a consumer care plan; and measure the effectiveness of the intervention. This sounds simple but is a complicated undertaking to determine what interventions are most effective in specific consumer groups. Mr. Zeiter explained, “We needed to come up with a response to value-based contracting. Defining value is difficult. We needed to take a step ahead of the external stakeholders. That has had a positive impact, and the payers have taken an interest in it, as a way to define true value. We wanted to root this into evidence-based practices.”

What were the key effects of this process at Grafton? Mr. Ulderich shared a few stats, showing that in their Assessment of Basic Language and Learning Skills, the overall consumer score increased from an average of 318.05 to an average of 545.62—up to 80% growth from prior assessment. And in the Assessment of Functional Living Skills Criterion, there was a 32% increase in overall consumer scores. Mr. Zeiter noted the success, saying, “Once we gave the staff that tool, it was incredibly effective, and the staff felt tremendously empowered. The message we wanted to give the staff at Grafton was, we are going to give you control of the data. It is going to emanate from you. We are going to give you that and give you the roadmap we are following in hopes that you will help us follow it.”

There were three big takeaways from the session—the importance of the tech infrastructure; the challenges of a shift in clinical culture to embrace MBC; and the possible strategic advantages of MBC in a market moving to value. The tech infrastructure discussion was interesting. The keys to success are the combination of access to “big data,” the ability to automate the compilation and reporting of that data, and the ability to customize dashboard views for Grafton teams.

Mr. Zeiter and Mr. Ulderich explained that this reveals the true promise in their work, to allow specialists to correlate variables like demographics, diagnoses, frequencies of concerning behavior, and evidence-based practices, to determine what factors were more effective in determining outcomes. The key is to begin “gathering the data pile.” Mr. Zeiter explained, “Historically we were concerned about precision when we talked about testing things. When you look at Silicon Valley, they are now less interested in precision and more interested in gathering as much as possible and then weeding through it to determine the correlations.”

And after you get the “data pile,” the key is automating the data collection and the production of customized dashboards for end users. Grafton is currently running 65 different reports to support its programs and has the potential to run as many reports as needed. Mr. Zeiter explained, “With the information, we can dashboard anything, but we are just scratching the surface of all the data we are collecting. At this point we have immediate access to data and can use it for a variety of reasons.”

But beyond getting the technology right, there is the challenge of creating a metrics-based culture, particularly among direct care staff and clinical professionals. It takes time to change the culture. As Mr. Zeiter noted, “There are many clinicians clearly still focused on relationships and process but that doesn’t exclude their interest in the data. They want to see the concrete impact of their interventions.” But it takes a lot of administrative time to ensure staff are using the tools correctly and staying on point with the treatment goals. Mr. Zeiter added, “Constantly having to follow behind to ensure the treatment goals are updated has been very work intensive. They need constant supervision.”

Most exciting was the Grafton view of the role of this information in their future strategy. Mr. Zeiter noted that by the end of this month, they will develop a data set with integration of all of their operating databases. The purpose is to use the assessment data, the behavior data, and the goal mastery to start to identify the factors that can predict the cost of care.

In 2021, health and human service budgets are going to be stressed—and all payers will be looking to get more “value” for their expenditures. The ability to tie services to outcomes and to cost will be a key competitive advantage.

As of June 9, 2020, 24 health care provider organizations each received over $100 million in relief funding from the federal Department of Health and Human Services (HHS) Provider Relief Fund created as part of the Coronavirus Aid, Relief, and Economic Security (CARES) Act. The New York and Presbyterian Hospital received and attested to the highest total amount—$567 million. The second largest Provider Relief Fund payments—$403 million—went to New York University Langone Hospitals.

The allocations are intended to help health care provider organizations cover lost revenue and increase costs during the public health emergency due to coronavirus disease 2019 (COVID-19). HHS has been distributing the funds since April 10, 2020. The data on relief fund allocations are available on the Centers for Disease Control and Prevention (CDC) website.

The CARES Act and the Paycheck Protection Program and Health Care Enhancement Act provided $175 billion in Provider Relief Funds to hospitals and other health care provider organizations. HHS is distributing the payments through the Health Resources and Services Administration (HRSA) for $50 billion general distribution, $12 billion targeted allocation to high impact areas, $10 billion targeted allocation to rural provider organizations, $4.9 billion to skilled nursing facilities, $500 million to Tribal Hospitals, Clinics, and Urban Health Centers.

Provider Organizations That Received More Than $100 Million In CARES Act Provider Relief Funds
Provider Organization Name State City Payment
The New York And Presbyterian Hospital New York New York $567,285,060
New York University Langone Hospitals New York New York $403,339,290
Hackensack Memorial Hospitals Corporation New Jersey Hackensack $356,441,388
Long Island Jewish Medical Center New York Westbury $326,631,509
Mount Sinai Hospital New York New York $262,819,360
Dignity Health Nevada Henderson $190,189,565
William Beaumont Hospital Michigan Southfield $179,686,440
North Shore University Hospital New York Manhasset $175,200,130
Advocate Health And Hospitals Corporation Illinois Downers Grove $160,977,911
Henry Ford Health System Michigan Detroit $157,899,088
Maimonides Medical Center New York Brooklyn $151,365,990
Ochsner Clinic Foundation Louisiana New Orleans $124,854,422
Beth Israel Medical Center New York New York $118,083,784
Regents Of The University Of Michigan Michigan Ann Arbor $116,857,156
University Hospital At Stony Brook New York Stony Brook $112,581,243
Vanderbilt University Medical Center Tennessee Nashville $108,292,719
Staten Island University Hospital New York Staten Island $106,912,606
Bronxcare Health System New York Bronx $105,345,390
New York-Presbyterian/Brooklyn Methodist New York Brooklyn $104,187,532
County Of Los Angeles California Commerce $103,853,772
Cedars-Sinai Medical Center California Los Angeles $103,347,125
The Cleveland Clinic Foundation Ohio Independence $103,289,897
St Josephs Hospital And Medical Center New Jersey Cedar Grove $102,568,689
Stanford Health Care California Palo Alto $102,405,229

HRSA released the allocations in a dataset on the CDC website that lists all provider organizations that received and attested to the Terms and Conditions for a payment from the General Distribution, High Impact Area, Skilled Nursing Facilities, Tribal, and/or the Rural Targeted Allocation of the Provider Relief Fund. Each organization listed has attested to receiving one or more payments and agreed to the terms and conditions within 90 days of payment.

HRSA released a separate dataset with payments to 395 hospitals who received a payment under the $12 billion High Impact Area Targeted Allocation. About $2 billion of the payments from the COVID-19 High-Impact Area Allocation were distributed to these hospitals based on their Medicare disproportionate share and uncompensated care payments.

Each of the 395 hospitals provided inpatient care for 100 or more people with COVID-19 through April 10, 2020. These hospitals accounted for 71% of COVID-19 inpatient admissions reported to HHS from nearly 6,000 hospitals around the country. The payments ranged in size from $7.6 million to $277 million. Twelve hospitals received payments of $100 million or more.

Hospitals Receiving Provider Relief Fund COVID-19 High-Impact Payments Of $100 Million Or More
Hospital Name State City Payment
Long Island Jewish Medical Center New York New Hyde Park $277,653,312.42
Holy Name Medical Center (AKA Holy Name Health) New Jersey Teaneck $213,428,946.86
Tisch Hospital New York New York $203,180,446.74
Montefiore Hospital – Moses Campus New York Bronx $156,708,591.59
NewYork-Presbyterian/Columbia University Irving Medical Center New York New York $152,747,325.41
NewYork-Presbyterian Queens New York Flushing $143,251,512.11
Mount Sinai Medical Center (AKA the Mount Sinai Hospital) New York New York $140,754,860.74
Sandra Atlas Bass Heart Hospital at North Shore University Hospital New York Manhasset $137,531,542.64
Maimonides Medical Center New York Brooklyn $131,500,615.31
NewYork-Presbyterian/Weill Cornell Medical Center New York New York $118,647,056.76
NYC Health and Hospitals – Elmhurst (FKA Elmhurst Hospital Center) New York Elmhurst $111,346,403.33
NYU Winthrop Hospital (FKA Winthrop University Hospital) New York Mineola $108,038,387.94

The data set of CARES Act Provider Relief Fund payments can be viewed online at

The data set of 395 hospitals that shared the $12 billion high impact allocation can be viewed online at

PsychU reported on the CARES Act Provider Relief Fund on May 4, 2020, in “HHS Begins Releasing $100 Billion CARES Act Funding To Provider Organizations For Relief Assistance & Treating The Uninsured” at

For more information, contact:

  • Health Resources and Services Administration, 5600 Fishers Lane, Rockville, Maryland 20857; Website:

Crises of any kind are known to increase mental health and addictive disorders. This pandemic crisis is no exception. The initial estimates are sobering.

An early April poll by the Kaiser Family Foundation shows that nearly half (45%) of all U.S. adults say the pandemic has affected their mental health, while 19% say it has had a “major impact.” Prescriptions for anti-anxiety drugs spiked 34% between February 16 and March 15, and also increased for antidepressants (18.6%) and anti-insomnia drugs (14.8%), according to a report from Express Scripts.  Companies like Ginger and TalkSpace delivering virtual mental health care have seen a massive surge in demand for services with COVID-19—with increases of 50% to 65% in February and March.

The scenario is ripe for increased addiction challenges as well. Millions of Americans with opioid use disorder who depend on face-to-face health care delivery are at increased risk. A Health Affairs blog notes that social distancing and self-quarantine are risk factors for relapse for people with addiction disorders. The fear and uncertainty associated with social and economic distress, along with mandated isolation, can aggravate anxiety and depression—and many people will self-medicate with drugs and alcohol to ease the stress. On a similar note, experts at the National Institute of Mental Health have stated that COVID-19 can be a trigger for those who already have anxiety disorder and obsessive-compulsive disorder as the “Purell is everywhere.” Rising alcohol sales maybe an early warning sign of an increase in addiction disorders—online alcohol sales increased 55% in the first two weeks of March, reported Nilesen. One alcohol delivery app, Drizy, serving 26 states and Washington D.C. said alcohol sales the week of March 16-21 were up about 300% from earlier in the year.

Trauma is another behavioral health challenge expected to be exacerbated by COVID-19. Researchers are warning that the coronavirus pandemic could inflict long-lasting emotional trauma on an unprecedented scale and leave millions wrestling with debilitating psychological disorders. The combined stressors—the global nature of the pandemic, the isolation and social distancing, unemployment, and impending recession—are taking their toll. “The scale of this outbreak as a traumatic event is almost beyond comprehension,” said Yuval Neria, the director of trauma and post-traumatic stress disorder at the New York State Psychiatric Institute and a professor of psychology at Columbia University Medical Center, talking to CNBC.

Lancet Psychiatry reports that suicide risk might increase because of stigma towards individuals with COVID-19 and their families and the increase in depression, anxiety, and post-traumatic stress among the general population and those with high levels of exposure to illness caused by COVID-19, such as essential workers. An 85% increase in gun sales in March (the highest ever sales recorded in the U.S.) also leaves experts concerned about a potential increase in gun-related suicides.

From this emerging early data, it appears that long after the acute health effects of the novel coronavirus on the population subside, we will see lasting effects in the form of increased demand for behavioral health services. For executives planning their post-recovery strategies, the unanswered questions are how the services will address these issues be delivered and how will they be funded.

While predictions are dangerous this early in the arc of the pandemic, there are a few factors that will shape the post-pandemic market. There will be increased political pressure for health benefit coverage for the entire U.S. population. But, like all things political, whether or not that happens will depend on the elections this fall. We do know that the pandemic will increase enrollment in Medicaid due to the burgeoning ranks of the unemployed—at a time when state budgets are strapped and policy suggestions like ‘state bankruptcy’ are floating around. But, like the pandemic itself drove rapid adoption of virtual care models, the financial consequences of the pandemic are likely to accelerate the use of integrated care and value-based reimbursement models for both managed care organizations and provider organizations. Regardless of the exact scenario, the successful strategy is likely to be one focused on ‘value’ defined as the low costs with a high value service to consumers.

On May 28, 2020, Capital BlueCross announced an advance payment program for its network provider organizations in Pennsylvania affected by revenue drops due to the coronavirus disease 2019 (COVID-19) public health emergency. The payments are intended for organizations that have a 40% or greater decrease in average payment for services provided to Capital BlueCross members during March and April 2020. The goal is to help those provider organizations “bridge the financial gap” as members gradually resume in-office visits and procedures.

Provider organizations can apply by contacting Capital BlueCross. The payments will be available through July 15, 2020. The amount of the funding advances is based on the provider organizations’ average monthly payments during 2019.

Capital BlueCross said it launched several initiatives to help its network provider organizations, its members, and the community during the pandemic. The initiatives for provider organizations and members include the following:

  • Relaxed the provider organization claims and appeals timeframes and extended pre-authorizations.
  • Expanded the types of provider organizations whose services are covered through telehealth.
  • Waived member costs (copayments, coinsurance, and deductibles) for COVID-19 diagnostic testing, related office visits, and in-network, inpatient hospital treatment for COVID-19.
  • Allowed early refill of prescription drugs for members with its pharmacy benefit.
  • Waived member costs for tele-dentistry for members with its dental coverage.

To assist the community, Capital BlueCross increased its funding support to food banks and other community organizations to help address food insecurity. The insurer is also providing meals to health care workers, first responders, and nursing home staff and residents as part of its effort to help communities and front-line workers.

Capital BlueCross is an independent licensee of the BlueCross BlueShield Association. It provides health insurance products, services, and technology solutions in Central Pennsylvania and the Lehigh Valley.

For more information, contact:

  • Melissa Fox, Supervisor, Public Relations and Social Media, Capital BlueCross, 2500 Elmerton Avenue, Harrisburg, Pennsylvania 17177; 717-541-6843; Email:; Website:

Plans of any type—including plans for crisis management and financial recovery—are only as good as their implementation. For most organizations, success of new plans depends on the leadership team that is charged with the planning and its implementation. That was the focus of Monica Oss’ closing remarks, Strategy In A Crisis – Staying Afloat Vs. Navigating; at The 2020 OPEN MINDS Strategy & Innovation Institute.

But what do leaders need to do to make that happen? The panelists—Charles Ingoglia, chief executive officer (CEO) at the National Council for Behavioral Health; David Klements, CEO at Qualifacts Systems, Inc., and Jon Wolf, CEO at Pyramid Healthcare, Inc., discussed specific leadership “must dos” in the session, Navigating The New Normal With COVID-19 Part 2: An Update On Sustainable Strategies For The Disrupted Market. They discussed twelve essential leadership actions in the session. But the real gems were the first-hand practices and advice from this group.

Mr. Klements spoke to the importance of data in planning for success and continuously reframing recovery efforts. As an example, he cited recent survey data on the evolving virtual care landscape. “Laptops are going to be three times more important to providers than tablets…90 days ago, the data would have suggested the opposite. And it turns out that internet access and poor connectivity are the biggest challenges to providers moving to virtual service delivery.” His point? The key to navigating is to keep on top of the data—and plan and act accordingly.

Mr. Wolf described their approach to communicating during virtual operations in a crisis, saying, “Communication is so important to the staff in this crisis. But we’ve learned a lot. We’ll never go back to meeting the way we once did.”

He also spoke of recalibrating the need to meet in person and the convenience of virtual meetings for both management and all employees. He explained that they have increased the number of team meetings at Pyramid, using travel time saved to actually meet more. “We’ve tried to ramp up the way we communicate,” he explained. “Using more chat functions—Team, Jabber, and the tools in the Qualifacts system. We also do a lot of internal staff webinars; we have an intranet for our employees, and we’ve set up a function to rapidly answer employee questions. There is still a lot of fear out there and staff want to know what is going on. Our system is set up for rapid communication to answer questions.”

Mr. Ingoglia also had an interesting perspective on communication. “When this started, I assumed we would be working off site for two weeks and I started a daily email to staff,” he said. “We’re way past two weeks, but I get feedback from staff to keep my daily email. I have more touchpoints with staff now than I did and I am trying to think about how to keep that in the future.”

These new communication models aren’t the only “learning” happening from the crisis. Mr. Wolf spoke about the shift in his organization to be more engaging with consumers. “One big problem in behavioral health is engagement,” he said. “Our numbers, the percentage of people going from an assessment to admission to services was 50% pre-COVID-19. It’s now 65%. We’ve changed. We’ve become more engaging, more customer focused. That is a magnificent thing. It would be absurd for us to go back.”

Both Mr. Klements and Mr. Wolf spoke about the need for nimble decision making and operational flexibility that only comes with a system that allows decentralization of management. Mr. Klements noted specifically, “There is critical-path work that needs to happen from the top down. Conversely, bottom up communication is from the teams closest to consumers. For example, they are the team members who identified our clients’ needs for more support with virtual health. It’s an interesting dynamic to manage fewer critical things from the top down, and let the staff identify what is important to consumers.”

At Pyramid, they have accomplished decentralized decision making with a new approach. Mr. Wolf explained, “We have segmented the operations into silos, like communication, protective personal equipment (PPE), managing consumers, and then we assigned leaders for each of those segments. The change was rapid, and there is the need for short-term and long-term strategic plans. Segmenting and focusing on the communication allow us to manage the change more broadly.”

At the close of the session, the group discussed the challenges of “returning to normal.” There are the practical considerations voiced by Mr. Klements, like the additional operating costs that will be required for technology, PPE, testing, and the process for reopening offices. “Right now we’re working on how to safely reopen our offices and have set up a cross-functional committee led by our chief financial officer to evaluate all the possibilities,” he said. “Opening varies by location and market sector.”

Mr. Ingoglia spoke of these differences across the country—including navigating the different rules and COVID rates varying by geography, that make it difficult to have a single approach. Mr. Wolf agreed about the differences between states, noting, “Every market is different, every state is different. You can’t apply the same rules and timeline.”

And on top of those differences, each CEO expressed frustrations of not knowing what the federal policies and supports will be for the health and human service sector in general, and for specialty provider organizations in particular. Mr. Ingoglia explained, “The larger issue is that our system operates on the periphery of federal health care policy. The dilemma is, what exactly is a substance use provider organization, or a mental health organization? We have no definitions in federal law. We are doing our best to advocate for the sector. But having some clarity would be helpful. We need a framework for legislators.”

At the close of the session, the three CEO colleagues were in unanimous agreement about one fact—the only certainty is uncertainty.

On May 22, 2020, the San Diego County Health and Human Services Agency, Housing and Community Development Services released a request for proposals (RFP 10141) seeking a contractor to provide comprehensive care coordination, service navigation, peer support, housing and housing-related assistance to veterans referred through the Veterans Moving Forward (VMF) program. The VMF program is a veteran-only, incentive-based housing unit for male veterans who served in the United States military and are held at the county’s Vista Detention Facility. VMF assists incarcerated veterans by providing necessary in-custody treatment, services, and community linkages to reduce the cycle of incarceration.

Currently the VMF services do not specifically include care coordination. There is no incumbent care coordination vendor. The San Diego County Sheriff’s Department formed VMF in 2013. It is a partnership with the VA, the Office of Military and Veterans Affairs, and community provider organizations. The VMF unit was created without any specialized funding. At that time, the Sheriff’s staff sought support from department leadership to work closely with the VA to reallocate staff to the program. The services were provided by Sheriff’s Department staff and by volunteers and others in the community. On October 15, 2019, the San Diego County Board of Supervisors accepted a proposed Community Care Coordination for Veterans Implementation Plan to enhance the VMF program using a peer support team to increase connections to services and reduce recidivism through housing assistance, care coordination, and increased opportunities for vocational training for local veterans.

Proposals are due by July 7, 2020. The county anticipates awarding a single county-wide cost reimbursement contract with one base year followed by four one-year option terms. The estimated allocation for the base year is a maximum of $1.15 million. For each subsequent year, the allocation is a maximum of $2.15 million, for a total contract cost not to exceed $9.75 million.

Startup funding is available for one-time costs associated with the development and implementation of the Community Care Coordination for Veterans Program. The start-up funding is included in the initial term maximum amount and cannot exceed 2.5% of the initial contract term amount. Start-up funds will be paid on a cost reimbursement basis.

VMF services will begin while the veteran is in custody and continue for up to 12 months in the community. Engagement, service navigation, and peer support will be provided in both a custodial (jail) setting and in the community. Services can include: case management, placement in immediate housing, transportation, peer support, benefit assistance, housing navigation for permanent housing, tenant support, landlord mediation, family reunification, system navigation to connect veterans to mental health services, addiction treatment, health care, and other needed supportive services that improve the veteran’s quality of life and reduces the risk of recidivism. The contractor must ensure that all veterans are connected to safe and secure housing immediately upon release from custody and linked to permanent housing within six months of exiting custody.

The selected contractor must have experience serving veterans. The peer support specialists should be part of the military community. The contractor will work closely with all partners, including, but not limited to, the Sheriff’s Department, United States Department of Veterans Affairs (VA), Probation Department, and various divisions within the county Health and Human Services Agency, including Housing and Community Development Services, Office of Military and Veterans Affairs, Self-Sufficiency, and Behavioral Health Services.

In March 2019, the initial VMF program outcomes were reported in “Veterans Moving Forward: Process and Impact Evaluation Results of the San Diego County Sheriff’s Department VMF Program” by Cynthia Burke, Ph.D.; Sandy Keaton, MA; Gregor Schroeder, MS; and Kandice Ocheltree, MA. The report was released by the San Diego Association of Governments, which had collaborated to launch the initial VMF program. The researchers conducted a program evaluation and surveys with 141 VMF participants at intake, exit, and six-months after exit. They interviewed key staff and deputies and analyzed program record data to track assessment and service provision. They analyzed justice system records to identify the participants’ criminal history, rule violation, and recidivism. Since 2013, 1,200 inmates have gone through the program.

The key findings were as follows:

  • Compared to a historical group of veterans who did not receive VMF services, VMF participants tracked from 2015 and 2016 had significantly fewer rule violations and were significantly less likely to have a conviction for a new offense in the 12-months following release. The VMF recidivism rate has been 16% compared to 27% for other veterans not in the program.
  • VMF clients received about 14 different classes on average and appeared to be involved in around 30 hours of programming on average per week.
  • The program had challenges maintaining program fidelity and consistency due to the reliance on program volunteers and simultaneous lack of dedicated funding. However, the use of volunteers and collaboration did contribute to the success of the VMF unit. Staff were positive about the program. Participants expressed thanks for the safe environment to work on their underlying needs and receive services not available in the general population. More than 95% of participants at exit and follow-up said they would recommend VMF to another veteran.

A link to the full text of “San Diego Board Of Supervisors October 15, 2019 Meeting: Approval Of The Community Care Coordination For Veterans Implementation Plan For Successful Reentry” may be found at

A link to the full text of “Veterans Moving Forward: Process & Impact Evaluation Results Of The San Diego County Sheriff’s Department VMF Program” may be found at

For more information, contact:

  • Cristina Duroiu, Procurement Contracting Officer, San Diego County Department of Purchasing and Contracting, 5560 Overland Avenue, Room B, San Diego, California 92123; 858-505-6358; Email:
  • Sarah Sweeney, Communications Officer for Health and Human Services Agency, San Diego County, 5560 Overland Avenue, Suite 270, San Diego, California 92123; 619-685-2522; Email:; Website:

Optimizing both population health and individual patient care will require major changes in how health care is delivered, starting with a systemic focus. In this webinar, three expert panelists from OPEN MINDS—Sharon Hicks, MBA, MSW; Richard Louis III; and Paul Duck—discuss the current paradoxical state of care delivery, in which providers are sometimes expected to achieve mutually incompatible goals. Their conversation covers the critical role that care management, clinical communication, and electronic interoperability must play for successful population management to occur. Additionally, the critical importance of the social determinants of health (SDoH) is considered.


  • Sharon Hicks, MBA, MSW
    Senior Associate, OPEN MINDS
    Former Chief Operating Officer, Community Care Behavioral Health
  • Richard Louis III
    Vice President–Western Region, OPEN MINDS
    Former Director of Development – Behavioral & Addiction Medicine, Southern California Hospitals Healthcare Systems Inc.
  • Paul Duck
    Senior Associate, OPEN MINDS
    Former Vice President–Strategy and Development, Beacon Health Options

Sharon Hicks, MBA, MSW, is a Senior Associate with OPEN MINDS and has more than 20 years of experience in the health and human services field, with expertise in health plan management, clinical operations management, and technology.

Richard Louis, III, is the Vice President–Western Region with OPEN MINDS and has extensive experience as a behavioral health care administrator, business development specialist, and innovator of new service lines for behavioral health care organizations.

Paul M. Duck has more than 30 years of experience in leadership and management, with a focus on managed care, health information technology organizations, strategy, business development, market expansion, and customer experience optimization. He serves as a Senior Associate with OPEN MINDS.

As of June 17, 2020, more than 120 behavioral health provider organizations had been awarded funding through the $200 million Federal Communications Commission (FCC) coronavirus disease 2019 (COVID-19) Telehealth Program. To date, the FCC has awarded about $128 million in approved funding for 367 health care provider organizations in 42 states plus the District of Columbia. The average award is about $349,393, and the median is $242,600, with amounts ranging from the low of $1,468 to Leyden Family Services and Mental Health Center to $1 million awarded to 14 hospital systems.

The COVID-19 Telehealth Program was created by the Coronavirus Aid, Relief, and Economic Security (CARES) Act to support the expansion of telehealth services during the coronavirus disease 2019 (COVID-19) pandemic. The CARES Act also created the three-year, $100 million Connected Care Pilot Program. The pilot will provide funding from the FCC’s Universal Service Fund (USF) to support 85% of health care provider organization costs for telehealth equipment and the cost of providing eligible services. The goal is to help assess how the USF can be used in the long-term to support telehealth. The FCC released the pilot program rules on April 9, 2020. Pilot program applications will be due by July 31, 2020. No awards have been made as of June 21, 2020. The anticipated number of awards or the award size have not been released.

On June 10, 2020, the FCC had announced that more than 100 behavioral health provider organizations had been awarded funding through the COVID-19 Telehealth Program of the 305 awarded as of that date. On June 17, the FCC announced 62 more awards. The list indicates that 21 awards were made to behavioral health provider organizations or community health centers that intended to use telehealth to provide behavioral health services.

The FCC COVID-19 Telehealth Program provides immediate support to eligible health care provider organizations responding to the COVID-19 pandemic by fully funding their telecommunications services, information services, and devices necessary to provide telehealth services until the program’s funds have been expended or the COVID-19 pandemic has ended. The funding can be used to purchase laptop computers, tablets, smartphones, videoconferencing equipment, mobile hot spots, video monitors, remote monitoring devices, software licenses, network upgrades, and subscriptions for telehealth platforms. The maximum grant is $1 million.

Rules for the Connected Care Pilot Program were released on April 2, 2020. The FCC released more information about the pilot in “Report & Order: Promoting Telehealth For Low-Income Consumers.” Participation in the pilot will be open to non-profit or public health care provider organizations including the following eight provider organization types:

  1. Post-secondary educational institutions offering health care instruction, teaching hospitals, and medical schools
  2. Community health centers or health centers providing health care to migrants
  3. Local health departments or agencies
  4. Community mental health centers
  5. Non-profit hospitals
  6. Rural health clinics
  7. Skilled nursing facilities
  8. Consortia of health care provider organizations consisting of one or more entities falling into the first seven categories

For the purpose of the pilot, the FCC considers “connected care” as a subset of telehealth that uses broadband internet access service-enabled technologies to deliver remote medical, diagnostic, and treatment-related services outside of traditional medical facilities and directly to consumers at their mobile location or residence. Connected care services can be provided by physicians, nurses, or other health care professionals. Also for the pilot, the FCC defines “telehealth” as the broad range of health care-related applications that depend upon broadband connectivity, including telemedicine; exchange of electronic health records; collection of data through Health Information Exchanges and other entities; exchange of large image files (e.g., X-ray, MRIs, and CAT scans); and the use of real-time and delayed video conferencing for a wide range of telemedicine, consultation, training, and other health care purposes.

The FCC released a list of the organizations and their projects for the COVID-19 Telehealth Program approved as of May 13, 2020. A link to the list may be found at

On June 10, the FCC released another list, but this list has only the organization names approved for the COVID-19 Telehealth Program. It does not have project descriptions. This list is available at

A link to the full text of “FCC Report & Order: Promoting Telehealth For Low-Income Consumers” may be found at

A link to the full text of “Promoting Telehealth For Low-Income Consumers; COVID-19 Telehealth Program” may be found at

PsychU last reported on the CARES Act in “HHS Begins Releasing $100 Billion CARES Act Funding To Provider Organizations For Relief Assistance & Treating The Uninsured,” which published on May 4, 2020. The article is available at

For more information, contact:

  • Will Wiquist, Media Contact, Federal Communications Commission, 445 12thStreet Southwest, Washington, District of Columbia 20554; 202-418-0509; Email:; Website:

For more information about the COVID-19 Telehealth Program, contact:

  • Email:; Website:

For more information about the Connected Care Pilot Program, contact:

  • Email:; Website: and

During the week ended April 25, 2020, Medicare received 1.4 million claims for services provided by telehealth. During the week ended March 7, 2020, before the coronavirus disease 2019 (COVID-19) pandemic national emergency, the Centers for Medicare & Medicaid Services (CMS) received about 13,000 claims for telehealth services.

According to a CMS spokesperson, the number of Medicare beneficiaries receiving telehealth services increased rapidly, from the 13,000 per week before the national emergency, to 1.1 million during the first week of April, just a month later. During April, telehealth claims continued to rise to 1.3 million during the week ended April 18 and again to the 1.4 million claims during the week ended April 25.

On May 26, 2020, CMS Administrator Seema Verma said CMS is evaluating its Medicare telehealth waivers to determine if they should be extended past the scope of the national emergency. She said CMS is in the rulemaking process, and she indicated that some temporary provisions will be made permanent. As of June 17, 2020, further information had not been released.

On March 30, 2020, after the national emergency was announced on March 13, 2020, CMS relaxed regulations on Medicare telehealth eligibility to allow all beneficiaries to receive many services via telehealth technologies. The goal was to help beneficiaries shelter in place during the national emergency. CMS allowed Medicare beneficiaries nationwide to receive services where they live, including residents of nursing homes or assisted living facilities, and those receiving home health or hospice benefits. Telehealth services can be used to fulfill many Medicare face-to-face visit requirements for clinical professionals to see beneficiaries in inpatient rehabilitation facilities, receiving hospice services, or receiving home health.

Prior to the new flexibilities, telehealth was available only to beneficiaries living within a rural health professional shortage area or in a county outside of a metropolitan statistical area. The beneficiary had to present at an approved originating site and be previously established with the remote professional. The services could be delivered only by physicians, nurse practitioners, physician assistants, nurse midwives, clinical nurse specialists, certified registered nurse anesthetists, clinical psychologists and clinical social workers, registered dietitians, or nutrition professionals. Only certain services could be delivered via telehealth.

A link to the full text of “COVID-19 Emergency Declaration Blanket Waivers For Health Care Providers” may be found at

For more information, contact:

  • Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Website:; or Email:

There is some confusion about where we are—economically—in the midst of the crisis caused by the coronavirus pandemic. We are in a recession and likely on the front edge of a depression. There is wide disagreement about the “shape” of the recovery. Unfortunately, “reopening” and “recovery” are being used interchangeably.

“Reopening” is the phrase being used for an end to some of the government-imposed restrictions on organizational operations in order to prevent the spread of coronavirus. Nearly all 50 states have moved to some level of reopening— “reopening” comes in all forms.

While “reopening” is often required for the financial “recovery” of many organizations, the terms are not synonymous. To reopen physical operations does not mean the return to profitability. There are increased costs of safety measures—from personal protective equipment, to testing, to ventilation systems, and more. In addition, restrictions on capacity are widespread. Limits on the proportion of restaurant capacity that can be used. Limits on the size of gatherings. Limits on the physical distance of consumers in establishments. There are also questions about how many consumers will return to “being served.”

For the health and human service field, the reopening versus recovery issues are many. In a recent discussion, a residential treatment provider organization executive said that given the design of their facility, for the foreseeable future, they would need to operate at 80% capacity to ensure the safety of consumers. There will likely be a significant decrease in rates for virtual services as the market capacity—and competition—increases. What ‘in office’ services will consumers be comfortable receiving is another question. If consumers want more service ‘at home’, how can they be delivered profitably—since home-based services were not profitable before the pandemic crisis.

In short, the reopening is tactical, but recovery as strategic. Reopening requires a policy, an implementation plan, and a budget. Recovery for most health and human service organizations will require not only a new strategic plan—but also new business models. What services an organization delivers, the operational framework for how they deliver those services, the breakeven volume and scalable profitability of each service, the overall portfolio mix of profitable and unprofitable services—these are the types of very fundamental questions that recovery planning needs to address.

On June 5, 2020, the National Committee for Quality Assurance (NCQA) announced adjustments to 40 Healthcare Effectiveness Data and Information Set (HEDIS) measures to support the use of telehealth during the coronavirus disease 2019 (COVID-19) pandemic and after. NCQA will apply the adjustment for measurement of health care quality starting in 2020. The adjustments align with guidance from the Centers for Medicare & Medicaid Services and other federal and state regulators.

NCQA is updating the measures in “HEDIS Volume 2 Technical Specifications,” which will be published on July 1, 2020. Telehealth revisions will be outlined in each measure specification’s “Summary of Changes” section. The guidance will specify how telehealth visits can be used, what will be included in the measure denominator and numerator, and what will be excluded. It will also specify what type of telehealth (e.g., synchronous telehealth visits, telephone visits or asynchronous e-visits or virtual check-ins) is permitted to meet the measure.

Eight of the adjustments affect behavioral health measures:

  1. Antidepressant Medication Management
  2. Follow-up Care for Children Prescribed ADHD Medication
  3. Follow-up After Hospitalization for Mental Illness
  4. Follow-up After Emergency Department Visit for Mental Illness
  5. Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medication
  6. Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia
  7. Diabetes Monitoring for People with Diabetes and Schizophrenia
  8. Adherence to Antipsychotic Medications for Individuals with Schizophrenia

The remaining measures with new telehealth accommodations concern prevention and screening, respiratory care, cardiovascular care, diabetes care, musculoskeletal conditions, care coordination, access and availability of care, utilization, and risk-adjusted utilization. The accommodations also affect measures reported using electronic clinical data systems. Within these remaining measures, some also affect behavioral health services.

Prevention and Screening

  1. Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents
  2. Breast Cancer Screening
  3. Colorectal Cancer Screening
  4. Care for Older Adults


  1. Use of Spirometry Testing in the Assessment and Diagnosis of COPD
  2. Asthma Medication Ratio

Cardiovascular Conditions

  1. Controlling High Blood Pressure
  2. Persistence of Beta-Blocker Treatment After a Heart Attack
  3. Statin Therapy for Patients with Cardiovascular Disease
  4. Cardiac Rehabilitation


  1. Comprehensive Diabetes Care
  2. Kidney Health Evaluation for Patients with Diabetes
  3. Statin Therapy for Patients with Diabetes

Musculoskeletal Conditions

  1. Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis- Scheduled for Retirement
  2. Osteoporosis Management in Women Who Had a Fracture
  3. Osteoporosis Screening in Older Women

Care Coordination

  1. Transitions of Care
  2. Follow-up After Emergency Department Visit for People with Multiple High-Risk Chronic Conditions
  3. Access/Availability of Care

Access/Availability of Care

  1. Prenatal and Postpartum Care
  2. Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics


  1. Well-Child Visits in the First 30 Months of Life
  2. Child and Adolescent Well Care Visits
  3. Mental Health Utilization

Risk-Adjusted Utilization

  1. Plan All-Cause Readmissions
  2. Hospitalization Following Discharge from a Skilled Nursing Facility
  3. Acute Hospital Utilization
  4. Emergency Department Utilization
  5. Hospitalization for Potentially Preventable Complications

Measures Reported Using Electronic Clinical Data Systems

  1. Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults
  2. Depression Screening and Follow-up for Adolescents and Adults
  3. Postpartum Depression Screening and Follow-up
  4. Prenatal Depression Screening and Follow-up
  5. Breast Cancer Screening
  6. Colorectal Cancer Screening
  7. Follow-up Care for Children Prescribed ADHD Medication

More information about the changes is posted at

For more information, contact:

  • Andy Reynolds, Assistant Vice President, Marketing And Communications, National Committee for Quality Assurance, 1100 13th Street Northwest, 3rd Floor, Washington, District of Columbia 20005; 202-955-3518; Email:; Website:
  • Matt Brock, Communications Director, National Committee for Quality Assurance, 1100 13th Street Northwest, 3rd Floor, Washington, District of Columbia 20005; 202-955-1739; Fax: 202-955-3599; Email:; Website:

Our coverage of primary care physicians’ views of addiction treatment and medication assisted treatment (MAT) brought quite a few comments. A recent study found that even though two thirds of physicians believe that addiction treatment is more effective with medication than without (67.1%)—and that consumers can safely use those medications (63.7%)—only 20% of physicians reported an interest in treating opioid use disorders (OUDs).

Add to this picture a primary care landscape where physicians seldom screen for addiction of their own accord, and nurse practitioners and physician assistants feel little responsibility or comfort addressing the issue at all. Only about 57% of primary care clinical professionals report screening consumers for any kind of addiction, only 46% provide any kind of intervention, and only 47% provide a referral for treatment.

The good news is that there are a number of “change management” models to increase the success of addiction treatment services in primary care. What these models share is a two-pronged approach to changing both systems and structure while addressing leadership and staff skills at the same time. But several readers suggested that an approach that is better than educating the broad primary care community about this issue is to turn the model around and embed primary care in addictions treatment.

One suggestion from OPEN MINDS Circle member Dr. Scot Adams, former Director of Nebraska Department of Health and Human Services, Division of Behavioral Health, is to move to a “whole person” model for addiction treatment—bringing primary care into addiction treatment organizations. He wrote, “One answer to the question of addictions treatment post-COVID is found in models like the Certified Community Behavioral Health Clinics (CCBHC). The Substance Abuse and Mental Health Services Administration (SAMHSA) has had three rounds of funding for these. In short, rather than bringing addictions treatment into the primary care office, they bring primary care into the addictions treatment center.”

Some addictions treatment provider organizations are well ahead on the integration journey. Lakeview Health has multi-site adult addiction treatment programs in Florida and Texas, treating alcohol use, opioid use, and substance use disorders (SUD) as well as co-occurring disorders. Lakeview Health’s staff includes a board-certified internist and a psychiatrist who is also a family practitioner—this helps the organization easily address the medical issues faced by its SUD consumers. Lantie Jorandby, M.D., Chief Medical Officer at Lakeview Health, explained how the integrated care model helped them provide holistic care during the pandemic crisis, test consumers for COVID-19, and address all of their co-occurring disorder treatment needs.

Tarzana Treatment Centers, Inc. (TTC) has been providing primary care services integrated with behavioral health since the mid-1990’s, and serves the underserved, low-income population of Los Angeles and surrounding counties. It currently contracts with primary care physicians to operate six primary care clinics that are co-located with TTC’s SUD and mental health treatment facilities. Chief Executive Officer and President Albert M. Senella explained that TTC’s primary care services are part of their whole person care approach integrating mental health, SUD, and primary care services for adults and youth. Their full range of mental health and SUD programs include outpatient, inpatient, and residential treatment, sober living services, a primary care assessment for consumers, and access to primary care treatment when needed. TTC created a “no wrong door” model to access, ensuring that all consumers in any of TTC’s programs or levels of care have access to primary care treatment. TTC also offers follow up primary care in consumers’ homes via telehealth. TTC is accredited by the Joint Commission as a Behavioral Health Home and Patient-Centered Medical Home.

Whatever the model, a key obstacle pointed out by Dr. Adams is the cultural difference between the mindsets of “traditional” addiction treatment professionals and other health care professionals. The reality is that primary care and addiction treatment (and behavioral health care overall) are very different cultures built on different approaches to clinical professional education, management, and business administration. Learning to communicate effectively with both sides of the house is a critical issue. He explained, “Many behavioral health practitioners who ‘grew up’ on the mental health side, without immersion into addictions, think it can be as simple as adding a 12-step meeting to routine mental health programming to call it ‘co-occurring treatment.’ Thus, they don’t really ‘hear’ the content. This dynamic in culture is important because persons in recovery are often better able to relate to and connect with persons actively immersed in addictive patterns. Missing the addiction can undermine all other treatments.”

Learning the critical skill of “code switching” becomes a priority when managing teams of different disciplines. In the post-crisis period, most analysts are predicting an increase in substance abuse and addictive disorders—and with it an increase in demand for treatment and related expenses. Payers and health plan executives will be in search of the treatment model with the best clinical outcomes and total cost of care. An integrated care model is most likely to deliver.

On June 19, 2020, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule to grant state Medicaid programs and other payers flexibility to enter value-based purchasing (VBP) arrangements with drug manufacturers. The proposed rule provides drug manufacturers with regulatory support to enter into VBPs with payers. VBP arrangements can be defined as “performance requirements” under the definition of a “bundled sale.” If a manufacturer is participating in a VBP arrangement, the drug manufacturer can report multiple best prices for a therapy—the prices tied to specific VBP arrangements— under the Medicaid Drug Rebate Program (MDRP).

In a fact sheet about the proposed rule, CMS said it believes providing state Medicaid programs with flexibility to enter into VBP arrangements with drug manufacturers is an important strategy to manage drug costs and promote beneficiary access to needed medications. CMS recognized that the current MDRP regulations were a barrier to medication related VBP arrangements. By changing the regulations, CMS intends to encourage states to enter into VBP arrangements for drug therapies, especially in cases when the therapy will safeguard against unnecessary utilization of other, more expensive medical services. To reach this goal, the proposed rule presented changes allowing manufacturers to do the following:

  • Report multiple “best prices” for a therapy under the MDRP if the prices are tied to a VBP arrangement.
  • Define a VBP arrangement in terms of evidence-based and outcomes-based measures.
  • Include certain VBP arrangements under the definition of “bundled sale.”
  • Revise average manufacturer’s price (AMP) and best price reporting beyond the current 36-month time limit to allow for revisions to pricing metrics as a result of VBP arrangements.

CMS also revised how a drug manufacturer must calculate the AMP of a brand-name drug that has an authorized generic, which are made by the original manufacturer of the brand-name drug. Currently, manufacturers are permitted to include the sales of the authorized generic in the AMP of the brand name drug. However, this practice lowers AMPs and reduces rebates paid for the brand name drugs. The proposed rule excludes sales of authorized generic drugs when brand manufacturers have approved, allowed, or otherwise permitted an authorized generic to be sold under the brand name drug’s new drug application (NDA).

Comments on the proposed rule, “Establishing Minimum Standards In Medicaid State Drug Utilization Review (DUR) And Supporting Value-Based Purchasing (VBP) For Drugs Covered In Medicaid, Revising Medicaid Drug Rebate And Third Party Liability,” are due by July 20, 2020. The proposed rule did not state a target implementation date.

A link to the full text of “Establishing Minimum Standards In Medicaid State Drug Utilization Review (DUR) And Supporting Value-Based Purchasing (VBP) For Drugs Covered In Medicaid, Revising Medicaid Drug Rebate And Third Party Liability” may be found at

For more information, contact:

  • Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Website:

For more information, contact (for both Humana and Healthmap Solutions): 

  • Alissa Krinsky, Corporate Communications, Humana, Inc., 550 West Adams Street, 5thFloor, Chicago, Illinois 60661; 312-441-5576; Email:; Website:

Physician-led accountable care organizations (ACOs) represented approximately 45% of all ACOs (about 549 of 1,221 total ACOs included in the study), as of December 2018. During this year, hospital-led ACOs accounted for approximately 25% of all ACOs, and joint-led ACOs represented 30%. ACOs consist of health care provider organizations that accept responsibility for the cost and quality outcomes of a defined population. Physician-led ACOs are defined as organizations that are involved in ACOs that do not involve hospitals directly in the payment arrangement, or in the broader organization.

As of December 2018, an estimated 28% of existing health systems or independent hospitals were participating in an ACO of the more than 1,700 hospitals or systems that could potentially form an ACO. Only an estimated 6% of the more than 8,200 physician groups that are large enough to ultimately form an ACO, have done so.

The researchers concluded that physician-led ACOs will likely be the dominant type of ACO in the future. This is due to the greater market potential of ACOs. However, current ACO policies and strategies that have been designed for hospitals and health systems must be restructured to better support physician-led ACOs. Additionally, policies should encourage the support of physician-led ACO partnerships with other organizations.

These findings were presented in “Accountable Care Organizations Are Increasingly Led by Physician Groups Rather Than Hospital Systems,” by David Muhlestein, Ph.D., J.D.; Tianna Tu, BA; and Carrie H. Colla, Ph.D. The researchers analyzed data from the Leavitt Partners ACO database, which tracks organizations that are participating in accountable care payment arrangements and includes information on organizational structure. This database represented 1,221 of 1,334 ACOs as of the end of 2018. The goal was to determine the overall structure of ACOs, and project the future of ACOs in the marketplace.

The full text of “Accountable Care Organizations Are Increasingly Led by Physician Groups Rather Than Hospital Systems” was published May 14, 2020 by The American Journal of Managed Care. A copy is available online at

PsychU last reported on this topic in “Physician-Led ACOs Generated Almost 7 Times More Savings Than Hospital-Led ACOs,” which published on December 2, 2019. The article can be found at

For more information, contact: 

  • David B. Muhlestein, Ph.D., J.D., Chief Strategy and Chief Research Officer, Leavitt Partners, 299 South Main Street, Suite 2300, Lake City, Utah 84111; 801-538-5082; Email:; Website:

So much discussion of canoes these days. Until 12 weeks ago, executives of specialty provider organizations had to balance “two canoes”—operating in a fee-for-service (FFS) or cost-based environment, with operating in a wide array of emerging performance-based and value-based reimbursement (VBR) models. But with the pandemic crisis, another layer of complexity has been added—surviving through the crisis while developing a sustainable (and innovative) post-crisis recovery strategy. This is a situation more akin to controlling four canoes.

A common question from executive teams is whether to temporarily shelve the plans for alternative payment models during this crisis period. The answer is two-fold. Certainly, putting a crisis management financial survival plan is a first-order priority. This means grappling with cash flow, maximizing revenue as much as possible, determining a temporary break-even, and reducing expenses to match. These crisis management financial survival plans are the reason we see continuing announcements of layoffs and furloughs in the press.

But one could argue that for most provider organizations, being able to accept more VBR, with more financial risk, will likely be part of any recovery plan. As of OPEN MINDS last survey in March 2020, about 74% of primary care organizations and 61% of behavioral health organizations are participating in some form of VBR, and 16% of those organizations have 20% or more of their revenue in this type of contract. If the prognostications of health plan executives we’ve recently interviewed are any indication, this will likely increase in the post-crisis period.

With that in mind, the discussion during The 2020 OPEN MINDS Strategy & Innovation Institute session, One Foot In Two Canoes: Managing Service Lines For Value-Based Reimbursement & Fee-For-Service At The Same Time, provided some great insights into navigating the transition to VBR. The session featured Friendship Community Care’s Chief Executive Officer, Cindy Mahan, and Executive Vice President of Strategy and Planning, Craig Cloud; as well as Centerstone’s Vice President of Quality, M. Brad Nunn, Ph.D., and Director of Healthcare Innovation, Mandi Ryan, and was moderated by OPEN MINDS Senior Associate, Joe Naughton-Travers.

Dr. Nunn and Ms. Ryan presented Centerstone’s work with the Tennessee Health Care Innovation Initiative Strategy, which includes patient-centered medical homes (PCMH); health homes for severe and persistent mental illness; reimbursement using episodes of care; and quality and acuity adjusted payments for long-term services and supports (LTSS). The payment structure includes case rate payments for health home services and financial incentives for high-performing provider organizations. It also includes episodes of care payments (two of 48 diagnoses are behavioral health) based on a FFS model with penalties for high costs and gainsharing payments if costs are kept below a threshold.

Friendship Community Care is participating in the Arkansas Medicaid initiative— “Provider-Led Arkansas Shared Savings Entities” (PASSEs). These are “organized care” models that are at risk for all services (physical health care services, behavioral health services, and specialized home- and community-based services) for approximately 40,000 individuals who have intensive levels of treatment or care due to mental illness, addiction, or intellectual/developmental disabilities. In this model, provider organization/health plan collaboratives assume the financial risk.

So, what should executives leading the shift toward VBR—while managing FFS reimbursements at the same time—be doing to keeping both canoes on course? Focus on three areas—staff skills and training, system integration and data management, and financial performance. While things are moving rapidly, and the crisis is shifting timelines for the transition, it is important not to rush, advised our speakers. Stop and do things right, because the transition demands care and dexterity.

  1. Staffing:Whether it’s FFS or VBR, clinical professionals are providing the same type and level of care with the goal of helping consumers get better. But it is managers who need to have two diametrically opposite perspectives. Can one person really manage two antithetical programs—one based on service volume and the other based on the right outcomes with less volume? Can they “switch from a left brain to right brain approach,” as Mr. Naughton-Travers put it? What we may need is two different managers to paddle the two canoes. Staff across the organization who have operated in a traditional FFS model will need to be trained in the new norms of VBR and will need a clear understanding of expected outcomes.
  2. Systems and data: Provider organizations collect a large volume of data but that usually happens in silos. If all systems are integrated (for example, if the electronic health records are integrated with the enterprise resource planning system) and you invest in staff skilled at business analytics—as both Friendship Community Care and Centerstone have done—executives will have the data they need to continuously monitor the variables for both FFS (productivity) and VBR (impact). Further, policies and procedures to manage each payment stream must be clearly laid out and shared with all staff.
  3. Financial performance: Balancing both canoes requires a laser focus on financial performance. Revenue cycling is critical as Ms. Mahan pointed out. Concurrent clinical documentation is key so billing can happen quickly and accurately. Billing staff must have experience in both types of billing and have access to the data that payers expect.

The pandemic crisis already calls for some exceptional navigation skills to steer through extreme market turbulence. Having one foot in the FFS canoe and the other in VBR makes it more precarious than ever before. But health plans and payers have told us that VBR is gaining traction and we can’t ignore the future even as we manage the present.

The adoption of value-based reimbursement (VBR) has been inconsistent over the past few years. But the consensus is that the recession that is upon us and the likely reduced federal/state budgets will drive more VBR and more financial risk transfers from managed care organizations to provider organizations.

OPEN MINDS does a lot of organizational assessments of ‘readiness’ for VBR—and they have developed a self-assessment tool to do just that. The tool has several key domains including provider network management; consumer access and service engagement; financial management; leadership and governance; technology and reporting; and clinical management and performance optimization. But, readiness assessments tend to focus on the organizational management infrastructure. A big question for executive teams is whether clinical programs are ready for VBR. That was the focus of the session, “Creating & Managing The Clinical Models You Need For Value-Based Reimbursement,” led by Dominick DiSalvo, MA, LPC, Corporate Director, Clinical Services, KidsPeace at The 2020 OPEN MINDS Strategy & Innovation Institute.

KidsPeace offers a full continuum of behavioral health care services for children and families, from serving youth in the foster care and child welfare system to providing residential treatment, accredited educational services, and a free-standing psychiatric hospital. Headquartered in Pennsylvania, its services span 10 states and the District of Columbia. Between 2016 and 2017, the organization followed the state of Pennsylvania in its initial journey to VBR. Since then, KidsPeace has participated in performance-based contracting, including pay-for-performance, with payments linked to a specific set of benchmarked outcomes.

But success with VBR doesn’t come without its challenges—it requires a significant shift in both leadership mindset and organizational infrastructure. As Mr. DiSalvo discussed, “The most difficult task we have is to limit risk by finding the balance between person/family-centered care and structured programs that reduce variability in services and outcomes.” His advice? Focus on trauma-informed care; synthesize evidence-based clinical models; use data to drive clinical decision-making; and engage clinical professionals to engage consumers.

Focus On Trauma-Informed Care
KidsPeace began the move to VBR by using the Trauma History Questionnaire (THQ), a 24-item self-report measure that examines an individual’s experience with possible traumatic events including crime, physical or sexual assault, and neglect. Mr. DiSalvo described this as a necessary first step in moving toward a value-based framework for care, because when trauma wasn’t factored in, the desired treatment outcomes were not being achieved. After it started to implement trauma-informed care, KidsPeace found that youth self-reported experiencing an average of 10 traumatic categories before entering the program. The new focus on trauma as an underlying cause required a considerable shift in how clinical professionals were supporting consumers—and how senior leaders were supporting clinical professionals. “This data really convinced our leadership team that we needed to have a complete change in focus—we needed to be family and youth driven, trauma-informed, and have data drive what is going on in our programs,” said Mr. DiSalvo.

Synthesize Evidence-Based Clinical Models
After understanding the “value” of becoming trauma-informed to provide more effective treatment—and ultimately—more meaningful and measurable outcomes, KidsPeace completely restructured their clinical programming by synthesizing a core set of evidence-based practices within each program. The restructure allowed each individualized treatment plan to be guided by both the youth and their family—and driven by objective and relevant data—an essential part in defining “value” for each consumer. The organization adopted four clinical practice models—including trauma focused-cognitive behavioral therapy (with all clinical leadership becoming or in the process of becoming Nationally Certified Trauma Therapists); motivational interviewing (to increase motivation and engagement among youth); community living (to prepare adolescents for young adulthood and community inclusion); and individualized treatment planning. By using these four clinical models, the organization has the flexibility to provide individualized care as well as the consistency and structure to meet the needs of all youth and families that are served.

Use Data To Drive Clinical Decision Making
Before they restructured clinical program models to focus on value, Mr. DiSalvo noted that KidsPeace had challenges with using data to drive treatment and decision making processes. “When I had conversations with our foster care program in Indiana versus conversations with our residential program in Georgia, the way they captured data and assessed youth were very different.” To ensure consistency across all programs, no matter the location or service line, the organization moved to a corporate wide electronic health record and adopted the use of a data dashboard to visually track key metrics over time. Those metrics included discharge disposition and post-discharge follow up surveys, high risk behaviors (e.g. suicidal ideation), clinical treatment benchmarks, length of stay, and individualized score cards in graph format. The data is then broken down further by day, time of day, over time, and total score. “We’ve even gotten as granular as examining if there is a particular staff member that youth are struggling more with and if we need to provide more training.” The key quality indicators (in a simple, color-coded format) are reviewed quarterly with the senior leadership team to quickly identify any pain points and make changes to maximize program efficiency. Mr. DiSalvo explained, “Not only can we track youth individually, but we are also able to track specific program progress from an aggregate level—and then make changes and help continuously improve that program.”

Engage Clinical Professionals To Engage Consumers
To truly drive optimal outcomes in value-based clinical programming, Mr. DiSalvo highlighted a final key component—engaging clinical professionals. “It’s impossible to succeed with risk-based payment models if staff aren’t engaged. If a child feels like a staff member is there simply to get a paycheck, they are not going to respond well.” Rather, a significant shift in mindset was necessary for many professionals to continuously find ways to improve the overall experience for youth, families, and staff. “Once we started to have the data inform practice, our clinicians started seeing clear, quantitative results. Once that happened, it was a ripple effect—our youth found more enjoyment in their experience. Ultimately, it’s the clinicians who then become the champions for change.”

Any significant transformation isn’t sustainable without embedding those changes within the organizational culture. Mr. DiSalvo discussed the importance of cultivating a cohesive culture to act as the foundation of any clinical program focused on providing value, “Our initiative at KidsPeace is to integrate all of our resources to improve safety, engagement, connection, clinical practice and outcomes for all staff, youth, and families but it doesn’t come naturally. It requires robust training and a strong understanding about what engagement actually looks like. Clinical professionals must move away from the mindset that ‘we are the ones who know best’ and understand that the family and youth are the experts. We are simply here to join them in their journey.”

The major takeaway from the session is that it’s not enough to have your administrative and financial infrastructure “ready” for VBR. Making clinical programs VBR-ready is a critical aspect of strategy development for sustainability.

The health care economy continues to shift from the fee-for-service model that has been in existence for decades to value-based payment. While many forms of value-based models are being trialed and implemented, there are examples of models that span slight experimentation through provider organizations partnering with payers to take on full medical risk for a population. In this webinar, our speakers discuss innovations around new payment models in a lively townhall format.


  • Deb Adler, CPHQ
    Senior Associate, OPEN MINDS
  • Steven Remillard, D.C.
    Senior Associate, OPEN MINDS
  • Paul Duck
    Senior Associate, OPEN MINDS

Deb Adler, CPHQ, has more than 20 years of experience in executive health care roles, serving in a variety of capacities, including network executive, quality management executive, and COO. She is the former Senior Vice President of Network Strategy for Optum, where she was responsible for behavioral health network development, contracting, and strategy for more than 185,000 providers. In this role, she developed the largest performance-tiered behavioral health network, the largest telemental health network, and the largest medication-assisted treatment (MAT) network. She was also responsible for implementing network initiatives to promote medical/behavioral integration, improve member outcomes, and reduce total cost of care through collaborative care models. Currently, she serves as a Senior Associate at OPEN MINDS. Ms. Adler earned her MA in psychology and evaluation from Catholic University of America and is a Certified Professional in Health Care Quality (CPHQ).

Steven Remillard, D.C. currently serves as a Senior Associate at OPEN MINDS. With more than 25 years of experience in the health and human services field, he leads projects related to value-based purchasing, integrated care programming, HEDIS measurement, data-driven organizational development, and the social determinants of health. Previously, Dr. Remillard served as the Special Assistant to the Secretary of the Pennsylvania Department of Human Services. In this role, Dr. Remillard directed a federal grant to promote innovation in hospital-based behavioral and physical health care integration. Dr. Remillard also supported various stakeholder groups in the implementation of integrated care planning.

Paul Duck currently serves as a Senior Associate at OPEN MINDS. He brings more than 30 years of experience in leadership and management, focusing on managed care, health information technology, strategy, business development and market expansion, and customer experience optimization to the OPEN MINDS team. Previously, Mr. Duck has served in roles such as Vice President, Strategy & Development for Beacon Health Options, the Vice President of Business Development for Netsmart Technologies, and Chief Executive Officer for Coastal Orthopedics. Mr. Duck earned his BA in business management from Case Western Reserve University. He earned his AA in electronic engineering technology from the Electronic Technology Institute.

Prior to the coronavirus disease 2019 (COVID-19) pandemic, the average primary care physician compensation rose by 2.5%, from $237,000 in 2019 to $243,000 in 2020. Between October 4, 2019 and February 10, 2020, average specialist salaries rose by 1.5%, from $341,000 in 2019 to $346,000 in 2020. The highest average annual compensation was for orthopedics at $511,000; the lowest was for pediatrics at $232,000. Average annual compensation for psychiatrists was $268,000.

For the time period reviewed, about 58% of primary care physician practices, and 55% of specialist practices offered an incentive bonus. Examples of incentive bonuses are collections bonuses (monies collected from consumers, resulting in a net profit) and work relative value unit (productivity measure) bonuses. The average incentive bonus for all health care workers is about $26,000; however, the average incentive bonuses for specialty physicians ranges from $31,000 to $96,000. PCP physicians usually earn 64% of an incentive bonus, while specialists usually earn 69% of an incentive bonus.

These statistics were released on May 14, 2020, in the Medscape “Physician Compensation Report 2020” by Leslie Kane, MA. The findings are based on analysis of survey responses collected between October 4, 2019 and February 10, 2020, from more than 17,000 physicians working in 30 specialties. The survey examined salary, incentive bonus, and denied claims, and their attitudes about the field of medicine.

The full text of the Medscape “Physician Compensation Report 2020,” was released on May 14, 2020. A copy is available online at

For more information, contact: 

  • Leslie Kane, MA, Business of Medicine, Medscape, 825 8thAvenue, New York, New York 10019; 212-301-6700; Email:; Website:

The Medicare Advantage 2021 final rules include changes to telehealth that will allow plans to count telehealth clinical professionals in 12 specialty areas towards meeting network adequacy standards. The specialty areas are dermatology, psychiatry, cardiology, otolaryngology, neurology, ophthalmology, allergy and immunology, nephrology, primary care, gynecology/OB/GYN, endocrinology, and infectious diseases. The changes are intended to make telehealth more widely available in Medicare Advantage, give members access to the latest telehealth technologies, and increase plan choices for beneficiaries residing in rural areas.

The Centers for Medicare & Medicaid Services (CMS) is strengthening network adequacy rules for Medicare Advantage plans by finalizing its existing network adequacy methodology and policies that address maximum time and distance standards in rural areas, telehealth, and Certificate of Need (CON) laws. The Bipartisan Budget Act of 2018 incentivized Medicare Advantage plans to offer additional telehealth benefits to cover beneficiary access to health care beginning in 2020. As a result, CMS has been examining its network adequacy standards overall to determine how contracted telehealth professionals should be considered when evaluating the adequacy of a Medicare Advantage plan network.

CMS reduced the percentage of beneficiaries that must reside within the maximum time and distance standards in non-urban counties from 99% to 85% in order for the plan to comply with network adequacy standards. Medicare Advantage plans will be eligible to receive the 10-percentage point credit towards the percentage of beneficiaries residing within published time and distance standards when they contract with telehealth professionals.

CMS released the finalized requirements in “Medicare Program: Contract Year 2021 Policy & Technical Changes To The Medicare Advantage Program, Medicare Prescription Drug Benefit Program & Medicare Cost Plan Program.” CMS finalized a subset of the proposed policies in advance of the June 1, 2020, Medicare Advantage and Part D bid deadline for the 2021 plan year. The remaining proposals will be finalized later in 2020; they will apply to the 2022 plan year.

For more information, contact:

  • Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Website:

On May 26, 2020, the Indiana Family and Social Services Administration (FSSA) awarded three contracts for Hoosier Care Connect, the state’s Medicaid managed care program for aged, blind, and disabled (ABD) beneficiaries, to incumbents Anthem and Centene/Managed Health Services (MHS), and to UnitedHealthcare. The full-risk contracts are worth a total of $6.4 billion. Implementation is expected April 1, 2021; the contracts will run for four years with two optional one-year renewals. Hoosier Care Connect serves approximately 90,000 individuals.

Hoosier Care Connect is a risk-based coordinated care program that launched on April 1, 2015. Currently, two MCOs—Anthem and Managed Health Services—serve approximately 90,000 beneficiaries with disabilities who are not eligible for Medicare, not living in an institution, and not enrolled in a waiver to receive home- and community-based services (HCBS). FSSA released the request for proposals (RFP 20-041) on October 21, 2019, with proposals due by January 6, 2020. Bids were also submitted by CareSource and MDwise.

Enrollment is mandatory for non-institutionalized aged, blind, or disabled individuals not eligible for Medicare; those receiving Supplemental Security Income; and individuals participating in the FSSA Medicaid for Employees with Disabilities (MED) Works buy-in program. MED Works offers the same coverage levels as regular Medicaid. It allows the participants to work without fear of losing Medicaid eligibility. Individuals in the following categories may voluntarily enroll in Hoosier Care Connect: children receiving adoption assistance, foster children, and former foster youth ages 18 to 26.

Hoosier Care Connect provides comprehensive coverage, including for Opioid Treatment Program (OTP) services. The plan covers short-term institutional care of up to 30 days. Members admitted to a state hospital for psychiatric treatment will be disenrolled; however, enrollment will only be suspended for members admitted to a psychiatric residential treatment facility. Hoosier Care Connect members who are admitted to an intermediate care facility for individuals with intellectual/developmental disabilities (ICF/IDD) are disenrolled and enrolled in Medicaid fee-for-service. Individuals approved for long-term services and supports are disenrolled, as are those who become eligible for Medicare. Hospice coverage is an exception and there is no limitation on days. Hoosier Care Connect has carve-outs for the following:

  • Certain high cost, low utilization drugs, such as hepatitis C and hemophilia drugs.
  • Diabetes supplies, such as test strips and meters.
  • Medicaid Rehabilitation Option (MRO) services, which are intensive community-based behavioral health services delivered exclusively by community mental health centers.
  • First Steps services.
  • School corporation services for student Medicaid beneficiaries with an individualized education plan for services provided by a school. However, the contractor must communicate and coordinate with the school to ensure continuity of care and avoid duplication of services.

The proposals were evaluated by assigning points to scoring categories; the maximum score was 103. Adherence to mandatory requirements was evaluated as pass/fail. For the scored components, 80 points were allocated to the management assessment/quality proposal. The remaining points were allocated at five points for each of the following preference categories: Buy Indiana, minority business enterprise subcontractor, women business enterprise subcontractor, and Indiana veteran business enterprise subcontractor. One bonus point for each of the last three preference categories (minority, women, and veteran) could also be earned.

For more information, contact: 

  • Jill Carnell, Chief Administrative Officer, Indiana Department of Administration, 402 West Washington Street, Room W-478, Indianapolis, Indiana 46204; 317-232-3150; Fax: 317-232-3153; Email:; Website:
  • Will Shanley, Director of Public Relations, United Healthcare, 5901 Lincoln Drive, Minneapolis, Minnesota 55436; 612-486-4361; Email:; Website:
  • Marcela Manjarrez-Hawn, Senior Vice President And Chief Communications Officer, Centene Corporation, 7700 Forsyth Boulevard, St. Louis, Missouri 63105; 314-445-0790; Email:; Website:
  • James Freeman, Media Contact, Anthem BlueCross BlueShield Indiana, 220 Virginia Avenue, Indianapolis, Indiana 46204; 215-756-2495; Email:; Website:

On May 29, 2020, the Kentucky Cabinet for Health and Family Services (CHFS) awarded five Medicaid managed care contracts with an aggregate value of about $8 billion. The five companies are Aetna, Humana, Molina Healthcare, UnitedHealthcare, and WellCare. Aetna will also serve children in Kentucky SKY, the Medicaid risk-based managed care delivery program for the state foster care program and the Department for Juvenile Justice. The plans are at-risk for all Medicaid physical health, behavioral health, and pharmacy services. The contracts are slated to go live on January 1, 2021 and will run through December 31, 2024. The contracts may be extended by six additional two-year periods.

The state’s current managed care contracts are with Aetna (via Coventry Cares), Anthem, Humana (via CareSource), Passport Health Plan, and WellCare. These contracts have been extended through December 31, 2020. About 1.3 million beneficiaries are enrolled in one of the five current Medicaid managed care plans.

The state issued the request for proposals (RFP 2000000202) on January 10, 2020. This was a rebid after the state cancelled contracts awarded on November 26, 2019, due to concerns about how the award process was handled. Proposals were due by February 7, 2020. Responses were also submitted by Anthem Kentucky Managed Care Plan, Inc.; and Passport Health Plan, Inc.

The proposals received the following scores:

  • Aetna received 1,653 points.
  • WellCare received 1,662 points.
  • Humana received 1,605 points.
  • UnitedHealthcare received 1,520.5 points.
  • Molina received 1,507 points.
  • Anthem received 1,491 points.
  • Passport received 1,409.5 points.

The proposals for Kentucky SKY received the following scores:

  • Aetna received 1,126.3 points.
  • WellCare received 1,120.6 points.
  • Humana received 1,066.6 points.
  • UnitedHealthcare received 1,044.2 points.
  • Molina received 1,017.4 points.

PsychU last reported on this topic in “Kentucky Announces Cancellation Of Medicaid Managed Care Contracts; To Be Rebid In January,” which published on January 5, 2020. The article is available at

For more information, contact: 

  • Susan Dunlap, Executive Director of Public Affairs, Kentucky Cabinet for Health and Family Services, 275 East Main Street, Frankfort, Kentucky 40621; 502-564-7042; Email:; Website:
  • Kate Marx, Corporate Communications, Humana, 500 West Main Street, Louisville, Kentucky 40202; 502-271-9288; Email:; Website:
  • Caroline Zubieta, Director of Public Relations, Molina Healthcare, Inc., 200 Oceangate, Suite 100, Long Beach, California 90802; 562-951-1588; Email:; Website:
  • Charles N. Talbert, Manager, External Communications, WellCare Health Plans, Inc., 211 Perimeter Center, Suite 800, Atlanta, Georgia 30346; 770-913-2181; Email:; Website:
  • Will Shanley, Director of Public Relations, United Healthcare, 5901 Lincoln Drive, Minneapolis, Minnesota 55436; 612-486-4361; Email:; Website:
  • Leigh M. Woodward, Senior Communications Partner, Aetna Medicaid, 4630 Woodland Corporate Boulevard, Tampa, Florida 33614; 860-900-6058; Email:; Website:

The Centers for Medicare & Medicaid Services (CMS) will require hospitals to adopt the Medicare Hybrid Hospital-Wide 30-Day Readmission (HWR) measure by 2023, and will begin a mandatory measurement period running from July 1, 2023 to June 30, 2024. In July 2025, the results will be posted to Medicare Hospital Compare. The HWR is based on electronic health record data and claims data for Medicare beneficiaries. CMS believes that the proliferation of EHR systems and standardization of extraction and reporting of clinical data for quality measurement provide an opportunity to integrate these data into measures of hospital performance. The HWR will replace the current Claims-Based Hospital-Wide All-Cause Readmission measure.

The new HWR measure was included in the Medicare 2020 Hospital Inpatient Prospective Payment System Final Rule, released on August 16, 2019. During 2019, 150 hospitals participated in a voluntary HWR pilot program. In preparation for the mandatory HWR reporting period that starts July 1, 2023, CMS will implement two voluntary year-long measurement periods, with the first starting on July 1, 2021 and running through June 30, 2022. The second period will start July 1, 2022, and run through June 30, 2023.

The HWR measure will be required as a part of each hospital’s inpatient quality reporting (IQR) program requirements. The Medicare Hospital IQR Program is a pay-for-reporting quality program which reduces payment to hospitals that fail to meet program requirements.

For the HWR measure, the numerator is unplanned all cause 30-day readmission. Readmission is defined as an inpatient admission to any acute care facility which occurs within 30 days of the discharge date of an earlier, eligible index admission. The denominator is admissions for Medicare fee-for-service (FFS) beneficiaries age 65 and older enrolled in Part A for the 12 months prior to admission who are matched in EHR and claims data and who are discharged alive, and not transferred to an acute care facility. The measure excludes the following populations:

  • Admitted to Prospective Payment System-exempt cancer hospitals
  • Without at least 30 days post-discharge enrollment in FFS Medicare
  • Discharged against medical advice
  • Admitted for primary psychiatric diagnoses
  • Admitted for rehabilitation
  • Admitted for medical treatment of cancer

The HWR measure uses clinical data elements from the EHR for risk adjustment in addition to claims data. The goal is to use clinical data, such as laboratory test values and vital signs, to risk adjust for consumer-level factors that influence readmission to adjust for severity of illness in hospital outcome measures.

Under the current Claims-Based Hospital-Wide All-Cause Readmission measure, CMS reports risk-standardized readmission rates for several conditions, including acute myocardial infarction, heart failure, pneumonia, and hip and knee arthroplasty. CMS has also developed hospital readmission measures for stroke and chronic obstructive pulmonary disease. In 2013, CMS began publicly reporting a hospital-wide, all-condition readmission measure that captures 92% of readmissions following eligible admissions.

For more information, contact:

  • Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Website:

On May 19, 2020, Microsoft announced that it has launched a “health care cloud service” called Micorsoft Cloud for Healthcare. The goal of the service is to assist payers and provider organizations more easily function during the coronavirus disease of 2019 (COVID-19) pandemic by providing assistance with telehealth, care management, and consumer engagement through apps that monitor data collected by medical devices linked to the cloud. Microsoft Cloud for Healthcare is available through a free trial through mid-November 2020.

The new cloud service is a conglomeration of products that are already available by the company, which sits on top of a common data model that makes it easier to share data between applications and analyze gathered data. Microsoft is working to add additional tools in the near future. The tools currently offered through the platform include:

  • Microsoft 365: a way for businesses to subscribe to both Windows and Office software
  • Microsoft Dynamics: a set of intelligent business applications that offer predictive insights through proprietary artificial intelligence
  • Microsoft Power Platform: a platform that allows users to create and deploy tailored applications that can be used on desktop and mobile devices
  • Microsoft Azure: cloud services for building, deploying, and managing intelligent applications through a global network of data centers

In addition to the above tools, Microsoft is also working with specialized partners to provide health care provider organizations with specialized services. Current partners in the effort include Epic (health-related software development), Allscripts (electronic health record (EHR) system), GE Healthcare (provider of health care technologies, digital infrastructure, data analytics, and decision support tools), Adaptive Biotechnologies (commercial-stage biotech company focused on adaptive immune system biology), and Nuance (computer software technology).

Microsoft will be rolling out additional, industry-specific cloud offerings related to doing business during COVID-19 in the near future. However, details about these offerings, including a timeline, is not yet available.

For more information, contact:

  • Microsoft Cloud for Healthcare, c/o Microsoft Media Relations, WE Communications, 225 108th Avenue Northeast, Suite 600, Bellevue, Washington 98004-5737; 425-638-7777; Fax: 425-638-7001; Email:; Website:

Iowa Medicaid expansion enrollees who participated in the Iowa Medicaid Healthy Behaviors Program (HBP) had substantial reductions in their utilization of hospital-based care. Compared to the non-participants, HBP participants from 2014 through 2017 were less likely to visit an emergency department; the likelihood was 9.6 percentage points lower. The HBP participants were also less likely to be hospitalized, at 2.8 percentage points lower. However, the HBP participants had total spending $1,594 higher than non-participants’ spending.

HBP is a mandatory program for Iowa Medicaid expansion enrollees. They must complete an annual wellness exam and health risk assessment. Those who fail to complete the exam and assessment must pay monthly premiums to avoid disenrollment.

These findings were reported in “Iowa’s Medicaid Healthy Behaviors Program Associated With Reduced Hospital-Based Care But Higher Spending, 2012–17” by Brad Wright, Youn Soo Jung, Natoshia M. Askelson, Elizabeth T. Momany, and Peter Damiano. They analyzed Medicaid data from 2012 through 2017, and HBP from 2014 through 2017 for a sample of beneficiaries who were continuously enrolled in IowaCare for at least one year before and after Medicaid expansion. The goal was to evaluate how HBP changed utilization and spending.

The full text of “Iowa’s Medicaid Healthy Behaviors Program Associated With Reduced Hospital-Based Care But Higher Spending, 2012–17” was published in the May 2020 issue of Health Affairs. An abstract is posted online at

For more information, contact:

  • Brad Wright, Director of Health Services and Outcomes Research, Department of Family Medicine and Associate Professor, Health Care Economics and Finance, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 590 Manning Drive, CB #7595, Chapel Hill, North Carolina 27599; 984-974-4536; Email:; Website:
  • Sue Ducat, Senior Director of Communications, Health Affairs, 7500 Old Georgetown Road, Suite 600, Bethesda, Maryland 20814; 301-841-9962; Email:; Website:

On April 21, 2020, the Centers for Medicare & Medicaid Services (CMS) urged Medicare Advantage organizations and Part D sponsors to halt their usual prior authorization requirements during the coronavirus disease 2019 (COVID-19) public health emergency. Absent a disaster or emergency, Medicare Advantage organizations and Part D sponsors have had flexibilities to waive prior authorization requirements at any time to facilitate access to services with less burden on beneficiaries, plans, and provider organizations. The relaxation or waiver must be uniformly provided to similarly situated enrollees who are affected by the disaster or emergency.

Additionally, the Families First Coronavirus Response Act (FFCRA) and the Coronavirus Aid, Relief, and Economic Security (CARES) Act directed Medicare Advantage organizations to make changes specific to COVID-19 for clinical laboratory tests to detect or diagnose the virus and administration of vaccines. Medicare Advantage organizations are not permitted to impose any prior authorization or other utilization management requirements with respect to the coverage of these services when those items or services are furnished on or after March 18, 2020 and during the applicable emergency period. The plans are also not permitted to charge cost sharing (including deductibles, copayments, and coinsurance).

Medicare Advantage organizations must follow already outlined requirements for disasters and emergencies to ensure access to benefits. They must cover Medicare Parts A and B services and supplemental Part C plan benefits furnished at non-contracted facilities that have participation agreements with Medicare. They must waive, in full, requirements for gatekeeper referrals where applicable. They must provide the same cost-sharing for the enrollee as if the service or benefit had been furnished at a plan-contracted facility.

For more information, contact:

  • Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Website:

On May 22, 2020, the federal Centers for Medicare & Medicaid Services (CMS) finalized its proposals for Medicare Advantage related to increasing access to telehealth. CMS also finalized requirements to expand access to Medicare Advantage for beneficiaries diagnosed with end-stage renal disease (ESRD). CMS finalized its proposal to phase out Medicare Advantage dual eligible special needs pan (D-SNP) look alikes.

Plans will be able count telehealth clinical professionals in certain specialty areas (such as Dermatology, Psychiatry, Cardiology, Ophthalmology, Nephrology, Primary Care, Gynecology, Endocrinology, and Infectious Diseases) towards meeting CMS network adequacy standards. The goal is to encourage plans to enhance their benefits to give beneficiaries access to the latest telehealth technologies and increase plan choices for beneficiaries residing in rural areas.

Previously, beneficiaries with ESRD were only allowed to enroll in Medicare Advantage plans in limited circumstances. Starting in 2021, due to changes made by the 21st Century Cures Act, all beneficiaries with ESRD will have the option to enroll in a Medicare Advantage plan, which CMS anticipates will give them access to supplemental benefits such as health and wellness programs, transportation, or home-delivered meals that are not available in Medicare fee-for-service. The cost of kidney acquisition for Medicare Advantage members with ESRD will be covered fee-for-service, and the costs will be excluded from Medicare Advantage benchmarks. CMS will offer a more flexible approach to meeting network adequacy standards for outpatient dialysis than the current pre-determined time and distance requirements.

D-SNP look alikes have similar levels of dual eligible enrollment as D-SNPs but avoid the related regulations and contracting requirements of a D-SNP. The Bipartisan Budget Act (BBA) of 2018 required CMS to establish additional requirements related to Medicaid integration for D-SNPs. CMS intends to phase out D-SNP look-alikes. A plan considered a D-SNP look-alike has 80% or more of members who are entitled to Medicaid. The phase-out timeline is as follows:

  • Beginning for the 2021 plan year, D-SNP look-alikes will be able to transition their membership into a D-SNP or another qualifying zero-premium plan offered by the Medicare Advantage organization.
  • Starting for the 2022 plan year, CMS will not contract with any new Medicare Advantage plan, other than a SNP, that projects in its bid that 80% or more of total plan members will be entitled to Medicaid.
  • Starting for the 2022 plan year, CMS will not contract with any new Medicare Advantage plan, other than a SNP, that project it will be a D-SNP look-alike. Starting in 2023, CMS will not contract with a renewing plan, other than a SNP, with enrollment meeting the definition of a D-SNP look alike, unless the plan has been active for less than one year and has enrollment of 200 or less at the time of determination.

CMS released the finalized requirements in “Medicare Program: Contract Year 2021 Policy & Technical Changes To The Medicare Advantage Program, Medicare Prescription Drug Benefit Program & Medicare Cost Plan Program.” CMS finalized a subset of the proposed policies in advance of the June 1, 2020, Medicare Advantage and Part D bid deadline for the 2021 plan year. The remaining proposals will be finalized later in 2020; they will apply to the 2022 plan year.

For more information, contact:

  • Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Website:

On May 8, 2020, the Pennsylvania (PA) Clinical Network announced that it entered a value-based contract for Aetna’s Medicare Advantage members in Pennsylvania. The organizations is a physician-led clinically integrated network. The contract calls for PA Clinical Network to enhance care coordination and increase quality for Aetna members.

According to Jaan Sidorov, M.D., chief executive officer for Pennsylvania Clinical Network, the arrangement provides incentive payments for meeting “a basket of quality metrics and utilization targets” during calendar year 2020. The incentive payments are designed to drive team-based improvement across the continuum of care. The benchmarks align with industry-wide standards and are configured to link increasing performance in patient care with increasing rewards. Aetna and the Pennsylvania Clinical Network are meeting regularly to monitor progress toward goals.

PA Clinical Network currently works with over 50 private practices with 150 advanced practice clinical professionals. Each practice is independent, but all have joined the clinically integrated network to pool their resources to serve their assigned Aetna members. The organization is supported by the Pennsylvania Medical Society and its Care Centered Collaborative.

Under the contract, PA Clinical Network will provide team-based and physician-led care management in addition to the HealthEC population-health data analytics platform. PA Clinical Network and Aetna will work through a Joint Operating Committee to monitor progress in a cycle of continuous improvement.

For more information, contact:

  • Jaan Sidorov, M.D., Chief Executive Officer, Pennsylvania Clinical Network, 777 East Park Drive, Harrisburg, Pennsylvania 17111; 866-441-2392; Email:; Website:
  • Ethan Slavin, Communications, Aetna, 2777 North Stemmons Freeway, 13th Floor, Dallas, Texas 75207; 214-200-8056; Email:; Website:
  • Laura Porto, Director of Marketing, HealthEC, 343 Thornall Street, Suite #630, Edison, New Jersey 08837; 732-271-0600; Email: laura.porto@HEALTHEC.COM; Website:

During the first quarter of 2020, $576 million in equity funding worldwide went to mental health startups, rising 400% from $115 million during the last quarter of 2019. There were 44 recorded deals involving mental health startups during the first quarter of 2020, up 18.9% from 37 in the last quarter of 2019. During the first quarter of 2019, there were 42 recorded deals in this sector with a value of $210 million.

Some of the companies involved in the first quarter 2020 investments were as follows:

  • Lyra Health received an investment of $75 million in March. The company offers a mental health platform based on evidence-based treatments.
  • Modern Health received an investment of $31 million in January. The company offers a suite of mental health solutions comprised of digital programs, virtual coaching, and clinical therapy.
  • Spring Health received an investment of $22 million in January. The company provides a platform that emphasizes a data-driven approach to delivering individualized behavioral health care through exercise, digital cognitive behavioral therapy, individual therapy sessions, and medication
  • Oxford VR received an investment of $13 million in February. The company offers a clinically validated virtual reality platform to treat mental health disorders.
  • Psychological Treatment by VR received a seed investment of $1.1 million in January. The company offers a virtual reality platform for health care professionals, including those practicing in mental health. The current applications include treating anxiety, addiction, and eating disorders.

Globally across the health care industry, equity funding grew by 4% between the last quarter of 2019 to the first quarter of 2020. The investments rose from $14.1 billion to $14.6 billion. The number of deals dropped by 6% between quarters, from 1,228 to 1,156.

In the United States, the total number of health care equity investments increased by 4.4%, from 636 in the last quarter of 2019 to 664 in the first quarter of 2020. In the first quarter of 2019, there were 645 investments. The number of “mega-rounds” (investments of $100 million or more) rose by 257%, from 7 in the last quarter of 2019 to 25 in the first quarter of 2020. During the first quarter of 2019, there were 14 mega rounds.

These findings were reported in “State Of Healthcare Q1’20 Report” by researchers with CB Insights. The researchers analyzed equity investment into emerging health care companies. They verified the investments via various federal and state regulatory filings, direct confirmation with firms or investors, or press releases. These financing vehicles include convertible notes, seed, Series A, Series B, Series C, Series D, Series E+, private equity, growth equity, other venture capital, and other investment rounds. The analysis also includes funding for only private companies. However, the analysis excludes funding rounds raised by public companies, even if they received investment from a venture firm. For tranched investments, the analysis only includes the investment made in a particular quarter. Further, the analysis included only the amount of investment that had closed. The researchers defined “digital health companies” as those in the health care sector that use technology/software as a key differentiator versus their competition. The digital health sector includes technologies focused on disease diagnostics, technology-enabled health, and artificial intelligence-driven drug discovery.

The full text of “State Of Healthcare Q1’20 Report” was published April 28, 2020, by CB Insights. A copy can be requested at

For more information, contact:

  • CB Insights, 498 7thAvenue, New York, New York 10018; 212-292-3148; Email:; Website:

About 87% of Medicare inpatient psychiatric facility (IPF) claims with outlier payments during 2014 and 2015 failed to meet the medical necessity or documentation requirements set by Medicare. During fiscal years (FYs) 2014 and 2015, the number of IPF claims with outlier payments increased by 28%. Total Medicare payments for the IPF claims with outlier payments rose by 19%, from $450 million to $534 million. The Office of the Inspector General (OIG) for the federal Department of Health and Human Services (HHS) estimates that Medicare overpaid IPFs by $93 million for stays that resulted in outlier payments, but were non-covered or partially non-covered because inpatient treatment was not medically necessary for all or part of the stay.

An audit of a random sample of 160 claims found that 142 had missing or inadequate medical record elements. Most were missing physician certifications. Of the 142 medical records, 12 did not clearly support that the IPF had protected the individual’s right to make informed decisions regarding care. Oversight by the Centers for Medicare & Medicaid Services was not adequate to prevent or detect the IPFs’ errors.

These findings were reported in “An Estimated 87 Percent of Inpatient Psychiatric Facility Claims With Outlier Payments Did Not Meet Medicare’s Medical Necessity or Documentation Requirements” by the OIG. The audit covered 36,120 inpatient claims with nearly $1 billion in total Medicare payments. The goal was to determine whether IPFs complied with Medicare coverage, payment, and participation requirements for services provided in FYs 2014 and 2015 that resulted in outlier payments.

A link to the full text of “An Estimated 87 Percent of Inpatient Psychiatric Facility Claims With Outlier Payments Did Not Meet Medicare’s Medical Necessity or Documentation Requirements” may be found at

For more information, contact:

  • Don White, Public Affairs Specialist, Office of Inspector General, U.S. Department of Health and Human Services, Federal Building, 90 7thStreet, Suite 3-650, San Francisco, California 94103; 202-528-5254; Email:; Website:

As of mid-April 2020, about 43% of community-based addiction treatment provider organizations in North Carolina lacked sufficient cash on hand to remain in business for the next 30 days due to financial constraints created by the coronavirus disease 2019 (COVID-19) outbreak and public health emergency. According to survey responses provided by 70 community-based addiction treatment provider organizations, in addition to the 43% that reported having no more than 30 days cash on hand to fund operations without receiving reimbursements, 10% reported having 31 to 45 days cash on hand, 13% reported having 46 to 60 days cash on hand, and 16% reported having 61 to 90 days cash on hand. The remaining 18% reported having more than 90 days cash on hand.

Across the state, addiction treatment provider organizations lost revenue as demand for treatment dropped during the public health emergency, while new expenses to acquire personal protective equipment (PPE) and to implement telehealth treatment increased. To respond to the financial stress, about 27% of the organizations have laid off staff or cut positions, and another 40% were considering staff cuts. About 33% were staffing as normal. More than half, 57%, have closed at least one program. About 10% of programs cannot admit new consumers. About 19% of the organizations said they were operating as normal without service disruptions.

These statistics are the result of a survey conducted by Addiction Professionals of North Carolina (APNC). From April 13 to 20, APNC surveyed 70 of its member addiction treatment provider organizations. APNC is a network of more than 650 provider organizations and professionals. The survey was sent to executives at its member organizations statewide. The respondents are representative of provider organizations across all regions of North Carolina in terms of revenue mix and consumer volume.

For more information, contact:

  • Sarah Potter, Executive Director, Addiction Professionals of North Carolina, 3373 National Drive, Suite 225, Raleigh, North Carolina 27612; 919-630-8134; Email:; Website:

On March 27, 2020, Kansas awarded its next correctional health care contract to Centurion of Kansas, LLC, a Centene subsidiary, replacing the incumbent Corizon, LLC. Centurion was awarded a two-year full-risk contract to provide comprehensive health care services in the Department of Corrections’ (KDOC) facilities. The contract is expected to commence on July 1, 2020 and run through June 30, 2022, followed by two additional two-year renewal periods. Centurion will provide medical, dental, behavioral health, and related support services for offenders in nine facilities across the state. The contract is valued at a maximum of $554 million if all options are exercised.

The Kansas Department of Administration released the request for proposals (RFP EVT0006973) on October 10, 2019. Proposals were due by January 10, 2020. The state’s procurement negotiating committee (PNC) considered five proposals. The responding bidders were Centurion of Kansas, LLC; Corizon, LLC; VitalCore Health Strategies, LLC; Kansas Health and Recovery Solutions PC/WellPath LLC; and Wexford Health Sources, Inc. After evaluating the technical and cost proposals, the PNC met with four bidders: Centurion of Kansas, LLC; Corizon, LLC; VitalCore Health Strategies, LLC; and Wexford Health Sources, Inc.

KDOC serves a current population of approximately 10,000 adult inmates and 165 juvenile offenders. It operates nine facilities and three satellite facilities. Specialized services may be provided through agreements with area provider organizations such as hospitals, clinics, medical specialists, laboratories, and other specialized services.

The RFP asked for the bidders to provide two cost proposals for scenarios in which the selected contractor would or would not be responsible for paying for hepatitis C (Hep C) medications. The KDOC offered opt-out testing for Hep C for the existing inmate population. That testing was implemented in October 2018 and concluded in March 2019. Opt-out Hep C testing continues to be offered at admission. KDOC estimates that about 500 offenders will require treatment annually thereafter.

The state’s PNC noted that Centurion had the second lowest pricing bid, but the proposal had other persuasive factors that led to its selection. A key factor was “a unique opportunity that no other vendor shares to partner with Sunflower Medicaid Provider in addressing discharge needs” which exists because Centene owns both Centurion and Sunflower, one of the state’s Medicaid managed care organizations. Additionally, Centurion demonstrated good understanding of physician recruiting, and offered to partner with the state to find the cheapest Hep C drug pricing including 340B and return any funds of the $7.5 million cap to KDOC.

For more information, contact:

  • Randall Bowman, Executive Director, Public Affairs, Kansas Department of Corrections, 714 Southwest Jackson Street, Topeka, Kansas 66603; 785-296-5656; Email:; Website:

On April 30, 2020, the Centers for Medicare & Medicaid Services (CMS) issued regulatory changes to further expand beneficiary access to telehealth services in their homes for the duration of the coronavirus disease 2019 (COVID-19) public health emergency. CMS is waiving limitations on the types of clinical practitioners and provider organizations that can furnish Medicare telehealth services, and is raising reimbursement rates for audio-only telephone services. CMS will reimburse for Medicare telehealth services provided by rural health clinics and federally qualified health clinics.

Prior to this change, only physicians, nurse practitioners, physician assistants, and certain others could deliver telehealth services. CMS will now allow physical therapists, occupational therapists, and speech language pathologists to provide telehealth services.

CMS will also allow hospitals to bill as the originating site for providing telehealth services to beneficiaries registered as hospital outpatients but who are staying at home. The beneficiary’s home can serve as a temporary “department of the hospital” where the beneficiary can receive counseling and educational service as well as therapy services via telehealth technology.

Reimbursement for audio-only telehealth services is increased to match the outpatient office rate, from a range of about $14 to $41 to about $46 to $110. The payments are retroactive to March 1, 2020.

In addition to raising reimbursement rates for audio-only telephone services, CMS also expanded the list of eligible audio-only telephone services to include many behavioral health and consumer education services. CMS is waiving the video requirement for certain telephone evaluation and management services, and adding them to the list of Medicare telehealth services because some Medicare beneficiaries may lack access to interactive audio-visual technology required for telehealth services. CMS also recognizes that some beneficiaries would choose not to use audio-visual telehealth services offered by their health care professionals.

For more information, contact:

  • Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Website:

On April 21, 2020, the Centers for Medicare & Medicaid Services (CMS) approved a Washington State Medicaid 1115 waiver that will allow the state to pay higher rates to home- and community-based services (HCBS) provider organizations to maintain capacity during the coronavirus disease 2019 (COVID-19) public health emergency. Most of the approved provisions affect long-term services and supports (LTSS). In particular, they extend HCBS flexibilities available under 1915 (c) to beneficiaries receiving LTSS through a state plan amendment.

Additional provisions will allow the Washington State Health Care Authority (HCA) to establish a COVID-19 Disaster Relief Fund. Under these provisions, HCA will be able to use Medicaid funds to stabilize provider organizations as they implement new and expanded care delivery sites while managing economic disruptions. The fund will help provider organizations access needed equipment, broaden access to COVID-19 testing and care, and respond to higher demand.

CMS approved the following additional provisions:

  • HCA can receive federal reimbursement for providing LTSS to beneficiaries, even if they are not timely, updated in the plan of care, or delivered in otherwise-allowable settings.
  • To reduce administrative burden on HCA and beneficiaries, individuals will be permitted to self-attest, or HCA could use an alternative verification of individuals’ income and assets, disability, and level-of-care to qualify for LTSS.
  • Delay initial assessments or annual reassessments for up to one year.
  • HCA can make retainer payments for many habilitation and personal care services provider organizations to maintain capacity during the emergency.
  • HCA can make retainer payments to those organizations that include personal care as a component.

The state had previously been approved for a 1135 Medicaid waiver on March 19, 2020. HCA submitted the 1115 waiver on March 24, 2020, two days after CMS announced the availability of such waivers.

The HCA waiver affects the independent “individual providers” who deliver personal care services but are not employed through a home care provider organization. It also affects an array of residential provider organizations, such as adult family homes, assisted living facilities, home care agencies, adult day health and adult day care programs. HCA also uses the term “provider” to refer to the clinic or hospital billing for the services delivered by an “individual provider.”

Retainer payments were available to be claimed as of May 4, 2020 for residential and adult day providers, along with the rate enhancements. They can claim retainer payments for up to 30 days at 70% of the individual consumer’s rate.

In Washington, payment and rates for residential facilities and individual providers are collectively bargained and ratified by the legislature. Any changes must be approved by SEIU 775 and the residential facility councils. As of May 11, 2020, an agreement had been reached regarding retainer payments for all residential facilities, but rate changes for “individual providers” and home care provider organizations were still pending due to Washington’s parity requirements

CMS was still evaluating HCA’s request for Medicaid expenditure authority to use the Disaster Relief Fund to cover costs associated with treatment for uninsured individuals with COVID-19, housing, nutrition supports, and other COVID related expenditures for states and individuals as well as retainer payments for more than 30 days for provider organizations. Several other requests are also under review. CMS denied HCA’s request to establish a temporary eligibility group for those with incomes 138% to 200% of the federal poverty level.

PsychU last reported on emergency waivers in “34 States Approved For Medicaid 1135 Waivers During COVID-19 Public Health Emergency,” which published on May 11, 2020. The article is available at .

For more information, contact:

  • Amy Blondin, Chief Communications Officer, Washington State Health Care Authority, Post Office Box 45502, Olympia, Washington 98504-5502; 360-725-1915; Email:; Website:

Editor’s note: this article was updated on May 12 to include clarifications from HCA about the retainer payments and rate enhancements. 

During the coronavirus disease 2019 (COVID-19) national public health emergency, behavioral health provider organizations can accept donations of mobile devices and data plans to facilitate telehealth treatment, according to the Office of the Inspector General (OIG) for the federal Department of Health and Human Services (HHS). Such an arrangement during the public health emergency would not violate federal anti-kickback regulations on providing inducements to beneficiaries. The OIG posted its opinion on April 23, 2020.

The OIG maintains an online document with its feedback on a variety of questions submitted by provider organizations seeking guidance on arrangements to facilitate provision of services during the COVID-19 public health emergency. The feedback explains the application of OIG’s administrative enforcement authorities as applied to arrangements in existence solely during the time period subject to the public health emergency. This feedback is different than an OIG advisory opinion, which is a legally binding decision between the OIG and the requesting organizations.

One or more behavioral health provider organizations asked if they could accept donations of mobile devices, data plans, or both to facilitate telehealth treatment during the COVID-19 disruption for consumers who are financially needy and who do not own their own cell phone. The OIG’s response made the following points:

  • Normally the provision of valuable technology and services to federal health care program beneficiaries for free or at a reduced cost likely implicates the federal anti-kickback statute and beneficiary inducements civil money penalty (CMP).
  • In the context of the COVID-19 outbreak and in light of flexibilities in coverage for various telehealth and other virtual services payable by federal health care programs, the provision of a mobile device, service or data plan, or both by a behavioral health provider organization to a consumer likely presents a sufficiently low risk of fraud and abuse if safeguards are implemented.
  • The safeguards include a good-faith determination that an established consumer is in financial need before the telecommunications technologies are provided and that the consumer needs the technologies to access medically necessary services related to behavioral health treatment. The services must be medically necessary to reduce the risk of overutilization or inappropriate utilization. The third-party funding must be used only for telecommunication technologies.
  • The provider organization must not market the telecommunication technologies or offer/provide free phones to generate business.
  • The devices must be returned and the data plans canceled at the end of the COVID-19 Declaration.

The OIG noted that under certain circumstances, such as the Federal Communications Commission (FCC) distributing grants to certain provider organizations to fund telecommunications technologies, the remuneration from the donor to the provider organization would not trigger federal fraud and abuse laws. However, under other circumstances, arrangements between the donor and the provider organization, or indirect financial relationships between the donor and the consumer, could present risk under the federal fraud and abuse laws. The OIG advised provider organizations to separately assess any fraud and abuse risks that may arise with respect to any direct or indirect financial relationships between the donor and the provider organization, or consumer.

The clarifications were posted at

For more information, contact:

  • Don White, Public Affairs Specialist, Office of Inspector General, U.S. Department of Health and Human Services, Federal Building, 90 7thStreet, Suite 3-650, San Francisco, California 94103; 202-528-5254; Email:; Website:

On April 30, 2020, Molina Healthcare announced a definitive agreement to acquire the Magellan Complete Care (MCC) business line from Magellan Health, Inc. for $820 million. Molina intends to fund the purchase with cash on hand. The acquisition will enable Molina to enter three new states—Arizona, Massachusetts, and Virginia—and expand into New York City. The transaction is expected to close in the first quarter of 2021, subject to federal and state regulatory approvals.

MCC, with revenue of over $2.7 billion in 2019, manages full-service Medicaid and Medicare health plans. As of December 31, 2019, MCC served approximately 180,000 members through the following plans:

  • Magellan Complete Care in Arizona, Florida, and Virginia
  • Senior Whole Health in Massachusetts and New York
  • TMG by Magellan in Wisconsin

With the addition of MCC, Molina will serve more than 3.6 million members in government-sponsored health care programs in 18 states. Pro-forma 2020 revenue after the acquisition closes is projected at over $20 billion. The transaction is expected to add approximately $3 billion in revenue by 2021 and presents an opportunity to significantly leverage Molina’s fixed cost base.

Molina believes that the acquisition of the MCC assets represents a strong strategic fit with its portfolio of core Medicaid, high-acuity, and duals businesses. The acquisition also creates new markets for growth opportunities in Medicare and Marketplace in an expanded Medicaid footprint.

Molina’s President and Chief Executive Officer, Joe Zubretsky said, “Acquiring MCC expands our geographic footprint in our core businesses of managed Medicaid, dual eligibles, and long-term services and supports. We believe it will allow us to scale our enterprise-wide platforms and benefit from both operating and fixed cost leverage.” He said, “We will also intensely focus on maintaining the continuity of care for MCC’s members and stability for its state partners.”

PsychU last reported on Molina in “Navajo Corporation Plans To Contract With Molina Healthcare For A New Mexico Medicaid Indian Managed-Health Care Entity,” which published on February 24, 2020. The article is available at

For more information, contact:

  • Caroline Zubieta, Director of Public Relations, Molina Healthcare, Inc., 200 Oceangate, Suite 100, Long Beach, California 90802; 562-951-1588; Email:; Website:
  • Lilly Ackley, Vice President, Corporate Communications, Magellan Health, 5 Nod Road, Avon, Connecticut 06001; 860-5071923; Email:; Website:

Between January 2013 and December 2016, the Iowa Medicaid program may have failed to adequately document about half of claims paid to health home provider organizations. Iowa’s health home provider organizations did not document core services, integrated health home outreach services, diagnoses, and enrollment with provider organizations. In addition, the health home provider organizations did not maintain documentation to support higher payments for intense integrated health home services and did not ensure that beneficiaries had full Medicaid benefits.

A review conducted by the Office of the Inspector General (OIG) for the federal Department of Health and Human Services (HHS) considered documentation of 130 health home payments selected at random. For each payment, the OIG reviewed the documentation submitted by the health home provider organization and the beneficiaries’ medical records. For 62 of the 130 payments, documentation was inadequate to support the claim. The OIG concluded that Iowa improperly claimed federal Medicaid reimbursement.

During this period, the state paid 795,000 health home claims totaling $107 million, with $92 million as the federal share and the remainder covered by state funds. Based on the improper payment rate in the sample, the OIG recommended that Iowa return $37.1 million. The state disagreed with most of the findings, but did say it was improving its monitoring of the health home program and that it was revising the state Medicaid plan.

These findings were reported in “Iowa Inadequately Monitored Its Medicaid Health Home Providers, Resulting In Tens Of Millions In Improperly Claimed Reimbursement” by the OIG for HHS. The goal was to determine whether Iowa’s claims for Medicaid reimbursement for payments made to health home providers complied with federal and state requirements.

During 2016, Iowa’s health home reimbursements accounted for 3% of the entire federal total nationwide, although Iowa’s population represents only 1% of the national population. For federal fiscal year 2016, nationwide, states claimed federal reimbursement of Medicaid health home services totaling $750 million, with the federal share at $431 million.

For more information, contact:

  • Don White, Public Affairs Specialist, Office of Inspector General, U.S. Department of Health and Human Services, Federal Building, 90 7th Street, Suite 3-650, San Francisco, California 94103; 202-528-5254; Email:; Website:
  • Matt Highland, Public Information Officer, Iowa Department of Human Services, 1305 E Walnut Street, Hoover Building, 1st Floor, Des Moines, Iowa 50319-0114; 515-281-4848; Email:; Website:

A recent survey of medical practices found that practices report a 55% decrease in revenue and 60% decrease in health care consumer volume since the beginning of the Coronavirus Disease 2019 (COVID-19) crisis. Overall, 97% of practices have experienced a negative financial impact directly or indirectly related to COVID-19.

At the same time, 48% of medical practices have furloughed staff since March 13, 2020, when the national public health emergency due to the Coronavirus Disease 2019 (COVID-19) pandemic was declared. Many practices that had not yet implemented staff layoffs or furloughs at the time of the study would consider doing so if conditions persist over the next 30 days. The survey respondents estimate that by May 8, 2020, 60% of medical practices will be forced to furlough staff, and 36% will be forced to lay off staff if, and 36% will be forced to lay off staff if conditions continue as they were during the survey.

These findings were reported in “COVID-19 Financial Impact on Medical Practices” by Medical Group Management Association (MGMA). On April 7 and April 8 of 2020, MGMA conducted a survey of medical practices across the United States. The survey included responses from 724 medical practices, of which approximately 75% of respondents were part of independent medical practices and employ less than 50 full-time equivalent (FTE) physicians. The goal was to gauge the economic impact of COVID-19 on the health care sector.

The full text of “COVID-19 Financial Impact on Medical Practices” was published on April 10, 2020, by Medical Group Management Association. A copy is available online at×11-MW-2.pdf.aspx?lang=en-US&ext=.pdf.

For more information, contact:

  • Terri Pollock, Associate Director of Public Affairs, Medical Group Management Association, 104 Inverness Terrace East, Englewood, Colorado 80112; Email:; Website:

The last decade has brought myriad innovations to digital technologies within the health and human services market. Health care payers and providers often turn to tech to boost access, improve adherence, and to provide cost-effective care. This trend holds true for both physical and mental health markets. However, as seen with previous tech waves, behavioral health providers’ adoption continues to trail behind physical health providers’ tech adoption.

For many, tech innovation offers a way to reach remote, often resource- and provider-limited settings to improve patient access and outcomes. Given the widespread, sustained workforce and access issues inherent in the current behavioral health field, why is mental health tech adoption still lagging? What is the hesitation to implement tech as a strategy to improve outcomes? Is the evidence base lacking? Are the research outcomes insignificant? Or is it a case of the unknown—a lack of storytelling about the effectiveness of the currently existing tech? Maybe the field just hasn’t taken stock of the ways that providers are, in fact, successfully utilizing tech across the globe to address disparities in mental health.

In an attempt to fill this knowledge gap, authors Nadi Nina Kaonga and Jonathan Morgan released their recent article, “Common Themes and Emerging Trends for the Use of Technology to Support Mental Health and Psychosocial Well-Being in Limited Resource Settings: A Review of the Literature,” which was published in Psychiatry Research.  In the study, the authors take the pulse of behavioral digital health by examining 67 articles, all focused on positive progress in resource-strapped locales. Their findings are specific to eMental health, a sub-category within the digital health market focused on providing web-, internet-, or telephonic-based mental health services and education to patients, caregivers, and providers.

The Positive Market “Pulse”

The authors spent two months in 2019 scouring three databases of peer-reviewed journal articles with topical search terms. Eligibility of identified research rested upon seven factors. Research had to:

  1. Be original.
  2. Focus on mental health and illness, substance abuse, or mental well-being. For the researchers this included measures of psychosocial well-being such as emotional distress or social issues.
  3. Utilize digital technology as a support mechanism for treatment or education.
  4. Report outcomes.
  5. Focus on settings with resource scarcity. The researchers defined “resource-limited settings” in two ways: (1) using the World Bank’s classifications for lower income countries; and (2) in cases where original studies identified locales as “’rural’, ‘low-income’ or ‘marginalized’”
  6. Be recent. For the authors this meant published no earlier than 2005.
  7. Report full-text English or French.

To cross-compare study results, the authors used qualitative mixed-methods text analysis and synthesized results to report on prevalent themes. The 67 studies included in the review spanned 19 countries, though approximately 35% were focused within the United States. The majority of implementation settings were community-based. Sample size of original research varied from 3 to 17,000 participants. The authors discussed their findings in terms of mental illness supported, type of tech intervention, service/education delivered, and common lessons learned from implementation.

Mental Illness Use Case. Search results indicated eMental Health tech was focused on two main use cases: depression (37%) and general mental health (31%). Other behavioral health issues were supported much more infrequently. They included (ordered by frequency): substance use, posttraumatic stress disorder, anxiety, attention deficit/hyperactivity disorder, autism, psychosis, adjustment disorder, bipolar disorder, personality disorder, and somatoform disorder. The authors indicated that approximately 9% of the previous research studied multiple mental health uses.

eMental Health Tech. Research analysis found an even division among tech types included in previous studies. Approximately one-third of the studies used short messaging service (SMS), another third used the web- or internet-based approaches, and the final third used other methods like telephone calls, smartphone apps, or audio recordings. Interestingly, the majority of the web- and internet-based interventions focused on video teleconferencing (74%).

Services/Education Delivered. Almost half the studies focused on delivering mental health services (47%), including interventions focused on behavioral change. Though much more infrequently mentioned, data collection, training, and diagnostic uses were also mentioned in the literature. Application use coalesced around six main themes:

  1. Treatment Adherence – Studies focused on adherence were more likely to utilize telephone or SMS interventions to provide appointment and treatment reminders. The one exception was a pilot SMS intervention used as supplemental intervention alongside cognitive behavioral therapy provided face-to-face. The main outcome assessed across studies was improved engagement.
  2. Real-Time Assessment – Previous research analyzed included five studies using SMS or telephonic interventions to collect self-reported momentary assessment data. This data allowed health workers to track and assess patient behavior and symptoms in real time. The main outcome assessed across studies was improved patient adherence.
  3. Daily Mood Improvement – Five studies focused on SMS and telephonic interventions that promoted well-being by sending encouraging, supportive messages to participants at set time intervals. The main outcome assessed across studies was patient perceptions of support and feelings of hope.
  4. Health Care Education – A total of nine analyzed studies included health education for either patients/caregivers or health care providers. The main outcome assessed across studies was evidence-based knowledge among participants.
  5. Telemedicine – Unsurprisingly, due to its increasing rates of adoption, telemedicine by phone, videoconferencing software, or SMS was included in more than 40% of studies analyzed (n=28). Many of the studies focused on cognitive behavioral therapy, and outcomes assessed varied from drops in no-show rates to perceptions of safety to cost-effectiveness.
  6. Machine Learning – Recent innovations in machine learning was evidenced in search results, which included five topical studies within the last three years. In the majority of studies, machine learning was coupled with neuroimaging to predict risk/outcome, analyze brain regions, or attempt to diagnose mental illness.

Lessons Learned – Finally, 18% of studies recommended considerations for eMental Health tech adoption and implementation, including ethics (e.g., informed consent), privacy (e.g., data protection), and quality control (e.g., maintaining the therapeutic relationship).

Field Diagnosis

This literature review provides an overview of the demonstrated positive outcomes associated with eMental Health tech for individuals in low-resource areas across the globe. However, limitations of this qualitative study (e.g., variable methodology, lack of long-term outcome measures, and lack of analysis on return-on-investment) reveal the need for additional, long-term trials and analysis to improve the reliability and generalizability of its findings.

The authors’ research was supported by REPSSI. The authors have no competing interests to declare.

This summary was developed independently of the authors.

The Centers for Medicare & Medicaid Services (CMS) project that aggregate payments to skilled nursing facilities (SNFs) will rise by 2.3% during federal fiscal year (FY) 2021, according to statements in the proposed rule updating the SNF prospective payment system (PPS). The proposed rule was issued on April 15, 2020. It makes changes to the case-mix classification code mappings used under the SNF PPS. The proposed rule also includes minor administrative proposals related to the Skilled Nursing Facility Value-Based Purchasing (VBP) Program that affects Medicare payment to SNFs. Comments are due by June 9, 2020.

Aggregate payments to SNFs during FY 2021 are projected to be $784 million higher than payments in FY 2020. The estimated increase is attributable to two PPS components: a 2.7% market basket increase factor with a 0.4 percentage point reduction for multifactor productivity adjustment.

The proposed changes to case mix classification code mappings are in response to stakeholder feedback about the Patient Driven Payment Model (PDPM), which went into effect on October 1, 2019 (the start of FY 2020). Under PDPM, SNF payment is linked to beneficiary characteristics, rather than volume. The PDPM uses International Classification of Diseases, Version 10 (ICD-10) codes to classify Medicare SNF beneficiaries into case mix payment groups. The unadjusted federal per diem rates are divided into six components, five of which are case-mix adjusted components: physical therapy, occupational therapy, speech-language pathology, nursing, and non-therapy ancillaries. The last is a non-case-mix component.

The SNF VBP program began distributing incentive payments on October 1, 2018. It scores SNFs on a single all-cause claims-based measure of hospital readmissions, and then adjusts Medicare fee-for-service payments under the SNF PPS. The goal is to reduce unplanned hospital readmissions. Under this program, payments to all SNFs are reduced by 2% to create a distribution pool. CMS redistributes between 50% to 70% of the pool to SNFs as incentive payments. CMS estimates that the SNF VBP program will reduce aggregate SNF payments by $199.54 million for FY 2021.

For FY 2021, CMS is not proposing to make any changes to the measures, SNF VBP scoring policies, or payment policies. The proposed administrative changes would apply the 30-day Phase One Review and Correction deadline to the baseline period quality measure quarterly report and establish performance periods and performance standards for upcoming program years.

Send comments to:

  • Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1737-P, Post Office Box 8016, Baltimore, Maryland 21244-8016.

On March 30, 2020, the Centers for Medicare & Medicaid Services (CMS) announced temporarily expanded access to telehealth services for Medicare beneficiaries nationwide to permit them receive services where they live, including residents of nursing homes or assisted living facilities, and those receiving home health or hospice benefits. If a physician determines that a Medicare beneficiary should not leave home because of a medical contraindication or due to suspected or confirmed COVID-19, and the beneficiary needs skilled services, the beneficiary will be considered homebound and will qualify for the Medicare home health benefit to receive telehealth services at home. During the COVID-19 public health emergency, Medicare is allowing telehealth to fulfill many face-to-face visit requirements for clinical professionals to see beneficiaries in inpatient rehabilitation facilities, receiving hospice services, or receiving home health.

With the goal of preventing the spread of COVID-19, Medicare will cover more than 80 additional services provided via telehealth technologies, and in some cases the services can be provided via telephone. Eligible services include:

  • Emergency department visits;
  • Initial nursing facility admission and discharge visits; and
  • Home visits.

Medicare still requires that the services be delivered by a clinical professional permitted to provide telehealth services. During the public health emergency, beneficiaries can use commonly available interactive apps with audio and video capabilities to visit with their health care professional. Previously, Medicare covered telehealth services only for beneficiaries in rural areas; they had to travel to an approved site to receive the services because homes were not an approved site.

The expansion will permit home health provider organizations to offer more services to beneficiaries via teleheath, as long as the services were part of the beneficiary’s plan of care and the telehealth services do not replace needed in-person visits ordered in the plan of care. Hospice provider organizations can offer Medicare beneficiaries routine home care through telehealth, a long as it is feasible and appropriate to deliver services in that way.

Physicians will be permitted to conduct Medicare Virtual Check-In services (brief check-ins) by audio or video devices for new and established consumers. Previously, the Virtual Check-In service was reserved only for consumers with an established relationship with the physician. Further, clinical professionals can provide remote monitoring services and collect vital sign data via devices to manage symptoms of a chronic condition or COVID-19.

PsychU last reported on this topic in “New Federal Coronavirus Bill Waives Medicare Telehealth Restrictions,” which published on March 16, 2020. The article is available at

For more information, contact:

  • Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Website:

Health care navigators, or “patient navigators,” cut emergency visits and hospitalization for high-risk health care consumers, according to an analysis of a navigator program implemented by Texas Tech University Health Sciences Center (TTUHSC). Among consumers who were assigned a navigator, emergency room visits dropped from 3.1 visits per person per year to 1.1 visits per person annually. Hospital admissions dropped from 1.5 per person annually to zero. Nearly three-quarters (74.9%) of those assigned navigators decreased both hospital and emergency room utilization. The effects of the navigator program persisted across various insurance types, and whether or not the person had a primary care physician.

The estimated value of the net reduction in hospital admissions and emergency department among those who were assigned a navigator was $1.2 million. Net estimated hospital admission savings attributable to the navigator program were $963,900, plus another $707,427 for emergency department visits resulted in total savings of $1.6 million. The cost of the TTUHSC navigator program averaged $404,754 with net savings of $1.2 million. Over three years, the navigator program cost an estimated $1.2 million to implement and produced estimated avoided costs of nearly $3.8 million.

These findings were reported in “An Evaluation of Interprofessional Patient Navigation Services in High Utilizers at a County Tertiary Teaching Health System” by Charles F. Seifert, Pharm.D., FCCP, BCPS; Taylor J. Horyna, Pharm.D., BCPS; Dolores Buscemi, M.D., FACP; and Rosalinda Jimenez, Ed.D., APRN, FNP-BC, PMHNP-BC, and Linda McMurry, DNP, RN, NEA-BC. The researchers analyzed results generated by 11 Medicare Coordinated Care Demonstration programs, which showed that coordinated care resulted in an 8% to 33% decrease in hospitalization among high-risk Medicare beneficiaries.

For the TTUHSC navigator program, the researchers recruited 364 low-income individuals age 50 and older with health conditions that put them at high risk of frequent hospitalization or emergency department visits. Their median age was 59 years. About 75% were enrolled in Medicaid or Medicare. About 70% had mental health issues. Most reported relying on a hospital emergency room for their primary care because they believed the best physicians worked at a hospital or they were skeptical of care provided outside a hospital. The goal of the TTUHSC program was to determine whether a navigator intervention had a positive effect on hospital and emergency room visits.

The program employed four navigators once fully implemented. Each navigator worked with an average of 150 individuals. The participants were required to host one home visit where they made face-to-face contact with the navigator. During home visits, navigators checked blood pressure, conducted medication adherence checks, and performed a home environment scan. The navigators were able to collaborate with nurse practitioners to arrange for education during a home visit if the participant did not understand the purpose of prescribed medications.

The full text of “An Evaluation of Interprofessional Patient Navigation Services in High Utilizers at a County Tertiary Teaching Health System” was published in the January- February 2020 issue of Journal of Healthcare Management. An abstract is available online at

For more information, contact: 

  • Charles F. Seifert, Pharm.D., FCCP, BCPS, Professor of Pharmacy Practice, Health Sciences Center, School of Pharmacy, Texas Tech University, 3601 4thStreet, Lubbock, Texas 79430-8162; 806-743-7639; Email:; Website:

On March 25, 2020, Metrocare Services announced it had reached a contract agreement with the North Texas Behavioral Health Authority (NTBHA), following a contract dispute about payment rates. The two entities had been in a dispute because NTBHA proposed reducing Metrocare’s contract rate by about $600,000 annually because NTBHA seeks to equalize its support to all of its contractors (about 24 organizations) that provide similar services, which would reduce how much state funding is directed to Metrocare. However, the new agreement allows for continuation of services without a reduction in funding through August 31, 2020, the end of the state fiscal year. The announcement did not disclose the contract amount or terms of the agreement. NTBHA opted to continue the contract under its previous terms to avoid disruption during the current COVID-19 public health emergency.

About 16% of the Metrocare budget had been from NTBHA. Metrocare said its funding should remain at the same level because it serves the most at-risk population in Dallas County. The situation was discussed at the NTBHA Board of Directors meetings on January 8, 2020, and February 12, 2020. According to the meeting minutes, the issues included the following:

  • Metrocare believes that the proposed contract with NTBHA “is so bad that if they were a private entity, they would walk away and that it actually costs them to do NTBHA business.”
  • NTBHA pays Metrocare $112 per person for each opened authorization, and pays an additional $1,000 per person for assertive community treatment.
  • NTBHA stated Metrocare’s rate pay per hour is more expensive for NTBHA compared to its other contractors. Overall, the Metrocare services are provided by individuals with lower types of credentials.

NTBHA is the Local Behavioral Health Authority (LBHA) contracted by the Texas Human Services Commission (HHSC) to provide mental health and addiction treatment services to qualified uninsured or indigent consumers in its six-county-region of Dallas, Ellis, Hunt, Kaufman, Navarro, and Rockwall counties. Metrocare is NTBHA’s largest contracted provider organization; it serves an average of 10,000 Dallas County residents per month, and more than 60,000 adults and children annually. In addition to behavioral health care, Metrocare provides primary care centers, services for veterans and their families, accessible pharmacies, housing and supportive social services.

For more information, contact:

  • North Texas Behavioral Health Authority, 9441 Lyndon B Johnson Freeway, #350, Dallas, Texas 75243; 214-366-9407; Email:; Website:
  • Calley McGee Herth, Marketing & Communications Manager, Metrocare Services, 1380 River Bend Drive, Dallas, Texas 75247; 214-743-6138; Email:; Website:

On March 12, 2020, the Joint Commission released eight new addiction treatment standards for accredited behavioral health organizations. The new standards go into effect as of July 1, 2020. The standards affect levels of care, transitions of care and follow-up, and proper use of urine drug testing.

The eight new standards have 14 new and revised elements of performance (EPs). One standard is related to the Leadership (LD) chapter of the accreditation manual, and seven are related to the Care, Treatment, and Services (CTS) chapter.

LD.04.02.03: Ethics guiding the organization’s business practices. A new EP has been added to require that the organizations provide the individual with information about the charges and financial responsibility for care, treatment, and services, which includes making the individual aware of responsibility for any travel or other expenses related to care, treatment, or services that the organization provides.

CTS 02.02.09: Process to provide medical histories, physical examinations, and diagnostic and laboratory tests. One EP has been updated, and a new EP was added. Previously the EPs in this standard referred to opioid treatment programs only, but the updated EPs (5 and 15) now refer to all addiction treatment programs.

  • Collecting toxicological specimens should take place in a way that demonstrates trust and respect, while taking reasonable steps to prevent falsification of samples. Direct observation may be necessary for some individuals in treatment, but observation is not necessary or appropriate for all individuals. Previously, the EP referred to “patients” rather than individuals.
  • Organizations that provide opioid treatment programs and medication assisted treatment (MAT) programs should initiate MAT by conducting medical assessments and testing according to current national guidelines established for the treatment being used. This is a new EP.

CTS.02.03.07: Assessments of the individual’s history of addictive behaviors. Three EPs have been updated, as follows:

  • In addition to age of onset, and duration, the history should include the method of acquiring the substance. The patterns of abuse examples have been expanded to include frequency, amounts, and route that the substance is taken, in addition to the previous examples: continuous, episodic, or binge.
  • The update deleted a question from the history about the consequences of dependence or addiction experienced by the individual, and added some of those consequences as examples to a question about the social consequences of dependence or addiction to include legal problems, divorce, loss of family members or friends, job-related incidents, financial difficulties, blackouts, and memory impairment.
  • The update added items about the individual’s belief system and the role of spirituality or religion on recovery; the individual’s readiness to change; and the individual’s current living arrangements and environment, and options for an alternative and supportive living environment. The individual’s treatment history should also include information about the individuals’ acute intoxication and/or withdrawal potential.

CTS.02.03.13: Appropriate levels of care. A new EP has been added. The organization providing care, treatment, or services to individuals with addiction must use an evidence-based, multidimensional admission assessment that includes, at a minimum, mental health, medical, and substance-use history for placement of the individual at the appropriate level of care.

CTS.02.03.15: Drug testing. Three new EPs have been added. Organizations must follow their written policies on performing drug testing, and the testing must consider when testing is appropriate based on the individual’s diagnosis, progress in treatment, history of use, and the professional’s clinical judgement. The organization must document in the individual’s clinical/case record the reasons for the drug testing, the results, and actions based on the results. Further, the organization must provide education and training for staff who are involved in drug testing to include at least test administration and storage of the specimen.

CTS.03.01.03: Treatment plans that reflect the individual’s assessed needs, strengths, preferences, and goals. A new EP has been added. The organization must develop a plan for care, treatment, or services at the time of admission or entry into care that reflects the assessed needs, strengths, preferences, and goals of the individual served.

CTS.04.03.35: Response to medical emergencies. One EP was updated and one was added. The updated EP adds MAT programs as responsible for having staff on duty who are trained and proficient in cardiopulmonary resuscitation, management of opiate overdose, and management of medical emergencies, and other relevant techniques. The new EP requires the organization to provide information on how to obtain life-saving medication, such as naloxone, in the case of opioid overdose from the organization or another source.

CTS.06.02.01: Continuity of care, treatment, or services when an individual is transferred or discharged. An EP was updated to clarify that the discharge planning process must address referrals for continuing outpatient care after the last dose of medication and the plan for re-entry to maintenance treatment if relapse occurs.

The Joint Commission presented these standards in “R3 Report Issue 25: Enhanced Substance Use Disorders Standards for Behavioral Health Organizations.” For the report, the Joint Commission evaluated literature and national guidelines, and stakeholder comments. The report explains the rationale and research behind the new and revised requirements. The goal was to determine how enhancing the standards would help improve the quality and safety of care.

The Joint Commission is an independent, non-profit organization that accredits and certifies nearly 21,000 health care organizations and programs in the United States. These accreditations include 3,310 addiction treatment organizations; and 7,026 addiction treatment sites. Joint Commission accreditation is recognized nationally as a symbol of quality that indicates a provider organization’s commitment to meeting certain performance standards.

The “Revised Requirements for Substance Use Disorder Treatment” was released on March 12, 2020. A copy is posted online at

The full text of “R3 Report Issue 25: Enhanced Substance Use Disorders Standards for Behavioral Health Organizations” was published in March 2020, by The Joint Commission. A copy is available online at

For more information, submit a question to The Joint Commission Standards Interpretation Group at:

On February 27, 2020, the Federal Trade Commission (FTC) issued an administrative complaint and authorized a federal court action to block the proposed merger of Jefferson Health and Albert Einstein Healthcare Network, which is projected to affect 70% of the inpatient acute rehabilitation (IRF) services market in the Philadelphia, Pennsylvania area. Collectively, Jefferson and Einstein operate six of the eight IRFs in the Philadelphia area in and around Einstein’s flagship Moss at Elkins Park facility.

The two organizations are academic medical centers that both provide inpatient general acute care hospital services and inpatient acute rehabilitation services in Philadelphia County and Montgomery County, Pennsylvania. They began pursuing the merger in March 2018 when they signed a letter of intent. In September 2018, they signed a binding agreement to the ideas and commitments described in the letter of intent. According to an announcement by Albert Einstein Healthcare Network on February 27, 2020, the key goals of the merger are to broaden the delivery of accessible and value-based care to consumers and provide an exceptional education and training experience for medical students.

Jefferson Health operates 11 general acute care hospitals in Pennsylvania (with four in Philadelphia and two in Montgomery County) and New Jersey, and three IRFs in Pennsylvania. Jefferson operates the largest number of hospital beds in the greater Philadelphia region. Systemwide, it discharges approximately 130,000 people annually. Additionally, it operates over 50 outpatient and urgent care locations in Pennsylvania and New Jersey. During fiscal year 2019, Jefferson Health generated revenue of $5.2 billion.

Albert Einstein Health System operates seven general acute care hospitals with three in Philadelphia and two in Montgomery County, as well as five IRFs. It also operates 15 outpatient centers. It discharges more than 30,000 people annually. During fiscal year 2019, it generated $1.2 billion in revenue.

If the merger proceeds, the FTC believes that in addition to controlling 70% of the IRF market, the merged system would provide 60% of general acute care services in North Philadelphia area and 45% of services in Montgomery county. The FTC believes the merger would “eliminate the robust competition between Jefferson and Einstein for inclusion in health insurance companies’ hospital networks” to the detriment of consumers.

The FTC issues administrative complaints when it has “reason to believe” that the law has been or is being violated, and it appears to the Commission that a proceeding is in the public interest. After an administrative complaint is issued, the allegations are tried in a formal hearing before an administrative law judge. The administrative trial is scheduled to begin on September 1, 2020.

A link to the full text of “FTC Complaint For Temporary Restraining Order & Preliminary Injunction Against Merger Of Jefferson Health & Albert Einstein Healthcare Network” may be found at

For more information, contact:

  • Betsy Lordan, Office of Public Affairs, Federal Trade Commission, 600 Pennsylvania Avenue Northwest, Washington, District of Columbia 20580; 202-326-3707; Email:; Website:
  • Jefferson University Hospitals, 833 Chestnut Street, Suite 1140, Philadelphia, Pennsylvania 19107; 215-955-6300; Email:; Website:
  • Damien Woods, Senior Director, Corporate Communications, Albert Einstein Healthcare Network, 5501 Old York Road, Philadelphia, Pennsylvania 19141; 215-456-7890; Email:; Website:

On April 22, 2020, the federal Department of Health and Human Services (HHS) announced it started releasing $100 billion in funding through the “Provider Relief Fund” created by the Coronavirus Aid, Relief, and Economic Security (CARES) Act, which was signed into law on March 27, 2020. The CARES Act provides emergency assistance and health care response for individuals, families, and businesses affected by the 2020 coronavirus pandemic. The Provider Relief Fund is intended to address both the economic harm across the entire health care system due to the stoppage of elective procedures, and the economic impact on provider organizations incurring additional expenses to care for people with COVID-19. A key provision will reimburse provider organizations for treatment provided to uninsured consumers.

The relief funds are available for two types of provider organizations. Half of relief funds are for provider organizations that receive Medicare fee-for-service (FFS) payments. The second half of funds will be shared among multiple types of provider organizations. The CARES Act provides targeted relief funds for provider organizations in high impact areas, and selected organizations that solely accept Medicaid. It also provides for reimbursement to any provider organizations that offer COVID-19 diagnosis and treatment for the uninsured.

$50 Billion General Distribution Immediate Relief Funds For Facilities & Provider Organizations That Receive Medicare FFS Payments

To receive the general distribution relief funds, provider organizations and eligible professionals must agree to the terms and conditions, one of which requires them to agree not to collect out-of-pocket payments from consumers with presumptive or confirmed COVID-19 for sums greater than what the consumer would have been required to pay if the care had been provided in-network. The terms and conditions also specify that reimbursement for treating uninsured people with COVID-19 will be at the Medicare FFS rate. A condition of receiving the payments requires the provider organizations to submit claims data to verify, and they must agree that if they submit for reimbursement for treating the uninsured, they will accept the Medicare FFS rate as payment in full. Provider organizations that do not agree to the terms will not receive the funding, and they will not be prevented from billing uninsured consumers for the full cost of treatment.

From April 10 through 17, HHS began releasing $30 billion in the first wave of relief funds to Medicare provider organizations and health care professionals. The funds are payments, not loans. The first wave of payments is based on the provider organization/professional share of the total $484 billion Medicare FFS reimbursements in 2019. On April 24, HHS will begin distributing the remaining $20 billion of the general distribution to these provider organizations and professionals to augment their allocation so that the whole $50 billion general distribution is allocated proportional to their share of 2018 net consumer revenue.

The relief payments are being made according to provider organization or health care professional tax identification numbers (TIN). Additional details are as follows:

  • Large organizations and health systems will receive relief payments for each of their billing TINs that bill Medicare. Each organization should look to the part of their organization that bills Medicare to identify details on Medicare payments for 2019 or to identify the accounts where they should expect relief payments.
  • Employed physicians should not expect to receive an individual payment directly. The employer organization will receive the relief payment as the billing organization.
  • Individual physicians and eligible health care professionals in a group practice are unlikely to receive individual payments directly, because the group practice will receive the relief fund payment as the billing organization. The eligible professionals should look to the part of their organization that bills Medicare to identify details on Medicare payments for 2019 or to identify the accounts where they should expect relief payments.
  • Solo clinical professionals who bill Medicare will receive a payment under the TIN used to bill Medicare.

A portion of provider organizations will automatically be sent an advance payment based off the revenue data submitted in CMS cost reports. Provider organizations without adequate cost report data on file will need to submit their revenue information to this portal, Provider organizations that receive an automatic advance payment will still need to submit their revenue information for verification. Payments will go out weekly as information is validated, with the first wave being delivered on April 24, 2020.

HHS partnered with UnitedHealth Group (UHG) to provide rapid payment to provider organizations and professionals eligible for the distribution of the initial $30 billion in funds. Payments to practices that are part of larger medical groups will be sent to the group’s central billing office. The relief payments are made to the billing organization according to its TIN. The payment will be via Automated Clearing House account information on file with UHG or CMS. The automatic payments will be delivered via Optum Bank with “HHSPAYMENT” as the payment description. Those who normally receive a paper check for reimbursement from CMS will receive a paper check in the mail for this payment as well, within the next few weeks. Within 30 days of receiving the payment, provider organizations (and solo professionals) must sign an attestation confirming receipt of the funds and agreeing to the terms and conditions of payment. Not returning the payment within 30 days of receipt will be viewed as acceptance of the Terms and Conditions.

At Least $20.4 Billion For Targeted Allocations To High Impact Areas, Rural Areas, Indian Health Service & Medicaid-Only Provider Organizations

Specific funding amounts have been allocated to provide additional relief to hospitals in areas with a high prevalence of COVID-19 cases and hospitalizations, and to provide relief to rural health clinics and hospitals, including those operated by the Indian Health Service. Separate funding will be available to skilled nursing facilities, dentists, and provider organizations that solely accept Medicaid; however, as of April 23, 2020, HHS had not released additional details about the additional Medicaid allocations.

A total of $10 billion will be allocated for targeted distribution to hospitals in areas that have been significantly impacted by the COVID-19 outbreak. HHS anticipates that hospitals in New York, which has more cases than any other state, will receive a large share of the funds. Eligible hospitals have already been contacted. To apply for these funds, hospitals had to provide four pieces of information by 3:00 PM (EDT) April 25, 2020. The information includes the hospital TIN, National Provider Identifier, the total number of intensive care unit beds as of April 10, 2020, and the total number of admissions with a positive diagnosis for COVID-19 from January 1, 2020 to April 10, 2020. HHS will use the information to determine which hospitals will qualify for a targeted distribution based on those that show the greatest impact from COVID-19. Supplying the information does not guarantee receipt of funds. The distribution will take into consideration the challenges faced by facilities serving a significantly disproportionate number of low-income individuals, as reflected by their Medicare Disproportionate Share Hospital (DSH) Adjustment.

For rural areas, $10 billion will be allocated for rural health clinics and hospitals. The funds will be distributed on the basis of operating expenses, using a methodology that distributes payments proportionately to each facility and clinic. HHS anticipates distributing the funds starting the last week of April 2020.

An allocation of $400 million is reserved for Indian Health Service facilities. It will be distributed on the basis of operating expenses. HHS anticipates distributing the funds starting the last week of April 2020. This funding complements other funding provided to Indian Health Service facilities.

Reimbursement Of Treatment For The Uninsured, Subject To Available Funding

Starting April 27, 2020, every health care provider organization or professional who provided treatment for uninsured COVID-19 consumers on or after February 4, 2020, can request claims reimbursement through the program and will be reimbursed at Medicare rates, subject to available funding. The size of this allocation has not been disclosed.

Registered provider organizations can begin submitting claims in early May 2020. Reimbursement will be made for qualifying testing for COVID-19 and treatment services with a primary COVID-19 diagnosis, including the following:

  • Specimen collection, diagnostic, and antibody testing.
  • Testing-related visits including in the following settings: office, urgent care, or emergency room or via telehealth.
  • Treatment-related office visits (including via telehealth), emergency room, inpatient, outpatient/observation, skilled nursing facility, long-term acute care (LTAC), acute inpatient rehab, home health, durable medical equipment (e.g., oxygen, ventilator), emergency ground ambulance transportation, non-emergent consumer transfers via ground ambulance, and FDA approved drugs as they become available for COVID-19 treatment and are administered as part of an inpatient stay.
  • When an FDA-approved vaccine becomes available, it will also be covered.
  • For inpatient claims, date of admittance must be on or after February 4, 2020.

Services not covered by traditional Medicare will also not be covered under this program. In addition, the following services are excluded:

  • Air and water ambulance
  • Any treatment without a COVID-19 primary diagnosis, except for pregnancy when the COVID-19 code may be listed as secondary
  • Hospice services
  • Outpatient prescription drugs covered under Medicare Part D

To request reimbursement, the provider organization must first register for the program and enroll at The provider organization must check the individual’s eligibility and benefits, submit information about the individual, submit claims, and receive payment via direct deposit. All claims submitted must be complete and final.

For more information, contact:

  • U.S. Department of Health and Human Services, 200 Independence Avenue SW, Washington, District of Columbia 20201; 202-690-6343; Email:; Website:

Between 1996 and 2016, inflation adjusted spending on treatment of behavioral health disorders in the United States rose by 2.7% per year, or 54% for the period, for a group of six behavioral health conditions with 2016 spending of $10 billion or higher. The six conditions include anxiety, attention deficit/hyperactivity disorder, bipolar disorder, depressive disorder, drug addiction, and schizophrenia. Over the same 20-year time period, health care spending rose by 121.4% and the consumer price index rose 52.97%. The size of the U.S. population increased by 20%.

For this group of conditions, after adjusting for changes in inflation, population size, and age group, spending by public payers (Medicare, Medicaid, other federal, other public/state/local government, and Veterans Affairs) rose by 2.4% annually. Spending by private payers (other private, TRICARE, and worker’s compensation) rose by 2.6% annually. Out-of-pocket spending rose by 1.1%

For the six specific behavioral health conditions, the annualized cost growth trend varied, as did the trend rates for public, private, and out-of-pocket payers. For example, between 1996 and 2016, costs for schizophrenia treatment dropped by 1.1% annually for all payer types. For public payers, costs dropped 1.0% annually. For private payers, spending dropped 0.4% annually. Out-of-pocket costs dropped by 3.2% annually.

These findings were reported in “US Health Care Spending by Payer and Health Condition, 1996-2016” by Joseph L. Dieleman, Ph.D.; Jackie Cao, MS; Abby Chapin, BA; et al. The researchers analyzed government budgets, insurance claims, facility records, household surveys, and official U.S. records from 1996 through 2016. The goal was to estimate spending on health care, for both private insurance, public insurance, and out-of-pocket spending in the U.S. The process used to generate spending estimates by payer were based on methods previously developed by the Institute for Health Metrics and Evaluations for the Disease Expenditure Project.

The full text of “US Health Care Spending by Payer and Health Condition, 1996-2016” was published March 3, 2020 by JAMA Network. An abstract is available online at

For more information, contact: 

  • Joseph L. Dieleman, Associate Professor, Global Health & Health Metrics Sciences at the University of Washington, Institute for Health Metrics and Evaluation, 2301 Fifth Avenue, Suite 500, Seattle, Washington 98121; 206-897-2800; Fax: 206-897-2899; Email:; Website:

The average adjusted cost per day of an inpatient hospital stay in state and local government community hospitals in the United States was $2,260 in 2018. For inpatient stays in non-profit hospitals, the average adjusted cost per day was $2,653. For inpatient stays in for-profit hospitals, the average cost per day was $2,093. “Community hospitals” are defined as all non-federal, short-term general, and specialty hospitals whose facilities and services are available to the public.

Highs and lows for these hospital categories by state include:

These findings were reported in “Hospital Adjusted Expenses per Inpatient Day by Ownership” by researchers with the Kaiser Family Foundation (KFF). Researchers with KFF analyzed information from the 2018 American Hospital Association Annual Survey. The goal was to determine the adjusted expenses per inpatient day in 2018 for the three hospital types in each state.

The full text of “Hospital Adjusted Expenses per Inpatient Day by Ownership” was published February 21, 2020 by Kaiser Family Foundation. An abstract is available online at

For more information, contact: 

  • Chris Lee, Senior Communications Officer, Kaiser Family Foundation, 1330 G Street NW, Washington, District of Columbia 20005; Email:; Website:

On February 27, 2020, the Massachusetts attorney general announced agreements with five health insurance companies and two companies that manage behavioral health coverage for insurers to improve access to behavioral health services and resolve violations of the federal Mental Health Parity and Addiction Equity Act (MHPAEA). The organizations are AllWays Health Partners; Blue Cross Blue Shield of Massachusetts (BCBS); Fallon Community Health Plan and Beacon Health Strategies; Harvard Pilgrim Health Care and United Behavioral Health, dba, Optum; and Tufts Health Plan. The state investigated the organizations’ compliance with behavioral health parity laws, as well as the accuracy of health insurers’ provider organization network directories.

Settlements with three of the insurance companies—AllWays, Fallon, and Harvard Pilgrim—resolved the state’s claims that they violated the MHPAEA. The three companies agreed to limit prior authorization for certain behavioral health care. The companies agreed to change, or have already changed, how they determine minimum reimbursement rates for outpatient behavioral health services at all clinical professional levels, including psychiatrists, psychologists, and social workers. All the companies agreed to make extensive changes to their directories to allow members to more easily reach behavioral health care professionals and provider organizations.

For Harvard Pilgrim, Fallon, and AllWays, the state alleged that the insurers used methods to establish base rates for outpatient behavioral health services that were not comparable to and were applied more stringently than the methods used to establish base rates for outpatient medical/surgical services; this methodology led to different base rates for behavioral health visits and medical/surgical office visits billed with the same evaluation and management codes. The companies allegedly used utilization management processes for inpatient and outpatient behavioral health services that were not comparable to and were applied more stringently than the processes used for medical/surgical care. The state alleged that all three published and maintained provider organization directories that were materially inaccurate and deceptive. The state alleged that the directories did not accurately reflect whether the listed professionals were accepting new consumers, whether the professional was in or out of network, and whether the contact information and practice location was correct.

  • A link to the full text of “Massachusetts AllWays Assurance Of Discontinuance” may be found in the at
  • A link to the full text of “Massachusetts Fallon/Beacon Assurance Of Discontinuance” may be found at
  • A link to the full text of “Massachusetts Harvard Pilgrim/Optum Assurance Of Discontinuance” may be found at

BCBS and Tufts allegedly published and maintained provider organization directories that were materially inaccurate and deceptive. The state alleged that the directories did not accurately reflect whether the listed professionals were accepting new consumers, whether the professional was in or out of network, and whether the contact information and practice location was correct.

  • A link to the full text of “Massachusetts Blue Cross Blue Shield Assurance Of Discontinuance” may be found at
  • A link to the full text of “Massachusetts Tufts Health Plan Assurance Of Discontinuance” may be found at

For more information, contact:

  • Meggie Quackenbush, Deputy Press Secretary, Massachusetts Attorney General’s Office, 1 Ashburton Place, 20thFloor, Boston, Massachusetts 02108; 617-727-2543; Email:; Website:

On March 4, 2020, Humana announced it had launched a Medicare Advantage value-based program (VBP) focused on addressing member social determinants of health (SDOH) such as food insecurity, social isolation, loneliness, and housing instability. The first participating provider organization is Ochsner Health, a large non-profit, academic health care system in Louisiana. A Humana spokesperson said the insurer intends to expand the program to include participation elsewhere in the country; however, the company does not currently have a set timeline for expansion.

The program provides compensation for providers for enhanced care coordination centered on three program components—SDOH screenings; documentation of assessment findings; and connecting the member to appropriate resources. Compensation is based on completion of the three pillars of the program. Humana has not released its baseline expectations, or the program performance targets, but the SDOH program takes place in the context of other VBP arrangements. The SDOH model offers provider organizations tools and resources to identify at-risk members and address their non-medical barriers to better health outcomes. Humana has not released additional details about the tools it will provide.

As of January 2020, Humana had approximately 4.4 million Medicare Advantage members. As of December 31, 2019, Humana had more than 2.4 million individual Medicare Advantage members and approximately 115,000 commercial members cared for by a primary care physician in value-based relationships with Humana, across 43 states and Puerto Rico.

In 2018, Ochsner Health served about 811,000 consumers from across the United States and from 70 countries. The organization was formed in 1941. It has nearly 1,500 group practice physicians and more than 3,200 affiliated physicians across the Louisiana. Humana approached Ochsner Health about participating in the SDOH VBP because Humana believed it fit with Ochsner‘s interest in value-based care, and its interest in tackling SDOH.

For more information, contact:

  • Alissa Krinsky, Humana Corporate Communications, Humana, Inc., 500 Adams Street, Chicago, Illinois 60661; 312-441-5576; Email:; Website:
  • Giselle Hecker, Director, Public Relations, Ochsner Healthcare System, 1450 Poydras Street, Suite 550, New Orleans, Louisiana 70112; 504-842-9219; Email:; Website:
  • Jennifer Bollinger, Vice President, Communications and Public Relations, Ochsner Accountable Care Network, 1450 Poydras Street, Suite 550, New Orleans, Louisiana 70121; 504-842-9268; Email:; Website:

The Drug Enforcement Administration (DEA) recently proposed revising its regulations for federally certified opioid treatment programs (OTPs) to allow the programs to operate a mobile component without obtaining a separate registration. Such programs could dispense narcotic drugs in schedules II-V at a remote location for the purpose of maintenance or detoxification treatment. The proposed rule would consider the mobile program to be a “coincident” activity.

Specifically, for OTPs with mobile components, the DEA said it would waive the requirement of a separate registration at each principal place of business or professional practice where controlled substances are dispensed, as long as the dispensing location is within the same state as the registration, and complies with the requirements of the proposed rule. The revisions are intended to make maintenance or detoxification treatments more widely available, while ensuring that safeguards are in place to reduce the likelihood of diversion.

The proposed rule, “Registration Requirements for Narcotic Treatment Programs With Mobile Components,” was issued on February 26, 2020. Comments will be accepted through April 27, 2020. Currently there are more than 1,700 narcotic treatment programs registered with DEA, including OTPs, detoxification treatment services that utilize methadone, and compounders. Before 2007, DEA authorized mobile NTPs on an ad hoc basis, but then imposed a moratorium on further authorizations. Since 2015, only 19 NTPs have operated a mobile component. Currently, only eight NTPs operate mobile units under those agreements.

The goal of the proposed rule is to expand access to evidence-based medication assisted treatment for addiction disorders, including opioid use disorder. The demand for treatment has expanded and in some areas, has resulted in long waiting lists and high service fees. In rural and other underserved communities, the distance to the nearest OTP or the lack of consistent access to transportation may pose a substantial barrier to accessing treatment. The proposed rule formalizes the requirements for operating a mobile NTP while maintaining controls to reduce the likelihood of diversion.

For more information, contact:

  • Scott A. Brinks, Drug Enforcement Administration, Attn: DEA Federal Register Representative/DPW, Diversion Control Division; Mailing Address: 8701 Morrissette Drive, Springfield, Virginia 22152; 571-362-3261; Website:
  • Public Affairs, Drug Enforcement Administration, U.S. Department of Justice, 700 Army-Navy Drive, Room W-12228, Arlington, Virginia 22202; 202-307-7977; Email:; Website:

The South Carolina Department of Mental Health (SCDMH) is updating its qualified provider organization list of community residential care facilities (CRCFs) available for people with mental illness who are at high risk for hospitalization. The list was created in 2011, and resubmitted following expiration in 2018. The SCDMH intends to use the new list to recommend placements for specific individuals currently served by three of its community mental health centers. SCDMH released the solicitation (5400019224) on March 23, 2020, with responses due by April 6, 2020. The initial 12-month contract term is followed by four one-year renewal options. The start date is April 20, 2020.

The state seeks to establish a fixed price contract with a source or sources to provide the services. The established maximum fixed price rate is $30.00 per resident per day.

CRCFs, unlike boarding homes, include not only room and board, but provide a degree of personal care for a period of time in excess of 24 consecutive hours for two or more persons, 18 years old or older. CRCFs are often referred to as “assisted living facilities.” They are licensed and monitored by the South Carolina Department of Health and Environmental Control’s Division of Health Licensing. A CRCF can be a transitional or a permanent placement depending on the preferences of the resident and their support networks/families for independent living settings.

Eligible CRCF residents are those who have had a serious mental illness or other behavioral health disorder and who have had a history of multiple hospitalizations and inpatient psychiatric treatment for 90 or more days, and/or who otherwise may be at significant risk of re-hospitalization. The three centers need the following number of CRCF beds:

  • Columbia Area Mental Health Center (CAMHC) needs 75 CRCF beds in Richland and Fairfield counties
  • Santee Wateree Mental Health Center needs 45 beds in Sumter and Kershaw counties
  • Coastal Empire Mental Health Center needs 45 beds across Beaufort, Hampton, Colleton, Allendale, and Jasper counties.

For more information, contact:

  • Tracy LaPointe, Public Information Director, South Carolina Department of Mental Health, Post Office Box 485, Columbia, South Carolina 29202; 803-898-8581; Email:; Website:

The Department of Veterans Affairs (VA) recently proposed standardizing eligibility criteria for its Program of Comprehensive Assistance for Family Caregivers (PCAFC). Specifically, the VA seeks to expand the definition of serious injury to include any service-connected disability, whether it resulted from an injury, an illness, or a disease. Further, the VA seeks refine the eligibility criteria for personal care services to capture the service needs of veterans and service members with cognitive or neurological impairment or mental health conditions. The VA also proposed changes to the PCAFC stipend payment methodology, definitions for financial planning and legal services, and procedures for revocation and discharge, to include advance notice requirements aimed at improving communication between VA and PFAFC participants. These changes are intended to ensure that the PCAFC regulations reflect changes required by the VA MISSION Act of 2018.

The proposed rule, “Program Of Comprehensive Assistance For Family Caregivers Improvements And Amendments Under The VA MISSION Act Of 2018,” was released on March 6, 2020. Comments will be accepted through May 5, 2020.

The PCAFC, established in 2011, is a component of the VA Caregiver Support Program, which provides services to family caregivers to help veterans with disabilities remain in their homes. It provides caregivers with training, peer mentoring, respite care, a telephone support line and self-care courses. The PCAFC provides additional benefits including a monthly stipend for qualifying family caregivers of eligible veterans who were seriously injured in the line of duty on or after September 11, 2001.

Under the MISSION Act, the VA will expand eligibility for PCAFC to veterans from all eras, starting with those who incurred or aggravated a serious injury in the line of duty on or before May 7, 1975. After that first expansion phase, PCAFC will be extended to eligible veterans who were seriously injured in the line of duty between May 7, 1975 and September 11, 2001. Prior to expanding, VA must fully implement an information technology system required by the MISSION Act.

PsychU last reported on this topic in “VA Expands Private Provider Options For Veterans Under MISSION Act,” which published on July 15, 2019. The article is available at

For more information, contact:

  • Elyse Kaplan, National Deputy Director, Caregiver Support Program, Care Management and Social Work, 10P4C, Veterans Health Administration, Department of Veterans Affairs, 810 Vermont Ave. NW, Washington, District of Columbia 20420; 202-461-7337; Website: and

The current COVID-19 epidemic is projected to raise Medicare costs from $38.5 billion to $115.4 billion over the next 12 months, according to an analysis by the National Association of Accountable Care Organizations (NAACOS). The projected costs due to COVID-19 represent between 6% to 18% of the $582 billion in Medicare spending during 2018.

According to the Kaiser Family Foundation, the cost range is based on the projected penetration rate of COVID-19 among the nearly 59 million Medicare beneficiaries aged 65 and older. If 20% of these beneficiaries’ contract COVID-19, 7,500 people will be affected and 1,689 will be hospitalized; costs are estimated at $38.5 billion. If 40% contract COVID-19, 15,000 will be affected and 3,378 will be hospitalized; costs are estimated at $77 billion. If 60% contract COVID-19, 22,500 will be affected and 5,067 will be hospitalized; costs are estimated at $115.4 billion.

About 20% of Medicare beneficiaries are served by a Medicare ACO through the Medicare Shared Savings Program (MSSP) or the Next Generation Model ACO program. Potential COVID-19-related costs for this subset of beneficiaries served by a Medicare ACO could range from $7.7 billion to $23.1 billion. In 2018, combined spending for beneficiaries attributed to a MSSP or NextGen ACO totaled $125 billion. The additional 6% to 18% in Medicare spending would completely overshadow the 1.6% cost savings generated by the MSSP ACOs and the 1.4% generated by the NextGen ACOs.

These estimates were presented in “Potential Impact Of COVID-19 On Medicare Spending: Implications For ACOs,” by the NAACOS. The estimate is based on the number of Medicare beneficiaries, with scenarios presented for infection rates of 20%, 40%, and 60%, and related inpatient admission rates over the next 12 to 18 months. The estimates are based on prevalence and hospitalization data from China. The average cost of a 90-day pneumonia hospitalization was used as a proxy for new Medicare spending. This includes clinically relevant services provided post-discharge. The estimate does not include COVID-19-related costs for beneficiaries who are not hospitalized. It also does not include hospital and health system costs for infection-control protocols and equipment.

In mid-March 2020, NAACOS and nine other leading health care organizations asked the Centers for Medicare & Medicaid Services (CMS) for relief so that provider organizations participating in alternative payment models are not inappropriately penalized for the extreme costs of handling the COVID-19 pandemic. Requests included holding clinicians harmless from performance-related penalties for 2020, making appropriate adjustments to spending targets, performance scores, consumer attribution and risk adjustment, and providing financial support and reinsurance. In the context of a global, public health pandemic, NAACOS believes that COVID-19 threatens to derail adoption of alternative payment models and the movement to value-based care. Without relief from CMS, ACOs may drop out of the program to avoid losses.

The full text of “Potential Impact Of COVID-19 On Medicare Spending: Implications For ACOs” was published on March 24, 2020, available online at–implications-for-acos.

For more information, contact:

  • David Pittman, Health Policy and Communications Advisor, National Association of Accountable Care Organizations, 601 13thStreet Northwest, Suite 900 South, Washington, District of Columbia 20005; 202-640-2689; Email:; Website:

The Medicaid and CHIP Payment and Access Commission (MACPAC) found that most state Medicaid programs use one or more legal authorities to use Medicaid funds to pay for residential or inpatient services provided by an institution of mental diseases (IMD). However, since 1965, the federal Medicaid program has excluded payment for IMD services to ensure that states alone fund inpatient psychiatric services. The goal of this exclusion was to encourage states to build community-based behavioral health capacity.

The federal Medicaid program defines an IMD as “a hospital, nursing facility, or other institution of more than 16 beds, that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care, and related services.” The term IMD is only relevant to Medicaid; they are not singled out by other payers, state licensure agencies, or accrediting bodies. For licensing purposes, IMDs can provide inpatient or residential mental health and addiction treatment as needed.

Medicaid authorities that states use to pay for services in IMDs include:

  • Demonstration waivers under Section 1115 of the Social Security Act gives the Secretary of Health and Human Services (HHS) authority to waive provisions of major health and welfare programs authorized under the Act, including certain Medicaid requirements, and to allow a state to use federal Medicaid funds in ways that are not otherwise allowed under federal rules. This authority is provided for “experimental, pilot, or demonstration” projects which, in the view of the Secretary, are “likely to assist in promoting the objectives of” the program.
  • In-lieu-of services in managed care are alternative services in a setting that are not included in the state plan or otherwise covered by the contract but are medically appropriate, cost-effective substitutes for state plan services included within a contract.
  • Statutory exceptions to the exclusion for services provided to adults age 65 and older and children and youth under age 21.
  • A new state plan option is in effect from October 1, 2019 to September 30, 2023. This option covers IMD services for up to 30 days in a year for individuals with addiction.

MACPAC also found that state licensure agencies, accrediting bodies, and other payers do not have standards specific to IMDs, given that the designation is unique to Medicaid. Instead, states regulate inpatient and residential treatment facilities separately, and standards vary according to whether a facility provides addiction treatment or mental health care. Federal standards for IMDs are largely determined by whether or not the facilities are Medicare provider organizations; however, there is no federal certification process for these organizations because Medicare does not pay for addiction treatment services in most free-standing facilities.

These findings were presented in “MACPAC Report To Congress: Oversight of Institutions for Mental Diseases.” The report fulfills a statutory requirement in the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT Act). The requirement is to identify and describe facilities designated as IMDs in selected states and summarize state licensure, certification, or accreditation requirements and Medicaid clinical and quality standards for these facilities. MACPAC estimated the number of IMDs accepting Medicaid in seven selected states (California, Colorado, Florida, Massachusetts, New Jersey, Ohio, and Texas) and determined the types of services these facilities offer. They also determined the roles of federal and state government agencies in the regulation and oversight of IMDs, and selected outpatient behavioral health facilities, including licensure requirements and licensure standard enforcement. Finally, they analyzed standards that select state Medicaid programs and managed care plans place on behavioral health facilities, including facilities that may be considered IMDs, how Medicaid agencies enforce these standards, and state laws governing consumer protection in IMDs.

For more information, contact: 

  • Kathryn Ceja, Director of Communications, Medicaid and Children’s Health Insurance Program Payment and Access Commission, 1800 M Street Northwest, Suite 650 South, Washington, District of Columbia 20036; 202-350-2000; Fax: 202-273-2452; Email:; Website:

On March 31, 2020, federal approval expired for the New York Medicaid Delivery System Reform Incentive Payment Program (DSRIP). The New York Department of Health (DOH) had asked the Centers for Medicare & Medicaid Services (CMS) to extend the DSRIP in two phases. The first phase would have extended the waiver through March 2021 and allowed the state to use $625 million in unspent funds from its original $7.4 billion program. The second phase, stretching into March 2024, sought $8 billion more in federal funding to continue the DSRIP. However, on February 21, 2020, CMS notified the New York Department of Health (DOH) that it would consider the first phase proposals but would not consider extending DSRIP.

CMS had approved the state’s waiver for the DSRIP on April 14, 2014. Under the current DSRIP waiver, Performing Provider Systems (PPS), regional networks of provider organizations, work in partnerships to collaborate in a regional project plan focused on improving health outcomes while reducing avoidable hospital readmissions. The projects included expanding medication assisted treatment into primary care and emergency room settings, targeting seriously mentally ill populations for enhanced supports, and addressing housing and other social determinants of health. Without the extension, the PPSs must decide whether they will continue to operate without federal support.

In its denial letter dated February 21, 2020, CMS noted that the initial DSRIP award in 2014 was intended to be a time-limited one-time investment in system transformation that could be sustained through ongoing reimbursement mechanisms and/or state and local initiatives. CMS said it intended to maintain that agreement and preserve the original expiration of the DSRIP expenditure authority. Further, the letter noted that if CMS were to approve an extension, it would be rebased consistent with new CMS policy. The rebasing would mean that the state basis would be limited to just five years of its current budget neutrality savings. As a result, CMS believes its staff would not be able to adequately assess New York’s proposal for the second phase. CMS said it was continuing to review the phase one proposal in light of the federal goal of increasing value-based care (VBC) in the Medicaid program. The state’s VBC efforts will continue beyond the planned expiration of the DSRIP program. Those plans were released in January 2020 as “New York State Roadmap For Medicaid Payment Reform, A Path Toward Value Based Payment: Annual Update June 2019: Year 5.”

The state’s Medicaid program serves more than 6 million beneficiaries. It contracts with more than 50 fully and partially capitated managed care plans. Eligible services include inpatient hospital care, outpatient hospital services, clinics, nursing homes, managed care, prescription drugs, home care and services provided in a variety of community-based settings (including mental health, addiction treatment, developmental disabilities services, school-based services, and foster care services). The proposed 2021 budget included $76.7 billion for the Medicaid program.

On March 19, 2020, the New York Medicaid Redesign Team II (MRT II) approved reforms to reduce the state’s Medicaid spending by $2.5 billion annually. The recommendations were sent to the governor and legislature for consideration in the state budget. Governor Andrew Cuomo had formed the MRT II on February 4, 2020 to develop proposals to restore financial sustainability to the Medicaid program while connecting other program initiatives that would advance core health care strategies.

On April 3, 2020, Governor Cuomo signed the state’s $177 billion fiscal year 2021 budget. It includes Medicaid changes recommended by MRT II to help close a $6 billion budget gap, but includes language to delay any provisions that might make the state ineligible for $6.7 billion in short-term federal aid to enhance Medicaid payments as part of the federal response to the COVID-19 public health emergency. On March 29, Governor Cuomo said he intended to refuse the short-term federal aid because the maintenance of effort requirements would prevent implementing the MRT II Medicaid redesign proposals, one of which would shift Medicaid costs from the state to localities.

For more information, contact:

  • Jonah Bruno, Director of Communications, New York State Department of Health, Empire State Plaza, Corning Tower, Albany, New York 12237; Email:; Website:

On April 8, 2020, the Centers for Disease Control and Prevention (CDC) issued interim workplace safety practices for critical infrastructure workers with potential exposure to a person with suspected or confirmed COVID-19. Critical infrastructure workers include those working in the following sectors:

  • Federal, state, and local law enforcement
  • 911 call center employees
  • Fusion Center employees (Fusion centers are state-owned and operated centers that organize localized domestic intelligence gathering of threat-related information. The centers receive, analyze, gather, and share data between the Department of Homeland Security; federal intelligence, law enforcement at the federal, state, local, tribal and territorial levels; and private sector partners.)
  • Hazardous material responders from government and the private sector
  • Janitorial staff and other custodial staff
  • Workers, including contracted vendors, in food and agriculture, critical manufacturing, informational technology, transportation, energy, and government facilities

This guidance does not pertain to health care, first responder, or correctional facility workers for which the CDC had already issued guidelines. The federal Occupational Safety and Health Administration (OSHA) requires employers of workers in the health care industry, emergency response organizations (e.g., emergency medical, firefighting, and law enforcement services), and correctional institutions to make work-relatedness determinations for cases of COVID-19. Employers outside these industries in areas where there is ongoing community transmission of COVID-19 will not be required to make work-relatedness determinations.

The CDC defined a potential exposure as being a household contact or having been in close contact (within six feet) of an individual with confirmed or suspected COVID-19 up to 48-hours before the individual started showing symptoms. Workers who have been exposed but are not showing symptoms can work, but should have their temperatures monitored before starting their shifts, and the worker should wear a face mask. Workers who become symptomatic during the day should be sent home immediately. The work site should compile information on other workers in close contact with an exposed worker being monitored. In the case that a worker becomes sick, other workers who had close contact with that worker should be considered exposed.

In workplaces where critical infrastructure workers were exposed to COVID-19 but remain asymptomatic, the employer and worker should adhere to the following practices prior to and during their work shift:

  • Pre-screen: Employers should measure the worker’s temperature and assess symptoms prior to them starting work. Ideally, temperature checks should happen before the individual enters the facility.
  • Regular monitoring: As long as the worker is asymptomatic (no temperature or symptoms), the worker should self-monitor under the supervision of the employer’s occupational health program.
  • Wear a mask: The worker should wear a face mask at all times while in the workplace for 14 days after last exposure. Employers can issue face masks or can approve worker’s supplied cloth face coverings in the event of shortages.
  • Social distance: The worker should maintain a six-foot distance from others (social distancing) as work duties permit in the workplace.
  • Disinfect and clean work spaces: The employer should ensure that shared common areas (offices, bathrooms, break rooms) and electronic equipment are cleaned and disinfected regularly.

Generally under OSHA’s recordkeeping requirements, COVID-19 is a recordable illness, and employers are responsible for recording cases of COVID-19 if the case is confirmed, and the case is work-related. However, in a guidance memo issued on April 10, 2020, OSHA advised that in areas where there is ongoing community transmission of COVID-19, it will not require other employers (other than health care, emergency response, and corrections) to make the same work-relatedness determinations unless there is objective evidence that a COVID-19 case may be work-related. This evidence could include a cluster of COVID-19 cases without an alternate explanation that develop among workers in close proximity or who share common areas, or could include information given to the employer by employees or in the ordinary course of managing its business and employees. This loosening is because employers, other than those in health care, emergency response, and corrections may have difficulties determining whether a worker contracted COVID-19 at work. This guidance is limited to the current public health crisis.

For more information, contact:

  • Division of Public Affairs, Centers for Disease Control & Prevention, 1600 Clifton Road, Atlanta, Georgia 30329-4027; 404-639-3286; Fax: 404-639-7394; Email:; Website:
  • Elizabeth Grossman, Director of the Office of Statistical Analysis, Occupational Safety and Health Administration, Department of Labor, 200 Constitution Avenue Northwest, Washington, District of Columbia 20210; 202-693-2225; Website:

On April 3, 2020, California launched Project Roomkey, an initiative to use hotel and motel rooms to isolate homeless individuals deemed extremely vulnerable to COVID-19 in an effort to limit the spread of the disease. Additionally, the state has also contracted with Chef José Andrés’s World Central Kitchen to provide three meals a day to select Project Roomkey hotels through a statewide contract to support local efforts as needed. The goals of Project Roomkey are to protect public health by isolating the medically vulnerable, reducing the shelter population for social distancing, slowing the rate of spread of COVID-19 and, in turn, flattening the curve.

The state secured approval from the Federal Emergency Management Agency (FEMA) for a 75% federal cost share for the rooms, and wraparound supports such as meals, security, and custodial services. Counties will pay the remaining 25% of the cost, as well as cover the cost of case managers and counselors. The state has distributed $150 million to counties to help pay for the rooms and other homelessness services.

Project Roomkey isolation units are intended for the following populations experiencing homelessness:

  • Individuals who are asymptomatic, but at high risk, such as people over 65 or who have certain underlying health conditions. The goal is to move them into motel or hotel units where they can more safely self-isolate and avoid exposure to COVID-19.
  • Individuals who have been exposed to COVID-19 or are COVID-19 positive (as documented by a state or local public health official, or medical health professional) who do not require hospitalization, but need isolation or quarantine to avoid further spread of COVID-19 in congregate shelter settings or homeless encampments.

The initiative targets hotels in counties with significant homeless populations that are also experiencing high concentrations of COVID-19 transmission. The state seeks to secure up to 15,000 rooms for this purpose. Some of the leases being negotiated include an option for the state or county to purchase the entire hotel/motel property to provide for permanent homeless housing. However, no information has been released about the status of these negotiations.

Local governments to date have secured 6,867 hotel and motel rooms for Project Roomkey. However, state and local health officials have not released a comprehensive list of participating hotels/motels. The local governments are responsible for identifying which shelter clients or encampment residents are selected for these hotel isolation placements and transporting them to the hotels for intake. The counties can contract with a provider organization to manage the isolation placements. As of early April, counties had moved 869 homeless individuals off the street and/or out of shelters into isolation. Essential behavioral health and health care services are being provided by the local governments and community partners, as needed.

For more information, contact: 

  • California Governor Gavin Newsom, 1303 10th Street, Suite 1173, Sacramento, California 95814; 916-445-2841; Fax: 916-558-3160; Website:

The President’s 2021 budget proposal for the Department of Health and Human Services (HHS) includes five provisions intended to expand behavioral health services. However, overall, the HHS budget request of $94.5 billion is about 10% lower than the 2020 enacted level of funding. The HHS budget proposes $1.6 trillion in net mandatory health savings and reducing longer-term deficits by eliminating wasteful spending.

The federal budget proposal was released on February 10, 2020, as “A Budget For America’s Future, Fiscal Year 2021.” A fact sheet about the budget highlighted the following provisions affecting behavioral health:

  • Combat the opioid epidemic. The budget allocates $5 billion to fund research, surveillance, prevention, treatment, access to overdose reversal drugs, and recovery support services. This funding includes $1.6 billion, an $85 million increase from the 2020 enacted level, for State Opioid Response grants, which support prevention, treatment, and recovery support services. States are also given flexibility to use these funds to address emerging drug issues, such as the increasing number of overdoses related to psychostimulants, including methamphetamines.
  • Fund Certified Community Behavioral Health Clinics (CCBHC) expansion grants. The budget includes $225 million for the CCBHC expansion grants and extends, through 2021, the CCBHC Medicaid demonstration programs to improve community mental health services for the eight states currently in the demonstration.
  • Fund mental health prevention and screening. The budget allocates $125 million to help schools, community organizations, first responders, and other entities identify mental health issues and help affected youth and other individuals get the needed treatment.
  • Fund primary health care services for homeless individuals. The budget allocates $25 million to expand primary care services for homeless individuals in cities with high rates of homelessness.
  • Modify the Medicaid funding exclusion on Institutions of Mental Disease (IMDs) to allow states flexibility to use IMDs to provide inpatient mental health services to Medicaid beneficiaries with serious mental illness (SMI) as part of a comprehensive strategy that includes improvements to community-based treatment. In 2018, 47.6 million adults had a mental illness, of whom 11.3 million had SMI, meaning their mental illness substantially interfered with or limited major life activities.

The fact sheet and a summary of the major savings and reforms called out additional proposals affecting the health and social service field. They address Medicare, Medicaid, rural health access, public health, and child welfare.


  • Eliminate wasteful Medicare spending, and incentivize quality and efficiency. The budget proposes to align payments for the four main post-acute care settings (skilled nursing facilities; home health provider organizations; inpatient rehabilitation facilities; and long-term care hospitals) and transition to site-neutral payments over five years (with certain exceptions for long-term care hospitals). Currently each setting uses a different prospective payment system. It revives a proposal to pay physicians the same fee whether services are provided by a hospital outpatient facility or a private practice.
  • Reform uncompensated care payments by removing the payment from the Medicare payment system, moderating the rate of growth of spending, and establishing a new process to distribute uncompensated care amounts to hospitals based on their share of charity care and non-Medicare bad debt.
  • Implement bipartisan drug pricing proposals. The budget supports legislative efforts to improve the Medicare Part D benefit by establishing an out-of-pocket maximum, improving incentives to contain costs, and reducing out-of-pocket expenses for seniors. It also calls on Congress to pass legislation to reduce the prices paid for prescription drugs. The administration also supports changes to Medicare Part D to reduce the cost of generic and biosimilar drugs. The budget proposal calls for spending $130 billion less for Medicare prescription drugs.
  • Allow people age 65 or older to opt out of Medicare entirely. Additionally, Medicare beneficiaries enrolled in a high-deductible health plan would be allowed to accumulate more tax-free savings for health expenses.


  • Improve consistency between work requirements in federally funded public assistance programs, such as Medicaid and Temporary Assistance for Needy Families (TANF). All able-bodied, working-age individuals, aged 18 to 65 years old and with or without children in the home, would be required to find employment or participate in individualized work activities for a minimum of 20 hours per week, in order to receive welfare and Medicaid benefits, unless they fall into an exempt category or have an individual or geographic hardship.
  • Create a permanent Money Follows the Person option, giving states flexibility to provide additional transitional services to promote care in the community. States with high rates of institutionalization would receive time-limited enhanced funding to support necessary structural changes.
  • Allow states to consider savings and other assets in determining Medicaid eligibility. The goal is to focus Medicaid spending on individuals who lack significant assets.

Rural health

  • Expand access to telemedicine services by offering increased flexibility to provider organizations who serve predominantly rural or vulnerable populations, including Indian Health Service (IHS) provider organizations and those participating in Medicare payment models requiring financial risk.
  • Modify payments to Rural Health Clinics to ensure that Medicare beneficiaries continue to benefit from primary care services in their communities.
  • To address the trend of rural hospital closures, the budget proposes to allow critical access hospitals to voluntarily convert to rural standalone emergency hospitals and remove the requirement to maintain inpatient beds.
  • Maintain funding for Rural Health Outreach grants in the Health Resources Services and Administration (HRSA).

Public health

  • Fund the initiative to end the HIV epidemic. The budget allocates $716 million for the initiative’s second year. The avocation includes $371 million for the Centers for Disease Control (CDC) and $302 million for Health Resources and Services Administration (HRSA) to deliver HIV care through the Ryan White HIV/AIDS Program and to supply testing, evaluation, prescription of PrEP, and associated medical costs through the Health Centers program; $27 million to the Indian Health Service (IHS) to tackle the epidemic in American Indian and Alaska Native communities; and $16 million for the National Institutes of Health (NIH) for evaluation activities to identify effective interventions to treat and prevent HIV.
  • Fund initiatives to improve maternal health. The budget allocates $74 million in new resources to reach the following goals: achieve healthy outcomes for women of reproductive age by improving prevention and treatment; prioritizing quality improvement for prenatal care and birth services; optimize postpartum health; and improve data and support research.

Other social services

  • Reduce the TANF block grant by 10%, and eliminate the TANF Contingency Fund, as it fails to provide well-targeted counter-cyclical funding to states. Add a requirement that states spent at least 30% of all TANF funds on activities that directly promote work. All TANF spending would be limited to families with income below 200% of the federal poverty line (FPL). All work-eligible individuals receiving TANF cash assistance would be expected to participate in individualized work activities a minimum of 20 hours per week, unless they fall into an exempt category or have individual or geographic hardship. New proposals require that TANF expenditures be directly related to achieving TANF’s purposes and by phasing out the ability for states to use TANF funds for, “activities authorized solely under prior law,” an outdated expenditure category; states would be accountable for achieving employment outcomes to incentivize cooperation and service integration between TANF and programs through the Workforce Innovation and Opportunity Act to promote work. All states
  • Eliminate funding for the Social Services Block Grant (SSBG). The budget notes that the administration believes that the SSBG lacks strong performance measures, is not well targeted, and is not a core function of the federal government. It funds services that are also funded through other federal programs, such as early childhood education.

For more information, contact:

  • The White House, 1600 Pennsylvania Avenue Northwest, Washington, District of Columbia 20500; 202-456-1414; Website:

On March 6, 2020, the Oklahoma Health Care Authority (OHCA) announced it had submitted a Medicaid state plan amendment to expand eligibility to the new adult group ages 19 to 64 with incomes at or below 133% of the federal poverty level. The requested effective date is July 1, 2020, contingent upon approval by the Centers for Medicare & Medicaid Services (CMS). The state is also developing plans for SoonerCare 2.0, (Oklahoma’s Medicaid program) which is based on implementing the new Medicaid Healthy Adult Opportunity waiver in a five-year demonstration, no sooner than July 1, 2021. OHCA estimates that 220,000 people will be eligible, and that 81% will ultimately enroll. The cost of the expansion is estimated at $1.24 billion annually. Currently, Oklahoma’s SoonerCare Choice programs offer managed care delivery of enhanced primary care case management.

On March 17, 2020, OHCA released a draft copy of the SoonerCare 2.0 Healthy Adult Opportunity Section 1115 Demonstration Application, and following a series of public virtual meetings, anticipates submitting the application in mid-April 2020. OHCA intends to implement outcome and value-based care coordination strategies for SoonerCare 2.0, introduce “private insurance concepts,” and include community engagement requirements. The plans will integrate physical and behavioral health services. Through its outcome-based payment model, OHCA anticipates improving member health outcomes, and focusing on quality improvement in specific population health goals. OHCA also anticipates that it will provide better care coordination by using modern technology and methods by building upon its successful Patient Centered Medical Home model. Everyone who meets the income guidelines of SoonerCare 2.0 is eligible for enrollment. The key provisions in the SoonerCare 2.0 plan are as follows:

Introduce private insurance concepts in a managed care plan design, such as premiums and commercial-like benefit packages to prepare members to move off Medicaid and into private coverage.

  • The amount of the premium will be linked to household income. Failure to pay the premium for three consecutive months will trigger an OHCA review to determine if the individual qualifies under another Medicaid eligibility category. If not, the member’s enrollment will be terminated. Anyone who is disenrolled due to non-payment will be permitted to reapply for coverage at any time. They will not be required to pay the unpaid premiums.
  • Some SoonerCare 2.0 members (those with HIV/AIDS, SUD, or SMI) will be exempt from premium payments, regardless of their household income. They will, however, be responsible for paying copayments for their services, as described in the state plan.
  • Two optional Medicaid benefits will be eliminated: non-emergency medical transportation (for most individuals), and Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefits for members aged 19 to 21. Members who have a demonstrated need for non-emergency medical transportation in accordance with their care coordination assessment and care plan will have access to the service on a case-by-case basis.
  • Eliminate retroactive coverage and hospital presumptive eligibility.
  • Implement an $8 copayment for non-emergency use of the emergency department to encourage appropriate use of urgent care and primary care providers.

Implement community engagement requirements.

  • Require individuals ages 19 through 60 to participate in paid or unpaid community engagement activities for at least 80 hours per month. Eligible activities include work, volunteering, and educational activities.
  • Adults ages 61 through 64; pregnant women; a parent or caretaker of a child under the age of six or of an incapacitated person; those participating in a substance use disorder rehabilitation program; individuals with a serious mental illness who are actively participating in behavioral health treatment; those unable to work because of a disability; and members of an American Indian/Alaska Native federally recognized tribe will be exempt from this requirement. Other exceptions are also outlined in the HAO application, as well as good cause exceptions.
  • Individuals recently released from jail or prison incarceration within six months prior to their application date will have a nine-month grace period to start reporting their community engagement activities.
  • The reporting requirement will be phased in during the first year with quarterly increases rising from no hours for the first quarter, 10 for the second, 15 for the third, 20 for the fourth, and 80 hours for each subsequent quarter.
  • Non-exempt SoonerCare 2.0 members who fail to comply with the reporting requirement will have eligibility terminated effective the first day of the month following the month in which the state determined the member was non-compliant with the number of community engagement hours required.

OHCA anticipates that the service delivery model will encourage members to increase use of preventive, primary, urgent, and specialty care, and decrease their reliance on emergency departments for services that could be better provided in less resource intensive care settings. Because OHCA will implement care coordination strategies for the SoonerCare 2.0 population, the state anticipates that members will have more timely access to care and a better consumer experience.

For more information, contact:

  • Katelynn Burns, Senior Public Information Representative, Oklahoma Health Care Authority, 4345 North Lincoln Boulevard, Oklahoma City, Oklahoma 73105; 405-443-9415; Email:; Website:

The federal Department of Justice (DOJ) concluded Maine’s system of services for people with intellectual/developmental disability (I/DD) violates the Americans with Disabilities Act (ADA) because it limits access to home- and community-based services (HCBS) under its Section 21 waiver. On February 10, 2020, the DOJ responded to a complaint filed in May 2018 by a Maine resident with I/DD. The DOJ concluded that Maine failed to provide necessary services in the most integrated setting appropriate to the individual’s needs. The Maine Department of Health and Human Services (DHHS) is determining how to respond.

The DOJ advised DHHS to promptly remedy the situation and prevent ADA civil right violations of people receiving Section 21 services by taking the following steps:

  1. Modify the Section 21 waiver’s 84-hour cap on Home Care Quarter Hour services by establishing and implementing a process for individuals to obtain an exception to the cap, such that individuals can receive Section 21 waiver services in the most integrated setting appropriate to their needs unless the provision of such services would constitute a fundamental alteration.
  2. Modify the Section 21 waiver’s service planning process to ensure that the services a member receives, and the setting(s) in which they are received, are determined by the member’s individual needs and preferences, rather than by provider organization preference.
  3. Inform individuals currently receiving, or who may be eligible to receive, Section 21 waiver services, including individuals currently receiving services in agency placements, those receiving Quarter Hour services, and those receiving Medicaid services in intermediate care facilities (ICFs) who may be eligible for Section 21 waiver services, about the exceptions process and providing personal planning that is sufficiently focused on the member’s individual needs and preferences.
  4. Inform state employees, agents, and contractors, including case managers, as well as others, including provider organizations, who serve on personal planning teams, and employees implementing the exceptions process, about the modifications implemented, including the exceptions process, how to apply for an exception under the process, and how the exceptions and personal planning processes should operate to ensure that individuals can receive services in the most integrated setting appropriate to their needs.
  5. Ensure that the state has sufficient provider capacity to fulfill the individual’s authorized Section 21 waiver service hours.
  6. Pay compensatory damages to the individual for injuries caused by the state’s actions.
  7. Provide the DOJ with written status reports delineating all steps taken to comply with these requirements, including the date(s) on which each step was taken, and, where applicable, information sufficient to demonstrate compliance.

Maine’s Medicaid Section 21 waiver provides comprehensive services for people with I/DD and autism who live in their own homes or in another home in the community, but not necessarily with their families. The available services include assistive communication assessment/technology, career planning, community support, counseling, crisis assessment and intervention services, employment specialist services, home accessibility upgrades, in-home support, medical equipment and supplies, therapy (occupational, physical, or speech), residential services, respite, shared living services, transportation, and work support.

The individual at the center of the DOJ complaint is an adult with several disabilities who lives with his parents. Since 2009 he has received Section 21 waiver home support services, which include personal assistance with activities of daily living and instrumental activities of daily living. In 2014, the state capped the individual’s service hours at 84 per week, citing the state’s cap on services Section 21 waiver recipients can receive while living in their own (or family) homes. The family challenged the denial. The state contested the challenge but acknowledged that the individual needed 168 hours of services per week. The DOJ noted that the state’s failure to provide needed in-home services resulted from the state’s service planning process, which determined his placement/services based on provider organization preference, rather than identifying the most integrated setting appropriate.

In February 2017, the administrative challenge was concluded, and the state cut the individual’s service hours to 84 per week. However, in March 2019, the state granted an exception to the cap during the DOJ investigation. The exception permitted the individual to receive 168 hours per week of home support services in his home; however, the 84-hour cap otherwise remained in force. Further the state failed to ensure that the licensed service provider organization actually fulfills the authorized hours, and the state failed to identify additional provider organizations to fill the gaps. Despite the exception, the individual continues to receive about 84 hours per week of in-home services.

As a result, the individual is at risk of being institutionalized to receive the needed services. The only alternative placements he has been offered are an ICF or a in a multi-person group home. An ICF is considered an institutional setting. If the individual lived in an ICF or a group home, he would not have access to the community at the same level as living at home with adequate services.

A link to the full text of “The United States’ Findings & Conclusions Based On Its Investigation Of The State Of Maine Under Title II Of The Americans With Disabilities Act” may be found at

For more information, contact:

  • Jackie Farwell, Communications Director, Maine Department of Health and Human Services, 109 Capitol Street, 11 State House Station, Augusta, Maine 04333; 207-446-3319; Email:; Website:

Community reentry following incarceration is more likely to be successful if the reentry interventions address dynamic factors that affect the overall success of reentries, according to a study by The Harvard University Institute of Politics. These dynamic factors include health, employment, housing, skill development, mentorship, and social networks.


Community-based organizations should prioritize providing reentering citizens with quality health care that properly addresses any mental and physical health conditions and addiction. This is especially important for female reentering citizens, who often have greater health-related needs than the general reentering population. The researchers recommend that organizations should specifically target services to women, especially in the form of trauma and counseling services.


Community-based programs are most effective when they provide training and placement services to returning citizens, using a holistic approach focused on both training and job placement. The success of these services also depends largely on the job opportunities available in the neighborhoods into which their clients are reentering. The researchers recommend that community organizations should partner with prisons to better advise incarcerated individuals on which neighborhoods to return to.


Community-based organizations that offer transitional housing, with the end goal of eventually securing an independent living situation, are effective at improving outcomes. Those programs that also provide housing in combination with other services (such as employment services, health services, and socio-emotional development) are also successful at improving outcomes. The researchers recommend that organizations and programs focus on communities with the highest risk of homelessness, namely women, Black and Hispanic individuals, and the elderly. For women, additional concern may be needed when children are involved in the reentry.

Skill Development

Assistance with both education and interpersonal skills (such as anger management, time
management, goal setting, and parenting) should be provided to those reentering the community. For education, the researchers recommend that community-based organizations should provide a variety of educational programs (such as employment training programs, college enrollment assistance and referrals, GED preparation, testing referrals, and vocational training), and these programs should be tailored to the unique education needs of different age demographics. For interpersonal skills, programs should target the skills listed above, target antisocial peer relationships, and offer appropriate cognitive behavioral programs.


The researchers recommend that community-based organizations that offer reentry services should also prioritize mentorship programs which match reentering citizens with mentors who share similar backgrounds. These matches could be based on gender, racial and ethnic identities, and age-related priorities.

Social Networks

The researchers also recommend programs that emphasize the role of family connection and cohesiveness, especially for young reentering individuals. Reentry programs should specifically address such needs through services that support building stronger familial ties and provide therapy, mentorship, life skills training, domestic violence education, and safe homes. They also recommend that programs subsidize or cover travel and communication costs to connect with family members when necessary.

These recommendations were presented in “Successful Reentry: A Community-Level Analysis” by researchers affiliated with the Harvard University Institute of Politics Criminal Justice Policy Group. The report focuses on how various factors significantly affect successful reentry and how existing community-based organizations tailor interventions to address those factors. The report also provides recommendations for the best practices community-based reentry programs can follow. The researchers analyzed a number of reentry case studies, social theory papers, and programs across the United States. The goal was to determine the ideal circumstances for successful outcomes for those exiting jails and prisons, and acclimating to community life.

The full text of “Successful Reentry: A Community-Level Analysis” was published in December 2019 by The Harvard University Institute of Politics’ Criminal Justice Policy Group. A copy is available online at

For more information, contact: 

  • Institute of Politics, Harvard University, 79 John F. Kennedy Street, Cambridge, Massachusetts 02138; 617-495-1360; Fax: 617-496-4344; Email:; Website:

On February 27, 2020, BlueCross BlueShield of Western New York (BCBSWNY) announced that it entered into a value-based reimbursement (VBR) arrangement with Value Network, LLC, IPA, a network of behavioral health provider organizations in Western New York. The contract includes an upside-risk agreement. Thomas Schenk, M.D., senior vice president and chief medical officer at BCBSWNY, said it is the organization’s “first payment model designed to directly enhance quality care for our members with mental health and/or substance use disorder diagnoses.”

The VBR arrangement with Value Network is based on the BCBSWNY “Best Practice” model, a consumer-centered, population-based care model that reimburses provider organizations based on the full scope of care management. The model uses a per member per month capitated payment along with some fee-for-service payments, specifically in preventive care. The capitation payments are based on historical claims and nontraditional consumer engagement methods such as telehealth. Provider organizations who serve consumers that require more complex care receive additional compensation. Value Network is eligible for bonus payments based on quality outcomes performance. A BCBSWNY spokesperson said the quality targets and metrics for the agreement are based on industry benchmarks around behavioral health care.

Value Network was formed in June 2017, and achieved state approval to become an Independent Practice Association (IPA) in January 2018. It is a collaborative of 23 provider organizations licensed through the New York State Office of Mental Health or New York State Office of Addiction Services and Supports, as well as designated home- and community-based service provider organizations. The network was founded by Howard Hitzel, chief executive officer (CEO) of BestSelf Behavioral Health; Anne Constantino, CEO of Horizon Health; Bruce Nisbet, CEO of Spectrum Health and Human Services; and Elizabeth Mauro, CEO at Endeavor Health Services.

The network has 65 other partners, including hospitals, primary care partners, prevention agencies, care coordination entities, and other organizations. Andrea J. Wanat, vice president of operations for Value Network, said the arrangement aligns with its mission to “design and implement a health service delivery system that improves the quality, cost effectiveness, and overall experience of care in Western New York.” Value Network serves about 70,000 people annually.

For more information, contact:

  • Amber M. Hartmann, Public Relations Manager, Marketing and Communications, BlueCross BlueShield of Western New York, 257 West Genesee Street, Buffalo, New York 14202; 716-887-8962; Fax: 716-887-7911; Email:; Website:
  • Bruce Nisbet, Value Network Co-founder, and President and Chief Executive Officer, Spectrum Health and Human Services, 2040 Seneca Street, Buffalo, New York 14210; 716-539-5329; Email:; Website:

As of September 2019, approximately 25% of provider organization revenue was via a value-based payment (VBP) arrangement; however the amount of revenue linked to VBP arrangements varied by organization type. For hospitals and health systems, VBP ranged from 11.7% to 37.9% of revenue. About 23.2% of physician groups’ revenue was via VBP arrangements.

Researchers found that the majority of provider organizations plan to enter into a VBP arrangement, or expand an existing one, in the next two years. About half of respondents expect VBP to become the primary revenue model by 2025. Better incentives and mandatory participation are the top factors that will drive higher participation and investment in VBP models.

Additional findings, as of September 2019, include:

  1. About 19% of respondents thought that VBP quality has improved significantly, while about 50% thought quality has improved moderately.
  2. About 2% of respondents thought that VBP financials have improved significantly, and about 43% thought that financials improved moderately.
  3. About 62% of respondents participate in an accountable care organization.
  4. About 51% of respondents participate in Medicare episode-specific bundled payment models.
  5. About 35% of respondents participate in a patient-centered medical home (PCMH).
  6. About 29% of respondents receive a capitated rate.

These findings were reported in “Market Report: The Next Leap In Value-Based Care” by researchers with Sage Growth Partners for DataGen. In September 2019, Sage Growth Partners surveyed 102 executives of hospitals, health systems, and physician groups located in 38 states about their views of VBP. The goal was to gain insight on the future of VBP.

The full text of “Market Report: The Next Leap In Value-Based Care” was published March 10, 2020, by DataGen. A copy is available online at

For more information, contact: 

  • Vanessa Ulrich, Contact point for DataGen, DataGen, One Empire Drive, Rensselaer, New York 12144; 410-534-1161; Email:; Website:

The Kentucky Medicaid program is rebidding its managed care organization (MCO) contracts to have them in place for a January 1, 2021 start date. The contracts will run through December 31, 2024, followed by six additional two-year periods. The request for proposals (RFP 2000000202) was released on January 10, 2020, and proposals were due by February 7, 2020. The plans are at-risk for all Medicaid physical health, behavioral health, and pharmacy services.

The state’s current Medicaid managed care contracts are with Anthem, Aetna Better Health of Kentucky (formerly Coventry Cares), Humana, Passport Health Plan, and WellCare. The contracts are set to expire on June 30, 2020, but the state intends to extend them until the new contracts go live. About 1.3 million beneficiaries are enrolled in one of the Medicaid managed care plans.

On December 23, 2019, Kentucky’s new Governor Andy Beshear canceled the state’s award of five Medicaid managed care contracts, valued at approximately $8 billion. The contracts had been awarded on November 26, 2019, by outgoing Governor Matt Bevin, to five Medicaid MCOs: Aetna Better Health of Kentucky; Humana Health Plan, Inc.; Molina Healthcare of Kentucky; UnitedHealthcare, dba, UnitedHealthcare Community Plan of Kentucky; and WellCare Health Insurance of Kentucky.

However, on December 7, the last day of Governor Bevin’s tenure, members of the State’s Government Contract Review Committee unanimously voted to reject the new contracts. According to Governor Beshear, the contracts were canceled due to concerns about how the award process was handled. Both Anthem and Passport Health Plan filed protests over the November awards. Governor Beshear also ended community engagement provisions of the Kentucky HEALTH 1115 Medicaid waiver that required beneficiaries to meet certain work or volunteer requirements to maintain health care coverage. The previous contracts had included provisions relevant to the now-vacated community engagement requirements.

PsychU last reported on this topic in “Kentucky Announces Cancellation Of Medicaid Managed Care Contracts; To Be Rebid In January,” which published on February 10, 2020. The article is available at

For more information, contact:

  • Office of Public Affairs, Kentucky Cabinet for Health and Family Services, 275 East Main Street, Frankfort, Kentucky 40621; 502-564-7042; Website:
  • Amy Monroe, Director, Division of Goods & Services Procurement, Kentucky Finance and Administration Cabinet, Office of Procurement Services 702, Capitol Annex, Room 096, Frankfort, Kentucky 40601; 502-564-8624; Fax: 502-564-6013; Email:; Website:

According to the U.S. Government Accountability Office (GAO), the Department of Veterans Affairs (VA) spending on long-term care services rose by 33%, from $6.8 in 2014 to $9.1 billion in 2018. During this period, the number of veterans using VA long-term care services rose by 14%, from 464,071 in 2014, to 530,327 veterans in 2018. Veteran eligibility for long-term care is primarily based on the extent of a service-connected disability. The VA projects that demand will continue to increase and that spending will double from about $6.9 billion in 2017, to about $14.3 billion by 2037.

VA-provided care ranges from assistance with daily activities of living, to clinical care for spinal injuries or dementia. The VA’s Geriatrics and Extended Care office (GEC) provides, or pays for, long-term care through three institutional programs, and 11 noninstitutional programs. Institutional programs typically provide more acute skilled nursing care in a residential facility. Noninstitutional programs provide care to veterans in their homes or communities. All veterans enrolled in the VA health care system are eligible for the VA’s basic medical benefits package, which includes certain institutional and noninstitutional long-term care services.

Additional findings include:

  • In fiscal years 2014 through 2018, the average daily census increased for two of VA’s three institutional programs: Community nursing homes increased by 26% (from 7,771 to 9,808); and state veterans homes increased by 1% (from 23,176 to 23,423).
  • In fiscal years 2014 through 2018, five of the 11 noninstitutional programs experienced increases in their workload over this period, ranging from 8% to 48%.
  • In fiscal years 2014 through 2018, institutional program obligations declined as a proportion of total obligations, from 74% to 67%, while the proportion of noninstitutional program obligations rose from 26% to 33%.

The GAO concluded that the VA must improve plans for providing long-term care to aging veterans. VA identified that there is not yet a consistent approach to managing the 14 long-term care programs; VA also identified an inconsistent approach in determining the amount of noninstitutional services veterans need, and has developed but not yet implemented a tool for VA medical centers to use to improve that consistency.

VA currently faces three key challenges meeting the growing demand for veteran long-term care: workforce shortages, geographic alignment of care (particularly for veterans in rural areas), and difficulty meeting veterans’ needs for specialty care. Therefore, VA must also develop measurable goals for addressing these challenges in meeting the demand for long-term care.

The GAO also recommended three executive actions to the Secretary of VA. These include:

  • Direct GEC leadership to develop measurable goals in effort to address the three key long-term care challenges listed previously.
  • Direct GEC leadership to set implementation time frames, and successfully implement a consistent GEC structure at VA Medical Centers.
  • Direct GEC leadership to set time frames for, and implement a VAMC-wide standardization of the tool for assessing the noninstitutional program needs of veterans.

These findings were reported in “VA Health Care: Veterans’ Use of Long-Term Care Is Increasing, and VA Faces Challenges in Meeting the Demand,” by the GAO. Researchers for the GAO analyzed VA data and documents on the long-term care programs that are overseen by VA’s GEC for fiscal years 2014 through 2018. VA also conducted interviews with VA officials about the programs. The goal was to describe the use of and spending for VA long-term care.

A link to the full text of “VA HEALTH CARE: Veterans’ Use Of Long-Term Care Is Increasing & VA Faces Challenges In Meeting the Demand” may be found at

For more information, contact:

  • Chuck Young, Managing Director, Public Affairs, U.S. Government Accountability Office, 441 G Street Northwest, Room 7149, Washington, District of Columbia 20548; 202-512-4800; Email:; Website:

From 2013 to 2016, private equity firms acquired 355 physician practices. This breaks down to 59 practices in 2013, 72 practices in 2014, 88 practices in 2015, and 136 practices in 2016. These acquisitions included 1,426 sites and 5,714 physicians. There are approximately 18,000 unique group medical practices in the U.S. Each practice has one or more sites.

Additional findings include:

  • The most commonly acquired medical groups were anesthesiology (19.4%), multispecialty (19.4%), emergency medicine (12.1%), family practice (11.0%), and dermatology (9.9%).
  • Within the acquired practices, anesthesiologists represented about 33.1% of all physicians; emergency medicine specialists represented 15.8%; family practitioners represented 9.0%, and dermatologists represented 5.8%.

The researchers concluded the results of their analysis support equity firms’ typical investment strategy of acquiring “platform” practices. These practices have large community footprints (with several sites and many physicians). Equity firms then increase the value of the acquisitions by recruiting additional physicians, acquiring smaller groups, and expanding market reach. They suggest further research to understand the effect of acquisitions by equity firms, and to mitigate unintended consequences of these acquisitions.

These findings were reported in “Private Equity Acquisitions of Physician Medical Groups Across Specialties, 2013-2016” by Jane M. Zhu, M.D., MPP, MSHP; Lynn M. Hua, BA; and Daniel Polsky, Ph.D., MPP. The researchers identified acquisitions by private equity firms through the Irving Levin Associates Health Care M&A data set, then lined those acquisitions to the SK&A data set, a commercial data set of verified physician- and practice-level characteristics for U.S. office-based practices. The goal was to report on acquisitions by private equity firms.

The full text of “Private Equity Acquisitions of Physician Medical Groups Across Specialties, 2013-2016” was published February 18, 2020 by JAMA Network. An abstract is available online at

For more information, contact:

  • Jane M. Zhu, M.D., MPP, MSHP, Assistant Professor, Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Portland, Oregon, 97239; Email:; Website:

The city of Denver’s new strategic framework for improving behavioral health calls for a greater use of data to guide policy to ensure that communities promote well-being, broadly improve access to care, provide early crisis services, and provide integrated and coordinated care. The goal is to improve existing services, systems, and responses to ensure they provide consistent and comprehensive care.

The framework recommends building on the Colorado Health Observation Regional Data Service (CHORDS), a regional partnership among the metro-Denver area public health departments that uses electronic health record data to aggregate medical and behavioral health data from provider organizations. CHORDS uses the data to support public health evaluation and monitoring efforts. To further leverage data to guide behavioral health policy, the framework recommends the following:

  • Develop data collection mechanisms for behavioral health status at the population level, including positive outcomes, as well as data by race, ethnicity, and gender and for people across the lifespan, new parents, immigrants and refugees, and individuals with intellectual/developmental disabilities (I/DD).
  • Develop an official data set for Denver that captures available addiction treatment services and the demand for those services.
  • Improve care coordination by implementing a data-sharing system among providers of mental health care, physical health care, jails, and social services.
  • Enact data sharing agreements that allow multiple stakeholders, including hospitals, medical professionals, and first responders, to enable secure and timely treatment.
  • Increase family and consumer support and education for understanding health data sharing, privacy, and release of information forms.

To improve access to services, the recommendations were as follows:

  • Create a platform for Denver residents to find and access support services based on unique circumstances. Build upon existing tools such as 211 and Colorado Crisis Services.
  • Train community members (e.g., schools, religious groups, workplaces) to recognize behavioral issues in themselves and others and how to engage appropriately.
  • Collaborate with employer groups to implement workforce supports and training.
  • Expand access to supportive services such as housing assistance, food, and transportation.
  • Identify and develop care navigation and coordination plans that address the needs of specific populations.
  • Increase funding opportunities for behavioral health services and other support services to share spaces.

To increase access to integrated, coordinated care, the recommendations were as follows:

  • Expand and support Denver’s behavioral health workforce through multiple strategies, including retain existing clinical professionals; train clinical professionals to offer trauma-informed services that meet the cultural and linguistic needs of different groups; identify pathways to hire individuals with lived experience with mental health and addiction; and boost access to effective supervision models and resiliency and peer support training.
  • Develop a center to provide 24/7 care for people with behavioral health conditions, including access to treatment, social support services, legal services, and transportation.
  • Provide an accessible continuum of addiction treatment that stretches from prevention to treatment to community-based recovery.
  • Align with efforts underway through the Denver Opioid Response Strategic Plan to increase access to harm reduction services and treatment on demand.
  • Eliminate systems-level barriers to providing comprehensive care, such as reimbursement and payment structures that prioritize treating one health issue instead of the whole person, and lack of training in treating addiction and mental health issues together.
  • Promote broad adoption and use of standardized screening and processes for mental health and addiction by all health care facilities in Denver, including primary care, school-based clinics, and emergency departments.
  • Identify and fund supportive, creative strategies that build trust and strengthen relationships between city residents and service provider organizations.

To ensure that crisis behavioral health services are provided early and in appropriate settings, the recommendations were as follows:

  • Establish a first response mechanism that is distinct from law enforcement, fire, and emergency medical professionals to connect people experiencing behavioral health crises with behavioral health provider organizations directly.
  • Support legislation to allow for diversion of people in crisis to appropriate treatment and care rather than sending them to jail or the emergency room.
  • Invest in and adopt alternative crisis response models.
  • Increase the availability and integration of peer support services.
  • Expand training in trauma-informed care for law enforcement, people who work in the criminal justice system, first responders, and others who make up Denver’s behavioral health crisis response system.

The recommendations were issued in “Road To Wellness: A Strategic Framework to Improve Behavioral Health in Denver.” The goal is to provide a roadmap for stakeholders in the behavioral health community to help navigate towards shared objectives around building a healthy community. The city began developing the plan in October 2018 when the mayor convened a steering committee. The committee was charged with scanning the current state of behavioral health services in Denver, identifying gaps, examining best practices, and providing recommendations. During the process, more than 100 individuals and 50 organizations participated to provide input.

A link to the full text of “Road To Wellness: A Strategic Framework to Improve Behavioral Health in Denver” at

For more information, contact:

  • Theresa Marchetta, Director, Strategic Communications and Media Policy, City and County of Denver and the Denver Health and Hospital Authority, 1437 North Bannock Street, Room 350, Denver, Colorado 80202-5390; 720-865-9000; Email:; Website:

Out-of-network (OON) primary care is associated with higher median quarterly costs for Medicare beneficiaries attributed to a Medicare Shared Savings Plan (MSSP) accountable care organization (ACO). Median per-beneficiary spending for ACO beneficiaries was $401 per quarter between 2012 and 2015. Each percentage point increase in OON primary care spending was associated with a $10.97 increase in total quarterly spending per beneficiary. Additionally, each percentage point increase in OON primary care was associated with quarterly per-beneficiary increases in outpatient costs, skilled nursing facility costs, and emergency department costs. Changes in OON specialty care were not significantly associated with total spending or spending in any specific setting.

About 82% of specialist care for ACO beneficiaries takes place OON. Some ACOs have focused on reducing specialty care. However, the researchers said their findings suggest that ACO administrators may have overlooked the impact of OON primary care in their efforts to reduce OON specialty care.

These findings were reported in “Out-Of-Network Primary Care Is Associated With Higher Per Beneficiary Spending In Medicare ACOs,” by Sunny C. Lin, Phyllis L. Yan, Nicholas M. Moloci, Emily J. Lawton, Andrew M. Ryan, et al. The researchers analyzed national Medicare data between 2012 and 2015 from 1,604,809 unique beneficiaries. The goal was to determine the relationship between out-of-network care and spending.

The full text of “Out-Of-Network Primary Care Is Associated With Higher Per Beneficiary Spending In Medicare ACOs” was published in the February 2020 issue of Health Affairs. An abstract is available online at

For more information, contact:

  • John M. Hollingsworth, M.D., MS, Associate Professor of Urology, Management and Policy, School of Public Health, University of Michigan, 2800 Plymouth Road, Building 16, 1st Floor, Room 112W, Ann Arbor, Michigan 48109; 734-763-2797; Fax: 734-232-2400; Email:; Website:

To improve behavioral health in the United States, Well Being Trust recommends that policymakers adopt a new framework with five engagement points to increase the frequency of behavioral health assessments and better facilitate access to care. The framework includes recommendations to promote mental wellness, prevent and/or treat mental illness, and maintain mental wellness. The five engagement points are health systems, judicial systems, education systems, workplace and unemployment, and “the whole community.” In this framework, promotion and prevention are supported by seven community conditions that provide civic belonging, a thriving natural world, reliable transportation, lifelong learning, meaningful work and wealth, humane housing, and basic needs for health and safety. The framework identifies barriers to behavioral wellness including stigma, cost, social isolation, and problems accessing behavioral health services.

The framework recommends that the federal government take the following five actions:

  1. Ensure that hospital payment models and quality programs encourage a mental health assessment at every interaction, not only during wellness visits. This should include integrating screening and treatment into episode-based payment models for health conditions for which there are frequent mental health co-morbidities, such as cardiovascular diseases, cancers, and pulmonary diseases.
  2. Provide long-term funding for states to continue programs such as Money Follows the Person and the Balancing Incentive Program to ensure that people with intellectual/developmental disabilities (I/DD) and behavioral health conditions have consistent access to comprehensive, high-quality services and support outside of institutional settings.
  3. Increase incentives for individuals to join the mental health workforce and for training programs to actively recruit and effectively train diverse individuals to meet underserved needs and provide more culturally competent care.
  4. Create a seed fund that supports primary care provider organizations, especially Federally Qualified Health Centers and Rural Health Centers, in developing the necessary capacity to begin seeking sustainable reimbursement for integrated mental health care services.
  5. Create incentives in funding programs for municipalities that have created effective policies or strategies for ensuring access to affordable housing.

Additionally, the framework recommends that special considerations be given to focus populations, as follows:

  1. Create incentives for policy reforms that improve school culture and/or student mental health and provide additional financing for schools that implement effective strategies that reduce disparities in belonging and safety for students who identify as LGBTQ, including specialized services for suicide prevention.
  2. Make Medicaid coverage for women up to one-year postpartum a mandatory eligibility category for coverage and include measures of screening and effective coordination of care for maternal behavioral health in hospital incentive programs for care transitions and quality/safety.
  3. Ensure that the Indian Health Service and the Veteran’s Health Administration are engaged in the same reform efforts as the Centers for Medicare & Medicaid Services for mental health and increase funding to build capacity.
  4. Make it impermissible that any information related to the seeking of behavioral health treatment be used in any aspect of immigration enforcement and provide funding to disseminate this information to immigrants and for education about the availability of behavioral health services as part of immigration services.
  5. Allow Medicaid funds to reimburse for the education of housing authorities concerning the risks of housing insecurity and what resources are available to meet those needs.

These recommendations were issued in “Healing the Nation: Advancing Mental Health and Addiction Policy” by Well Being Trust. The framework focuses on multiple angles for engagement with a specific emphasis on five main entry points for policy. It also specifically highlights populations that have been impacted differently by current mental health and addiction treatment crises. In total, the report makes 50 recommendations.

Well Being Trust is a national foundation focused on advancing mental, social, and spiritual health. The organization was created to include participation from organizations across sectors and perspectives to innovate and address mental health challenges facing America, and to transform individual and community well-being.

The full text of “Healing the Nation: Advancing Mental Health and Addiction Policy” was published in January 2020 by Well Being Trust, available online at

For more information, contact:

  • Benjamin F. Miller, Psy.D., Chief Strategy Officer, Well Being Trust, 436 14thStreet, Suite 1120, Oakland, California 94612; Email:; Website:

On February 14, 2020, a federal circuit court in Washington, D.C., ruled that the federal Department of Health and Human Services (HHS) acted capriciously when it approved Medicaid waivers submitted by Arkansas and Kentucky to impose community engagement and work requirements as a condition of Medicaid eligibility. The Circuit Court upheld a District Court ruling that vacated HHS approval for the waivers.

The District Court for the District of Columbia had previously held that HHS had acted in an arbitrary and capricious manner because it failed to analyze whether the waiver demonstrations would promote Medicaid’s primary objective of furnishing medical assistance. Kentucky subsequently ended its demonstration project in late 2019. The Arkansas Works demonstration is ongoing, and requires beneficiaries to participate in at least 80 hours of work or community engagement activities monthly, and to report those hours in a timely manner. Failure to meet the threshold or to report for three continuous months results in loss of Medicaid eligibility for the rest of the year. During the first five months of Arkansas Works, about 25% of those subject to the work requirement lost coverage, representing more than 18,000 people.

The Circuit Court considered whether the HHS authorization of the Arkansas demonstration was legal, and agreed with the District Court that approval of the plan was arbitrary and capricious. The ruling noted that HHS prioritized a non-statutory objective to the exclusion of the statutory purpose of Medicaid. Because the HHS approval of the Arkansas waiver was deemed as such, the Circuit Court affirmed the district court judgment vacating HHS approval.

The Circuit Court noted that instead of analyzing whether the demonstrations would promote Medicaid’s primary objective of providing coverage for health care services, HHS identified the following three alternative objectives:

  1. Whether the demonstration as amended was likely to assist in improving health outcomes;
  2. Whether it would address behavioral and social factors that influence health outcomes; and
  3. Whether it would incentivize beneficiaries to engage in their own health care and achieve better health outcomes.

The opinion noted that while the three alternative objectives point to better health outcomes as the objective of Medicaid, the current Medicaid statutes do not mention that objective, and specifically address only coverage. Additionally, both Arkansas and HHS characterized the HHS approval letter as stating that transitioning beneficiaries away from governmental benefits through financial independence or commercial coverage as an objective promoted by the Arkansas Works demonstration. The Circuit Court said that argument misrepresents the HHS Secretary’s approval letter, which has a section for the determination that the project will assist in promoting the objectives of Medicaid. The letter cites the health outcome goals, but does not mention transitioning beneficiaries away from benefits. The letter has no reference to commercial coverage. The only reference to beneficiary financial independence is in a section summarizing public comments. The letter does not justify the approval based on a belief that the demonstration will help Medicaid-eligible people gain sufficient financial resources to be able to purchase private insurance. The Circuit Court said that while it is not arbitrary or capricious to prioritize one statutorily identified objective over another, it is an entirely different matter to prioritize non-statutory objectives to the exclusion of the statutory purpose.

PsychU last reported on this topic in “From June To November 2018, 17,000 People Lost Arkansas Medicaid Benefits Over Failure To Meet Work Requirements,” which published on February 18, 2019. The article is available at

PsychU last reported on Kentucky’s effort to implement community engagement requirements in the following articles:

  • “Under Kentucky Medicaid Work Requirements, About 15% Of Non-Exempt Beneficiaries Would Fail To Meet Criteria,” which published as a News Report on September 9, 2019, at
  • “Kentucky Announces Cancellation Of Medicaid Managed Care Contracts; To Be Rebid In January,” which published as a News Report on February 10, 2020, at

For more information about Gresham v. Azar, contact:

  • Andy Diantonio, Communications Associate, National Health Law Program, 1444 I Street NW, Suite 1105, Washington, District of Columbia 20005; Email:; Website:
  • Kevin De Liban, Attorney and Economic Justice Practice Group Leader, Legal Aid of Arkansas – West Memphis, 310 Mid-Continent Plaza, Suite 420, West Memphis, Arkansas 72301; 870-732-6370, ext. 2206; Email:; Website:
  • Trevor Hawkins, Staff Attorney, Legal Aid of Arkansas, 714 South Main Street, Jonesboro, Arkansas 72401; 870-972-9224, ext. 6313; Email:; Website:

On February 3, 2020, the Texas Department of Family and Protective Services (DFPS) reported that turnover for its Adult Protective Services (APS) caseworker fell from 25.2% in fiscal year 2018, to 20.7% in fiscal year 2019. Based on data from the first quarter of fiscal year 2020, DFPS believes that turnover could be 17% or lower in fiscal year 2020.

DFPS believes that the decrease in turnover can be partially attributed to three events:

  • A recent legislative decision to provide APS caseworkers and front-line supervisors a raise of $750 a month.
  • More than 40 caseworkers were added to the statewide workforce, and placed in areas with the most need.
  • A mentorship program for APS caseworkers was implemented in the state.

As of August 31, 2019, APS had 512 caseworkers on staff. Of these caseworkers, 97 had been hired within the year prior, 142 had been on staff for one to three years, and 273 had been on staff for more than three years. The Arlington region had the most active caseworkers (103), followed by Houston (97), San Antonio (64), and Austin (56). During fiscal year 2019, both the Beaumont and Tyler regions had 0% turnover. El Paso region (4.8%, with just 1 turnover out of 20.8 average active caseworkers) and Lubbuck (7.1%, with just 2 turnovers out of 28.3 average active caseworkers) join these regions in the lowest turnover rates in the state.

DFPS maintains an interactive webpage with statistics at

For more information, contact: 

  • Patrick Crimmins, Media Relations Manager, Texas Department of Family and Protective Services, Post Office Box 149030, Austin, Texas 78714-9030; Email:; Website:

A recent report revealed that from 2010 to 2017, the number of nurse practitioners (NPs) increased from about 91,000 to 190,000, which resulted in the RN workforce contracting by as much as 80,000. RNs returning to school to become NPs is a phenomenon occurring in every region of the country. At the same time, more than one million RNs are approaching retirement.

Additional findings in the report include:

  1. Employment for NPs was concentrated in hospitals, physician offices, and outpatient care centers.
  2. The fastest growth for NP employment overall was in outpatient care centers, which also had the highest salaries.
  3. Growth of NPs was most rapid in the east south-central region of the country, which includes Alabama, Kentucky, Mississippi, and Tennessee.
  4.  It is projected that there will be two NPs for every five physicians in 2030, compared to one NP per five physicians in 2016.

The researchers concluded that hospitals must determine and test new ways to replace RNs who have left their positions to become NPs. Hospitals must also determine solutions in response to low, or fluctuating, RN staffing.

These findings were reported in “Implications Of The Rapid Growth Of The Nurse Practitioner Workforce In The US” by David Auerbach, Peter Buerhaus, and Douglas Staiger, as published in Health Affairs. The researchers analyzed occupational data from the Census Bureau’s American Community Survey (ACS).

The full text of “Implications Of The Rapid Growth Of The Nurse Practitioner Workforce In The US” was published in February 2020 by Health Affairs. An abstract is available online at

PsychU last reported on this topic in “Nurse Practitioners May Represent 27% Of The Family Practice Workforce By 2025,” which published on May 23, 2018. The article is available at

For more information, contact: 

  • David I. Auerbach, Center for Interdisciplinary Health Workforce Studies, College of Nursing, Montana State University, Anna Pearl Sherrick Hall, Bozeman, Montana 59717; Email:; Website:

Jane Guo, MBA, PharmD, is a Managed Market Liaison­, Northeastern Region, with Otsuka. Her career started in retail pharmacy. She then moved over to managed care at Express Scripts as a Pharmacist Supervisor in front-end operations. At Otsuka, she works on the managed care side as well, focusing on relevant products and on-demand resources. Guo graduated from the Albany College of Pharmacy and Health Sciences with a Doctor of Pharmacy degree, and she has a Master of Business Administration degree from The College of William and Mary.

Guo agreed to be interviewed by PsychU about the clinical and payer implications of the study outlined in “Telemedicine Provision: One State as Case Study,” based on research conducted in Minnesota.

The conversation has been edited for clarity and brevity.

PsychU: What is the hope of telemedicine? What do we want it to do for us?

Guo: Mostly it is the convenience factor. Individuals who live in rural areas and those who seek specialists face difficulty gaining access to services. Telemedicine allows them to connect with a medical professional able to provide quality care.

Also, we are seeing a newer generation of individuals who grew up with technology, and telemedicine may seem natural to them. You have a new mother with a baby, and she can connect with someone who will prescribe antibiotics for an ear infection. She doesn’t have to schedule an appointment and wait a day or more for it, then get in the car, or go to urgent care and sit there for an hour or two. So ease of access and convenience are definitely key.

From a payer perspective, it’s a long-term investment. You have to look at it from that vantage point because you’re seeking to improve overall health by providing better access, which hopefully will lead to lower costs because you have a healthier population.

PsychU: The research study referenced in the summary found that telemedicine was used differently in metropolitan versus rural regions. Could you speak to that?

Guo: Sure. In non-metropolitan areas, it is more about access to specialists, particularly psychiatrists and other mental health care professionals—there is a well-known shortage of them. When I am out in the field, in more rural areas, I hear, “We don’t have the clinicians we need.”

In metropolitan regions, it’s the opposite. In New York City, for instance, what I hear instead is there are plenty of providers, but sometimes it’s just difficult to schedule an appointment and then take time out of your day to go to it. In the city, telemedicine tends to be more about improving access to primary care. The convenience factor, for people on the go.

Another difference the study found was that in rural areas, telemedicine tends to be real-time provider-initiated care; in metropolitan areas, consumers are more likely to initiate the encounter.

In both metropolitan and non-metropolitan locales, I think telemedicine will play a large role in coordinating care.

PsychU: That’s interesting. As you know, our theme for 2020 is bridging the care continuum. How does telemedicine close care gaps and become part of integrated care?

Guo: Well, telemedicine allows a doctor or nurse practitioner to easily put a patient in touch with a specialist. It can be a warm handoff, as opposed to a primary care provider writing a referral to a specialist. That’s when you sometimes lose that patient. By supplementing care—rather than supplanting it—telemedicine care help bridge care gaps.

PsychU: Would you say that alternative payment models that require providers to take on financial risk, such as accountable care organizations (ACOs), foster innovative uses of telemedicine?

Guo: I don’t know if those payment models do or not, but from a quality standpoint, there is an incentive to use telemedicine to improve continuity of care, thereby improving quality of care. When you improve care and outcomes, while managing costs, you get a bigger reward in the form of a better quality ranking or bigger bonus reimbursement from the government.

PsychU: What do you see ahead?

Guo: Increasing buy-in from both patients and providers. For anyone, really, the focus is “What can this do for me?” I think clinicians will increasingly see how telemedicine can improve outcomes efficiently, while being convenient. And it is likely to increase patient satisfaction, another positive attribute. If reimbursement increased, that obviously would drive adoption.

As for individuals, convenience is key. Ease of use will encourage more individuals to try it and hopefully like it.

During 2019, merger and acquisition volume within the United States health care sector dropped by 1.5%, from 1,239 in 2018 to 1,221 in 2019. Total deal value was $91.2 billion in 2019. This is a 26.6% decrease from $66.9 billion in 2018. Health service sub-sectors analyzed include hospitals, home and hospice business, managed care plans, rehabilitation, physician medical groups labs, behavioral care, and “other services.” No definition for “other services” is provided.

Additional findings include:

  • “Hospitals” was the only sub-sector whose volumes grew on a year-over-year basis in each of the last three quarters of 2019. However, the home health and hospice, and managed care plans subsectors also finished the year with a stronger positive volume growth.
  • Three sub-sectors grew in terms of both volume and value: Managed care, long-term care, and hospitals. Additionally, Labs, MRI, and Dialysis deal value grew 503%; however, volume was flat.
  • Four sub-sectors experienced deal value declines: Physician medical groups, other services, behavioral care, and home health and hospice.

These findings were reported in “US Health Services Deals Insights Year-End 2019 Online Report” by PwC. The researchers analyzed publicly announced merger and acquisition transactions in specified sub-sectors. The goal was to compile data metrics and analysis of the announced 2019 mergers and acquisitions in the U.S. health care sector.

The full text of “US Health Services Deals Insights Year-End 2019,” was published in January 2020 by PwC. A free copy is available online at

For more information, contact:

  • Nick Donkar, Partner and West Region Health Services Deals Leader, PwC US, PricewaterhouseCoopers LLP, 300 Madison Avenue, New York, New York 10017; Website: 

The number of announced behavioral health acquisitions slowed by 21% between the third and fourth quarters of 2019, from 19 in the third quarter to 15 in the fourth quarter. The fourth quarter 2019 deal volume was 46% below the 28 deals announced for the fourth quarter 2018.

Discovery Behavioral Health was the most active acquirer during the quarter, with a total of three transactions targeting companies specializing in drug and alcohol treatment programs: Authentic Recovery Center in Los Angeles, California; Casa Palmera in San Diego, California; and New Life Addiction Counseling & Mental Health Services in Pasadena, Maryland. Of the 15 announced transactions in the fourth quarter, only one disclosed a transaction price: Thomas H. Lee Partners acquired Centria Healthcare from Martis Capital and Lorient Capital for $415 million.

These findings were reported in “The Behavioral Health Care Acquisition Report 2019” by Irving Levin and Associates. The researchers analyzed publicly announced merger and acquisition transactions and pricing statistics. The goal was to compile data metrics and analysis of the 2019 mergers and acquisitions market.

For more information, contact: 

  • Irving Levin Associates, Inc., 268 ½ Main Avenue, Norwalk, Connecticut 06851; 203-846-6800; Fax: 203-846-8300; Email:; Website:

On January 21, 2020, the California Department of Corrections and Rehabilitation (CDCR) and the California Correctional Health Care Services (CCHCS) began screening inmates at all 35 state institutions for an enhanced integrated substance use disorder treatment (ISUDT) program. The program will offer participants medicated assisted treatment (MAT), comprehensive cognitive behavioral interventions, and safe, therapeutic housing. This initiative will focus on whole-person treatment from incarceration through return to the community.

During roll out, CDCR is focusing on three priority populations; however, an individual not identified in one of these groups can request assessment and treatment. At full capacity, the program will be available to any inmate needing treatment for addiction disorder. The three priority populations are:

  • Those currently receiving MAT
  • Those leaving within 15 to 24 months
  • Those considered high risk due to previous overdose, current clinical symptoms, Hepatitis C, or infections

The ISUDT provides services within the state facilities. CCHCS and CDCR have hired new staff to administer the program, and current staff are also being trained. Contracted cognitive behavioral intervention counselors will use a standardized curriculum based on the American Society of Addiction Medicine criteria.

The CDCR’s plans for ISUDT were noted in “CDCR Vision, Mission, Values, and Goals.” The program is just one method CDCR will use to continue toward the goal of “reflecting the joint priorities of creating a prison environment that provides the incarcerated population with the tools necessary to be drug-free, healthy, and employable members of society upon their release.” Additional steps the CDCR has taken to uphold this goal include:

  • Addressing criminality: The CDCR has increased capacity in cognitive behavioral intervention (CBI) programs focused on criminal thinking, anger management, family relationships, and victim impact by almost 300% since 2015.
  • Career training: The CDCR has more than doubled the capacity of career technical education opportunities for real-world job skills. They have also launched “Microhome” initiatives at the Correctional Training Facility in Soledad, and Folsom State Prison in Sacramento, which provide training for in-demand trades and careers to help individuals succeed when they return to society.
  • College education: The CDCR offers face-to-face community college programming in 34 prisons. A total of 740 people have enrolled, with an additional 200 enrolled in distance learning courses. Face-to-face instruction at Kern Valley State Prison, offered through Bakersfield College, has served 498 individuals.
  • Restorative justice: In 2019, The CDCR awarded grants to eligible non-profit organizations to implement victim impact programs in California prisons. These programs share a common goal of giving victims the opportunity for their voices to be heard, and for incarcerated men and women to fully understand the consequences of their actions.
  • Reentry: Since 2014 and 2015, The CDCR has increased its “Transitions” reentry program capacity 753% from 2,430 to 20,734. Transitions is a five-week program, provided near the end of an individual’s incarceration, to focus on their community reentry needs (such as financial literacy, job search skills, and community resources).
  • Community partnerships: The CDCR cultivates relationships with community partners throughout the state. Through a partnership with CAL FIRE, California Conservation Corps, and the Anti-Recidivism Coalition, CDCR opened an innovative firefighter training program for recently-paroled individuals who served as firefighters while incarcerated.

The full text of “CDCR Vision, Mission, Values, and Goals” was published January 7, 2020. An online copy is available at

For more information, contact:

  • Krissi Khokhobashvili, Chief, External Communications, Office of Public and Employee Communications (OPEC), California Department of Corrections and Rehabilitation, 1515 S Street, Sacramento, California 95811; 916-445-4950; Email:; Website:
  • Elizabeth Gransee, Communications, California Correctional Health Care Services, Post Office Box 588500, Elk Grove, California 95758; 916-691-6714; Fax: 916-691-6183; Email:; Website:

On December 4, 2019, the New Mexico Human Services Department (HSD) announced it had settled with the last five of the 10 behavioral health provider organizations that sued the state because their Medicaid reimbursements were frozen in June 2013 due to allegations of fraud by the previous administration of Governor Susana Martinez. The five organizations are Santa Maria El Mirador (formerly Easter Seals El Mirador); Border Area Mental Health Services; Southwest Counseling Center, Inc.; Southern New Mexico Human Development, Inc.; and Families and Youth, Inc. They agreed to share a settlement of $10 million.

In 2013, the Martinez administration hired an independent auditor that estimated that 15 behavioral health provider organizations had been overpaid by $36 million over a three-year period. The state said this represented a “credible allegation of fraud” and imposed a Medicaid payhold. The payhold meant that the organizations could not bill for any new Medicaid claims and would not be paid for $11.5 million in unpaid claims submitted before the payhold was imposed. Without the state Medicaid payments, many of the organizations could not sustain operations and went out of business within a few months. In 2015, 10 of the provider organizations sued the state to protest the audit methodology. As of June 2017, HSD, the state Medicaid agency, had held fair hearings with eight of the organizations. An HSD spokesperson said these hearings “established in excess of $5 million in overpayments.” On July 7, 2017, the governor’s office alleged that at least $9.4 million in overpayments were received by the provider organizations. By July 2017, the attorney general’s investigations had cleared each of the organizations; the investigations alleged approximately $1.16 million in overbilling by the organizations, but found no evidence of fraud. The investigation findings were forwarded to HSD for further action.

In 2019, the newly-elected administration of Governor Michelle Lujan Grisham reached agreements with the behavioral health provider organizations. In the settlements, the state admitted no liability, and each organization agreed that it would not appeal or otherwise revive its lawsuit. Additionally, Governor Grisham charged HSD with fixing New Mexico’s “broken” behavioral health care system by working with the New Mexico Behavioral Health Collaborative to build a new behavioral health provider network, develop community-based mental health services for children and families, effectively address addiction disorder, and effectively address the behavioral health needs of justice-involved individuals.

The provider organizations agreed to settle their lawsuits, and to share a $10 million settlement. In addition to the settlement agreement/addendum, three of the organizations will receive additional funds. The settlements are as follows:

  • Santa Maria El Mirador (formerly Easter Seals El Mirador) will receive 29.4% of the $10 million settlement. The organization and its attorneys Davis & Gilchrist, P.C. will also receive $127,240.40.
  • Border Area Mental Health Services will receive 21.4% of the settlement. The organization and its attorneys Davis & Gilchrist, P.C. will also receive $96,201.73. Another $226.27 in fee-for-service amounts will be paid to HSD.
  • Southwest Counseling Center, Inc., will receive 21.4% of the settlement.
  • Southern New Mexico Human Development, Inc., will receive 10.4% of the settlement. The organization and its attorneys Davis & Gilchrist, P.C. will also receive $88,239.79. Another $157.21 in fee-for-service amounts will be paid to HSD.
  • Families and Youth, Inc. will receive 17.4% of the settlement.

For more information, contact:

  • Jodi McGinnis-Porter, Director, Communications, New Mexico Human Services Department, Post Office Box 2348, Santa Fe, New Mexico 87504; 505-476-7203; Email:; Website:
  • Angie Carreón, Executive Assistant, Families and Youth, Inc., 1320 South Solano Drive, Las Cruces, New Mexico 88001; 575-522-4004; Email:; Website:
  • Southern New Mexico Human Development, Inc., 820 Highway 478, Anthony, New Mexico 88021; 575-882-5101
  • Kathy Luzmoor, Board Chair, Southwest Counseling Center, Inc., 2300 Foothill Boulevard, Rockwell Springs, Wyoming 82901; 307-352-6677; Fax: 307-352-6614; Email:; Website:
  • Border Area Mental Health Services, 315 North Hudson Street, #6, Silver City, New Mexico 88061; 575-388-4497; Email:; Website:
  • Patsy Romero, Chief Executive Officer, Santa Maria El Mirador, 10 A Van Nu Po, Santa Fe, New Mexico 87508; 505-424-7707; Email:; Website:

The first-known telepsychiatry-enabled model of perinatal integrated care resulted in a 100% perinatal/postpartum depression screening rate, and a higher than expected treatment engagement rate. About 19% of the mothers screened were found to have perinatal depression and/or behavioral health needs, and about 96% of them started treatment. Available data indicate that only 15% to 20% of mothers receive routine perinatal depression screening, and that of those identified, only 60% start treatment. Perinatal depression is defined as depression during pregnancy or up to one year after giving birth.

The telehealth-enabled integrated care model was implemented within a specialty obstetrics clinic serving an at-risk, socioeconomically disadvantaged population. It consisted of three components:

  • Universal depression screening: The Edinburgh Postnatal Depression Scale (EPDS) was administered at a post-natal appointment for all consumers, and the two-question Patient Health Questionnaire (PHQ-2) was administered at all other perinatal visits.
  • Virtually embedded behavioral health clinical professional (BHC): A BHC was embedded at the clinic via video conferencing to oversee the perinatal screenings, follow up on positive screens and other referrals, support coordination of virtual psychiatric consultation, provide brief intervention and treatment as needed, and refer and coordinate ongoing behavioral health and social services.
  • Virtual integration of telepsychiatry services into an evidence-based collaborative care model in primary care: The BHC served as the coordinator across the care team, consulting with the care team to make diagnostic and medication-related recommendations.

Additional findings include:

  • Under the telepsychiatry-enabled model, 12% of non-twin infants of mothers with perinatal depression were born at a low birth weight. Nationally, about 23.5% of infants of mothers with perinatal depression are born at a low birth weight.
  • Positive intervention outcomes have provided new support for the expansion of telepsychiatry-supported models of integrated care from primary care into specialty care settings.
  • There was evidence demonstrating a bidirectional relationship such that depression was associated with lower rates of breastfeeding. Among those mothers who attended their six-week postnatal visit and were able to breast feed, 85% engaged in breastfeeding.

The researchers concluded that the program improved screening and diagnosis of perinatal behavioral health issues, increased access to treatment and consumer engagement, and improved consumer outcomes. The researchers also noted that telepsychiatry is a potentially effective tool for expanding models of perinatal-integrated care.

These findings were reported in “Evaluation of Telepsychiatry-Enabled Perinatal Integrated Care” by Jay H. Shore, M.D., MPH., Maryann Waugh, M.Ed., Jacqueline Calderone, M.D., Amy Donahue, M.D., Jennifer Rodriguez, LCSW, Danielle Peters, LCSW, Marshall Thomas, M.D., and Alexis Giese, M.D. The researchers collected behavioral health screening data from 712 consumers at an urban women’s clinic, as well as in-depth process and outcome measures for 135 consumers from this same clinic. The goal was to describe the implementation of the first known telepsychiatry-enabled model of perinatal integrated care and to report initial results following implementation.

The full text of “Evaluation of Telepsychiatry-Enabled Perinatal Integrated Care” was published February 5, 2020 by Psychiatric Services. An abstract is available online at

For more information, contact: 

  • Jay H. Shore, M.D., Director of Telemedicine, Helen and Arthur E. Johnson Depression Center, University of Colorado Anschutz Medical Campus, 13199 East Montview Boulevard, Suite 330, MS F550, Aurora, Colorado 80045; Email:; Website:

Federal legislation signed into law on March 6, 2020 to address national preparation and response to 2019-Novel Coronavirus (COVID-19) includes provisions that waive Medicare restrictions on telehealth for care related to COVID-19. The bill, House Resolution (HR) 6074 – Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020, provides a total of $8.3 billion, with $7.76 billion to federal, state, and local agencies to combat the virus and authorizes an additional $500 million to pay for the waivers of Medicare telehealth restrictions. About $2.2 billion is earmarked for activities to prevent virus spread, and another $3 billion is earmarked for vaccine research.

COVID-19 is a new virus that presents with a fever and respiratory symptoms, similar to influenza, from two to 14 days after exposure. The symptoms range from mild to severe. It emerged in Wuhan City, Hubei Province, China. The first infections were linked to a live animal market; however, the virus is now spreading person-to-person. The Centers for Disease Control and Prevention (CDC) says that the virus seems to be spreading easily in the community, meaning that people are infected, but it is not sure how or where they were exposed. Globally, as of March 9, 2020, there had been 109,578 confirmed cases and 3,809 deaths, a death rate of 3.5%. Cases had been identified in 105 countries/territories. On March 13, 2020, the United States declared a national state of emergency due to COVID-19.

The legislation will allow Medicare fee-for-service beneficiaries living in a COVID-19 emergency area (or a portion of such an area) to receive telehealth services related to coronavirus during any portion of any emergency period. Services related to COVID-19 include a virtual check-in to discuss possible COVID-19 symptoms that the beneficiary may be experiencing. If the beneficiary shows more physical symptoms, a subsequent virtual check-in can allow a health care professional to offer recommendations about next steps and precautions that the beneficiary should take before visiting a physician office or hospital. The goal is to keep beneficiaries with mild symptoms in their homes, while increasing access to health care professionals. However, for any other services not specifically related to potential symptoms of COVID-19, Medicare’s normal telehealth restrictions apply. Medicare beneficiaries living in rural areas can continue to use communication technology to have full visits with their health care professionals.

Prior to this bill, Medicare limited payment for telehealth visits to services furnished to beneficiaries in certain types of health care facilities located in rural areas. Beneficiaries in rural areas could not receive telehealth visits in their home except under certain exceptions for the treatment of addiction or a co-occurring mental health disorder, or for monthly clinical assessments related to end-stage renal disease (ESRD).

The telehealth virtual check-ins for COVID-19 are billable services, and the Medicare coinsurance and deductible would apply to these services. The virtual check-ins must be provided by a clinical professional who has an established relationship with the beneficiary or who is in the same practice as the professional who has that relationship. Covered telehealth services can be provided via a smartphone with audio and video capabilities sufficient to provide two-way, real-time interactive communication. Physicians and other authorized clinical professionals may bill for these virtual check-in services furnished through several communication technology modalities, such as telephone (HCPCS code G2012) or captured video or image (HCPCS code G2010).

Medicare also pays for beneficiaries to communicate with their physicians by using online consumer health portals. The individual communications, like the virtual check ins, must be initiated by the beneficiary; however, health care professionals may educate beneficiaries on the availability of this kind of service prior to initiation. The communications can occur over a seven-day period. The services may be billed using CPT codes 99421-99423 and HCPCS codes G2061-G206, as applicable. The Medicare coinsurance and deductible would apply to these services.

For more information, contact:

  • Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Website:
  • Center for the National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Email:; Website:; or Michelle Bonds, Director, Division of Public Affairs, Office of the Associate Director for Communication, Centers for Disease Control and Prevention, 1600 Clifton Road Northeast, MS D-25, Atlanta, Georgia 30333; Email:; Website:

On January 1, 2020, Blue Cross and Blue Shield of North Carolina (Blue Cross NC), in collaboration with Quartet Health, launched a new value-based payment model called Blue Premier Behavioral Health. Behavioral health professionals who meet or exceed quality benchmarks will be able to earn higher reimbursement rates. Independent, outpatient behavioral health professionals who serve members of Blue Cross NC commercial (non-government) plans may enroll by May 31, 2020.

Behavioral health professional performance will be evaluated on a series of measures in three domains: Access, communication with primary care, and health outcomes. The participants can receive a maximum bonus payment of up to 10% of their total behavioral health service reimbursement for the year. For those with quality scores greater than 95%, Blue Cross NC will offer an additional $5,000 bonus. This new value-based payment program is part of Blue Premier, an initiative launched by Blue Cross NC in 2019 to enhance primary care services, integrate behavioral health into primary care, and move to reimbursement based on performance.

This Blue Cross NC value-based payment initiative is using the Quartet Health technology platform to measure quality of behavioral health care. Participating professionals will use Quartet’s technology to facilitate referrals and enable data collection and measurement of quality outcomes. Physicians and case managers can refer consumers for mental health care through the platform. The platform facilitates on-going communication between primary care physicians and behavioral health professionals.

In 2019, Blue Cross NC began efforts to better integrate behavioral health with physical health and to transform health care through value-based payments. This new approach also integrates with Blue Premier, the company’s value-based care program that holds network provider organizations and Blue Cross NC jointly accountable for improving care and lowering costs. As part of the integration efforts in 2019, Blue Cross NC began offering Quartet’s services to primary care and behavioral health provider organizations free of charge.

Blue Cross NC is an independent licensee of the Blue Cross and Blue Shield Association. It serves more than 3.9 million members, including approximately 1.1 million served on behalf of other Blue plans. Kate Hobbs Knutson, M.D., Blue Cross NC head of behavioral health said, “Blue Premier Behavioral Health will expand access, improve coordination with primary care, and help achieve better health outcomes.”

PsychU last reported on this topic in “Sutter Health Teams Up With Quartet Health To Better Integrate Mental & Physical Health Care,” which published on October 16, 2017. The article is available at

For more information, contact:

  • Kevin Kumler, Chief Operating Officer, Quartet Health, 119 West 40th Street, 5th Floor, New York, New York 10018; Email:; Website:
  • Susan Foosness, Senior Business Operations Advisor, BlueCross BlueShield of North Carolina, 1965 Ivy Creek Boulevard, Durham, North Carolina 27707; 984-960-3697; Email:; Website:

During 2019, salaries for assisted living community administrators averaged $100,622, up 3.6% over the 2018 average salary of $97,126, according to a year-to-year trend analysis for facilities that participated in salary surveys in both 2018 and 2019. Across all facilities that reported in 2019, the national average administrator salary was $76,939. Across the states, average administrator salaries ranged from $63,452 in North Carolina to $97,349 in Maryland.

At smaller facilities (74 beds or less), administrator salaries averaged $71,882. At facilities with 75 or more beds, administrator salaries averaged $80,676. At for-profit facilities, administrator salaries averaged $74,933. At non-profit facilities, administrator salaries averaged $87,380.

These statistics were reported in the 22nd annual “Assisted Living Salary & Benefits Report” by Hospital & Healthcare Compensation Service. The report was published in cooperation with LeadingAge and supported by the National Center for Assisted Living. The report covers 20 management and 29 non‐management positions. In total, 1,360 assisted living communities participated in the study and provided data for over 87,400 employees. The report includes data from communities structured as assisted living facilities (80%), personal care facilities (5%), and residential care facilities (16%). The data are reported according to for‐profit (86%) and non-profit (14%) status, revenue size, unit‐size, state, and geographic region.

The full text of “Assisted Living Salary & Benefits Report” was published by Hospital & Healthcare Compensation Service. It can be purchased at

For more information, contact:

  • Rich Cioffe, Client Services, Hospital Healthcare & Compensation Service, Post Office Box 376, Oakland, New Jersey 08436; 201-405-0075, ext. 10; Email:; Website:

The Arizona Health Care Cost Containment System (AHCCCS) and the three Medicaid managed care organizations (MCOs) for the Arizona Long Term Care System (ALTCS) are implementing initiatives to increase the size of the state’s Medicaid long-term care workforce. The MCO contracts require the MCOs to build a long-term care workforce within their AHCCCS networks.

The ALTCS MCOs are Mercy Care, Banner-University Family Care, and United Healthcare Community Plan. The three organizations were awarded contracts in 2017. ALTCS provides acute care, long term care, behavioral health, home- and community-based services, and case management for two Medicaid populations that are served through separate contracting arrangements. AHCCCS requires in contract that each MCO hire a Workforce Development Administrator to routinely assess the capacity and capabilities of the contracted health care workforce, produce a Workforce Development Plan, and create and support workforce development initiatives that strengthen the long-term care workforce.

The ALTCS population includes nearly 56,000 beneficiaries who are aged 65 and older, blind, or disabled and who are at risk of institutionalization. More than 30,000 ALTCS beneficiaries have developmental disabilities. Their services are provided by UnitedHealthcare Community Plan and Mercy Care under contracts with the Arizona Department of Economic Security (DES) Division of Developmental Disabilities (DDD) effective October 1, 2019. AHCCCS also requires the DDD to have a workforce development administrator to build the long-term care workforce.

The state’s goal is “to ensure that Arizona is prepared to meet the projected need for licensed and unlicensed” caregivers in the coming decades, according to AHCCCS spokeswoman Heidi Capriotti. Ms. Capriotti said the MCO initiatives include supporting innovative high school-based technical education programs, developed by the Arizona Department of Education, that prepare graduating seniors to enter the long-term-care workforce. She also added that AHCCCS supports legislation to require training and testing of direct-care workers and assisted-living caregivers to help increase career mobility and decrease training and hiring costs..

PsychU last reported on this topic in “Arizona Medicaid Announces ALTCS Managed Long-Term Care Contract Awards,” which published on April 3, 2017. The article is available at

For more information, contact:

  • Heidi Capriotti, Media Relations and Public Information Officer, Arizona Health Care Cost Containment System, 801 East Jefferson Street, Phoenix, Arizona 85034; 602-417-4729; Email:; Website:

The Texas Health and Human Services Commission (HHSC) is expanding its Texas Targeted Opioid Response (TTOR) Emergency Medical Service (EMS) Emergency Response pilot program into the Austin area. TTOR uses emergency response services to connect opioid overdose survivors to integrated services needed for long-term recovery. These services include providing individuals, their families, and supportive allies with overdose reversal medication, as well as information on how to reverse an overdose. Those served are offered same-day initiation of medications used to treat opioid use disorder and alleviate withdrawal symptoms. Paramedics and peer recovery coaches also provide ongoing support to individuals to assist in their recovery and engagement in long-term treatment. Paramedics and peer recovery coaches can refer individuals to outside services when needed.

HHSC is working with Austin-Travis County Emergency Medical Services (ATCEMS) to help provide TTOR services. On September 19, 2018, the Substance Abuse and Mental Health Administration (SAMHSA) awarded Texas $46.2 million in State Opioid Response (SOR) funds to extend and expand HHSC’s response to the opioid crisis. On May 6, 2019, the state received a $24.1 million supplemental award under this grant bringing total potential SOR funding to over $116 million over the two-year period.

Since 2018, the state has implemented TTOR in Bexar, Harris, and Williamson counties. Each site receives about $500,000 annually from the HHSC to fund the pilot services. The pilot sites are selected according to various characteristics such as overdose rates, existing community resources, existing infrastructure, and population, to test models that could be easily replicated in other counties. HHSC said in Harris County, 85% of the program’s 500 participants received and remained in treatment for more than 30 days. HHSC will select nine additional pilot sites based on community need, interest, and the ability to implement the program, however a timeline for future implementation has not been established.

The TTOR program was originally created in May 2017. TTOR funding comes to HHSC through federal grants awarded by SAMHSA. Federal grant funding covers the cost of the evidence-based prevention, treatment, and recovery support strategies. As soon as a person participating in an EMS Opioid Response pilot program transitions from the treatment induction phase into long-term treatment, a determination is made whether the cost of long-term treatment is covered by private health care insurance, Medicaid, or if the person is eligible for state-funded treatment. TTOR encompasses four grant opportunities from SAMHSA totaling more than $176 million over the expected funding periods. The funding for all grants is awarded evenly on an annual basis, with the ability to extend contingent on availability of federal funds. The grants include:

  1. State Targeted Response (STR) funds: $54,724,714. This was a two-year grant in effect from May 1, 2017 to April 30, 2019.
  2. SOR funds: $116,589,770. This is a two-year grant in effect from September 30, 2018 to September 29, 2020.
  3. The Texas Strategic Prevention Framework for Prescription Drugs (SPF-Rx) grant: $1,858,080. This is a five-year grant in effect from September 1, 2016 to August 31, 2021.
  4. The Texas First Responders – Comprehensive Addiction and Recovery Act (FR-CARA) grant: $3,200,000. This is a four-year grant in effect from September 30, 2017 to September 29, 2021.

For more information, contact: Lisa Ramirez, Director, Texas Targeted Opioid Response, Texas Health and Human Services Commission, 4900 North Lamar Boulevard, Austin, Texas 78751-2316; 512-380-4955; Email:; Website:

On February 3, 2020, Epic, an electronic health record (EHR) vendor, asked its health system clients to sign on to a letter urging the federal Department of Health and Human Services (HHS) to modify a pending federal interoperability rule to address concerns about consumer privacy, non-standardized data exchange, lack of protection of the intellectual property of EHR developers, and the proposed implementation timeline for fines. The letter says, “While we support HHS’ goal of empowering patients with their health data and reducing costs through the 21st Century Cures Act, we are concerned that ONC’s Proposed Rule on interoperability will be overly burdensome on our health system and will endanger patient privacy. Specifically, the scope of regulated data, the timeline for compliance, and the significant costs and penalties will make it extraordinarily difficult for us to comply.” Some 60 health systems signed the letter, which was then sent to the federal Department of Health and Human Services (HHS).

HHS is preparing to release two interoperability rules, one from the Office of the National Coordinator of Health Information Technology (ONC) and the other from the Centers for Medicare & Medicaid Services (CMS) to support the 21st Cures Act and MyHealthEData. The ONC proposed rule was released in March 2019; the final rule is expected in early 2020. It had not been released as of February 16, 2020. ONC proposed adopting Health Level Seven’s (HL7®) Fast Healthcare Interoperability Resources (FHIR®) standards as the standard to which developers must certify their application programming interfaces (APIs) and proposes language to support an ecosystem for the secure flow of information. The goal is to promote secure and more immediate access to health information for consumers and their health care professionals. Use of standardized APIs is intended to allow individuals to use smartphones and other mobile devices to easily and securely access structured and unstructured electronic health information.

In the letter, Epic and the health systems recommended that HHS make the following changes to the proposed rule:

  • Allow health systems to hold companies that seek access to consumer data to the same privacy and security standards elsewhere in the health care industry. Health information about family members should not be used or disclosed by non-HIPAA regulated organizations without family members’ knowledge and permission.
  • Standardize data exchange, and focus the rule on the medical and financial data that is most useful to the consumer and can be exchanged in a standardized format. The rule should not require exchange of non-standardized data, even if there are existing APIs.
  • Protect the intellectual property of EHR developers to allow them to continue to innovate for health systems and consumers.
  • Give organizations at least 12 months to prepare before information blocking is enforced and 36 months for development of new technology required by the rule. Further, HHS should allow a grace period for education before fines are levied.

Epic’s letter was signed by the following health systems: Access Community Health Centers; Community Health Center Network, Alameda Health Consortium; Altru Health System; Atrius Health; Adventist Health Portland; Affirmant Health Partners; Lovelace Health System; Arc; UT Health Athens; Ardent Health Services; Bay Health; Buffalo Medical Group; Christie Clinic; Deaconess Health System; Genesis Healthcare System; Catholic Health; Community Health Network; Exact Sciences, Group Health Cooperative, South Central Wisconsin; Charlotte Eye Ear Nose & Throat Associates; Confluence Health; Fresenius Medical Care; Gundersen Health System; Guthrie; HonorHealth; Institute for Family Health; Mercy; UnityPoint Health-Meriter Hospital; Hospital Sisters; HSHS Wisconsin; Iowa Specialty Hospitals & Clinics; Mercy Care; VHS; HSHS St. Clare Memorial Hospital; HSHS St Joseph’s; HSHS Illinois; Mary Washington Healthcare; Mercy Health Services; Middlesex Health; Beth Israel Lahey Health, Mt. Auburn; NYU Langone Health; PeaceHealth; Piedmont Healthcare; Northshore’s Evanston Hospital; OhioHealth; Pembia County Memorial Hospital; Pine Rest Christian Mental Health Services; Norton Healthcare; Parkview Health; Permanente Dental Associates; Prevea Health; River Valley Primary Care Services; Singing River Health System; University Health System; Vancouver Clinic; Riverside; Southcoast Health; Titus Regional Medical Center; UT Health San Antonio; Wellstar Medical Group; Self Regional Healthcare; SSM Health; UHS Inc. and UHS Hospitals; UW Health; and West Virginia University Health System.

PsychU reported on the ONC proposed rule in “HHS Issues A Proposed Rule For API Standards For Electronic Health Information,” which published on April 1, 2019. The article is available at

For more information, contact:

  • Epic Systems, 1979 Milky Way, Verona, Wisconsin 53593; 608-271-9000; Fax: 608-271-7237; Email:; Website:
  • Peter Ashkenaz, Media Contact, Office of the National Coordinator for Health Information Technology, U.S. Department of Health and Human Services, 330 C Street Southwest, Floor 7, Washington, District of Columbia 20201; 202-260-6342; Email:; Website:
  • Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Website:

On November 21, 2019, the U.S. Department of Justice (DOJ) indicted four former employees of Outcome Health—including the two co-founders and two former executives—for defrauding the company’s clients, lenders, and investors of an estimated $1 billion. Prior to January 2017, the company was known as ContextMedia. It sold digital advertising in physician offices; most of its clients were pharmaceutical companies. The defendants are accused of selling millions of dollars of advertising inventory from 2011 to 2017 that did not exist, which inflated its financial statements. The DOJ alleged that the former executives used the inflated financials to raise nearly $1 billion in debt and equity financing in 2016 and 2017.

Outcome Health itself is not under indictment; it entered a Non-Prosecution Agreement (NPA) with the DOJ on October 30, 2019. After the fraud surfaced, Outcome Health engaged in “extensive remedial measures” including requiring the co-founders to give up all financial interests in the company or representation on the company’s board, and retaining a new management team. Additionally, Outcome Health provided more than $65 million in restitution to its client pharmaceutical companies.

The company provided physician practices with free waiting-room video screens, consumer-education tablets, wallboards, wi-fi access points, and free health education content. The platform provided consumers at the physician practices with health care information and advertising. The content library included assessments, 3D anatomical models, recipes for healthy living, and information about treatment options. ContextMedia/Outcome Health generated revenue by selling ads on the platform.

The DOJ alleged that Outcome sold advertising inventory—digital tablets in physician offices—that the company did not have, and then under-delivered on its advertising campaigns. Outcome allegedly invoiced its clients as if it had delivered in full. The indicted former executives and employees are accused of concealing the under-deliveries by falsifying affidavits and proofs of performance to make it appear that Outcome was meeting its contract requirements. The defendants allegedly inflated consumer engagement metrics for how frequently consumers in the physician offices engaged with Outcome’s tablets that provided health education and targeted advertising. Additionally, some of the contracts included return on investment (ROI) guarantees. One of the defendants is accused of altering studies presented to clients to make it appear that the digital campaigns were more effective than they actually were.

The under-delivery resulted in a material overstatement of Outcome’s revenue for 2015 and 2016. The company’s outside auditor signed off on the 2015 and 2016 revenue numbers because the indicted individuals fabricated data to conceal the under-deliveries from the auditor. The inflated revenue figures in Outcome’s 2015 and 2016 audited financial statements were allegedly used to raise $110 million in debt financing in April 2016, $375 million in debt financing in December 2016, and $487.5 million in equity financing in early 2017. The co-founders were allegedly paid dividends totaling $37.7 million on the $110 million debt financing. The $487.5 million equity financing allegedly resulted in a $225 million dividend to the co-founders.

On November 7, 2017, the investors sued the founders of the Company and related entities following a report that from 2014 through 2016 the company misled advertisers about the number of physician offices using the health education platform. The lawsuit, Global Private Opportunities, et al., v. Rishi Shah; Outcome Holdings, LLC; ContextMedia Health Holdings, LLC; Outcome, Inc.; Gravitas Holdings, LLC; and Shradha Agarwal, came after the company had announced on September 27, 2017 that its network included more than 140,000 installed devices, and that it had also recently received independent certification from BPA Worldwide iCompli that the platform size estimates and audience qualification complied with industry standards. On October 19, 2017, Outcome Health announced it was taking steps to ensure transparent and accurate impression measurement. On November 15, 2017, the company announced it had joined the IAB, a large trade association for digital advertising and marketing comprised of more than 650 media and technology companies that sell, deliver, and optimize digital advertising and marketing campaigns.

A link to the full text of “October 17, 2019 Letter From the DOJ Regarding Outcome Health” may be found at

A link to the full text of “Department Of Justice Indictment Of Former Outcome Health Employees” may be found at

A link to the full text of the 2017 investor lawsuit, “Global Private Opportunities, et al., v. Outcome Health, et al.,” may be found at

For more information about Outcome Health, contact:

  • Kendall Day, Partner, Gibson, Dunn & Crutcher, LLP, 1050 Connecticut Avenue Northwest, Washington, District of Columbia 20036-5306; Email:; Website:

For 2020, about 2% of eligible clinical professionals participating in the Medicare Merit-based Incentive Payment System (MIPS) earned a negative payment adjustment ranging from -0.01% to -5.00%. The remaining 98% of MIPS participants received a positive or neutral payment adjustment, ranging from 1.68% to 0.00%, based on their 2018 MIPS performance data. The Centers for Medicare & Medicaid Services (CMS) noted that the positive payment adjustment received in 2020 is modest because under current law, the positive and negative payment adjustments must be budget-neutral. In general, if a clinical professional is eligible for MIPS, they will choose whether to participate at the individual or group level.

CMS reported the 2018 Quality Payment Program (QPP) performance results and payment adjustments in a January 6, 2020 blog post. In total, 889,995 clinical professionals received a MIPS payment adjustment in 2018, either positive, neutral, or negative. Of the total number of clinical professionals receiving a payment adjustment, 872,148 MIPS eligible clinical professionals will receive a neutral or positive payment adjustment through their individual, group, or Alternative Payment Model (APM) participation.

In total, 183,306 eligible clinical professionals earned Qualifying APM Participant (QP) status under the Advanced APM track of the QPP. Another 47 eligible clinical professionals received partial QP status during 2018. In 2017, the number of eligible clinical professionals who met QP status was 99,076 and partial QP status was 52.

CMS noted significant successes in MIPS participation during the second year of the program. The MIPS participation rate was higher in 2018 than in 2017, which was the first year of the program. More clinical professionals avoided a negative payment adjustment, 2% in 2018 compared to 5% in 2017. The overall national average and median MIPS scores increased from 2017. Additionally, those who participated in MIPS through an APM had a mean score of 98.77 and a median score of 100.

Based on MIPS 2018 data, the payment adjustments were as follows:

  • 84% of MIPS eligible clinical professionals received an additional adjustment for exceptional performance (with scores of 70.00 to 100.00 points). The minimum payment adjustment for this group was 0.21% and the maximum was 1.68%.
  • 13% of MIPS eligible clinical professionals received a positive adjustment for earning between 15.01 and 69.99 points. The minimum payment adjustment was 0.00% and the maximum was 0.20%.
  • No MIPS eligible clinical professionals earned 15.00 points to earn a neutral payment adjustment of zero.
  • 2% of MIPS eligible clinical professionals earned 0 points to receive a negative payment adjustment ranging from -0.01% to -5.00%.
  • 97% of MIPS eligible clinical professionals in rural practices received a positive payment adjustment, compared to 93% in 2017.
  • 84% of MIPS eligible clinical professionals in small practices received a positive payment adjustment, up from 74% in 2017.

MIPS is one track of the QPP established to implement certain provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). MIPS requires eligible clinical professionals to submit performance data on certain measures and activities in four categories: Quality, Cost, Improvement Activities, and Promoting Interoperability. Performance in the four categories determines whether participating MIPS eligible clinical professionals receive a positive, neutral, or negative adjustment to their Medicare part B allowed charges for covered professional service under the Physician Fee Schedule. Three of the four performance categories allow the MIPS eligible clinical professional to choose the measures and activities they report. In the 2017 and 2018 performance years, MIPS eligible clinical professionals included physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, osteopathic practitioners, and chiropractors who billed Medicare Part B covered professional services. MIPS eligible clinical professionals who did not participate in MIPS for the 2017 performance period were subject to a negative 4% payment adjustment in 2019.

The CMS announcement is posted online at (accessed January 22, 2020).

For more information, contact

  • Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Email:; Website:

Serious mental illness (SMI) is a disabling condition—and because it develops early in life, it brings with it a lifetime of costs. But while researchers have long believed that early intervention for SMI has lifelong benefits for patients, there has been little evidence that weighs whether these efforts can be considered cost effective.

This led a team of researchers and scientists to employ a simulation model to attempt to estimate the lifetime costs of SMI for patients diagnosed by age 25. In “Measuring the Lifetime Costs of Serious Mental Illness and the Mitigating Effects of Educational Attainment,” these scholars provide current outcome statistics and present their methodology and the conclusions for measuring the potential economic effect of early intervention.

SMI’s Effects and the Intervention Opportunity: A Quick Overview

As noted, serious mental illness (SMI)—including psychoses, major depressive disorder, and bipolar disorder—is disabling and costly, with an economic impact that is similar to that of cancer and diabetes. And since it is often diagnosed between the ages of 15 and 30, SMI carries other costs, too. It impacts educational attainment and dropout rates, employment status, annual earnings, and even life expectancy, with previous reports documenting anywhere from 10 to 30 years of potential life lost.

But the trend toward early diagnosis and treatment of SMI as a means to improve patient-based and economic outcomes has continued to grow. Potential strategies integrate patient-centered interventions—such as addressing substance use disorders and relationship issues—with clinical trials that demonstrate the benefits of early interventions like medication management, family involvement, and education/employment support. Indeed, a variety of studies have shown such positive early intervention outcomes as:

  • Improved quality of life
  • Reduced depression
  • Increases in academic enrollment, course completion, and employment

However, evidence that defines the economic impact of these interventions has been limited.

Research Aimed at “Filling the Gap”

Based upon findings of various studies, it might be logical to infer that intervention strategies resulting in increased educational attainment and employment could improve the quality of life and reduce the lifetime financial burden of people with SMI. In fact, policy makers in the United States have been actively exploring potential strategies.

But efforts may be hindered because long-term benefits of these strategies have not been measured—and there is limited evidence of these interventions’ long-term return on investment (ROI). Researchers Seth A. Seabury et al. have thus attempted to fill that gap by providing new data on the lifetime benefits of improving educational or employment outcomes for people who experience SMI early in life, using a research model to project the impact on health and economic outcomes.

A Brief Look at Methodology

With the growing emphasis on early identification and treatment of mental illness to help improve long-term health and economic outlooks, the research team sought to obtain evidence via simulated differences in life expectancy, quality of life, medical spending, and economic outcomes.

The research team simulated lifelong outcomes using the Future Americans Model (FAM), a dynamic microsimulation model that uses data on Americans ages 25 and older to project health, medical spending, social service use, and economic outcomes over time. FAM builds estimates based on the paths of individual health and economic outcomes rather than on average characteristics—thus allowing for more accurate estimations.

FAM combines data from several large, nationally representative surveys. As a result, it enabled the research team to:

  • Estimate transitions between health state;
  • Project health care spending; and
  • Assess quality of life.

FAM also allowed the team to compare people with a self-reported diagnosis of SMI by age twenty-five to those without a diagnosis of SMI by age twenty-five, including those diagnosed later in life.

How FAM Was Used

The model measured transition probabilities for specified health states based upon predictors such as age, gender, and health condition as derived from questions in the nationally representative Panel Study of Income Dynamics (PSID).

Detailed information on simulation scenarios, trial details, and study limitations can be found in the report referenced below.

Simulation Revealed Key Findings

While outcomes varied based upon educational attainment, the overall findings during one year of simulation showed that those with an SMI diagnosis by age 25:

  • Have lower educational attainment. In the simulation, about 23.4% had less than a high school diploma, compared to 11.3 percent for those who never developed SMI.
  • A re more likely to be female and white. They also had more restrictions to activities of daily
  • Have a lower life expectancy. The average life expectancy from age 25 was 45.7 years—10.4 years (19%) lower than those without SMI by age
  • Have substantially higher lifetime medical spending. Total lifetime medical spending was $96,500 (24%) higher, even though people with SMI are much more likely to be on Medicaid or uninsured.
  • Earn substantially less over their lifetime. Earnings were an average of $537,100 (48%) less per person, with 2 (55 %) fewer years of full-time work. This also corresponded to increased lifetime benefit payments of 500% for Social Security Disability Insurance and 809% for Supplemental Security Income (SSI).

What Comes Next?

While early intervention to improve the educational attainment of people with SMI has clear benefits, interventions can be costly. But at the same time, a significant number of Seabury et al.’s simulations also demonstrated that, at least in part, early intervention can reduce the high economic burden.

Recap: The Opportunities and the Challenges

Overall, the simulation’s findings highlight both the opportunities and the challenges to improve SMI’s economic outcomes.

The Good News

  • An estimated $1.85 million per-patient cost can be reduced by $73,600 through use of an education-based intervention. Indeed, SMI patients as a whole experience nearly a quarter of a trillion dollars in economic burden, and improvement in educational attainment would reduce that by over $8.9 billion.
  • Relatively low-cost interventions that focus on helping young SMI patients enroll in school and have accommodations from/interaction with teachers and administrators can have large impacts on school participation.

The Challenge

While intervention can flexible and implemented across a variety of geographic settings (urban, suburban, and rural), these gains would be spread across many years, which suggests:

  • The potential need for public investment or subsidy
  • The hiring and training of additional providers

Many assessments of intervention programs focus on outcomes that can’t easily measure long-term effects, but Seabury et al.’s work has provided new evidence.

And resulting from their generally optimistic findings, the Seabury et al. team urges that future interventions and evaluations should use objective and clearly defined outcome measures that can be linked to publicly available data sources.

This, in turn, could foster additional measurement of the long-term economic impact of early interventions—and, potentially, provide further evidence that supports their adoption and leads to lifelong benefits for SMI patients.

This summation was developed independently of the authors.

In 2017, states spent 17% of state-generated funds on Medicaid, which represents a 41% increase from 2000 to 2017. The states spent $0.17 of every state-generated dollar on Medicaid in 2017, up from $0.12 per dollar in 2000.

Every state except Illinois spent a larger share of its own dollars on Medicaid in 2017 than in 2000. The state with the largest increase was Louisiana, at 11.5 cents higher than 2000, spending 22% of its revenue (or 22 cents per state-generated dollar) on Medicaid in 2017. Illinois spent the same on Medicaid in 2017 as it did in 2000, largely due to extreme delays in payments to health care provider organizations.

Medicaid provides medical coverage for eligible groups of children, adults, people with disabilities, and the elderly. Medicaid is most states’ largest expense, following education expenses. Medicaid is paid for by both the state, and the federal government. However, in 2017, states collectively spent $228.2 billion of their own resources to provide health benefits for 73.8 million Medicaid recipients. Additional findings include:

  • Besides Illinois, three states had increases of less than one cent per state-generated dollar spent on Medicaid since 2000: Tennessee (0.7 cent), Michigan (0.8 cent), and Hawaii (0.9 cent).
  • Besides Louisiana, just one other state had an increase of more than 10 cents per state-generated dollar spent on Medicaid since 2000: Alaska (10.5 cents).
  • The 13 states where Medicaid in 2017 was at its highest level since 2000 were Arkansas, Colorado, Delaware, Kentucky, Massachusetts, Mississippi, Nebraska, New Hampshire, North Dakota, Oklahoma, Vermont, Virginia, and Wyoming.

The states that spent the lowest share of their own dollars on Medicaid in 2017 were Utah (5.8%), Hawaii (8.2%), Nevada (9.4%), and Idaho (9.9%).

These findings were reported in “States Collectively Spend 17 Percent of Their Revenue on Medicaid” by Barb Rosewicz, Justin Theal, and Katy Ascanio for Pew Charitable Trusts (Pew). Researchers at Pew analyzed data from the Centers for Medicare & Medicaid Service (CMS), the National Association of State Budget Officers, and the U.S. Census Bureau. The goal was to highlight trends in state Medicaid spending, relative to states’ own revenue, to allow policymakers to examine budgetary implications of their Medicaid programs over time.

The full text of “States Collectively Spend 17 Percent of Their Revenue on Medicaid” was published January 9, 2020 by The Pew Charitable Trusts. The content is available online at (accessed January 27, 2020).

For more information, contact:

  • Jim Gavin, Director of Communications and Media, Indiana Family and Social Services Administration, 402 West Washington Street, W461, Indianapolis, Indiana 46204-2739, Phone: 317-234-0197, Fax: 317-233-4693, Email:, Website:

The year after Cascadia Behavioral Healthcare (Cascadia) implemented a certified Community Behavioral Health Clinic (CCBHC) integrated care model, the number of emergency department (ED) visits was reduced by 18% and inpatient admissions by 23% among individuals who’d previously utilized the ED or inpatient facilities. Before implementing the CCBHC integrated care model in 2017, Cascadia reported 3.74 ED visits/inpatient admissions per consumer for April 2016 through April 2017. After becoming a CCBHC, Cascadia reported 3.07 ED visits/inpatient admissions per consumer for 2018. Cascadia reported the outcomes on December 17, 2019.

Cascadia anticipates that the reduction will result in substantially lower annual health care costs. The cost savings estimates are based on data from HealthShare, one of the state’s Medicaid coordinated care organizations (CCO). The CCO tracks ER utilization for adults age 18 and older with mental illness as a quality measure to reduce disparity in outcomes. The goal is to reduce the disproportionately higher emergency department utilization among those experiencing mental illness by increasing awareness and engagement with appropriate points of primary and mental health care. ED visits for mental health and chemical dependency services are not included in the ED visit count.

As a CCBHC, Cascadia introduced care coordination and primary care services to its continuum of care. Cascadia currently serves over 3,700 consumers.

Cascadia’s Chief Medical Officer Jeffrey Eisen said “These are significant results that support the need for continued funding for the CCBHC model, which has enabled an integrated care approach for our clients. By providing preventative and proactive services, we can significantly change quality of care and health outcomes for individuals, as well as reduce financial strain on our health care system and our payers.” Cascadia is continuing to refine its integrated model through population health efforts that emphasize diabetes management, chronic pain management, decreased emergency department utilization and medical admissions, and tobacco cessation.

For more information, contact:

  • Jennifer Moffatt, Senior Director of Communications, Cascadia Behavioral Healthcare, Post Office Box 8459, Portland, Oregon 97207; 503-402-8117; Email:; Website:

Cigna reports its commercial members with integrated medical, pharmacy, and behavioral benefits had annual medical costs of averaging $207 less per covered life than members enrolled in non-integrated plans. For Cigna members with health improvement opportunities (such as weight management and smoking cessation), being enrolled in a plan with integrated benefits reduced annual medical costs by an average of $850 per person.

Per-person savings were realized for members with more intensive health needs who were enrolled in a combined plan. Per-person savings attributable to the combined plan totaled $7,372 for members with conditions requiring a specialty medication. For members with an oncology diagnosis, per-person savings totaled $11,679 and their inpatient oncology costs were 24% lower.

Members of Cigna’s integrated plans also were found to have:

  • 17% higher engagement in wellness programs including counseling for conditions such as diabetes and heart disease; lifestyle or wellness coaching to help with weight management and smoking cessation; and personal case management for complex conditions such as rheumatoid arthritis or cancer.
  • 32% lower mental health readmission rates.
  • 18% fewer out-of-network behavioral claims.
  • 5% higher utilization of in-network high-performing provider organizations.
  • 4% lower out-of-network claims.
  • 15% higher treatment rate for opioid misuse, and 30% reduction in subsequent post-treatment overdoses compared to the previous year.

Cigna reported these findings as the key outcomes of its fourth annual 2019 Value of Integration report. These findings are based on a two-year internal analysis of more than 2.3 million claims from Cigna customers who receive coverage through their employer. Half of the population had comprehensive medical, behavioral, and pharmacy benefits administered by Cigna, while the other half had only medical benefits with minimal behavioral benefits administered by Cigna. Customers were matched between the two groups on key attributes, including demographics, health condition, access to health improvement services, plan design, and geographies. The study methodology was reviewed and validated by KPMG LLP in 2018. However, KPMG did not conduct an independent analysis to verify any results, and KPMG did not audit the data or the programming code used to conduct the study.

Based on the findings, Cigna asserts that with connected medical, pharmacy, and behavioral health benefits customers are more engaged in their health and well-being and are more likely to stay in-network for their care. Cigna also believes that consumers enrolled in a plan with integrated benefits are more informed about their care options.

Cigna reported the 2019 Value of Integration report findings at (accessed January 23, 2020).

For more information, contact:

  • Meaghan MacDonald, Enterprise Media Relations, External Communications, Cigna Corporation, 3 Waterside Crossing, Windsor, Connecticut 06095; 860-226-0576; Email:; Website:

On December 11, 2019, the Naat’áanii Development Corporation (NDC), a federally chartered business development arm of the Navajo Nation, announced plans to contract with Molina Healthcare, Inc. to create an Indian Managed Care Entity (IMCE) health care offering under New Mexico’s Centennial Care Medicaid program. Molina will provide full-risk plan operations for the IMCE, including a full array of Medicaid managed care services.

The IMCE is a program authorized under the state’s most recent Medicaid 1115 waiver. NDC will provide direction for the IMCE to determine its priorities, engage Navajo stakeholders, and ensure that the program includes Navajo culture. NDC will also lead education and marketing for the program. The IMCE differs from other Medicaid managed care plans in that it is uniquely tailored to Navajo health priorities.

In a statement about the arrangement, an NDC spokesperson said the organization selected Molina based on Molina’s experience serving New Mexico’s Medicaid beneficiaries for two decades and its dedication to serving Native Americans in the state. About 75,000 Medicaid-eligible Navajos live in New Mexico.

In December 2018, the Centers for Medicare & Medicaid Services (CMS) approved the New Mexico Human Services Department (HSD) Centennial Care 2.0 waiver program renewal, which included plans for an IMCE. In January 2019, the NDC responded to an HSD request for information seeking proposals on how an IMCE could be established. In September 2019, HSD issued an outline of the plans in “The New Mexico Naat’áanii IMCE Program: Improving Access & Outcomes for the State’s American Indians / Alaska Natives.” In October 2019, HSD held a tribal consultation with the Navajo Nation about the NDC IMCE. This consultation focused on benefit design, delivery model, quality measurements, and enrollment methodology. On December 2, 2019, the Navajo Nation Council began considering legislation to request the State of New Mexico to issue all necessary approvals to the NDC and Molina Healthcare, Inc. to launch an IMCE using a passive enrollment system. The legislation passed two Committees of the Navajo Nation Council, and is slated to be reviewed by the full sub-Committee, before the legislation becomes the Navajo Nation governing body’s official position. Additional details about the planned NDC-Molina IMCE are as follows:

  • Coverage will be geographically focused on the Northwest corner of New Mexico but will cover members wherever they travel in the Navajo Nation, which includes parts of Arizona and Utah.
  • All New Mexico Medicaid Centennial Care benefits will be covered, including key tribal services such as traditional healing, tribal care coordinators within Indian Health Service facilities, and tribal peer specialists. Programs will be developed to address key social determinants of health, such as housing, employment, food insecurity, and enhanced transportation. The plans also will offer enhanced dental benefits, wellness incentives for diabetes and cancer screenings, diabetes food boxes, workforce development and employment counseling services, enhanced transportation services, and free school physicals.
  • The IMCE will provide members with comprehensive access to a statewide provider organization network in New Mexico. The network will include primary care, specialists, hospitals, core service agencies, and will also allow members to have direct access to Indian Health Services facilities and professionals.

A link to the full text of Navajo Nation Legislation titled, “An Action Relating To Health, Education & Human Services & Naabik’íyáti’ Committee To Launch The Naat’áanii Development Corporation – Molina Healthcare, Inc. Indian Managed Care Entity” can be viewed online at  (accessed January 20, 2020).

For more information, contact:

  • Robert Joe, MEB, Interim Chief Executive Officer, Naat’áanii Development Corporation, Post Office Box 4560, Window Rock, Arizona 86515, Phone: 520-301-8111
  • Mellor C. Willie, Public Affairs, Naat’áanii Development Corporation, Post Office Box 4560, Window Rock, Arizona 86515, Phone: 505-870-2006, Email:
  • Caroline Zubieta, Director of Public Relations, Molina Healthcare, Inc., 200 Oceangate, Suite 100, Long Beach, California 90802, Phone: 562-951-1588, Email:, Website:
  • Jodi McGinnis Porter, Director of Communications, External Affairs, New Mexico Human Services Department, Post Office Box 2348, Santa Fe, New Mexico 87504, Phone: 505-476-7203, Fax: 505-827-6286, Email:, Website:
  • Theresa Belanger, Acting Native American Liaison, New Mexico Human Services Department, Post Office Box 2348, Santa Fe, New Mexico 87504, Phone: 505-827-3122, Email:, Website:
  • Megan Pfeffer, Deputy Director, New Mexico Department of Health, 1190 South Saint Francis Drive, Santa Fe, New Mexico 87505, Email:, Website:
  • David Morgan, Media & Social Media Manager, Office of the Secretary New Mexico Department of Health, 1190 South Saint Francis Drive, Santa Fe, New Mexico 87505, Phone: 575-649-0754, Email:, Website:

On December 11, 2019, Blue Cross Blue Shield of Michigan (BCBSM) announced a new “Blueprint for Affordability” payment model. Under the model, seven preferred provider organizations (PPOs) that provide care to BCBSM members will share financial risk for consumer care and consumer outcomes.

The risk-sharing agreements became effective January 1, 2020 and cover Blue Cross Commercial PPO and Medicare Advantage PPO plans. “Blueprint for Affordability” participating organizations represent approximately 30% of the state’s total Commercial PPO and Medicare Advantage market. The seven PPOs include:

  • Ascension Michigan (Genesys Provider Health Organization physician-hospital organization (PHO), Partners in Care, St. Mary’s PHO)
  • Henry Ford Health System
  • Michigan Medicine
  • Oakland Southfield Physicians
  • The Physician Alliance
  • Trinity Health – Michigan (Saint Joseph Mercy Health System, Mercy Health, Mercy Health Physician Partners, Integrated Healthcare Associates)
  • United Physicians

The goals of the Blueprint for Affordability payment model include: improve quality of care; avoid unnecessary tests, scans, and emergency room visits; reduce complications and rehospitalizations; and better coordinate consumer care across all points of service. Under the model, health systems and physician organizations agree to annual targets for the cost of providing care to Blue Cross members. Aggregate costs that come in below those financial targets will result in financial rewards for the provider organizations involved. If costs cannot be managed within the target, the provider organization will rebate Blue Cross, and ultimately its consumers, a portion of the amount spent beyond the target. This enables costs to be predictable for Blue Cross customers, and encourages the provider organizations to improve care delivery cost, quality, efficiency, and coordination.

For more information, contact: 

  • Meghan O’Brien, Public Relations & Social Media Manager, Blue Cross Blue Shield of Michigan
    600 East Lafayette Boulevard, Detroit, Michigan 48226-2927, Phone: 313-549-9884, Email:, Website:

Approximately 87.8% of workers with disabilities had health insurance in 2017. This was a 7.9 percentage point increase from 79.9% in 2009, prior to the implementation of the Patient Protection and Affordable Care Act (PPACA). Despite coverage gains, cost-related barriers to accessing medical care did not change much after the PPACA for any group. Workers with disabilities experienced an increase in structural access barriers, from 18.4% before PPACA to 24.8% after PPACA. People with disabilities are defined as those who report being limited in the type or amount of work they can perform due to a physical, mental, or emotional problem.

The increase in health insurance for workers with disabilities was the result of an 11 percentage point increase in the share of that population with Medicaid coverage between 2014 and 2017 (compared with 2001 through 2009), and a five percentage point increase in privately purchased coverage over those periods. These increases were accompanied by an 11 percentage point decline in the share with employer-sponsored coverage.

Researchers concluded that the gain in insurance coverage for workers with disabilities is an important benefit of the PPACA. However, they recommended more investigation and monitoring to understand whether PPACA coverage will translate into improvements in access to needed health care.

These findings were reported in “Insurance Coverage And Access To Care For Workers With Disabilities, 2001–2017” by Anna Hill, M.H.A., Ph.D.; and Jody Schimmel Hyde, Ph.D. The researchers analyzed data from 2007 through 2017 from the National Health Interview Survey. The goal was to determine how PPACA changed insurance coverage and access to care for workers with disabilities, and compare those changes to changes among other groups.

The full text of “Insurance Coverage And Access To Care For Workers With Disabilities, 2001–2017” was published in January 2020 by Disability and Health Journal. An abstract is available online at (accessed January 20, 2020).

For more information, contact:

  • Jody Schimmel Hyde, Ph.D., Researcher, Mathematica Policy Research, 1100 First Street Northeast, 12th Floor, Washington, District of Columbia 20002, Email:, Website:

On January 1, 2020, Indiana implemented a Medicaid waiver amendment that will allow the state to receive reimbursement for short-term services for people age 19 to 64 with serious mental illness (SMI) who are treated at privately run institutions for mental disease (IMD). The waiver excludes treatment provided at Indiana’s six state-operated psychiatric hospitals. This waiver amendment augments an earlier waiver approved on February 1, 2018, that allows the Indiana Family and Social Services Administration (FSSA) to reimburse for inpatient treatment in private IMDs for Medicaid members with a primary diagnosis of an addiction disorder. FSSA implemented that waiver’s IMD provisions in early 2018, and according to an interim evaluation released in October 2019, by the end of calendar year 2018, there were 17 Medicaid-enrolled IMDs that provided addiction treatment to 4,026 beneficiaries. Without the waivers, Medicaid statutes prohibit federal reimbursement for services provided in an IMD, which is defined as any hospital, nursing facility, or other institution with more than 16 beds that provides treatment primarily for people with mental illness.

Under this new waiver amendment, the IMD services will be covered for beneficiaries with SMI who are primarily receiving withdrawal management services or short-term inpatient or residential treatment for an addiction disorder. The goal is to create consistency in treatment for the 25% of beneficiaries with SMI with a co-occurring addiction disorder.

FSSA can claim federal financial participation (FFP) for individual stays of up to 60 days, as long as by a mid-point assessment at December 31, 2022, the state can show that the average length of stay (ALOS) is 30 days or less. If the state does not meet the ALOS target by the assessment, FSSA will only be able to claim FFP for stays of up to 45 days until it meets the ALOS target.

Special terms and conditions (STCs) of the waiver require FSSA to ensure that psychiatric hospitals provide intensive pre-discharge, care coordination services to help beneficiaries transition into appropriate community-based outpatient services. The STCs include the following requirements:

  • Involve community-based provider organizations in transition efforts, such as allowing initial contact with a community-based provider organization while the beneficiary is still at the IMD, or by hiring peer support specialists to help beneficiaries connect with available community-based provider organizations and make plans for employment.
  • Assess the housing situation of a beneficiary transitioning to the community, and connect those who are homeless or who have unsuitable or unstable housing with provider organizations that coordinate housing services.
  • Require psychiatric hospitals to have protocols in place to ensure contact is made by the treatment setting with each beneficiary within 72 hours of discharge, and ensure follow-up care is accessed by those individuals by contacting them directly and by contacting the community-based provider organizations to which they were referred.
  • Implement strategies to prevent or decrease the length of stay in emergency departments (EDs) among beneficiaries with SMI/serious emotional disturbance (SED) or SED. This could include the use of peers and psychiatric consultants in EDs to help with discharge and treatment referral.
  • Develop and enhance interoperability and data sharing between disparate physical, addiction treatment, and mental health provider organizations to enhance coordination and improve clinical outcomes for beneficiaries with SMI/SED or SED

The STCs require FSSA to increase access to a continuum of care, including crisis stabilization services by doing the following:

  • Establish a process focused on crisis stabilization services to annually assess the availability of mental health services throughout the state. The assessment must provide updates on steps taken to increase availability.
  • Commit to implementing the SMI/SED financing plan included in the approved waiver.
  • Improve the state’s capacity to track available inpatient and crisis stabilization beds to help connect individuals in need with that level of care as soon as possible.
  • Require provider organizations, plans, and utilization review entities to use an evidence-based, publicly available consumer assessment tool, preferably endorsed by a mental health provider organization association to determine appropriate level of care and length of stay.

Further, FSSA must implement strategies to facilitate earlier identification and engagement in treatment for those with SMI/SED or SED, as follows:

  • Identify and engage adolescents and young adults in treatment earlier through supported employment and education programs.
  • Increase integration of behavioral health care in non-specialty care settings including schools and primary care practices, to improve early identification and improve awareness of and linkages to specialty treatment provider organizations.
  • Establish specialized settings and services, including crisis stabilization services, focused on the needs of young people.

The intent of the waiver amendment is to shift services for beneficiaries with SMI from less appropriate settings to facilities such as hospitals and larger mental health treatment facilities. As a result, FSSA anticipates that costs related to lack of access to appropriate care settings and overuse of the emergency department for mental health problems and psychiatric crises will decrease. The IMD services will be for eligible individuals with SMI who are primarily receiving short-term treatment and withdrawal management services.

FSSA had submitted the “SMI/SED Amendment Request for the Healthy Indiana Plan (HIP) Section 1115 Waiver (Project Number 11-W-00296/5)” on June 24, 2019. FSSA data indicates that in state fiscal year 2019, about half of Indiana’s traditional Medicaid members receiving inpatient psychiatric services received them at an IMD.

For more information, contact:

  • Jim Gavin, Director of Communications and Media, Indiana Family and Social Services Administration, 402 West Washington Street, W461, Indianapolis, Indiana 46204-2739, Phone: 317-234-0197, Fax: 317-233-4693, Email:, Website:

On January 1, 2020, Optum Maryland went live as the administrative services organization (ASO) for the Maryland public behavioral health system, replacing Beacon Health Options. The contract, valued at $198 million, has a five-year base period, followed by one two-year option. The ASO is responsible for managing behavioral health services for individuals with Medicaid eligibility, as well as certain uninsured and grant-funded individuals. The ASO also will manage the provider organization network and service utilization for the Applied Behavioral Analyst (ABA) program for children and youth with autism.

The Maryland Department of Health (MDH) released the request for proposals (RFP MDH/OPASS 20-18319) on November 29, 2018, seeking an ASO for the state’s public behavioral health system. The ASO manages behavioral health authorizations, utilization control, claims processing, health care professional education, training, compliance, and auditing functions. The ASO also provides reimbursement for recovery and support services, including mental health case management, mobile treatment/assertive community treatment, psychiatric rehabilitation, residential rehabilitation, supported employment, rehabilitation services, and specific addiction treatment services.

By the due date of January 22, 2019, MDH had received proposals from Optum Maryland and Beacon Health Options. Optum’s total evaluated bid price of $188.4 million was 27% lower than Beacon’s evaluated bid price of $260.5 million. MDH ranked Optum’s technical proposal higher than Beacon’s. The contract was approved by the Maryland Board of Public Works on July 24, 2019.

The award amount and total evaluated price are different. The total evaluated price was based upon a model for firm fixed prices for the six different parts of the contract:

  1. Implementation
  2. Medicaid enrollees
  3. Non-Medicaid services
  4. Cost-based pool
  5. Provider organization quality incentive pool
  6. Optional features or services

For evaluation purposes, the optional features or services were weighted at 20%. However, MDH included the full amount of the optional features or services in the award amount, based on the decision to accept those features and services into the contract. Three major optional services outlined in the contract are provider quality incentives, flexible funds for specialty services not otherwise covered, and developing the crisis response system. All three optional services would require additional budget initiatives and utilize Optum’s national and Maryland-specific experience. These initiatives will largely be informed by the work MDH has done in its System of Care Workgroup with managed care organizations and behavioral health provider organizations.

For more information, contact:

  • Deidre McCabe, Director of Communications, Maryland Department of Health, 201 West Preston Street, Baltimore, Maryland 21201-2399; 410-767-3536; Email:; Website:
  • Gwen Holliday, External Communications, Optum, 11000 Optum Circle, Eden Prairie, Minnesota 55344; 202-549-3429; Email:; Website:
  • Chris Curran, Brand Strategy, Beacon Health Options, 200 State Street, Boston, Massachusetts 02109; 857-243-0472; Email:; Website:

During the last decade, the number of states that have moved to include behavioral health in their Medicaid health plan contracts has almost doubled. In 2011, only 15 (25%) states included behavioral health in their health plan contracts. And, at that time, 29 states (48%) had a primary Medicaid behavioral health carve-out.


Currently, 31 states have included behavioral health in their health plan contracts and 17 states (28%) have a primary Medicaid behavioral health carve-out (i.e., primary carve-out to a Medicaid fee-for-service or care management organization). Approximately 34.9 million (48%) of the 72.8 million Medicaid beneficiaries are enrolled in Medicaid health plans with integrated behavioral health financing, according to a new report, State Medicaid Behavioral Health Carve-Outs: The OPEN MINDS 2020 Annual Update. And another 3 million (6% of total Medicaid beneficiaries) are enrolled in vertical consumer-specific specialty carve-out plans for individuals with serious mental illness.

In the last year, there have been a few interesting developments. One state, Washington, completed the transition to integrated financing from a traditional specialty carve-out (see Washington State To Launch Behavioral Health System Transformation). Additionally, integration efforts in three states with traditional specialty carve-outs stalled or ended. North Carolina suspended the move to integrated financing indefinitely. And, Michigan cancelled integrated financing pilots due to disagreements over the model but is working to implement specialty integrated plans (see Michigan Cancels Behavioral Health Integration Pilots). Finally, Pennsylvania’s integration efforts ended before the state proposed an official plan.

So what does the integration of behavioral health in Medicaid health plans look like? Ohio’s system provides a good example. In 2018, Ohio officially integrated behavioral health financing into Medicaid health plans. As a result, Medicaid beneficiaries’ traditional and specialty behavioral health services are provided by one of the five health plans.

Strategies for behavioral health provider organizations serving Medicaid beneficiaries are dependent on the state Medicaid plan’s decisions about behavioral health benefits – and the selection of primary contractors that control the Medicaid behavioral health spending. Medicaid plans are now relying on health plans and provider organizations to make integrated care coordination models work and deliver comprehensive behavioral health services. Going forward, it is important to consider how health plan policies, procedures, and financial alignment initiatives differ by state.


On December 23, 2019, Kentucky Governor Andy Beshear announced the cancellation of the state’s five Medicaid managed care contracts, valued at approximately $8 billion. The contracts had been awarded by Governor Beshear’s predecessor, then-Governor Matt Bevin on November 26, 2019. However, on December 7, the last day of Governor Bevin’s tenure, members of the State’s Government Contract Review Committee unanimously voted to reject those contracts. According to Governor Beshear, the contracts were cancelled due to concerns about how the award process was handled. Governor Beshear also ended the 1115 Medicaid waiver that required Kentuckians to meet certain work or volunteer requirements to have health care coverage.

The contracts will be rebid in January 2020. In the meantime, Medicaid managed care plans currently operated by Anthem, Aetna Better Health of Kentucky (formerly Coventry Cares), Humana, Passport Health Plan, and WellCare will remain in effect. About 1.3 million beneficiaries are enrolled in one of the Medicaid managed care plans.

The now-cancelled contracts were awarded in November 2019 to five Medicaid managed care organizations (MCOs): Aetna Better Health of Kentucky, Humana Health Plan, Inc., Molina Healthcare of Kentucky, UnitedHealthcare, dba, UnitedHealthcare Community Plan of Kentucky, and WellCare Health Insurance of Kentucky. The contracts were scheduled to start on July 1, 2020, running more than 15 years. The plans were at-risk for all Medicaid physical health, behavioral health, and pharmacy services. Both Anthem and Passport Health Plan filed protests over the November awards.

For more information, contact: Office of Public Affairs, Kentucky Cabinet for Health and Family Services, 275 East Main Street, Frankfort, Kentucky 40621; 502-564-7042; Website:

New technologies, changing reimbursements, and corporate consolidations are amongst the many drivers evolving the health care landscape.1 During this webinar archive, the speakers discuss strategies for future sustainability in ever-changing industry.


  • Kimberly Bond
    Senior Associate, OPEN MINDS
  • Paul Duck
    Senior Associate, OPEN MINDS

Kimberly Bond brings over thirty years of experience providing behavioral health treatment in the public and community settings to the OPEN MINDS team. She currently serves as the Executive Vice President of Business Development and Marketing. Prior to joining OPEN MINDS, Ms. Bond served concurrently as a Program Coordinator III and Clinical Manager of Adult Services and a Program Coordinator II and Clinical Manager of Recovery Services for the Ozark Guidance Center. In these roles, Ms. Bond was responsible for the administrative and clinical oversight of the adult outpatient and adult intensive mental health services on the Springdale Campus and the adult recovery/co-occurring services, including domestic violence and anger management treatment as well as treatment services for Drug Court.

Paul Duck currently serves as a Senior Associate at OPEN MINDS. He brings over 40 years of experience in leadership and management focusing on managed care, health information technology organizations, strategy, business development and market expansion, and customer experience optimization to the OPEN MINDS team. Previously, Mr. Duck has served in roles such as Vice President, Strategy & Development for Beacon Health Options, the Vice President of Business Development for Netsmart Technologies, and Chief Executive Officer for Coastal Orthopedics. Mr. Duck earned his Bachelor of Arts in Business Management from Case Western Reserve University.  He earned his Associate of Arts in Electronic Engineering Technology from the Electronic Technology Institute.

New technologies, changing reimbursements, and corporate consolidations are amongst the many drivers evolving the health care landscape.1 During this webinar archive, the speakers discuss strategies for future sustainability in ever-changing industry.


  • Kimberly Bond
    Senior Associate, OPEN MINDS
  • Paul Duck
    Senior Associate, OPEN MINDS

Kimberly Bond brings over thirty years of experience providing behavioral health treatment in the public and community settings to the OPEN MINDS team. She currently serves as the Executive Vice President of Business Development and Marketing. Prior to joining OPEN MINDS, Ms. Bond served concurrently as a Program Coordinator III and Clinical Manager of Adult Services and a Program Coordinator II and Clinical Manager of Recovery Services for the Ozark Guidance Center. In these roles, Ms. Bond was responsible for the administrative and clinical oversight of the adult outpatient and adult intensive mental health services on the Springdale Campus and the adult recovery/co-occurring services, including domestic violence and anger management treatment as well as treatment services for Drug Court.

Paul Duck currently serves as a Senior Associate at OPEN MINDS. He brings over 40 years of experience in leadership and management focusing on managed care, health information technology organizations, strategy, business development and market expansion, and customer experience optimization to the OPEN MINDS team. Previously, Mr. Duck has served in roles such as Vice President, Strategy & Development for Beacon Health Options, the Vice President of Business Development for Netsmart Technologies, and Chief Executive Officer for Coastal Orthopedics. Mr. Duck earned his Bachelor of Arts in Business Management from Case Western Reserve University.  He earned his Associate of Arts in Electronic Engineering Technology from the Electronic Technology Institute.

From 2013 to 2017, the Medicare Shared Savings Program (MSSP) generated $755 million in net savings to the Centers for Medicare & Medicaid Services (CMS). Net savings are the total savings ACOs produce, minus what CMS pays to accountable care organizations (ACOs) for reaching spending targets and quality measures. The MSSP includes 518 ACOs.

Additional findings include:

  • From 2013 to 2017, gross savings from ACOs was $3.5 billion.
  • Gross federal savings in the MSSP have increased every year that was studied. In 2013, ACOs delivered $357 million in gross savings for CMS; however, that number reached $930 million in 2017.

The analysts concluded that the over-time MSSP savings continue to increase. These savings translate to an approximate 1% to 2% savings over time, compared to spending in unattributed beneficiaries.

These findings were reported in “2017 Update: MSSP Savings Estimates; Program Financial Performance 2013-2017” by researchers with Dobson, DaVanzo & Associates. The report was commissioned by the National Association of Accountable Care Organizations (NAACOs). The researchers analyzed public files from CMS. They also built on previous analysis by adding data on provider organization participation and spending, for both assigned and unassigned Medicare beneficiaries. The goal was to present MSSP Performance Year 2017 ACO savings estimates.

The full text of “2017 Update: MSSP Savings Estimates; Program Financial Performance 2013-2017” was published December 3, 2019 by the National Association of Accountable Care Organizations. A copy is available online at (accessed December 23, 2019).

PsychU last reported on this topic in “Physician-Led ACOs Generated Almost 7 Times More Savings Than Hospital-Led ACOs,” which published on December 2, 2019. The article is available at

For more information, contact:

  • Dobson, DaVanzo & Associates, LLC., 450 Maple Avenue East, Suite 300, Vienna, Virginia 22180; 703-260-1760; Email:; Website:
  • David Pittman, Health Policy and Communications Advisor, National Association of Accountable Care Organizations, 601 13th Street Northwest, Suite 900 South, Washington, District of Columbia 20005; 202-640-2689; Email:; Website:

The Michigan Department of Health and Human Services (MDHHS) proposed integrating Medicaid physical and behavioral health services through new statewide specialty integrated plans (SIPs). SIPs will replace the state’s current behavioral health carve-out.

The proposal was released on December 4, 2019 in an MDHHS fact sheet, “Michigan DHHS Future of Behavioral Health Fact Sheet & FAQ.” Currently, Medicaid beneficiaries with significant behavioral health needs or developmental disabilities have two managed care plans, a Medicaid health plan (MHP) for physical health and a prepaid inpatient health plan (PIHP) for behavioral health.

The SIPs will be provided by qualified managed care entities including health plans, provider organizations, hospitals, public behavioral health authorities, or new partnerships between these organizations. MDHHS intends to seek public input on application requirements to ensure that each organization has the needed expertise and commitments. They will receive a capitated risk-based payment for every enrolled member. The SIP will provide all services currently provided through the MHP and PIHP systems, including support services and investments to address social determinants of health, not just traditional medical services. In this model, non-Medicaid safety net behavioral health services for any Michigander in need will continue to be funded and managed through the Community Mental Health Services programs (CMHs). MDHHS intends to ensure that a clearly defined set of core CMH services will be available everywhere with separate dedicated funding to support the services.

MDHHS developed the new proposal after negotiations collapsed in October 2019 on pilots for a financial integration model. The pilots were called the Section 298 model (named for a section of the state budget) in which the state sought to include individuals with behavioral health needs in the MHPs, which would have managed all funds and have responsibility for care management. The new SIP concept differs from the Section 298 model in that it establishes new entities that combine the skills of the MHPs and the expertise and enhanced services of behavioral health organizations. In the new plan, a more diverse set of organizations will have the opportunity to lead. At least one plan is expected to be led by the public behavioral health authorities.

During January 2020, MDHHS will schedule four open forums to solicit public comment. MDHHS will work with the legislature to identify needed statutory changes and pass any necessary bills. Design decisions will be made through a collaborative process with provider organizations, payers, and consumers.

PsychU last reported on this topic in “Michigan Cancels Behavioral Health Integration Pilots,” which published on December 16, 2019. The article is available at

For more information, contact: Lynn Sutfin, Public Information Officer, Michigan Department of Health and Human Services, Post Office Box 30195, Lansing, Michigan 48909; 517-284-4772; Email:; Website:,5885,7-339-71550_2941_96949—,00.html.

Making the new gainsharing, value-based partnerships between health plans and provider organizations work requires changes from both parties, and a clear understanding of what success requires. This discussion was prompted by a new report from Harvard and UnitedHealthcare with a three-dimension framework for building these new payer/provider partnership relationships.

The framework is built on performance incentives for cost reduction, performance incentives for consumer outcomes improvement, and the provider infrastructure needed to make value-based reimbursement (VBR) work. For provider organization executives to succeed in these new relationships, that ‘provider infrastructure’ brings a few key requirements – shared data, increased care management capacity, collaborative and innovative program design, and organizational evolution and leadership.

Shared data is front and center along with providing care coordination tools for provider organization partners. But, having the data and tools is not enough for success. Provider organizations need to develop care management skills to ensure access, improve consumer outcomes, and develop a value equation (the balance between performance improvement and cost reduction). While there is ongoing contention about the responsibility for care coordination, the more provider organizations are at financial risk, the more robust provider-led care coordination is essential.

Another issue is innovation. Most executives of provider organizations that have active risk-based (particularly case rates and sub-capitated arrangements) reimbursement arrangements cite the ability to do something new and creative to improve consumer outcomes as the greatest benefit of VBR. These new provider-payer organization relationships can facilitate innovative program development by providing financial upside through aligned goals.

Finally, there is the issue of organizational change and the leadership required to implement it. Delivering on VBR requires an entirely different type of organization. Every detail of the day-to-day running of provider operations needs to be reconfigured to succeed with VBR, which is why a leadership commitment is so essential. And, many times, new approaches to care are required along with an enhanced tech infrastructure to ensure that data can be tracked and used in actionable ways. He advises executive teams to assess their capacity for success early on and ask about a range of organizational competencies – including intake and eligibility determination systems, care managers who can conduct concurrent reviews, and the ability to collect deductibles and copayments.

The move to value-based care is changing the relationship between health plans and provider organizations. Ultimately, the relationships that are most successful will have leaders (on both sides of the equation) who understand that the commodity-oriented network model of the past is (slowly) being replaced by mutually-dependent partnerships. To learn more about preparing for VBR, check out the following resources in the PsychU Resource Library:

  1. VBR @ Scale—Changes Required
  2. Crawl, Walk, Run To VBR

 Adoption of value-based reimbursement (VBR) models is glacial—slow to occur but changing the delivery system in its wake. It’s an issue we’ve written about before — VBR @ Scale—Changes Required, and Preparing For The Very Glacial VBR Rollout In Some Markets and will continue to help health and human service organizations find their footing. In the field, two different conversations are happening: Health plan executives talk about the lack of readiness of provider organizations while managers of provider organizations talk about the difficulty in moving VBR proposals forward with health plan customers. How do we make these partnerships evolve more smoothly? I think observations and advice from Alyna T. Chien, M.D., MS, Harvard Medical School, and Professor Meredith B. Rosenthal, Harvard T.H. Chan School of Public Health in the report, A 3D Model For Value-Based Care: The Next Frontier In Financial incentives And Relationship Support1 provide a great foundation for that discussion.

The authors present a three-part framework for considering the health plan shift to VBR – financial incentives for reduced spending, financial incentives for improving quality, and infrastructure support for their partner provider organizations. Their infrastructure support includes performance management information (both access to raw data and analyzed data), limitations on financial exposure from risk contracts, care coordination tools, technical assistance, and infrastructure payments.

What is interesting is that these were the very issues brought up by provider organization executives during a session at the 2019 OPEN MINDS Executive Leadership Retreat. Access to data and limitation on financial downside were high on the list.

To make this three-dimensional model for VBR a reality, there are some specific actions that managers in health plans, accountable care organizations, and state and county government can take. Two key issues stood out as potentially having the greatest impact: Increasing the amount of revenue tied to VBR and aligning performance measures across payer contracts.

One of the common concerns from provider organization executives is that the upside in the value-based contracts is not enough to justify infrastructure expenses. This is a fiscal reality at two levels in any individual payer contract. Is the incremental increased revenue of quality-based performance bonuses or shared financial savings enough to justify new operating infrastructure? Second is the volume of consumers served great enough to warrant dedicated service capacity (it’s addressing that ‘one foot in two canoes’ issue that provider organization managers face).

OPEN MINDS Senior Associate Drew Digiovanni urges industry members to walk before they run with VBR contracts that include financial risk:

Establish a pathway for providers who are entering into VBR agreements for the first time. Assess their abilities and offer limited performance measures in the first year to help them ramp up for success, before entering into more robust risk contracts.

The other issue is one that comes up every year during the OPEN MINDS Performance Management Institute – can’t health plans get together and agree on the same performance measures? From the provider organization perspective, almost every VBR-based contract is a ‘one off’ with different measures that have different definitions.

Admittedly, the adoption of NCQA HEDIS and CMS STARS are starting to create some “standardization” of measures, but provider organization managers need very flexible (and very expensive to maintain) performance reporting tools that can be customized for each contract. Almost any initiative to standardize measures would be welcome on the service delivery side of this equation.

Moving forward, how do health plan executives make their provider partnerships a success, sooner rather than later? OPEN MINDS Senior Associate Paul M. Duck suggests that transparency and investments in technology need to be front and center in VBR discussions:

Provider and payer organizations benefit from technology implementation. If a tool like a telepsychiatry platform is implemented, the payer benefits by increasing access to care, which lowers costs and prevents emergency room admissions. Provider organizations benefit by delivering a new service, which opens the door for additional revenue. It expands access for a larger population and delivers services in places where a group might not have a physical presence, such as rural communities. In other words, it’s a win-win.

For more on the path to VBR, check out:

  1. Current Insights Into Population Health Management Value-Based Models In Managing High-Risk, High-Cost Patients
  2. Structuring (& Budgeting For) Analytics


“Show don’t tell” is one of the first lessons journalists learn and one that’s increasingly applicable to executives of health care organizations. The increasing use of value-based contracts is changing communication between provider organizations and health plans to focus on data. Yet few executive teams harness their data in actionable ways judging by the discussion during the “Building A Data Infrastructure For Performance Management” town hall discussion at The 2019 OPEN MINDS Technology & Informatics Institute.

“With value-based purchasing, it’s even more essential for providers to understand spending patterns at the consumer level,” said Susanna Kramer, director of performance evaluation at Community Behavioral Health, a Philadelphia-based managed behavioral health organization. She stressed that using data in actionable ways is essential for success with case rates. Organizations need to identify how to optimize service delivery—the most effective processes, how to handle consumers who regularly reschedule or no-show, the best way to match consumer needs with treatment, and more—“so you can predict what your case rate payments are and what shared savings may amount to.”

Consensus from these three panelists was that provider organization managers need to understand utilization and costs to negotiate reimbursement rates and terms: Ms. Kramer provided a health plan perspective; Karen Fridg, director of EHR systems for Community Intervention Services Inc., offered a provider organization perspective; and Jaclyn O’Donnell, executive vice president for Credible Behavioral Health Software, gave a technology vendor’s perspective.

Understanding customer performance perspectives—This process starts with understanding performance expectations to improve success. “It’s key for provider organization executives to know exactly how they’re being assessed” and use those measures to improve care delivery and efficiency, said OPEN MINDS Senior Associate Joe Naughton-Travers. While most measures focus on processes, not outcomes, and reports are not public for now, executives who seek to build or retain a competitive edge understand what payers want, create data-driven cultures, and speak openly about how to improve their numbers. “We are very interested in understanding what payers are looking for and what constitutes quality of care,” said Ms. Fridg.

Start with actionable metrics—Identify a few metrics and assemble a small committee to review data and identify anomalies and solutions, Ms. O’Donnell suggested. While there’s no magic number of metrics, teams should seek metrics that are strategic and companywide. “You want to limit what you’re looking at to ensure that what you’re collecting is meaningful, informs changes, and how we look at staff,” she said.

It’s important to balance the number of metrics with diversity of delivery and service provision, added Ms. Kramer with a nod to the unique aspects of behavioral health. “It’s not like a knee operation where you know the surgery was a success because the knee healed or [the consumer] followed expected patterns of rehabilitation. However, we try to limit most providers to around three financial and quality targets outside fee-for-service (FFS) and value-based reimbursement (VBR) purchasing standards that they are required to meet.”

Start with what you have and make sure the data you’re collecting is actionable, she added. “You don’t need to have a shiny dashboard, which is great, but you can start with basic reporting. Create habits of using data and give in to that cadence. There are things you can do each day, each week to lay the framework to make that more manageable.”

Ms. Fridg agreed. “It’s never too soon to start talking about what your goals and expectations are, to see what data you have, and ask how you can utilize what’s already there.” Begin the conversation with your leadership team, start with a small set of metrics, and use that experience to develop the process of implementing from beginning to end. Then repeat the process as you identify and prioritize additional measures.

Her organization created metrics with a multidisciplinary team that sees monthly reports for the performance of its six affiliated organizations. It started with a scorecard created by the chief executive officer with more than 200 metrics in four domains (clinical, finance, people, and growth). The clinical team then selected three key metrics deemed to be most meaningful and actionable.

Being data-driven requires internal transparency—Making data visible and public was an important step for the Community Intervention Services team. Selected performance metrics were used to create standardized dashboards and presented organization-wide during monthly meetings, which allowed each team to benefit from the experience and success of others. “Managing by metrics has proven to be very effective” because it informs team members about their status and how to improve, said Ms. Fridg.

This type of transparency is key to gaining staff buy-in, said Ms. O’Donnell, who explained that more than half the company’s partners use a business intelligence reporting tool that allows organization-wide data sharing. “The ones who are most successful make data transparent, they build a data culture and show that data is not to be feared.” Her advice: Acknowledge failures but focus on lessons learned and steps to improve. “You use it like a tool,” she added.

Townhall panelists wrapped up the session with a discussion of organizational competency in measuring performance, driving performance improvement, and public transparency of data. Improving operational efficiencies and clinical outcomes, regardless of reimbursement model, was at the top of their list for areas of focus but they all agreed that value-based reimbursement will increasingly drive strategy. On the transparency side, health plans and third parties are making provider organization performance and fee information public. This will emphasize the importance of data and the need for a data-driven culture will rise to a whole new level.

Get more information on using data for strategic success with these PsychU resources:

  1. The Age Of Priceline Health Care
  2. Is ‘Unblackboxing’ The Key To Reducing Health Care Costs?
  3. Why Guidelines Matter
  4. How Do You Measure Access?

On November 25, 2019, the Centers for Medicare and Medicaid Services (CMS) Innovation Center released a request for applications (RFA) for its “Direct Contracting” initiative. For this initiative, CMS is inviting health care professionals to participate in Direct Contracting agreements with CMS. Direct Contracting is a set of three voluntary payment model options aimed at reducing expenditures and preserving or enhancing quality of care for beneficiaries in Medicare fee-for-service (FFS). The payment model options available under Direct Contracting test new risk- sharing arrangements to produce value and high quality health care. Direct Contracting model options build on lessons learned from initiatives involving Medicare accountable care organizations (ACOs), such as the Medicare Shared Savings Program (MSSP) and the Next Generation ACO (NGACO) Model, and approaches from Medicare Advantage and private sector risk-sharing arrangements.

The Direct Contracting RFA seeks direct contracting entities (DCEs) to participate in direct contracting through two models: professional payment models, and global payment models. These two models will start with an initial implementation period in 2020 with a five-year performance period that begins in 2021. More information about a third model, the geographic model, will be released during 2020.

DCEs are similar to Medicare Advantage plans and ACOs in that the DCEs are risk-bearing entities managing the care of a panel of Medicare beneficiaries. However, similar to an ACO, the DCEs will manage only FFS Medicare beneficiaries. Like a Medicare Advantage plan, the DCEs will receive upfront, at-risk, capitated payments to pay their downstream provider organizations and suppliers for services, allowing the DCE to better coordinate care delivery. The DCEs’ financial methodology uses a benchmark based on the Medicare Advantage rate book; the DCEs also have a new risk-adjustment strategy that mitigates coding intensity and improves the accuracy of risk adjustments for complex, high-risk beneficiaries.

Applications will be accepted through February 25, 2020. In the spring of 2020, CMS will release an application for organizations interested in starting in the first performance year. Direct Contracting aims to reduce administrative burden, support a focus on complex, chronically ill beneficiaries, and encourage organizations to participate that have not typically participated in Medicare FFS or CMS Innovation Center value-based models.

Direct Contracting is part of the Medicare Primary Cares Initiative announced in April 2019. Direct Contracting is a six-year demonstration with three contracting options that will begin in January 2020. The other Primary Cares Initiative is called Primary Care First, a five-year multi-payer demonstration with two options that will also begin in January 2020.

The DCE must be a legal entity that contracts with Direct Contracting participant provider organizations, an entity that is a Medicare-enrolled provider organization or supplier and is identified by CMS as a participant provider organization. Current Medicare ACOs interested in continuing and deepening their participation in Medicare risk arrangements will be eligible to participate in all three Direct Contracting payment model options. The DCE may also contract with preferred provider organizations and professionals, entities that are Medicare-enrolled provider organizations or suppliers and are identified by CMS as Direct Contracting participant provider organizations.

Direct Contracting participants may include, but are not limited to, physicians or other clinical professionals in group practices; networks of individual practices of physicians or other clinical professionals; and hospitals employing physicians or other clinical professionals. A DCE is not required to be a Medicare-enrolled provider organization or supplier in order to apply to participate in Direct Contracting; however, each participant and preferred provider organization under the DCE must be a Medicare-enrolled provider organization or supplier by no later than June 30, 2020.

There will be three types of DCEs:

  • Standard DCEs are comprised of organizations that generally have experience serving Medicare FFS beneficiaries, including dual eligible beneficiaries. These organizations may have previously participated in section 1115A models involving shared savings or the Shared Savings Program. New organizations composed of existing Medicare FFS provider organizations and suppliers may be created in order to participate as this DCE type. Beneficiaries will be aligned to Standard DCEs through voluntary alignment and claims-based alignment.
  • New Entrant DCEs are organizations that have not traditionally provided services to a Medicare FFS population and that will primarily rely on voluntary alignment. Claims-based alignment will also be utilized.
  • High Needs Population DCEs serve Medicare FFS beneficiaries with complex needs, including dual eligible beneficiaries, who are aligned to the DCE through voluntary alignment or claims-based alignment. These DCEs are expected to use a model of care designed to serve individuals with complex needs, similar to the Programs of All-Inclusive Care for the Elderly (PACE), to coordinate care for their aligned beneficiaries.

There are two voluntary risk-sharing payment model options, as well as a third payment model option for which CMS will release more information later this year. Additional information about the two risk-sharing models is as follows:

  • Professional offers the lower risk-sharing arrangement and provides Primary Care Capitation, a capitated, risk- adjusted monthly payment for enhanced primary care services.
  • Global offers the highest risk-sharing arrangement and provides two payment options: Primary Care Capitation or Total Care Capitation, capitated, risk-adjusted monthly payment for all services provided by DPC participants and preferred provider organizations with whom the DCE has an agreement.

CMS will link a meaningful percentage of the DCE benchmark to performance on quality of care to help ensure that care quality improves and beneficiary choice and access are protected. CMS will also monitor to ensure that beneficiaries’ access to care is not adversely affected as a result of the model. With the new payment model options, CMS seeks to test novel methods for organizations to manage Medicare FFS expenditures.

For more information, contact: Direct Provider Contracting, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Email:; Website:

On October 30, 2019, the Tennessee Division of TennCare released a request for information (RFI 31865-00702) seeking comments regarding its plans for the next statewide Medicaid managed care re-procurement. The Division is preparing to rebid its Medicaid managed care organization (MCO) contracts. Responses to the RFI were due by November 22, 2019. The current MCO contract expires on December 31, 2020. The state did not indicate when during 2020 the TennCare RFP might be released.

The RFI sought information about how to promote quality and innovation in long-term services and supports, delivery system transformation, and quality and access to care. The information requested seeks improvements to clinical models of care, with a focus on integration, addressing social determinants of health, ensuring efficiency in pharmacy, and achieving administrative simplification.

The state will not release the RFI responses until after the state completes its evaluation of any responses to the (as of December 6, 2019 unreleased) MCO procurement. If for some reason, the state chooses not to go further in the procurement process and responses are never evaluated, the responses to the RFI will be considered confidential. TennCare is the state of Tennessee’s Medicaid program that provides health care for approximately 1.4 million Tennesseans and operates with an annual budget of roughly $12 billion.

For more information, contact:

  • Matt Brimm, Director of Contracts, Division of TennCare, Tennessee Division of Health Care Finance and Administration, 310 Great Circle Road, Nashville, Tennessee 37243; Email:; Website:
  • Sarah Tanksley, Director of Communications, Division of TennCare, Tennessee Division of Health Care Finance and Administration, 310 Great Circle Road, Nashville, Tennessee 37243; Email:; Website:

The Blue Cross Blue Shield Association (BCBSA) is creating a national provider organization network composed of health care provider organizations and professionals who routinely offer high quality care at lower prices. BCBSA announced the new network on November 13, 2019. The network will be called Blue High Performance Network (HPN); it is slated to launch in January 2021 in 55 markets.

Blue HPN is designed for large national and regional employers. It is expected to reach more than 185 million people. BCBSA represents 36 independent Blue companies. The goal is that Blue HPN will provide more consistent pricing to help large employers control medical costs and enhance care for their workers. About 16% of large employers have built a high performance network into their health plan. BCBSA predicts that Blue HPN could generate more than 10% average cost savings on top of the savings already offered by the existing BCBS preferred provider organization network.

In June 2019, BCBSA issued an infographic explaining how it defines a high-performance network. Provider organizations will be selected for Blue HPN by the independent Blue plans based on existing quality measures and relationships. About 70% of the 74 million BCBS members are already in a value-based contract. Provider organizations selected for Blue HPN will be provided with data and insights; BCBSA will also align financial incentives for the participating provider organizations.

BCBSA released the full text of “Defining High-Performance Networks” and the info graphic in June 2019. A free copy is available online at (accessed December 10, 2019).

For more information, contact: Tess Thomson, Media Contact, Blue Cross Blue Shield, 225 North Michigan Avenue, Chicago, Illinois 60601; 202-942-1082; Email:; Website:

On November 19, 2019, the North Carolina Department of Health and Human Services (DHHS) suspended implementation of managed care because the General Assembly adjourned without providing required new spending and program authority for the transition. As a result, managed care will not go live on February 1, 2020. The wind-down process began November 20, 2019. DHHS stated that it will not decide on a new go-live date until it has program authority within a budget that supports its ability to provide critical oversight and accountability of managed care.

Open enrollment, which had launched statewide in October, is suspended. The Medicaid Managed Care Call Center will remain open to answer questions through December 13, 2019. DHHS will send notices to beneficiaries to inform them to continue accessing services as they currently do. North Carolina Medicaid will continue to operate under its current fee-for-service model. Behavioral health services will continue to be provided by Local Management Entities/Managed Care Organizations. All current Medicaid-enrolled provider organizations and clinical professionals will continue to bill the state through NCTracks.

A recently issued request for proposals (RFP), released on November 5, 2019, that was linked to implementation of managed care and approved in the same 1115 Medicaid waiver has not been suspended or canceled. NC DHHS released the RFP (RFP 30-2019-052 DHB) seeking contractors to serve as Lead Pilot Entities as part of the Healthy Opportunities Pilot in up to three geographic areas of the state. The pilot is intended to test evidence-based interventions to reduce costs and improve health by addressing housing instability, transportation insecurity, food insecurity, interpersonal violence, and toxic stress for eligible Medicaid beneficiaries. The competitive bidding process is continuing, and proposals are due January 21, 2020. It is possible, however, that awards may be impacted by the suspension of Medicaid Managed Care.

The transition to Medicaid managed care began in 2015, when the North Carolina General Assembly enacted legislation directing DHHS to shift Medicaid and NC Health Choice from fee-for-service to managed care, and ended the state’s behavioral health carve-out. The plan called for Standard Plans to integrate physical health, behavioral health, long-term services and supports (LTSS), and pharmacy services for the general Medicaid population. Tailored Plans, vertical health plans, for the subset of beneficiaries with behavioral health disorders and/or developmental disabilities would provide integrated physical health, LTSS, pharmacy unmet resource needs services, plus a more robust behavioral health and I/DD benefit package than the Standard Plans.

DHHS submitted a 1115 Medicaid waiver, which was approved on October 19, 2018 by the Centers for Medicare & Medicaid Services (CMS). The five-year waiver went into effect on November 1, 2019, and runs through October 31, 2024. In addition to implementing integrated managed care via Standard and Tailored Plans, the waiver permitted DHHS and managed care plans to cover services provided in institutions of mental disease (IMD). It also permitted the state to implement Healthy Opportunities Pilots to address social determinants of health, such as housing, food, transportation, employment, and interpersonal safety services.

On February 4, 2019, DHHS selected one regional and four statewide prepaid health plan (PHP) contractors to operate Standard Plans for the general Medicaid population. Statewide PHP contracts were awarded to AmeriHealth Caritas North Carolina, Inc.; Blue Cross and Blue Shield of North Carolina; UnitedHealthcare of North Carolina, Inc.; and WellCare of North Carolina, Inc. Carolina Complete Health, Inc., a Provider-Led Entity PHP, was awarded two regional contracts for Regions 3 and 5 in February, and subsequently awarded Region 4 as part of a settlement agreement associated with protest of the Department’s awards. Standard Plans in two regions were to begin transitioning to managed care in November 2019; the remaining four regions were to transition in February 2020. The Tailored Plans were slated to go live in 2021.

PsychU last reported on this topic in “North Carolina Medicaid Selects Five Health Plans—One Regional & Four Statewide,” which published on March 4, 2019. The article is available at

PsychU also reported on this topic in “CMS Approves North Carolina’s 1115 Medicaid Managed Care Waiver, Ending The Behavioral Health Carve-Out,” which published on December 8, 2018. The article is available at

For more information about the suspension, contact: Chris Mackey, Office of Communications, North Carolina Department of Health and Human Services, 101 Blair Drive, Adams Building, 2001 Mail Service Center, Raleigh, North Carolina, 27699-2000; 919-855-4840; Fax: 919-733-7447; Email:; Website:

For more information about the RFP for the Healthy Opportunities Pilot, contact: Division of Health Benefit, North Carolina Department of Health and Human Services, 101 Blair Drive, Adams Building, 2001 Mail Service Center, Raleigh, North Carolina, 27699-2000; 919-527-7236; Fax: 919-733-7447; Email:; Website:

Care coordination models matter. The approach that a payer takes to care coordination fundamentally changes the service delivery system—and provider reimbursement. For specialty provider organization executive teams, understanding the care coordination models preferred by payers is critical to strategy, referral generation, revenue and growth, reimbursement, and marketing planning.

The OPEN MINDS team conducted an analysis of the Medicaid care coordination models used in each state in their report, State Medicaid Care Coordination Initiatives: The 2019 Update. They looked at seven models ranging from models that change provider roles within the existing system such as patient-centered medical homes (PCMH), health homes, and certified community behavioral health centers (CCBHCs) to models that restructure the basic financing of benefits like accountable care organizations (ACOs), managed long-term services and supports (MLTSS) plans, dual eligible integration initiatives, and vertical/specialty health plans.

What did they find? The most common model was PCMHs in 30 state Medicaid plans. There are MLTSS plans in 22 states and health homes in 21 state Medicaid plans. The models that are least common are Medicaid ACOs, dual demonstration initiatives, and CCBHCs (note that CCBHCs are limited to the states that received grants).

What is the general direction of Medicaid care coordination? There are a few recent developments to consider. First, four states (Arkansas, California, West Virginia, and Illinois) added specialty consumer health plans in the last year. Funding for CCBHCs keeps getting short-term extensions, but we are still waiting to see if Congress will expand the program.1 An increase in “health homes” is likely with the child-focused health home initiative starting in late 2022.

Each of the integration models adopted by Medicaid have specific opportunities and strategic challenges for specialty provider organizations. The creation of new health plans—MLTSS plans, specialty consumer plans, and Medicare-Medicaid dual plans—bring new consumers into the managed care-oriented service delivery systems. This increases the share of health care spending in local markets that is controlled by health plans. The expansion of ACOs typically shifts health care spending to hospital systems, and the expansion of medical homes and health homes concentrates care coordination in a smaller group of provider organizations.

To learn more about each of the care coordination models, check out these resources in our PsychU Resource Library:

  1. Patient-centered medical homes – see Integration Strategies For The Complex Consumer Market1
  2. Certified community behavioral health centers – see What Is The Future Of The CCBHC?2 and Successfully Managing Bundled Rates—The Voice Of Experience3
  3. Accountable care organizations – see ACOs Saved Medicare $1.7 Billion In 20184 and The Growing Push For Medicaid ACOs5
  4. Medi-Medi dual eligible integration initiatives – see The Path Forward In Serving The Dual Eligible Population6 and CMS Forwarding Three Opportunities For State Integrated Care For Dually Eligible Individuals7


During the 2020 Medicare Advantage enrollment season, a total of 3,148 plans are available to beneficiaries. For the 2020 plan year, there are 15% more plans (414 more plans) for beneficiaries to choose from. The average beneficiary will be able to choose from 28 Medicare Advantage plans offered by seven insurers. About 90% of the plans will include prescription drug coverage. About two-thirds of plans (64%) are structured as health maintenance organizations (HMOs).

In metropolitan counties, beneficiaries can choose from an average of 31 plans. Beneficiaries in non-metropolitan counties can choose from an average of 16 plans.

  • In the 10% of counties that account for 40% of Medicare enrollment, beneficiaries have a choice of more than 30 plans. In 131 counties, beneficiaries have a choice of more than 40 plans. In four Ohio counties (Mahoning, Medina, Trumbull, and Summit) and two Pennsylvania counties (Bucks and Lancaster), more than 60 plans will be available.
  • In 6% of counties, accounting for just 1% of Medicare enrollment, beneficiaries can choose from two or fewer Medicare Advantage plans. This includes 59 counties in which only one plan will be available. In 77 counties, no Medicare Advantage plans are available. Additionally, no Medicare Advantage plans are available in territories other than Puerto Rico.

More than 100 insurers are offering Medicare Advantage plans in 2020. UnitedHealthcare and Humana have the most Medicare Advantage enrollees, and each offers plans in most counties. UnitedHealthcare offers plans in 60% of counties, while Humana offers plans in 83% of counties. Both offer plans in 53% of counties. About 85% of Medicare beneficiaries have access to at least one Humana plan, and 82% have access to at least one UnitedHealthcare plan.

Thirteen plan sponsors are offering Medicare Advantage plans for the first time in 2020. Each of these new entrants is offering plans in one of these 10 states: Florida, Illinois, Louisiana, Michigan, North Carolina, New York, South Carolina, Tennessee, Texas, and Virginia. These new sponsors are:

  1. ApexHealth, Inc., offering plans in North Carolina, South Carolina, Tennessee, and Virginia.
  2. Clarion Health, offering one plan in Florida.
  3. Community Health Choice, offering a plan in Texas.
  4. Dignity Health Plan, offering one plan in Louisiana.
  5. El Paso Health Advantage, offering one plan in Texas.
  6. Experience Health, Inc., offering one plan in North Carolina.
  7. Mary Washington Medicare Advantage, offering two plans in Virginia.
  8. MoreCare, offering four plans in Illinois.
  9. Oscar, offering two plans in New York and in Texas.
  10. PHP Medicare, offering six plans in Michigan.
  11. Reliance Medicare Advantage, offering two plans in Michigan.
  12. Troy Medicare, offering one plan in North Carolina.
  13. Zing Health, offering one plan in Illinois.

These statistics were reported in “Medicare Advantage 2020 Spotlight: First Look” by Gretchen Jacobson, Meredith Freed, and Tricia Neuman of the Kaiser Family Foundation, and Anthony Damico, an independent consultant. The plan numbers exclude employer or union-sponsored group plans. The count also excludes Special Needs Plans (SNPs), which are only available to select populations. During 2020, 855 SNPs will be available, up 19% from the 717 offered in 2019.

The full text of “Medicare Advantage 2020 Spotlight” was published October 24, 2019 by Kaiser Family Foundation. An abstract is available online at (accessed November 27, 2019).

For more information, contact: Chris Lee, Senior Communications Officer, Kaiser Family Foundation, 1330 G Street Northwest, Washington, District of Columbia 20005; Email:; Website:

On November 1, 2019, the Centers for Medicare & Medicaid Services (CMS) began enrolling opioid treatment programs (OTPs) as Medicare provider organizations to receive payment for a new Medicare addiction treatment benefit that begins on January 1, 2020. Medicare will pay OTPs through bundled payments for opioid use disorder (OUD) treatment services in an episode of care provided to people with Medicare Part B. OTPs must be enrolled in the Medicare program to receive reimbursement for services provided to beneficiaries.

CMS finalized the episode of care as one continuous seven-day period, in part because OTPs already are paid by weekly episodes and have billing processes in place. There is no maximum on the number of episodes. Each weekly bundle can consist of a range of service frequencies, depending on whether the beneficiary is at the initial phase or maintenance phase of treatment. CMS will consider the requirements to bill for the full weekly bundle to be met if the beneficiary is receiving the majority of the services identified in their treatment plan at that time. For the purposes of valuation, CMS assumed one addiction counseling session, one individual therapy session, and one group therapy session per week and one toxicology test per month.

OTP treatment services for OUD include the following:

  • Dispensing and administration of medication assisted treatment (MAT), if applicable.
  • Addiction counseling by a professional to the extent authorized under state law to furnish such services.
  • Individual and group therapy with a physician or psychologist (or other mental health professional to the extent authorized under state law).
  • Toxicology testing.
  • Other items and services that CMS determines are appropriate (but in no event to include meals or transportation).

The details of the new OTP benefit were finalized in the Calendar Year (CY) 2020 Physician Fee Schedule final rule. CMS estimates that there are about 1,700 certified and accredited OTPs eligible for Medicare enrollment. All states except Wyoming have OTPs. Over the next three years, another 200 OTPs are projected to become certified by the Substance Abuse and Mental Health Services Administration (SAMHSA) at a pace of roughly 67 per year, bringing the total amount of OTPs eligible to enroll in Medicare to approximately 1,900 over the next three years. OTPs provide treatment with opioid agonist and antagonist medications (including oral, injected, or implanted versions) that are approved by the Food and Drug Administration (FDA).

To enroll as an OTP service provider organization with Medicare, the OTP must have current, valid, and full certification by SAMHSA, and meet all SAMHSA criteria. These criteria include Drug Enforcement Administration (DEA) registration, state licensure, and accreditation. OTPs must submit an application to their regional Medicare Administrative Contractor (MAC). The MAC will verify the SAMHSA certification on the SAMHSA OTP directory. The OTP must send its letter of certification from SAMHSA with the Medicare provider enrollment application. MACs will not accept applications without full SAMHSA certification and will deny applications for OTPs with “provisional” SAMHSA certification status.

Enrollment information is available at the OTP webpage (accessed November 27, 2019).

For more information, contact: Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Email:; Website:

On October 29, 2019, the California Department of Health Care Services (DHCS) formally released the California Advancing & Innovating Medi-Cal (CalAIM) proposal. CalAIM is a multi-year initiative to prepare for renewing the state’s current 1115 and 1915(b) Medicaid waivers, which expire in 2020. By January 2021, DHCS proposes to standardize managed care plan benefits such that all Medicaid managed care plans provide the same benefit package. The plans will carve-in institutional long-term care and major organ transplants, and carve-out pharmacy. By 2026, managed long-term-services and supports will be implemented statewide in Medicaid managed care. These plans will replace the current variety of 1915(b) Medicaid waiver plans, which have capped enrollment and are not statewide.

DHCS intends for the CalAIM initiative to serve as a framework for the upcoming waiver renewals. The state seeks to improve the quality of life and health outcomes of Medicaid beneficiaries by implementing broad delivery system, program, and payment reform across the Medi-Cal program. The proposals address homelessness, behavioral health access, clinical needs of justice-involved individuals, children with complex medical conditions, and the needs of adults aged 65 and older. Through the CalAIM workgroup process, DHCS intends to explore the following five key issues:

  1. Requiring Medi-Cal managed care plans to submit population health management strategies and moving to annual Medi-Cal managed care plan open enrollment.
  2. Adding a new enhanced care management benefit and a set of “in lieu of” services, designed to focus on critical populations such as children, high-cost/high-need populations, and the homeless.
  3. Behavioral health payment reform and delivery system transformation.
  4. Requiring Medi-Cal managed care plans to obtain accreditation from the National Committee on Quality Assurance (NCQA).
  5. Considerations for creation of full integration plans where one entity would be responsible for the physical, behavioral, and oral health needs of their members.

DHCS introduced the CalAIM proposal at the Stakeholder Advisory Committee (SAC) and Behavioral Health Stakeholder Advisory Committee (BH-SAC) meetings. Throughout the remainder of 2019 and 2020, DHCS will conduct extensive stakeholder engagement for both CalAIM and the renewal of the state’s Medicaid 1115 and 1915(b) waivers. The major components of CalAIM build upon the successful outcomes of various pilots (including, but not limited to, the Whole Person Care Pilots, Health Homes, and the Coordinated Care Initiative) from the previous federal waivers. This will result in better quality of life for Medi-Cal members as well as long-term cost savings/avoidance.

DHCS has three primary goals for CalAIM:

  • Identify and manage member risk and need through the Whole Person Care pilot approaches and addressing social determinants of health
  • Move Medi-Cal to a more consistent and seamless system by reducing complexity and increasing flexibility
  • Improve quality outcomes and drive delivery system transformation through value-based initiatives, modernization of systems, and payment reform

Whole Person Care Approaches

DHCS proposed the following recommendations that use a whole person care approach that address beneficiary needs in terms of physical, behavioral, and non-medical social determinants of health. The goal is to improve quality of life and reduce overall costs for the Medi-Cal population. The recommendations are as follows:

  1. Require plans to submit local population health management plans.
  2. Implement new statewide enhanced care management benefit.
  3. Implement in lieu of services (e.g., housing navigation/supporting services, recuperative care, respite, sobering center, etc.).
  4. Implement incentive payments to drive plans and provider organizations to invest in the necessary infrastructure, build appropriate enhanced care management, and in lieu of services capacity statewide.
  5. Evaluate participation in the federal Institutions for Mental Disease Serious Mental Illness/Serious Emotional Disturbance Section 1115 Expenditure Waiver. Counties would participate on an opt-in basis.
  6. Require screening and enrollment for Medi-Cal prior to release from county jail.
  7. Pilot full integration of physical health, behavioral health, and oral health under one contracted entity in a county or region.
  8. Develop a long-term plan for improving health outcomes and delivery of health care for foster care children and youth.

To transition Medicaid managed care plans to a standardized benefit package with integrated long-term services and supports (LTSS), DHCS proposed discontinuing the Cal MediConnect pilot program at the end of calendar year 2022. Cal MediConnect is the state’s dual eligible demonstration project operating in eight counties; it is part of the state’s Connected Care Initiative (CCI). The CCI is a Medicaid LTSS program available in all counties. Enrollment in CCI or Cal MediConnect is mandatory for people eligible for both Medicare and Medicaid. DHCS proposes to transition from the pilot approach of the CCI to standardized mandatory enrollment of people dually eligible for Medicare and Medicaid into a Medicaid managed care plan for Medicaid benefits and integration of long-term care into managed care for all Medi-Cal populations statewide. DHCS anticipates two phases:

  • By January 2021, the CCI will continue, but Multipurpose Senior Services Programs will be carved out, and all institutional long-term care services will be carved into managed care for all populations statewide.
  • By January 2023, the CCI will fully transition to mandatory managed care enrollment into managed care in all counties and plan models. Medicaid managed care plans will be required to operate Medicare Dual Special Needs Plans.

For more information about CalAIM, contact: California Department of Health Care Services, 1501 Capitol Avenue, MS 0000, Post Office Box 997413, Sacramento, California 95899; Email:; Website:

Following-up to the 2019 Trends In Behavioral Health: A Population Health Manager’s Reference Guide On The U.S. Behavioral Health Financing & Delivery System, 2nd Edition, Deb Adler and Paul Duck discuss trends and shifts in the market and the impacts on population health management. From 2017 to 2019, specialty care coordination programs increased by 50%, behavioral health readmissions prevention programs increased by 74%, and emergency department diversion programs for behavioral emergencies increased by 43% for all health plans1. Service provider organizations are adapting to this shift by utilizing peer support specialists, adopting telehealth, and increasing consumer engagement via emails and text messages.


  • Deb Adler, CPHQ
    Senior Associate at OPEN MINDS
  • Paul Duck
    Senior Associate at OPEN MINDS

Deb Adler, CPHQ, has more than 20 years of experience in executive health care roles, serving in a variety of capacities, including network executive, quality management executive, and COO. She is the former Senior Vice President of Network Strategy for Optum, where she was responsible for behavioral health network development, contracting, and strategy for over 185,000 providers. In this role, she developed the largest performance-tiered behavioral health network, the largest telemental health network, and the largest medication-assisted treatment (MAT) network. She was also responsible for implementing network initiatives to promote medical/behavioral integration, improve member outcomes, and reduce total cost of care through collaborative care models. Currently, she serves as a Senior Associate at OPEN MINDS. Ms. Adler earned her MA in psychology and evaluation from Catholic University of America and is a Certified Professional in Health Care Quality (CPHQ).

Paul Duck currently serves as a Senior Associate at OPEN MINDS. He brings over 40 years of experience in leadership and management, focusing on managed care, health information technology organizations, strategy, business development and market expansion, and customer experience optimization to the OPEN MINDS team. Previously, Mr. Duck has served in roles such as Vice President, Strategy & Development for Beacon Health Options, the Vice President of Business Development for Netsmart Technologies, and Chief Executive Officer for Coastal Orthopedics. Mr. Duck earned his Bachelor of Arts in Business Management from Case Western Reserve University.  He earned his Associate of Arts in Electronic Engineering Technology from the Electronic Technology Institute.

Following-up to the 2019 Trends In Behavioral Health: A Population Health Manager’s Reference Guide On The U.S. Behavioral Health Financing & Delivery System, 2nd Edition, Deb Adler and Paul Duck discuss trends and shifts in the market and the impacts on population health management. From 2017 to 2019, specialty care coordination programs increased by 50%, behavioral health readmissions prevention programs increased by 74%, and emergency department diversion programs for behavioral emergencies increased by 43% for all health plans1. Service provider organizations are adapting to this shift by utilizing peer support specialists, adopting telehealth, and increasing consumer engagement via emails and text messages.


    • Deb Adler, CPHQ
      Senior Associate at OPEN MINDS
  • Paul Duck
    Senior Associate at OPEN MINDS

Deb Adler, CPHQ, has more than 20 years of experience in executive health care roles, serving in a variety of capacities, including network executive, quality management executive, and COO. She is the former Senior Vice President of Network Strategy for Optum, where she was responsible for behavioral health network development, contracting, and strategy for over 185,000 providers. In this role, she developed the largest performance-tiered behavioral health network, the largest telemental health network, and the largest medication-assisted treatment (MAT) network. She was also responsible for implementing network initiatives to promote medical/behavioral integration, improve member outcomes, and reduce total cost of care through collaborative care models. Currently, she serves as a Senior Associate at OPEN MINDS. Ms. Adler earned her MA in psychology and evaluation from Catholic University of America and is a Certified Professional in Health Care Quality (CPHQ).

Paul Duck currently serves as a Senior Associate at OPEN MINDS. He brings over 40 years of experience in leadership and management, focusing on managed care, health information technology organizations, strategy, business development and market expansion, and customer experience optimization to the OPEN MINDS team. Previously, Mr. Duck has served in roles such as Vice President, Strategy & Development for Beacon Health Options, the Vice President of Business Development for Netsmart Technologies, and Chief Executive Officer for Coastal Orthopedics. Mr. Duck earned his Bachelor of Arts in Business Management from Case Western Reserve University.  He earned his Associate of Arts in Electronic Engineering Technology from the Electronic Technology Institute.

On October 21, 2019, the Michigan Department of Health and Human Services (MDHHS) announced that it canceled plans for pilots to integrate Medicaid behavioral health specialty services and physical health services. The state, the health maintenance organizations (HMOs) for physical health services, and the regional behavioral health authorities were unable to reach an agreement on the financial model. MDHHS still intends to pursue improvements and changes to the Medicaid system that will promote physical and behavioral health integration.

MDHHS Director Robert Gordon said, “These pilots were supposed to be built on agreement among all participants. After years of work to reach consensus, it has become clear that agreement will not be reached. We remain committed to making our behavioral health system work better for all Michiganders, and it is time to look for new ways to achieve this goal.”

The initiative began with a provision in Section 298 of the Governor’s 2016 executive budget, which started a statewide discussion on the best approach for integrating physical and behavioral health services. A task force was created to make recommendations to fix the system. The Michigan Legislature used the task force recommendations to direct MDHHS to develop a set of recommendations regarding the most effective financing model and policies for behavioral health services for individuals with mental illnesses, intellectual and developmental disabilities, and addiction disorders. The 2017 budget revised Section 298 to direct MDHHS to create up to three pilots to test the financial integration of Medicaid-funded physical health and specialty behavioral health services. In March 2018, MDHHS selected community mental health centers to participate in the pilots.

Pilot implementation was set to initially begin on October 1, 2019. However, in June 2019, MDHHS delayed implementation until the following year to allow more time to design a financial integration model. The pilots were canceled because the parties could not agree on two issues: start-up costs and automatic statewide scaling of the model.

PsychU last reported on this topic in “Michigan DHHS Announces Delay In Pilot Of Integrated Physical Health Services & Specialty Behavioral Health Services,” which published on August 5, 2019. The article is available at

For more information, contact: Lynn Sutfin, Public Information Officer, Michigan Department of Health and Human Services, Post Office Box 30195, Lansing, Michigan 48909; 517-284-4772; Email:; Website:

On October 25, 2019, officials with Universal Health Services (UHS) told investors that the company wrote off $147 million of the value of its addiction treatment unit, Foundations Recovery Network LLC (Foundations). UHS had acquired Foundations in 2015 for $350 million. UHS asserts that since 2015, payer control over treatment has been increasing and fewer consumers are covered for out-of-network services. Additionally, consumers are less willing to travel to obtain addiction treatment services.

When UHS acquired Foundations, there were four Foundations inpatient facilities with a total of 322 beds operating in California, Georgia, and Tennessee, and eight outpatient centers. In addition to limited coverage and fewer consumers traveling for services, Steve Filton, chief financial officer of UHS, said the marketing model that Foundations used was not a good fit with current UHS payer practices. Foundations had focused on involving direct-to-consumer marketing, consumer travel for treatment, and seeking insurance coverage for out-of-network services.

UHS operates 350 inpatient acute care hospitals and behavioral health facilities, as well as 30 outpatient and other facilities located in 37 states, Washington, D.C., Puerto Rico, and the United Kingdom. The organization serves more than 2.6 million health care consumers per year. UHS reported $97.2 million in net income on $2.8 billion in revenue in the quarter ending September 30, compared with $171.7 million in net income on $2.6 billion in revenue in the same period of 2018.

PsychU last reported on this topic in “Universal Health Services Creates Primary Care Service Line With Vera Whole Health,” which published on May 29, 2019. The article is available at

For more information, contact: Jane Crawford, Director, Corporate Public Relations, Universal Health Services, Inc., Post Office Box 61558, King of Prussia, Pennsylvania 19406; 610-382-4830; Email:; Website:

The National Quality Forum (NQF) has recommended policy alignment, payment innovation, and standardizing data collection in effort to address social determinants of health (SDOH). NQF is a non-profit, nonpartisan, membership-based organization that gives health care stakeholders a voice in driving improvement of measurable health outcomes. Specifically, the recommendations include: aligning policy and payment across public and private stakeholders; improving the use and collection of standardized SDOH data; and designing incentives to address SDOH. The recommendations are as follows:

  1. Align policies, funding, and reimbursement across private and public payers, community-based organizations, social services entities, health systems, and provider organizations. This will improve data collection, system integration, workforce development, and the capacity to address SDOH.
  2. Develop consistent measures for SDOH. Selected measures should be shared by health care and community-based organizations, This will allow for communities to prioritize specific population subgroups based on their most pressing needs and largest health disparities.
  3. Execute the recommendations from the Social Determinants of Health Action Team to capture meaningful, standardized, and locally actionable data; enable data exchange and interoperability; enable collaboration at all levels, especially at the community level; and monitor progress using a standardized set of community and clinical outcome measures.
  4. Provide funding to test, collect data, assess, and measure the feasibility and effectiveness of community-based SDOH models and targeted interventions to improve health outcomes. Funding should support sustainable financing for community-based organizations and pay for social services that address SDOH. Organizations should share and apply data to enable continuous quality improvement and build a real-world evidence base for effective initiatives.
  5. Provide incentives and rewards for addressing and improving SDOH. Incentives may include payment, contracting, and non-financial rewards. Actions should help communities in which the health system operates, and a percentage of payment to health systems and clinicians should be tied to collaborating with the community-based workforce.

The recommendations were offered in “A National Call to Action: Quality And Payment Innovation In Social Determinants Of Health” by NQF and were released at a Congressional Hill Briefing on October 24, 2019. Through an initiative supported by Aetna Foundation, NQF collaborated with nearly 60 health care stakeholders from across the United States at the SDOH Payment Summit in August 2019. At the summit, the group discussed national strategies, barriers, and recommendations for addressing social determinants through payment and quality innovation.

The full text of “A National Call to Action: Quality And Payment Innovation In Social Determinants Of Health” was published October 22, 2019 by NQF. A copy is available online at (accessed November 18, 2019).

For more information, contact: Information Office, National Quality Forum, 1099 14th Street Northwest, Suite 500, Washington, District of Columbia 20005; 202-783-1300; Fax: 202-783-3434; Email:; Website:

Medicaid health plans are moving ahead with the shift to alternate payment methodologies (APM) at a relatively rapid rate. Twenty-two states require health plans to move to value-based reimbursement and eleven states use Medicaid accountable care organizations.

Is Medicaid financing for physical health, behavioral health, and pharmacy properly aligned for value-based reimbursement (VBR)? If integrated care coordination and VBR are going to have a meaningful impact on “bending the cost curve”, financial alignment is important. The more fragmented the financing, the less impact care coordination can have on consumer resource use.

Of the 49 states with a fee-for-service (FFS) system, 39 align all services – physical health, behavioral health, and pharmacy. In those FFS systems, 10 align physical health and pharmacy services, but not behavioral health services.

Of the 41 states with Medicaid managed care, financial alignment is less uniform. In 26 states, the Medicaid health plans are financially responsible for all services – physical health, behavioral health, and pharmacy. In the other states with Medicaid health plans, two states align physical and behavioral health, but not pharmacy; seven align physical health and pharmacy only, two align behavioral health and pharmacy, and two have no alignment of any services. Additionally, there were two states (Hawaii and Maryland) that align physical health and physical health pharmacy and then separately finance, but align behavioral health and behavioral health pharmacy.

Why financial alignment matters is clear. Care coordination and incentives based on ‘total cost of care’ are possible where financial risk is aligned. Setting targets for reduction of total spend is not possible if those funding streams aren’t aligned. In states where behavioral health is not in same financial pool as physical health, it is not possible to incentive behavioral health provider organizations on medical cost-offset as a ‘value measure’.

Overall, Medicaid plans are increasingly eliminating ‘carve outs’ of behavioral health and pharmacy benefits and relying on health plans to make integrated care coordination models work. Going forward, it is health plan policies and initiatives that are going to determine the incentives in pay-for-value arrangements. Whether those models work is a subject for a different analysis. For a current snapshot of health plan practices, see 2019 Trends In Behavioral Health: A Population Health Manager’s Reference Guide On The U.S. Behavioral Health Financing & Delivery System, 2nd Edition.

During 2018, the 548 Medicare accountable care organizations (ACOs) collectively saved Medicare $1.7 billion. After accounting for shared savings bonuses and collecting shared loss payments, net savings were $739 million. ACOs that received shared savings payments had decreases in inpatient, emergency room, and post-acute care spending and utilization. ACOs that increased spending relative to their targets tended to show increases in these areas.

Of the 548 ACOs in 2018, 205 ACOs generated savings and 70 generated losses; the remaining 273 generated no savings or losses. In total, 205 ACOs earned savings; 11 ACOs had losses (negative earned savings), and 332 ACOs had no earned savings or losses.

In a blog post about the 2018 ACO financial results, Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma wrote that CMS analyzed the data to sort ACOs into low-revenue and high-revenue groups according to the Pathways to Success final rule. The low-revenue ACOs outperformed high-revenue ACOs in terms of their average spending reduction relative to their targets. The majority of low-revenue ACOs are physician-led. The majority of high-revenue ACOs are led by hospitals.

The low-revenue ACOs had an average reduction of $180 per beneficiary, compared to $27 per beneficiary for high-revenue ACOs. CMS concluded that ACOs led by physicians outperformed ACOs led by hospitals. Ms. Verma wrote, “Given the success of low-revenue ACOs to date, the Pathways to Success final rule provides these ACOs with the option to elect more time under one-sided risk (generally three years), before requiring them to take on downside risk, to encourage their participation in the Shared Savings Program.”

In the post, Ms. Verma noted that ACOs responsible for downside risk performed better than ACOs that did not accept risk. ACOs taking on downside risk showed an average reduction in spending, relative to their targets, of $96 per beneficiary, compared to $68 for ACOs that did not take on downside risk.

The CMS ACO MSSP Public Use File for 2018 is posted online at (accessed November 4, 2019).

Seema Verma’s statements were in a blog post “Interest In ‘Pathways To Success’ Grows: 2018 ACO Results Show Trends Supporting Program Redesign Continue” published September 30, 2019, by Health Affairs. A copy is available online at (accessed November 4, 2019).

For more information, contact: Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Email:; Website:

Physician-led Medicare accountable care organizations (ACOs) in the Medicare Shared Savings Program (MSSP) achieved nearly seven times more Medicare savings per beneficiary than hospital-led ACOs. For all ACOs in 2018, aggregate savings per-beneficiary totaled $73.23. Physician-led ACOs, which tend to be “low revenue” ACOs, generated savings of $180.41 per Medicare beneficiary. Hospital-led ACOs, which tend to be high revenue, generated savings of $26.76 per Medicare beneficiaries.

MSSP ACOs continue to achieve higher savings the longer they participate in the program. Overall in 2018, ACOs in their first performance year had higher per-beneficiary spending. However, those that had been in the program longer had spending lower than baseline each year, and the savings increased.

  • Per beneficiary spending for first year ACOs was $20.20 higher than the baseline; however, for those in the second year, per-beneficiary spending was lower than baseline by $56.41.
  • In the third year, spending was $50.30 lower than baseline, representing an 11% change from the previous year savings.
  • In the fourth year, spending was $84.51 lower than baseline, representing a 68% change from the previous year savings.
  • In the fifth year, per-beneficiary spending was $122.68 lower, representing a 45% change from the previous year savings.
  • In the sixth year, per-beneficiary spending was $141.48 lower for ACOs in their sixth year, representing a 15% change from the previous year savings.

These findings were reported in “Physician-Led Accountable Care Organizations Outperform Hospital-Led Counterparts” by researchers with Avalere. They analyzed data from the Centers for Medicare & Medicaid Services (CMS) 2018 Shared Savings Program Accountable Care Organizations Public Use File (PUF). For the analysis, they estimated the net impact on Medicare spending from the MSSP and aggregated the results across the program by each ACO’s experience with the program, performance year, and CMS categorization of “low revenue” and “high revenue.” Under the Medicare Pathways to Success changes to the MSSP, CMS designates an ACO as “low” or “high” revenue based on a threshold of Medicare Parts A and B revenue associated with the ACO’s assigned beneficiaries.

In 2018, 548 MSSP ACOs provided care to over 10 million Medicare beneficiaries and reduced Medicare spending by $739 million. In 2018, 235 ACOs (43%) were considered low revenue and 313 ACOs (57%) were considered high revenue.

The full text of “Physician-Led Accountable Care Organizations Outperform Hospital-Led Counterparts” was published October 15, 2019. A copy is available online at (accessed November 4, 2019).

For more information, contact:

  • John Feore, Associate Principal, Avalere Health, 1350 Connecticut Avenue Northwest, Suite 900, Washington, District of Columbia 20036; 202-207-1300; Email:; Website:
  • Gabe Sullivan, Consultant I, Avalere Health, 1350 Connecticut Avenue Northwest, Suite 900, Washington, District of Columbia 20036; 202-207-1300; Email:; Website:


Payers use a variety of methods to control prescription drug costs including different financing arrangements, prior authorization, preferred drug lists, and co-payments – each of which target a different part of the financing and delivery system. This week, our team examined the uniform preferred drug list (PDL).

What exactly is a PDL and what is a uniform PDL? A PDL is list of medications that a payer or health plan “prefers” and therefore will cover without prior authorization (these medications may still be subject to quantity and dosage limits or safety edits). Typically, medications that are preferred are either a generic formulation or the payer has been able to negotiate a major discount on the cost by listing the medication as preferred. Generally, the PDL is broken up by class of drugs: for example, antipsychotics vs. antidepressants vs. steroids vs. beta blockers. Payers can include all drug classes on the PDL or choose to exclude certain classes. In general, when a class is excluded, all drugs in that class are considered preferred.

While PDLs are used by all payers—Medicare, Medicaid, and commercial—the uniform PDL is unique to Medicaid. When a state Medicaid program puts a uniform PDL in place, it standardizes the preferred drugs across the Medicaid health plans and the fee-for-service (FFS) program. In states without a uniform PDL, the PDL can vary between the FFS plans and the health plans. A variety of names are used to describe this practice including single PDL, statewide PDL, and unified PDL.

What are the advantages of a uniform PDLs? For provider organization clinical teams, uniform PDLs for Medicaid can simplify the process for prescribing medications. Instead of checking the PDL of each health plan, prescribers can be fairly confident in knowing the availability and access to medications for all Medicaid beneficiaries. For consumers, uniform PDLs can help eliminate some of the confusion with choosing a health plan and can make switching between health plans less complicated.

How many state Medicaid programs have uniform PDLs? Of the 30 states with Medicaid managed care, 13 use a uniform PDL. All of these states include at least one mental health and addiction drug class on the uniform PDL. There are no states that have uniform PDLs only for mental health drugs. In 2019, seven of the 13 states with uniform PDLs set their own prior authorization requirements, clinical criteria, and other restrictions.

During the last couple of years more states have moved to a uniform PDL. Between 2017 and 2019, Arkansas, Louisiana, Minnesota, and Virginia added a uniform PDL (note that West Virginia ended its integrated financing arrangement for pharmacy). In the future, at least two states are planning to implement uniform PDLs. Ohio plans to implement a uniform PDL for its health plans on January 1, 2020 (see Unified Preferred Drug List)1. Pennsylvania is also planning to implement a uniform PDL for its health plans on January 1, 2020.2

In 2018, Medicare beneficiaries over age 65 with UnitedHealthcare commercial insurance who saw high-value physicians for more than 75% of their care had about 21% lower risk-adjusted spending compared to beneficiaries who saw physicians who were not considered “high-value.” UnitedHealthcare defines a high-value physician as one that meets the quality and cost-efficiency criteria established by the UnitedHealth Premium Program. Members who saw high-value physicians had 64% fewer inpatient hospital days, and 35% fewer emergency department visits. As a result, their risk-adjusted spending was $95 lower per member per month.

These findings were reported in “High-Value Physicians Can Save the Medicare Program over $286 Billion in Health Care Costs” by researchers with UnitedHealth Group. The UnitedHealth Premium Program draws upon quality metrics from the National Quality Forum, the National Committee for Quality Assurance (NCQA), and other leading clinical quality organizations. Cost-efficiency measures are based on local market benchmarks for cost-efficient use of resources and referral patterns in providing care.

Additional findings include:

  • The greatest average per-consumer or per-episode Medicare savings for those who saw high-value physicians was for those who saw nephrology professionals, which totaled 11.8% in savings. This was followed by those who saw neurology professionals (11.1% in savings), and those who saw cardiology professionals (10.1% in savings).
  • Of all specialties evaluated, primary care physicians saw the highest volume of consumers (58.7%). Improving the cost-efficiency of these physicians represents the greatest total savings opportunity of an estimated $14.5 billion in 2020, and $202.9 billion by 2029, for those who already meet the quality criteria.
  • Improving the cost-efficiency of cardiologists, neurologists, and pulmonologists who already meet the quality criteria could save seniors and the Medicare fee-for-service program $4.3 billion in 2020, and $61.2 billion by 2029.

The full text of “High-Value Physicians Can Save The Medicare Program Over $286 Billion In Health Care Costs” was published September 25, 2019 by UnitedHealth Group. An abstract is available online at (accessed October 28, 2019).

To learn more about the criteria for the UnitedHealth Premium Program, go to (accessed October 28, 2019).

PsychU last reported on this topic in “Medicare Fee-For-Service Spending For Primary Care Ranges From 2% To 5%,” which published on September 23, 2019. The article is available at

For more information, contact: Eric Hausman, Corporate Communications, UnitedHealth Group, Post Office Box 1459, Minneapolis, Minnesota 55440-1459; 952-936-3963; Email:; Website:

The top three factors associated with higher dual eligible enrollment in financial alignment plans (FAI) are passive enrollment, alignment with existing state Medicaid managed long-term services and supports (MLTSS) programs, and beneficiaries’ relationships with care coordinators. Across the ten states with FAI plans, plan enrollment among eligible beneficiaries ranged from a high of 67% in Ohio to a low of 4% in New York. The participating states are California, Illinois, Massachusetts, Michigan, New York, Ohio, Rhode Island, South Carolina, Texas, and Virginia.

Researchers concluded that higher enrollment rates are dependent upon strategic passive enrollment and marketing the alignment of key design features between the state’s dual demonstration and Medicaid MLTSS programs. To increase enrollment, the researchers made two suggestions for state policymakers. First, state policymakers should conduct passive enrollment at the start of a program and on a rolling basis each month with newly eligible beneficiaries. The second, state policymakers should align the design of state MLTSS and Medicare–Medicaid integrated care programs so that dually eligible beneficiary groups, state regions, and participating plans are the same in both programs.

These findings were reported in “Enticing Dually Eligible Beneficiaries to Enroll in Integrated Care Plans” by Debra J. Lipson and Erin Weir Lakhmani of Mathematica. The report was published by Milbank Memorial Fund. The researchers conducted a study on FAI enrollment with support from the Medicaid and CHIP Payment and Access Commission. Also called the “duals demo,” FAI is a 10-state demonstration as part of an effort to improve the quality of care and lower spending for low-income people who are dually-eligible for both Medicare and Medicaid.

Through the FAI, each of the states and the Centers for Medicare and Medicaid Services (CMS) contracted with integrated Medicare–Medicaid plans (MMPs). The MMPs are paid a fixed monthly rate for each member to provide and coordinate Medicare and Medicaid benefits. The researchers focused primarily on passive enrollment and demonstration/MLTSS alignment as program-level factors that affect enrollment.

Passive Enrollment:

All 10 participating states used passive enrollment, in which states automatically enroll eligible beneficiaries into an MMP. Enrollment in all 10 states typically spiked during or immediately after the implementation of a passive enrollment “wave.” States that continuously conducted monthly passive enrollment for individuals who became newly dually eligible during the course of the demonstration had higher participation rates than those that conducted annual passive enrollment. States with higher participation rates were more likely to passively enroll dually eligible people who were already enrolled in a Medicare Advantage plan, if the plan’s parent company also sponsored an MMP.

Alignment with Medicaid Managed Long-Term Services & Supports:

The researchers found that higher enrollment in MMPs was associated with greater alignment of key design features between the state’s dual demonstration and its Medicaid MLTSS program. By sharing the same eligibility criteria, geographic areas of operation, and participating health plans, the state agencies and health plans were able to communicate more effectively the advantages of choosing one plan to provide both Medicare and Medicaid services.

Degree Of Program Feature Alignment Between State FAI Duals Demonstrations & MLTSS Programs
Ohio California Illinois Massachusetts Michigan New York Rhode Island Texas
Same program name for demonstration and MLTSS Yes No No No No No Not completely No
Rolled out demonstration and MLTSS simultaneously Yes Yes No No No No No No
Eligible populations are identical Yes Not completely Yes No Not completely Not completely Not completely Not completely
Participating counties identical for both programs Yes Yes Not completely Not completely Not completely Not completely Yes Not completely
Same health plans offer MMP and MLTSS plans in each demonstration county Yes Not completely Not completely Not completely No Not completely Yes Yes

The table includes eight of the 10 FAI demonstration states whose MLTSS programs have run concurrently with the demonstration. South Carolina did not operate a concurrent MLTSS program, and Virginia’s MLTSS program began after the state’s FAI demonstration ended.

The full text of “Enticing Dually Eligible Beneficiaries to Enroll in Integrated Care Plans” was published in October 2019 by Millbank Memorial Fund. A copy is available online at (accessed October 28, 2019).

For more information, contact: Debra J. Lipson, Senior Fellow, Mathematica, 1100 First Street Northeast, 12th Floor, Washington, District of Columbia 20002-4221; 202-238-3325; Email:; Website:

On September 26, 2019, Sam’s Club announced the launch of “Sam’s Club Care Accelerator Together with Humana,” a discount health program for Sam’s Club members. The pilot launched in early October 2019 in Michigan, Pennsylvania, and North Carolina.

Sam’s Club will offer its members four different health care options, packaged as “bundles”:

  • Starter A bundle: For $50 per year, members have access to free select generic medications at Sam’s Club, primary care telehealth visits for $1, discounted eye care at $60 per visit and 20% off eyewear at Sam’s Club, and a $5 prepaid health debit card.
  • Starter B bundle: For $50 per year, Starter B bundle members can trade telehealth visits for savings on dental care. Members of the Starter B plan will have also have access to free select generic medications at Sam’s Club, discounted eye care at $60 per visit and 20% off eyewear at Sam’s Club, and a $5 prepaid health debit card.
  • Standard bundle: For $100 per year, standard bundle members have access to free select generic medications at Sam’s Club, primary care telehealth visits for $1, discounted eye care at $60 per visit and 20% off eyewear at Sam’s Club, discounted dental services, and a $40 prepaid health debit card.
  • Premium bundle: For $240 per year, members have access to free select generic medications at Sam’s Club, primary care visits by phone for $1, discounted eye care at $60 per visit and 20% off eyewear at Sam’s Club, discounted dental services, and a $100 prepaid health debit card. Premium bundle members also receive free preventative screening for early detection of heart disease and diabetes, up to 30% off alternative medicine, and 10% off hearing aids at Sam’s Club. The premium bundle, also offered as a family bundle, covers up to six family members.

To provide the services offered through the Care Accelerator Bundles, Sam’s Club has teamed up with Humana, 98point6, and Quest Diagnostics. Humana will aid in the offering of discount dental services through its network of health care provider organizations in the selected states. Telehealth services will be provided through 98point6. Preventative health screenings for early detection of heart disease and diabetes will be provided by Quest Diagnostics. Care Accelerator members will be responsible for paying the health care professional or provider organizations the discounted rate at the time of service.

For more information, contact: Media Relations, Walmart, 702 Southwest 8th Street, Bentonville, Arkansas 72716; Website:

State Medicaid plan costs to implement and administer work requirements range from $6.1 million in New Hampshire to $271 million in Arkansas, according to early data from the first five states that have implemented them. The five states include Kentucky, Wisconsin, Indiana, Arkansas, and New Hampshire. Since January 2019, these five states that received approval for work requirements from the Centers for Medicare & Medicaid (CMS) reported a range of up-front costs for administrative activities.

Estimated Cost To Administer Medicaid Work Requirements For First Five States With Waivers As Of November 2018
State Number of Beneficiaries Subject to Requirements Estimated Costs (dollars in millions) Estimated Federal Share (percentage)
Kentucky 620,000 $271.6 87%
Wisconsin 150,000 $69.4 55%
Indiana 420,000 $35.1 86%
Arkansas 115,000 $26.1 83%
New Hampshire 50,000 $6.1 79%


These findings were reported in “Medicaid Demonstrations: Actions Needed to Address Weaknesses in Oversight of Costs to Administer Work Requirements” by the United States Government Accountability Office (GAO). In the report, the GAO examined the states’ estimates of costs of administering work requirements To examine these estimates, the GAO reviewed state data and documentation for the five selected states that had received approval as of November 2018. The data included estimates of the administrative costs for implementing and administering work requirements over the course of the three-to-five year demonstration approval including the states’ estimates of federal and non-federal costs.

The estimates were based on information the states had readily available, such as the costs of contracted activities for information technology (IT) systems and beneficiary outreach. Additionally, the estimates primarily reflect up-front costs.

Breaking down the costs:

  • Kentucky’s estimated costs of $271.6 million included $220.9 million in IT costs for the Medicaid demonstration as a whole, including work requirements, for fiscal years 2019 and 2020. The estimate also included $50.7 million in payments for managed care organizations’ cost to administer work and other beneficiary requirements for the period of July 2018 through June 2020. The estimate does not include expected costs for evaluating work requirements. Expenditures from the application date in August 2016 through 2018 equaled more than $99.5 million.
  • Wisconsin’s estimated costs of $69.4 million included $57.3 million for beneficiary outreach, evaluation, and other services from July 2019 through June 2021, and $12.1 million in fiscal year 2019 for IT systems changes for the Medicaid demonstration as a whole. There were no expenditures reported from the time of application through 2016.
  • Indiana’s estimated costs of $35.1 million included $14.4 million for IT systems for fiscal years 2018 through 2021, and $20.7 million for managed care organizations’ activities in 2019. Expenditures from the application date in July 2017 through 2018 equaled more than $800,000.
  • Arkansas’s estimated costs of $26.1 million included contracts in place from July 2017 through June 2019 for IT systems, beneficiary outreach, and other activities, such as data analysis. Expenditures from the application date in June 2017 through 2018 equaled more than $24.1 million.
  • New Hampshire’s estimated costs of $6.1 million included $4.5 million for IT system and other contracts in place from July 2018 through June 2019, and $1.6 million for evaluation activities from 2019 through 2025. Expenditures from the application date in October 2017 through 2018 equaled more than $4.4 million.

Factors such as differences in changes to information technology systems and numbers of beneficiaries subject to the requirements may have contributed to the variation in estimates. The estimates do not include all costs, such as ongoing costs states expect to incur throughout the demonstration. All five selected states expected to receive federal funds for the majority of estimated costs and expenditures for implementing work requirements.

PsychU last reported on this topic in the following articles:

For more information, contact:

  • Carolyn L. Yocom, Media Contact, United States Government Accountability Office, 441 G Street Northwest, Washington, District of Columbia 20548; 202-512-7114; Email:; Website:
  •  Chuck Young, Office of Public Affairs, United States Government Accountability Office, 441 G Street Northwest, Washington, District of Columbia 20548; 202-512-4800; Email:; Website:

Social factors are primary impediments to managing care for high-cost Medicaid beneficiaries. These factors create barriers that impede beneficiary participation in care management services, creating challenges for states trying to improve outcomes and reduce costs for high-expenditure Medicaid beneficiaries. The biggest barriers include lack of transportation to medical appointments, lack of stable housing, and inconsistent access to food and other basic resources. Additional barriers to effective care management include staff shortages in rural areas and state or Medicaid managed care organization (MCO) difficulties contacting beneficiaries due to outdated contact information or limited beneficiary mobile phone minutes.

A review of seven state Medicaid program care management strategies to manage costs and care for high-expenditure beneficiaries found mixed results. The review was conducted by the Government Accountability Office (GAO); the outcomes were reported in “Efforts to Identify, Predict, or Manage High-Expenditure Beneficiaries.” It briefly mentioned barriers cited by the states and MCOs to beneficiary engagement with care management but did not go into detail to analyze the impact of the barriers on outcomes or costs.

Six of the seven states reported on their assessment of care management program efforts to manage costs and care for high-expenditure beneficiaries. Four of the states—Pennsylvania, South Dakota, Vermont, and Washington—said their assessment showed positive results, such as cost savings or reductions in the use of expensive services. The Indiana and Nevada Medicaid agencies reported mixed or inconclusive findings related to the impact on cost or quality of their programs for high expenditure Medicaid beneficiaries. In addition to providing care management services, some states (South Carolina, Nevada, Pennsylvania, and Indiana) used additional strategies, such as coverage policy changes, payment incentives, and restrictions on the use of provider organizations.

The GAO examined state and federal efforts to manage costs and improve care coordination for high-expenditure Medicaid beneficiaries. For this performance audit, the GAO interviewed officials from the Centers for Medicare & Medicaid Services (CMS), Medicaid officials from the seven states, and officials from five Medicaid managed care organizations (MCOs) operating in Indiana, Nevada, Pennsylvania, South Carolina, and Washington; and Vermont’s all-payer accountable care organization (ACO). The MCOs were not named in the report. South Dakota does not use managed care. For this report, the GAO defined “high-expenditure” as the subset of beneficiaries who account for a disproportionately large share of Medicaid expenditures, or are at-risk for doing so in the future. The goal was to report on approaches the states have used to identify or predict high-expenditure Medicaid beneficiaries; strategies used to manage beneficiaries’ health care costs while ensuring quality of care; and resources to help states identify, predict, or better manage high-expenditure beneficiaries.

For this report, the GAO defined care management programs as an effort to manage the cost and quality of health care services delivered to high-expenditure Medicaid populations with the goal of both improving health outcomes and achieving cost savings. The GAO included any programs that provided care coordination, case management, and/or disease management to assess consumer need and to coordinate care across multiple health care professionals.

Four states—Pennsylvania, South Dakota, Vermont, and Washington—reported positive outcomes, as follows:

  • Pennsylvania: The state’s Integrated Care Plan program for high-expenditure beneficiaries with persistent serious mental illness resulted in improvements in utilization, including reductions in inpatient hospitalizations and readmissions.
  • South Dakota: For 2017, health home participants cost $204 less per month than a comparison group, and had an 8% decline in emergency room visits from the prior year, compared to a 10% increase for the comparison group.
  • Vermont: The state reported in 2018 that the rate of inpatient visits per thousand beneficiaries in care management decreased from 600 to 393, and the annual rate of emergency visits per thousand beneficiaries decreased from 1,536 to 1,003.
  • Washington: The Health Homes program for dual eligible saved $107 million over its first 42 months.

Two states—Indiana and Nevada—reported mixed outcomes, as follows:

  • Indiana: The Right Choices Program generated low cost savings, with the exception of pharmacy costs, which were lower among beneficiaries with addiction disorders.
  • Nevada: The fee-for-service (FFS) care management organization (CMO) appeared to achieve some cost savings, but had little effect on quality of care after the program was implemented in 2013.

All seven states, the five MCOs, and the ACO used at least one approach to identify or predict high-expenditure beneficiaries. Some used more than one approach. States said they used various approaches to identify high-expenditure beneficiaries among different Medicaid population segments, such as FFS beneficiaries, or those with certain chronic conditions. The approaches included risk scores, statistical outliers, diagnosis type, service utilization and claims expenditure thresholds, and clinical judgment.

Officials in each of the selected states, the MCOs, and the ACO identified barriers to implementing care management for some high-expenditure Medicaid beneficiaries. In addition to noting the barriers posed by social determinants of health, the officials said missing outdated contact information for beneficiaries was a problem. They also noted that staff shortages in rural areas interfered.

For more information, contact: Carolyn L. Yocom, U.S. Government Accountability Office, 441 G Street, NW, Room 7149, Washington, District of Columbia 20548; 202-512-7114; Email:; Website:; or Chuck Young, Managing Director, Public Affairs, U.S. Government Accountability Office, 441 G Street, NW, Room 7149, Washington, District of Columbia 20548; 202-512-4800; Email:; Website: 

There is great debate over whether consumers shop for health care services; like comparing prices and using performance and quality data to make decisions. A recent story about a man who drove five hours for hernia surgery because he discovered a cost difference of $30,000 versus $3,000 (see Man Drives Five Hours For Surgery Insurance Won’t Cover)1 and news that about 1.9 million Americans have become medical tourists to get cheaper care (see U.S. Medical Tourists Seek Cheap Health Care Abroad)2 make me believe we’re entering a new phase of health care consumerism.

While price transparency is a priority (see Presidential Order Requires Price Transparency For Hospital Charges And Out-Of-Pocket Expenses), there is controversy over mandates for transparency and experts question why consumers are not really shopping to get the best prices.

What’s causing the delay? One health care executive, quoted in a Los Angeles Times story, said, “We overestimated the ability of consumers to be good stewards of their health care dollars.”

We may need more time to see a real shift from a doctor-knows-best environment to one in which consumers, like the Texas man noted above, look at health care like other purchases.

There are a few trends that might support more active consumerism. First, employers like Walmart are taking action to steer employees to specific physicians in its markets based on quality data. And Walmart is not alone. An increasing number of employers and health plans are implementing strategies to influence consumer health choices with value-based benefit designs and decision support tools (see Trends in Behavioral Health: A Population Health Manager’s Reference Guide on the U.S. Behavioral Health Financing and Delivery System).

The Center for Medicare & Medicaid Services (CMS) has several new initiatives that are focused on engaging consumers in health care decisions. CMS implemented a new rating system for nursing homes this month, Nursing Home Compare (try out the tool: And starting October 23, CMS will add a graphic alert to listings for nursing homes cited for abuse, neglect or exploration.

CMS is also requiring health plans to use its star ratings, which are influenced by consumer satisfaction, on health insurance exchanges (see CMS Requiring Star Ratings Displayed For Health Plans Sold On 2020 Health Exchanges). And it’s planning to update and expand the Hospital Compare site in 2021 based on public hearings and other stakeholder input.

When you combine these efforts with existing NCQA, HEDIS and health plan efforts to highlight health provider performance ratings, consumers will have more information at their fingertips. We see evidence that out-of-pocket costs will increasingly influence consumer choice (see News Reports about a Weakening Economy Impacting How Some Patients Seek Medical Treatment)3 and lead them to use these tools. The bigger question is how do we teach consumers how to use this information the same way they use Rotten Tomatoes to assess movie choices and Yelp when looking for restaurants?

“We are moving quickly toward Priceline health care,” said OPEN MINDS Senior Associate, Paul Duck. As consumers gain a better understanding of their options, shopping will become more common, which is why he advises executives to prepare. A few approaches to consider:

  • Review your organization’s ratings from health plans and independent organizations.
  • Assess how consumers find you online.
  • Review the consumer experience on your website.
  • Assess wait times for consumers scheduling appointments on the phone.

Learn more in upcoming coverage of the consumerism issue and check out these resources in the PsychU Resource Library:

  1. The Next Wave Of Consumer Price Shopping For Health Care
  2. Considering Cash & Consumerism in Service Line Planning
  3. Integration, Interoperability & Consumer Engagement
  4. The Big Rewards Of Health Care Through The Consumer Lens
  5. Answering The Question – Who Can Afford Their Health Services?



Between 2017 and 2018, the rate of health insurance coverage in the U.S. dropped from 92.1% of the 325.14 million population to 91.5% of the 327.16 million population in 2018. The uninsured rate rose from 7.9% to 8.5%; this rate counted people who had no insurance for any part of the year. Between 2017 and 2018, the U.S. population rose by 0.4%, from 322.5 million in 2017 to 323.7 million in 2018.

Of the total population, for all or part of 2018, about 67.3% was covered by a private health plan, such as employment-based coverage, direct-purchase coverage, or VA TRICARE. About 55.1% of the total population was covered by an employer-sponsored plan for all or part of the year. In 2017, 55.4% were covered by an employer-sponsored plan for all or part of the year.

Another 34.4% was covered for all or part of 2018 by a publicly funded health plan (Medicare, Medicaid, and VA or CHAMPVA). The share of people covered by a publicly funded health plan declined slightly from 34.8% in 2017 to 34.4% in 2018. About 17.8% of the population was covered by Medicare, up from 17.4% in 2017. About 17.9% were covered by Medicaid, down by 0.7 percentage points from 18.6% in 2017.

These findings were reported in “Health Insurance Coverage in the United States: 2018” by the U.S. Census Bureau. This report presents statistics on health insurance coverage in the U.S. based on information collected in the Current Population Survey Annual Social and Economic Supplement (CPS ASEC) and the American Community Survey (ACS). The goal was to report trends in health insurance coverage in the U.S.

Additional findings include:

  1. In 2018, about 8.5% percent of people, or 27.5 million, did not have health insurance at any point during the year.
  2. Of the subtypes of health insurance coverage, employer-based insurance was the most common in 2018, covering about 55.1% of the population for all or part of the calendar year.
  3. Between 2017 and 2018, the percentage of people with employment-based coverage, direct-purchase coverage, TRICARE, and VA or CHAMPVA health care did not show a statistically significant change.
  4. Between 2017 and 2018, the percentage of people without health insurance coverage at the time of the interview decreased in three states (New York, South Carolina, and Wyoming), and increased in eight states (Alabama, Arizona, Idaho, Michigan, Ohio, Tennessee, Texas, and Washington).

PsychU last reported on this topic in “Medicaid Covered 19.6% Of Americans In 2015,” which published on January 17, 2017. The article is available at

For more information, contact: Public Information Office, United States Census Bureau, 4600 Silver Hill Road, Washington, District of Columbia 20233; 301-763-3030; Email:; Website:

The number of primary Medicaid behavioral health carve-outs is on the decline. In our annual analysis, we’ve seen a decrease in the number of states with behavioral health carve-outs and an increase in the number of states with integrated financing. While the trend is toward integrated financing for physical and behavioral health services, does this apply to pharmacy benefits?

In a recent OPEN MINDS report, State Medicaid Mental Health Pharmacy Carve-Outs, they analyzed the market. Before diving into the findings, it is important to level set on exactly what we mean by integrated financing versus carve-outs for pharmacy benefits. State Medicaid financing of pharmacy benefits can take one of three forms:

  1. The pharmacy benefit can be integrated with financing for physical health across the plan (either within the fee-for-service [FFS] plan or a Medicaid health plan)
  2. The entire pharmacy benefit can be separately managed and/or financed via a primary carve-out for all pharmacy
  3. A portion of the pharmacy benefit—such as mental health pharmacy—can be separately managed and/or financed via a primary carve-out for behavioral health pharmacy (some states have primary carve-outs for other specialty drugs, but they are not the focus of this report)

OPEN MINDS found that in 2019, 44 states have integrated financing models for pharmacy benefits (either integrated in the FFS plans or in the Medicaid health plans) and 10 states have primary carve-outs. (Note, the total exceeds the number of states because some states utilize more than one financing arrangement.) Of those states with a primary carve-out, four had a primary carve-out for all pharmacy and six had a primary carve-out for mental health pharmacy only.

How does this compare with the past? There is not much change overall from a national perspective. Since 2017, one state has moved from an integrated financing model to a primary carve-out for all pharmacy. One state moved from a primary carve-out for all pharmacy to integrated financing in health plans and one state moved from a primary carve-out for mental health pharmacy to integrated financing with health plans.

Essentially, Medicaid pharmacy benefits are all over the place. Some states are integrating pharmacy benefits while others are instituting carve-outs. Three states have announced plans to implement primary carve-outs of pharmacy benefits. California plans to implement a carve-out for prescription drugs by 2021, Michigan released a notice to implement a carve-out for prescription drugs by December of this year, and North Dakota plans to implement a primary carve-out for pharmacy for the Medicaid expansion population in January 2020 (see New California Governor Orders Medi-Cal To Move Pharmacy To FFS Carve-Out Model.

What does this mean for provider organizations managing complex consumer populations? On one level, the move toward managing pharmacy benefits through a primary carve-out arrangement can simplify the administration of benefits. All Medicaid consumers will have exactly the same benefit and prior authorization requirements – regardless of the consumer’s health plan. On the other hand, the use of a primary carve-out might make it more difficult to coordinate benefits. Provider organizations’ clinical teams might have to take a more active role in making sure services and medications are coordinated.

There are a couple other factors to consider. On a more global basis, pharmacy benefit carve-out models make it more difficult to use total medical spend as a performance measure in value-based contracts. And, aside from the more common use of carve-out models and pharmacy benefit managers, we’re seeing the first states using value-based reimbursement contracts with specific manufacturers for specific medications. The effects of these models are still unknown, but could change how pharmacy benefits are delivered.

On September 13, 2019, three addiction and mental health treatment centers sued United Behavioral Health (UBH), UnitedHealthcare’s mental health subsidiary. The centers alleged that UBH wrongfully denied $5 million in behavioral health treatment claims for self-insured and fully insured employer health plans for residential and outpatient treatment from 2011 to 2017. The case involves claims for 157 employer group health plan members, including children.

The complaint claims that UBH guidelines for coverage are overly restrictive and violate federal and state law. Meridian Treatment Services; iRecover Treatment, Inc.; and Harmony Hollywood Treatment Center of California are listed as the primary plaintiffs. They allege that UBH used a cost-focused method of deciding whether to grant or deny pre-authorizations, and to grant or deny coverage for services that did not require pre-authorization. The plaintiffs asked the U.S. District Court of Northern California to have a neutral third party re-process the claims believed to be wrongfully denied.

The case stems from two consolidated class action lawsuits filed against UBH in 2014. The consolidated case went to trial in October 2017 before U.S. Chief Magistrate Judge Joseph Spero in San Francisco. The case was subsequently granted class-action status on September 16, 2016, in conjunction with these earlier lawsuits. In the current suits, the plaintiffs are asking the court to certify two classes—one covering residential treatment claims, and one class encompassing outpatient and intensive outpatient treatments that were not covered. The plaintiffs claim that as many as 3,000 health plans and 10,000 care facilities could be involved in the resulting complaints.

Meridian Treatment Solutions, Inc., offers sub-acute treatment for individuals suffering from mental health, addiction, and other co-occurring disorders in Lauderdale-By-The-Sea, Florida. Meridian provides mental health and addiction treatment to those covered under health insurance plans sold or administered by UBH.

iRecover Treatment Inc., dba, Serenity Palms Detox, offers sub-acute treatment for individuals suffering from mental health, addiction, and other co-occurring disorders in Palm Desert, and Cathedral City, California. Serenity provides mental health and addiction treatment services to those covered under health insurance plans sold or administered by UBH.

Harmony Hollywood offers sub-acute treatment for individuals suffering from mental health, addiction, and other co-occurring disorders in Los Angeles, California. Harmony provides mental health and addiction treatment services to consumers covered under health insurance plans sold or administered by UBH.

PsychU last reported on this topic in “Four Provider Organizations File $40 Million Lawsuit Against BCBS Of Michigan For Underpayment Of Out-Of-Network Addiction Treatment Claims,” which published on September 30, 2019. The article is available at

For more information about the plaintiffs’ claims, contact: Napoli Shkolnik, PLLC, 360 Lexington Avenue, 11th Floor, New York, New York 10017; Email:; Website:

For UBH, contact: Maria Gordon Shydlo, Media Contact for Employer & Individual, United Healthcare, Post Office Box 1459, Minneapolis, Minnesota 55440-1459; 612-486-4361; Email:; Website:

On October 1, 2019, the Alabama Medicaid Agency implemented the Alabama Coordinated Health Network (ACHN) to replace its Medicaid health home program and three other care coordination programs. The ACHN is a single care coordination delivery system intended to link consumers, primary care physician (PCP) groups, and community resources in each of seven newly-defined regions. In this new program, the regional networks and PCP groups are incentivized to achieve quality goals in the areas of childhood obesity, infant mortality rates, and addiction disorders. The ACHN does not change Medicaid benefits, and delivery of medical services is not the program focus. The state will continue to pay provider organizations directly. The goal is to improve the quality of care provided to Medicaid recipients, and to drive better health outcomes.

The ACHN will serve approximately 750,000 Alabama Medicaid recipients. The ACHN is for full-benefit, non-institutionalized children, pregnant women, and aged/blind/disabled beneficiaries in the Patient 1st population, maternity care population, and Plan First (family planning) population. Excluded populations include people dually eligible for Medicare and Medicaid, those in an institutional setting (including prison or jail), those enrolled in the state’s home- and community-based services waiver, children in custody of the Department of Youth Services, and people using hospice services.

Previously, Alabama operated four programs that each included care coordination functions. For the ACHN, the state selected seven primary care case management entities (PCCM-Es) in April 2019 to manage regional care coordination in the new regions. The aggregate value of the first-year PCCM-E contracts is about $40.9 million; the maximum contract values for each of the seven regions range from $5.5 million to $6.6 million. The PCCM-Es are as follows:

  • My Care Alabama for three regions: Northwest, Central, and East.
  • Alabama Care Network for two regions: Midstate and Southeast.
  • North Alabama Community Care for the Northeast region.
  • Gulf Coast Total Care for the Southwest region.

Participating PCPs will qualify for Participation Rates (enhanced payments for certain services) and bonus payments. To be eligible for these enhanced rates and bonus payments, the PCPs must also do the following:

  • Actively participate with the network entity in developing individualized and comprehensive care plans
  • Participate in the ACHN entity’s Multi-Disciplinary Care Team
  • Participate in program initiatives centered around quality measures, reviewing data provided by the ACHN entity to help achieve state and region quality goals
  • Participate in person in at least two quarterly medical management meetings and one webinar/facilitation exercise with the ACHN entity’s medical director over a 12-month period

In year one, all PCPs working toward patient centered medical home (PCMH) recognition will receive a bonus payment. In year two, all PCPs who have achieved PCMH recognition at any level will continue to receive the bonus payment.

Cost effectiveness bonus rates will be calculated to reward PCPs who control costs. Bonus participation is based on the risk-adjusted, average monthly cost of members attributed to the PCP provider organization group when compared to other similar PCP provider organization groups. Members who do not receive services are excluded from the calculation. Bonuses for improving quality will be awarded based on the achievement of certain scores on nationally recognized quality metrics.

Members will be attributed to the PCP based on the members’ primary care utilization over the past two years. This review will include preventative and regular office visits along with prescriptions for chronic care. A score will be calculated for each member/PCP combination. More recent claims and preventive care visits will receive higher values. The member will be attributed to the PCP with the highest score. Attribution will be updated quarterly.

PCP groups were required to complete an ACHN enrollment agreement with the Alabama Medicaid Agency before July 1, 2019 to avoid any delay in receiving ACHN bonus and participation payments. Care coordination referrals may be requested by provider organizations, recipients, or community sources. The care coordination services can be provided in a setting of the recipient’s choice to include provider organization offices, hospitals, ACHN-entity offices, public locations, or in the recipient’s home. Federally Qualified Health Clinics and Rural Health Clinics can participate in the regional AHCNs. If FQHCs and RHCs contract with their regional PCCM-E, their PCPs will also be eligible for bonus payments based on quality, cost effectiveness, and Patient Centered Medical Home (PCMH) recognition. Participating in the ACHN will not affect the prospective payment system reimbursement for FQHCs and RHCs.

PsychU last reported on this topic in “Alabama Medicaid Awards Contracts For Alabama Coordinated Health Network,” which published on July 8, 2019. The article is available at

For more information, contact: Melanie Cleveland, Communications Director, Alabama Medicaid Agency, 501 Dexter Avenue, Montgomery, Alabama 36104; 334-353-9363; Email:; Website:

More than half of physicians (53.8%) participated in an accountable care organization (ACO) during 2018, up from 44.0% in 2016. Of those physicians that participated in an ACO, 38.2% of participated in a Medicare ACO in 2018, 26.3% participated in a Medicaid ACO, and 39.0% participated in a commercial ACO. A subset participated in two or three ACO types. 31.9% worked in a practice that belonged to a medical home.

These findings were reported in “Policy Research Perspectives: Payment and Delivery in 2018: Participation in Medical Homes and Accountable Care Organizations on the Rise While Fee-for-Service Revenue Remains Stable” by Apoorva Rama for the American Medical Association (AMA). Ms. Rama analyzed 2012 through 2018 data from the American Medical Association’s (AMA) Physician Practice Benchmark Surveys. These surveys contain physician-level data on involvement with various care delivery models and payment methods. The goal was to determine physician involvement in ACOs, fee-for-service (FFS), and alternative payment methods (APMs). APMs included pay-for-performance, bundled payments, shared savings, and capitation.

Additional findings include:

  1. Among physicians in solo practices, 11.1% belonged to a medical home; 22.6% belonged to a Medicare ACO; 14.6% belonged to a Medicaid ACO; and 27.2% belonged to a commercial ACO.
  2. Participation rates for each ACO model were between 6 and 14 percentage points higher for physicians in single specialty practices compared to solo practices.
  3. Participation in medical homes and ACOs was 26 percentage points higher among physicians in practices that had at least some primary care physicians (40.8%), compared to those in practices without any primary care physicians (14.5%).
  4. Approximately 63.1% of physicians worked in practices that received at least some revenue from an APM.
  5. About 43.1% of physicians were unaware of their practice’s participation in at least one of the three ACO types (Medicaid ACOs, commercial ACOs, or Medicare ACOs).
  6. An average of 70% of practice revenue came from FFS, while only 30% came from APMs.

The full text of “Policy Research Perspectives: Payment and Delivery in 2018: Participation in Medical Homes and Accountable Care Organizations on the Rise While Fee-for-Service Revenue Remains Stable” was published in September 2019 by the American Medical Association. A copy is available online at (accessed October 14, 2019).

PsychU last reported on this topic in “71% Of Physician Practice Revenue In Fee-For-Service,” which published on February 21, 2018. The article is available at

For more information, contact: Carol Kane, Director of Economic and Health Policy Research, American Medical Association, 330 North Wabash Avenue, Suite 39300, Chicago, Illinois 60611-5885; 312-464-4819; Email:; Website:

While most executive teams focus planning time on ‘the next big thing’ to position their organizations for the future (see Coming Up With The Next Big Thing, that future is dependent on having a better bottom line for investment. Revenue cycle management is critical to that bottom line to make sure your organization is paid for every eligible service it delivers. Learning how to “beef up” reimbursement was the focus of the “Executive Strategies To Optimize Reimbursement In A Changing Marketplace” session led by Matthew Zabolotny, Netsmart’s Vice President/General Manager of Revenue Cycle Practice during the 2019 OPEN MINDS Executive Leadership Retreat.

How does revenue cycle management help you optimize performance and margins with your current services? It is the process for capturing consumer service revenue, a process that extends from the “first contact” with consumers, such as appointment scheduling and eligibility determination to point-of-service and service authorizations through service coding, billing, and collections (see Have You Mastered These 4 Financial Management Skills For VBR?). Mr. Zabolotny discussed three key elements for ensuring success with service revenue collections: The right people, real-time information for eligibility determinations and service authorizations, and a data-driven approach to managing claims denials.

Right people today, right people tomorrow: No matter what tools provider organizations invest in for revenue cycle management, they all need people who can use those tools effectively and understand the billing and collections process. And, due to high turnover rates for experienced billing team members, Mr. Zabolotny discussed the importance of creative incentive plans and the ability to scale up capacity with contract help when needed. Organizations that want to maximize their investments in revenue cycle management need to start with staffing plans that include better training, incentives, and/or outsourcing.

Eligibility verification and service authorizations in real time: One big factor in improving collections is improving the care authorization process. More than 25% of denied claims stem from authorization issues – making processes for real-time benefit eligibility verification an essential ingredient for success. Mr. Zabolotny also discussed the need to structure (and frequently update) processes and information about the prior authorization process for each payer including benefit coverage and medical necessity documentation requirements.

Data-driven management of claims denials: The key to managing claims denial rates is to prevent claims denials. While a speedy and reactive approach to responding to each denied claim is essential, the ‘big win’ comes with using data to improve the process. Having data to understand which claims are denied and why helps your organization continuously improve its revenue cycle management process.

As provider organization executives look to the future, optimizing revenue cycle management in the here and now can improve margins – and support the resources needed for future growth. For more on improving service revenue collections, check out these resources in the OPEN MINDS Industry Library:

  1. Have You Mastered These 4 Financial Management Skills For VBR?
  2. The Coordination Of Benefits Issue: A Sticky Wicket For Some

Blue Shield of California Promise Health Plan and L.A. Care Health Plan are planning to invest $146 million in expanding Community Resource Centers (CRC) in Los Angeles County, California. The program is part of a five-year commitment to expand CRCs across the county. Currently, the health plans operate seven CRCs and at full expansion, they will jointly operate 14. The expansion plans call for L.A. Care and Blue Shield Promise to jointly open seven new CRCs, remodel four existing centers, and relocate three other existing CRCs to larger locations.

The CRCs will connect members from both Blue Shield Promise and L.A. Care health plans, and the Los Angeles community, to classes and personalized services that foster community connections, address social needs, and keep them active, healthy, and informed. CRCs offer:

  • Fitness and health education classes
  • Preventive health, training and screenings
  • Nutrition and healthy cooking classes, and a registered dietitian onsite
  • Social service assistance (housing, financial literacy, food insecurity)
  • Support groups
  • On site Department of Public Social Services worker

The new CRCs will continue to offer services that are currently available at existing locations, as well as new services for health plan members such as telehealth, digital applications support, and care management. The centers will provide previously-offered preventative health screenings and new on-site care management for health plan members. The centers will also offer on-site support from community social service organizations focused on addressing social needs of health, such as food and income insecurity. Child care is offered at no cost to ensure that parents in each community can take full advantage of the classes.

L.A. Care currently serves approximately 2.2 million members in four product lines, one of which (Medi-Cal) is contracted with Blue Shield of California Promise Health Plan. Each new center will serve approximately 72,000 people per year when services and staff are fully built out, serving more than one million Angelenos annually. Both L.A. Care and Blue Shield Promise will have staff at the CRCs. Additionally, local community-based organizations will be invited to provide social services support as appropriate. Services and free classes, such as Zumba and Pilates, will be offered to the community. Members can be referred by a physician, but it is not a requirement in order to attend.

For more information, contact:

  • Kellie Todd Griffin, Senior Director, Community and Provider Engagement, Blue Shield of California Promise Health Plan, 601 Potrero Grande Drive, Monterey Park, California 91755; 800-605-2556; Email:; Website:
  • Francisco Oaxaca, Senior Director, Communications and Community Relations, L.A. Care Health Plan, 1055 7th Street, Los Angeles, California 90017; 213-694-1250; Email:; Website:

On September 17, 2019, The Alliance for Addiction Payment Reform (Alliance) announced value-based pilot projects underway in five states and Washington D.C. One of the first projects includes a statewide rollout in North Carolina of Eleanor Health, a new integrated health provider organization that treats addiction disorders with a “whole-person” approach, and manages addition as a chronic disease.

On September 4, 2019, Eleanor Health announced its first location in Mooresville, North Carolina. Additional sites will open first in North Carolina, and then at yet-to-be-announced locations across other markets in the United States. Specific dates for these additional locations have not been announced; however, market expansion is planned during 2020.

Eleanor Health is a member of the Alliance and has committed to implementing a related value-based payment program built from principles within the Addiction Recover Medical Home – Alternative Payment Model (ARMH-APM). A spokesperson for the Alliance said the additional projects are being developed by other Alliance members—Anthem, Superior Health Plans, Amerihealth Caritas, and Select Health. Each is exploring projects that would launch in late 2019 or early 2020.

The ARMH-APM elements address payment, quality measures, integrated care, long-term recovery, and treatment and recovery planning. The goal is to holistically address the clinical and non-clinical factors of managing addiction and recovery.

The Eleanor Health treatment model starts with an initial meeting between the consumer and the organization’s clinical professionals, therapists, and community recovery partners. The team will develop a personalized “whole-person” treatment plan, specific to the needs of the individual. Treatment plans will include a combination of medical services, individual and group therapy, and community-based support services. Comprehensive treatment support will be offered in-person and via treatment technology, including medication assisted treatment (MAT) for opioid use disorder and other addiction disorders. The length of treatment will depend on the needs of the individual.

The payment model uses a blend of capitation/bundled payments to reward the provider organization for its performance on recovery-linked quality measures. The capitated/bundled payments support the provision of more integrated and personalized care. A portion of the capitated/bundled payment is tied to achievement of successful consumer outcomes. The provider organization may be eligible to share in additional savings created from better coordinating care across all health care services, including addiction, behavioral, and physical services.

Eleanor Health launched operations on September 4, 2019, in North Carolina. The company is led by Corbin Petro as chief executive officer; Ms. Petro co-founded Eleanor Health with the assistance of venture capital investment firms Oxeon and Town Hall Ventures. Mosaic Health Solutions, a subsidiary of Blue Cross and Blue Shield of North Carolina (Blue Cross NC) invested in Eleanor Health in a July 2019 funding round. Blue Cross NC is also collaborating with Eleanor Health to expand access to Eleanor Health’s comprehensive treatment services.

The Alliance is comprised of dozens of health care institutions and professionals. The Alliance developed a value-based alternative payment model, the ARMH-APM, to establish a structure that promotes the type of integration and consumer care capable of producing improved outcomes for consumers, payers, and health systems long-term by aligning all incentives. The 2018 ARMH-APM was initially developed by a multi-sector process convened by Leavitt Partners, Facing Addiction with the National Council on Alcoholism and Drug Dependence, Inc. (NCADD), and Third Horizon Strategies. In 2019, Third Horizon Strategies continued to manage the work on behalf of the Alliance and released an updated paper coinciding with the announcement of pilot explorations of the model in local markets.

The full text of the “Addiction Recovery Medical Home – Alternative Payment Model” 2019 update was released on September 24, 2019. A copy is available online at (accessed September 17, 2019).

PsychU last reported on this topic in “New Health Care Alliance Launches Addiction Medical Home Model,” which published on November 26, 2018. The article is available at

For more information about the Alliance for Addiction Payment Reform, contact: Greg Williams, Managing Director, Alliance for Addiction Payment Reform; Third Horizon Strategies, 444 North Michigan Avenue, Chicago, Illinois 60611; 312-374-8934; Email:; Website:

During the 2019 OPEN MINDS Executive Leadership Retreat in Gettysburg, they discussed the was struck by the many challenges that health and human service organization executive teams face in building the organizational size and scale needed for success. Most often, the discussion focuses on getting more “revenue”—almost all discussions of scale are posed in terms of revenue. But to make that revenue growth happen, there is also the parallel challenge of building the administrative infrastructure needed to support the scale—human resources, financial, marketing, technology, regulatory compliance, and more.

One option in a high-change, high-growth environment is for those executive teams to consider using outsourcing to build capacity in non-core service areas, allowing them to focus on building more service revenue. How to consider the outsourcing option and make it happen was the focus of Hope Winkowski, Vice President of Product Services at Credible Behavioral Health Software, in her presentation Opting To Outsource: An Executive’s Guide To Identifying, Selecting & Managing A Vendor For Outsourced Services.

First, provider organization executive teams need teed to consider the pros and cons to outsourcing. Positives include cost saving opportunities, better efficiency, greater operations transparency, an easy way to “adopt” best practices, and keeping organizational focus on core competencies. But there are a few downsides that need to be kept in mind. There is the issue of control and customization. And, there can be liability issues (which party is “responsible” when something goes wrong) and likely higher costs.

What should you look for when outsourcing services and how do you make your decision? Ms. Winkowski recommends using a request-for-proposal (RFP) process. The RFP should include expected performance metrics, clarify any shared risk, establish communication expectations, and establish criteria for terminating the outsourcing relationship. The RFP process—the response, presentations, and negotiations—will provide an opportunity to negotiate costs, confirm all service delivery assumptions, and provide insights into the vendors’ processes..

Outsourcing is a potential tool for rapid growth and achieving operational scale. Executive teams should consider the many outsourcing options as part of their strategic growth plans. For more on outsourcing and vendor selection, check out these resources from The PsychU Resource Library:

  1. A Chaotic Environment Demands Fluid Strategic Planning
  2. Building Your Foundation & Your Castle
  3. What Should Your Organization Be Spending On Tech?

On September 3, 2019, UCHealth in Colorado announced plans to invest at least $100 million over five years to enhance its behavioral health services. As part of this effort, within six months, UCHealth plans to launch virtual behavioral health services in its emergency departments. Within the next year, UCHealth anticipates collocating behavioral health workers in pilot primary care locations.

A key goal of the investments is to provide earlier detection and treatment for consumers with addiction and mood disorders, and increase access to new addiction treatment services. UCHealth intends to remove barriers by providing the right care at the right time. The funding will be used for the following three initiatives:

  • Integrating behavioral health with primary care: Teams of licensed clinical social workers and psychologists will work hand-in-hand with primary care physicians to provide immediate resources to the largest number of consumers in need.
  • Tele-behavioral health consultation services: When consumers and clinical professionals in emergency departments, primary care clinics, or inpatient hospitals need consultations with a psychiatrist, UCHealth’s Virtual Health Center will provide the video connection.
  • A new inpatient behavioral health unit: The expansion of the University of Colorado Hospital will enable a new inpatient behavioral health unit to expand the services already available in other UCHealth locations. The new inpatient behavioral health unit will likely open in late 2023.

For more information, contact: Dan Weaver, Vice President, Communications, UCHealth University of Colorado Hospital, 12605 East 16th Avenue, Aurora, Colorado 80045; 720-848-7852; Email:; Website:

When you ask about the state of payer/provider organization partnerships—with innovative programming and value-based reimbursement (VBR)—executives on both sides of the equation say there is more talk than action. Yet several examples of success were shared during The Innovative Treatment Programs For Value-Based Partnerships: An OPEN MINDS Summit. Executives who attended this first summit, held two weeks ago at The 2019 OPEN MINDS Executive Leadership Retreat, learned firsthand from executives who are making these partnership work:

  • Marie Wenzel, PEACE Program Director of Horizon House, developed early psychosis intervention services paid with a bundled rate in partnership with a payer.
  • Andrew F. Vitullo, Vice President of Development of Kolmac Outpatient Recovery, which provides an outpatient addiction treatment detoxification and rehabilitation program using a bundled payment.
  • Brandi Phillips, Chief Executive Officer of Allegheny HealthChoices, is private non-profit that performs oversight of a local Medicaid behavioral health managed care program that uses alternative payment models to fund ACT services.
  • Lee Anne Langhurst, Vice President, Account Management at Talkspace and Kathleen Mahieu, Lead Business Consultant for Strategy & Innovation for Aetna Behavioral Health, providing a virtual behavioral health service for Aetna members.

Throughout the day of detailed discussion, there were three common elements to the successful payer/provider organization partnerships—bringing innovative program ideas to payers that answer some very specific questions; having a plan to take pilot programs to scale; and doing what is needed to create a true partnership.

Think big and bring innovative program ideas to payers that answer some very specific questions

One key element in making payer/provider organization partnerships work is innovation paired with data. Payers are looking for innovations that increase their value, which means addressing issues like consumer access, tracking key performance metrics, accepting VBR, and managing across the health and human service continuum.

All the provider organization executives presented impressive performance data, which was a key component to partnering with payers. I touched base with Ken Carr, Senior Associate, OPEN MINDS, after the event and he emphasized the value of payer and provider organization representatives working collaboratively to innovate new approaches to care, agree on how success will be measured, and deliver services in consumer-centric ways.

Mr. Carr added that while networking is critical to getting a foot in the door with health plans, provider organization representatives need to do two things: Identify the person highest up at the organization you can talk to and have the data to “prove” your solution works.

All of the provider organization executives presented impressive performance data. Ms. Wenzel illustrated the value of data to moving to a value-based reimbursement model for PEACE. Initially, her organization wasn’t positioned to do this. But, they are systematically measuring performance – measures like their 80% decrease in number of participants hospitalized at 6-month follow-up; their 88% decrease in hospital days at 6-month follow-up; and consumer employment rates increased by 133% at 12-month made that possible.

Ms. Wenzel noted: “To build those relationships, you have to know who to talk to and have the meat and potatoes to show that you are really doing this. Also, define everything for yourself. If we have something that is proven to work, that takes the burden off the managed care organization to define things.”

Have a plan to bring the innovative program to scale

Often the only way in the health plan door is to conduct a “pilot” of an innovative treatment program for a health plan. But often, those pilots are not profitable —getting “to scale” is often a key to sustainability.

On the health plan side, a service delivery network model that can incorporate innovative programming with alternative reimbursement models is necessary. On the provider organization side, having an innovative program with a defined clinical model driven by decision support tools, as well as an administrative model that can grow with volume, is necessary.

Mr. Vitullo noted: “Payer organizations aren’t afraid to think big. They see the need for best practices to expand. Understand what your service delivery is and understand if it is replicable. How do you quantify the outcomes, how do you track it, and how do you agree on it with your payer-partner?”

Do what is needed to create a relationship that is a partnership

Finally, to make partnerships work in the long run, creating the framework for a partnership is key. Mr. Vitullo spoke of the need to start with aligned incentives – the consumer, the payer, and the provider organization.

Ms. Mahieu spoke to the period when Aetna Behavioral Health began talks to partner with Talkspace, Aetna came to the table with a key question—when you are approached every day with a new solution by a new potential partner, what is actually valuable to their members and what solves the problems you are trying to address? Talkspace’s value includes reaching 70% of consumers who reported they wouldn’t have sought face-to-face services, and a 50-57% symptom reduction in depression or anxiety after 3 months.

Ms. Mahieu also noted, “As we investigate the new solutions and partners, they all sound great. One of the key challenges is to determine how they work together to support our members across the continuum of care. How do we create the right ecosystem so that they all make sense to the member? We don’t all know the answers so we value our strong partnerships so we can solve it together.”

If the future of health and human services is value-based, then the future requires a different relationship between health plans and the provider organizations serving their members – a relationship based on partnership. For provider organization executives who see these relationships in their future, innovation, performance metrics, scalability, and new account management model are minimum requirements for success.

Over the years, we’ve written about the federal Certified Community Behavioral Health Clinic (CCBHC) initiative (see CCBHCs Are Moving Forward – What This Means If Your State Isn’t Moving Forward, Are You Ready To Be A Certified Community Behavioral Health Center?, CCBHCs In 8 States Projected To Serve 380,000 Individuals In First Year). And this summer, the demonstration was slated to end, leaving states, Congress, and provider organizations scurrying to figure out what to do next. So where are states now and what does the future look like?

As a reminder, CCBHCs are behavioral health provider organizations that receive a prospective payment rate for delivering care in return for meeting six key criteria related to staffing mix; service access and availability; coordination of services; scope of services; quality improvement and reporting; organizational, authority, governance, and accreditation. In order to help states prepare for the demonstration, planning grants were awarded to 24 states in 2015 and then eight states were selected to actually participate in the demonstration. Those states are Minnesota, Missouri, Nevada, New York, New Jersey, Oklahoma, Oregon, and Pennsylvania.

Technically, the demonstration ended on June 30, 2019 after two years. In August, Congress extended funding for the demonstration to September 13, 2019, and in September the Senate cleared a short-term spending bill that includes an extension of the CCBHC until November 21. Continued funding for the program is included in the President’s budget and is expected to have bipartisan support.

Regardless of the decisions at the federal level, six of the eight states are committed to continuing to fund the program. Only Pennsylvania and New Jersey are awaiting federal funding to make their decision to continue the program. In order to continue the demonstration, most states are submitting state plan amendments (SPA) to the Centers for Medicaid & Medicare Services (CMS).

  1. Minnesota- Continued payment for the CCBHC program was included in the state’s 1115 demonstration waiver approved in June 2019. The approval is for one year in order to allow the state to submit the necessary SPAs and documentation to continue the program (see Minnesota Medicaid To Expand Addiction Treatment Via CCBHCs & Short-Term Residential Treatment Benefit).
  2. Missouri – In June, the state received approval of their SPA to continue the CCBHC program (see Missouri Medicaid To Continue Prospective Payments To 15 CCBHOs).
  3. Nevada – The state plans to continue paying a bundled rate for services and will certify seven additional clinics. Until the SPA is approved, the three clinics will receive about 75% of their average monthly billing.
  4. New York – Official documents on the continuation of the program is not available, however the state is expected to submit a state plan amendment.
  5. Oklahoma – CMS approved Oklahoma’s SPA to continue the CCBHC program on July 1, 2019. The state plans to certify new CCBHCs.
  6. Oregon – The state has indicated that they plan to submit a SPA right.

Overall, the fact that six states are planning to permanently continue to the CCBHC program is promising. It indicates that they are committed to new model for delivering and financing behavioral health services. For provider organizations, who do not serve these states, the results of the demonstration are still relevant. CCBHCs really serve as a model for the future, the key competencies required of the organizations include the adoption of technology, tracking of outcomes, new financing models, and coordination of services. Organizations can use the CCBHC model as a benchmark for their organization and as a model for developing core competencies for operating in a value-based environment.

As the primary care industry moves toward value-based payment (VBP), primary care practices participating in risk-based models will need additional staff who offer a richer skill mix. The additional skills include consumer education, care planning and coordination of care, as well as support for community services to meet needs of consumers with complex health and behavioral health conditions. Pharmacists, behavioral health professionals, nutritionists, and social workers may be needed to support community services. As a result, a practice participating in a risk-based model could need registered nurses (RNs), licensed practical nurses (LPNs), medical assistants (MAs), behavioral health social workers, nutritionists, and pharmacists.

Currently, fee-for-service (FFS) practices rely on RNs, LPNs, and MAs. The majority of practices, (54%) are staffed with a combination of nurses (either RNs only or LPNs only), plus MAs. About 24% of practices are staffed with all three current staff types including RNs, LPNs, and MAs. About 22% use an MA-only staffing model.

These findings were reported in “Optimizing Primary Care Model Design to Improve Performance” by researchers with Premier Inc. The researchers analyzed Premier’s database of physician practice information, which includes more than 30,000 clinical professionals. They benchmarked 2018 data from 257 family medicine and primary care practices comprised of more than 885 physicians and 1,445 staff. The report noted that for most of the practices, FFS revenue represents the majority of revenue. However, the report did not split out results by level of FFS revenue or risk-based revenue. The goal of studying current staffing models was to gain insight on how clinical staffing variation can help physician practices design the most effective staffing model.

Supported by the data gathered from the physician practice database, Premier made the following observations about aligning primary care practice staffing and effectiveness with payment model design.

  • Physician practices should understand where they are on the journey to value-based care and be intentional about moving toward staffing models that will support that path, such as leveraging staff in relation to volume. Value-based arrangements require specific clinical, technical, and administrative capabilities; as primary care practices move further along the value chain, they will likely need a higher level of staff skill mix to support more proactive coordination of care for consumers.
  • Consumer education, care planning, and coordination of care for the highly complex or vulnerable populations will further improve efficiency and effectiveness in a VBP model.
  • Provider organizations that are not interested in participating in VBP, or other advanced models of care, may want to reconsider their staffing models if they currently have staff with a richer skill mix (RNs and LPNs) since this model may only be contributing to higher practice expense and ineffective use of resources relative to licensed staff.
  • The MA-only staffing model may be the most practical and cost-effective option for primary care provider organizations intending to remain in FFS. Compared to nurses, MAs have similar productivity, but have lower wage costs.

Productivity of the current primary care staffing models was measured in terms of work relative value units (wRVUs) associated with each medical code. RVUs are set by the Centers for Medicare & Medicaid Services (CMS). The value is based on how much effort CMS believes is required to perform a service. In the current FFS practice models, wRVUs were very similar for the three staffing models, as follows:

  • The wRVUs for the MA-only model averaged 4,763 per professional.
  • The wRVUs for the nurse (RN or LPN) plus MA model averaged 4,536 per professional.
  • The wRVUs for the RN, LPN, and MA model averaged 4,786 per professional.

The researchers concluded that the staff skill mix was not a determining factor in overall professional productivity in the three models. Further, clinics with MA-only models and comparable staff to physician clinical full-time equivalent (CFTE) ratios were just as likely to achieve top quartile performance as higher skill mix models inclusive of RNs. The highest performing clinics (in terms of productivity) had more numbers of support staff per physician CFTE than clinics in the bottom quartile. The overall staff cost per wRVU falls as the practices achieve economies of scale.

  • The RN, LPN, and MA model in the top quartile had 2.4 staff per physician CFTE at a cost of $17 per wRVU, compared to 1.7 at a cost of $23 per wRVU in the bottom quartile
  • The RN or LPN plus MA model in the top quartile had 2.2 staff per physician CFTE at a cost of $13 per wRVU, compared to 1.7 at a cost of $31 per wRVU in the bottom quartile.
  • The MA model in the top quartile had 1.8 staff per physician CFTE at a cost of $9 per wRVU, compared to 1.3 at a cost of $18 per wRVU in the bottom quartile.

The researchers concluded that movement towards value-based payment requires primary care provider organizations to consider alternative care delivery and payment model options. They said that primary care provider organizations will need to methodically adjust their staffing models to include staff with a richer skill set that can support a more coordinated model of care. The researchers concluded that a richer skill mix is a cost-effective option in the shift to value-based payment.

The full text of “Optimizing Primary Care Model Design to Improve Performance” was published in August 2019 by Premier Inc. A copy is available online at (accessed September 20, 2019).

For more information, contact: Morgan Guthrie, Media Contact, Premier, Inc., 13034 Ballantyne Corporate Place, Charlotte, North Carolina 28277; 212-901-1356; Email:; Website:

What a week at the 2019 OPEN MINDS Executive Leadership Retreat! They covered a lot about the challenges of value-based reimbursement (VBR) to non-profit board governance, the rising proportion of chief executive officers (CEO) of specialty provider organization executives getting ready to retire, the challenges of bringing trauma-informed care to scale, and much more. And, in a sense, these topics were the focus of Monica Oss’s closing keynote, The Complexity Leadership Challenge: How To Prepare Your Organization—& Yourself—For Success In A New Era. Ms. Oss reviewed the structural changes shaping the field, the implications for strategy, and how best to position specialty provider organizations for the future. And, then she asked the audience the question—how prepared are they as executives to lead this change?

The challenge is that many fundamentals—the business models for behavioral health and primary care, reimbursement models, consumerism, and technology—are in motion. What is obvious is that most organizations will need new service lines and new market positioning for long-term sustainability.

While the specifics of that new market positioning will vary based on the consumers served and their service needs, the successful sustainable services will be the services with the highest value equation. Those services will most likely be community-based, tech-enabled, and consumer-centric. And the design, delivery, and management of those services will be driven by performance metrics, with performance defined by payer, health plan, and consumer customers.”

We’ve written a lot about how to plan for this “big leap” in market positioning. Essentials include a new approach to organizational strategy for sustainability and a rigorous approach to strategy implementation (see Coming Up With The Next Big Thing and Adjust Your Strategic Sails!). But, having the plan and preparing the organization for a successful evolution is only part of what is required. I’m a big believer in the Peter Drucker observation, “Strategy is a commodity and execution is an art.” The question for every executive is: are you also prepared to provide the strategic leadership needed for this transitional phase of your organization’s existence?

Strategic leadership is defined as the ability to handle complex problems for which there is no obvious short-term solution. While most executives in the health and human service field got to their current positions because of great transaction leadership skills success in the new environment requires new leadership talents. Strategic leadership—the ability to transform organizations in a complex environment—is key.

The good news is that strategic leadership can be learned and improved. Executives can practice the strategic leadership—and build their strategic leadership “muscle.” This is based on the concept of neuroplasticity, in which the brain can change, and self-directed neuroplasticity, or that we can make brain changes happen.

Ms. Oss find that practiced and disciplined behavior, meditation, mindfulness, and visualization are keys to building your leadership skills. The issue for executives is how assess where they are with core strategic leadership practices and if they want to put in the hard work to move their leadership skills from the transactional to the transformational. If the answer is yes, there are some specific actions in decision making and management that can enhance their strategic leadership skill set.

The fate of many organizations in the field will rise or fall based on the strategic leadership skills of their executive teams. Keep in mind the adage of Malcolm Forbes, “An organization can never rise above its leader.” For more on leadership topics, check out these articles and presentations in the PsychU Resource Library:

  1. Are You A Change Agent Leader? Take The Test
  2. The Complexity Challenge Keeping You Up At Night? Former Execs Advise. . .
  3. Long-Distance Leadership
  4. Staff Not Performing? What Does That Mean?

At the 2019 OPEN MINDS Executive Leadership Retreat Ray Wolfe J.D. and George Braunstein, Senior Associates at OPEN MINDS, presented a seminar on Aligning Non-Profit Health & Health Human Service Boards for Sustainability With The New Market Landscape.

For governing boards of provider organizations, new reimbursement models can be challenging. This is especially true considering a third of non-profit board members are unsatisfied with how the board evaluates organizational performance, and over a quarter of board directors believe their fellow associates lack an understanding of the organizational mission and strategic plan. For a provider organization to meet change successfully, the board members, structures, and operations must align with the organization’s mission—either the old mission, or a VBR-defined mission.

The board must be more educated and do more evaluation, in terms of financing and risk. For education, board members must understand the changing reimbursement models and obtain the necessary skills to support an organization with a VBR model. And for evaluation, the board needs to do more in planning and evaluating itself in terms of the skills that are required for optimal functioning, the expectations of commitment from each member, and the overall processes of the board, with feedback provided as needed.

Historically, the role of board members hasn’t focused on the challenges of managing financial risk and variable revenue streams. Mr. Wolfe discussed how traditional boards operate with a few very active members meeting at a regular time, often two or three months apart. This is not effective in a value-based world where the financial issues can change unexpectedly, and timely judgment calls are necessary. Put simply, traditional models of governance are not effective.

So, how does board governance need to change? Board members need an understanding of value-based reimbursement models and potential risk; they need a more operational understanding of how consumer care and coordination of services works; and they need different financial data.

Understanding value-based reimbursement models and potential risk—Board members must have an understanding of the changes in health care, different reimbursement models, and financing, particularly in the context of a value-based health care model. Boards must understand the coordination of services and care, how clinical professionals and provider organizations are paid based on consumer health outcomes, and how provider organizations are reimbursed for improved outcomes. Mr. Wolfe discussed:

A significant problem with board members is their lack of knowledge of a value-based reimbursement model as well as the changes in health care. As changes emerge when adopting these new models, this change places tension between the board and the organization. Models can have moderate risk to high risk, but how many board members have this understanding of health care financing? If board members don’t have that type of background or education, they need to have an expert or someone who is able to provide the support and advice on which contracts to sign, or not sign.

Operational understanding of consumer care and coordination of services—In the process of building a team for a governing board, a board should consist of a diverse group of individuals who are able to bring their different backgrounds and different perspectives together on the same issues. To best serve and understand what consumers truly need, the board needs to be composed of community leaders, social service and health care leaders, individuals and families who are directly impacted, and business leaders. But this should also be representative of the community—diverse in gender, ethnicity, and age. Mr. Wolfe discussed:

Consumerism is the driver of the shift to VBR. To truly understand consumerism, collaboration among individuals from diverse backgrounds is needed on the governing board. It’s not enough to just match a skill set to the board, it’s necessary to find the right people who are willing to have the education and the skill sets that are needed to fulfill the functions and the mission of the organization. Boards should be composed of family members who will be directly affected, persons in the community who can offer their perspective, and experts with specific clinical and business knowledge. A diverse group of board members can provide their unique skill sets along with their unique perspectives.

Financial data to measure organizational performance—For organizations that have shifted to value-based contracts, a shift also needs to occur from traditional reports. In the context of risk calculation and monitoring of income, traditional means of reporting are not able to provide the level of detail for VBR. For the governing board of a provider organization with a VBR model, “best practice” starts to look different. New skill sets are needed to support the changing reimbursement model including ensuring a quality assurance process is in place for measuring performance. This means embracing different techniques to identify and stratify risk, making informed decisions, and taking appropriate action based on the strategic analysis. Mr. Wolfe discussed:

The shift to a value-based contract isn’t just an incentive to do better, it shifts the risk onto the organization that is providing care. These levels of risk need to be analyzed for proper maintenance, which needs to be effectively conducted by the board members. Boards need to determine how much risk is on the company, and traditional means of analysis simply don’t provide enough detail when determining if there is too much risk on the company. The income statement and metrics are important, along with income monitoring. Contracts are written around the possibility that reductions are taken out, and then given back only if those performance outcomes are met; risk calculation has to be determined with a close monitoring of cash, 60 to 90 day cash projections, and an income statement broken down by value-based and non-value-based structures, as well as the metrics and impact of the metrics as they presently stand. Without this, it would essentially be impossible to successfully oversee the financial operations of the organization.

The key to sustainable success with VBR begins with organizational leadership, and this requires acceptance at the level of the governing board members. The modern health care board is changing with the shift to VBR, and the board requires a new set of unique perspectives and skill sets across the continuum of the health care system.

 Attributes of a good board member—A good starting point lies in the personality characteristics and attributes of the board members that are sought out during the recruitment process. This requires a focus on aligning the attributes of each board member to the mission and expectations of the organization and leadership. And it’s not just about matching specific skill sets to the board, it’s about finding the right people who are motivated and willing to build the necessary skills through education, which includes having the ability and willingness to see the changing market in new ways. Good board members should be motivated to preserve the mission; however, they should also know the difference between when to pursue it, and when to redefine it.

In the context of strategy, leaders have to embrace the change (and the risk) that comes with this constantly changing environment. Aligning this new strategy with board leadership and the changing reimbursement methods will be the ultimate driver in reaching optimal organizational performance.

Check out these resources from the PsychU Resource Library.

  1. Have You Mastered These 4 Financial Management Skills For VBR?
  2. The Strategic Challenges On The Road To Value-Based Reimbursement
  3. From An Extension Of Government Policy To Competitive Service Providers – The Strategy Evolution For Non-Profit Executives

On August 1, 2019, New York City launched “NYC Care”, a health care program to provide access to health care services for uninsured city residents. Enrollment in the Bronx began on August 1. All services are provided by NYC Health + Hospitals. NYC Care will be expanded city-wide by the end of 2020. At full-scale, the program will cost approximately $100 million annually.

NYC Care member benefits include:

  • Primary care, and members who are new to NYC Health + Hospitals will be able to secure a primary care appointment within two weeks of enrollment.
  • Mental health services and addiction treatment services.
  • A 24/7 customer assistance line where members can ask questions about NYC Care and speak to an on-call clinical professional for all of their needs, including prescription refills.
  • 24/7 access to medications in the Bronx. This includes expanded pharmacy hours at the five NYC Health + Hospitals pharmacies in the Bronx.

NYC Health + Hospital has a multi-pronged strategy to reach NYC Care-eligible residents, including partnerships with the New York City Mayor’s Office of Immigrant Affairs and New York City Mayor’s Fund to Advance New York City. NYC Health + Hospitals is also leveraging GetCoveredNYC’s existing outreach to uninsured New Yorkers in the Bronx to refer eligible people to NYC Care for enrollment. In addition, New Yorkers who apply for public health insurance through MetroPlus, and are found ineligible or are unable to afford any options, will be directed to NYC Care. The health system has contracted with five community-based organizations to facilitate outreach. These organizations will identify, recruit, and refer uninsured New Yorkers for screening and enrollment in NYC Care. The five organizations are BronxWorks, Emerald Isle, Northwest Bronx Community and Clergy Coalition, Mekong NYC, and Sauti Yetu Center for African Women.

For more information, contact:

  • Press Office, The Office of the New York City Mayor Bill de Blasio, City Hall, New York, New York 10007; Email:; Website:
  • Chris Miller, Media Contact, NYC Health+Hospitals, 125 Worth Street, New York, New York 10013; 347-396-4177; Email:; Website:

On July 31, 2019, four Michigan addiction treatment centers sued Blue Cross Blue Shield of Michigan (BCBSM), alleging that they have been underpaid for their out-of-network claims for addiction treatment for Blue Cross Blue Shield (BCBS) commercial members. The four provider organizations are Serenity Point Recovery, Inc.; Forever Recovery; Behavioral Rehabilitation Services; and Best Drug Rehabilitation. The organizations allege that from April 2016 and forward, claims that were wrongfully denied, underpaid, or incorrectly processed by BCBSM total not less than $40 million. The plaintiffs requested a jury trial.

The case is the Serenity Point Recovery, Inc, et al. v. Blue Cross Blue Shield of Michigan (case number 19-cv-00620) in the U.S. District Court for the Western District of Michigan. The centers have no written agreement with BCBSM or any BCBS plan, although one of the plaintiffs, Best Drug Rehabilitation, joined BCBSM’s Traditional Network of participating provider organizations. The plaintiffs provide 1,000 beds for residential addiction and mental health treatment. The lawsuit involves claims related to at least 4,066 consumers purportedly covered by BCBSM. The plaintiffs alleged that each consumer who received or currently receives treatment at the plaintiffs’ facilities was asked to execute a notarized, durable power of attorney and endorse a separate assignment of benefits form to the respective facility. Based on these documents, the facilities claim the same rights as the health plan members to appeal, litigate, and receive payment under the health plan benefits.

The treatment centers allege that BCBSM failed to process their out-of-network claims and often rejected them even when the consumers were covered by an out-of-state BCBS “home plan,” other than BCBSM that explicitly provided benefits to be paid to out-of-network provider organizations. They further allege that BCBSM lacked staff, processes, and systems to accept claims for out-of-state members with out-of-network benefits and process them through the Blue Card program. As a result, the plaintiffs said, BCBSM simply denied the claims. After negotiation, BCBSM allegedly agreed to process claims submitted by mail. The plaintiffs said they were not permitted to submit claims electronically.

The treatment centers allege that between April and July 2016, BCBSM cut reimbursement for their daily inpatient rates from $900 per day to $150 per day. The plaintiffs asserted that in March 2017, BCBSM informed them that the lower rates were the standard “in-network rates” that would be paid, regardless of network status. Additionally, BCBSM allegedly told the plaintiffs that it would no longer reimburse at a per diem rate. Instead, the plaintiffs said BCBSM told them they would be required to submit unbundled billing for each service provided during the day. Further, the plaintiffs allege that some claims were wrongfully denied. After the reimbursements were cut, the treatment centers billed the consumers for the difference.

On August 26, 2019, BCBSM requested a pre-motion conference for the purpose of filing a motion to dismiss the lawsuit by the four nonparticipating out-of-network addiction treatment facilities in Michigan, which are commonly owned by Nevada-based U.S. Addiction Inc. BCBSM alleges that the claims are vague and flawed, in part because the plaintiffs do not identify a benefit plan or policy term that entitles them to the additional payments they seek. In a statement, BCBSM noted that U.S. Addiction Inc. bases its claims on alleged “assignments” of rights from consumers, which are not valid under BCBSM policies.

On August 29, 2019, the attorneys for the plaintiffs said that three of the four facilities are incorporated under Nevada law, but they are not owned by U.S. Addictions; the fourth facility is a Michigan corporation. They clarified that the claims are not brought under “assignment” but directly by the provider organization to which BCBSM has an independent duty. The claims under the Employee Retirement Income Security Act of 1974 (ERISA) are also not an “assignment,” but are brought under the health care power of attorney designations executed by the consumers treated by the plaintiff facilities.

For more information about the plaintiffs’ claims, contact: Napoli Shkolnik, PLLC, 360 Lexington Avenue, 11th Floor, New York, New York 10017; Email:; Website:

For more information about BCBSM policies, contact: Blue Cross Blue Shield of Michigan, 600 East Lafayette Boulevard, Detroit, Michigan 48226-2927; 313-549-9884; Email:; Website:

The Oregon Department of Human Services (DHS) and the Family Independence Initiative (FII) launched a pilot project to support self-sufficiency among low-income families in Jefferson and Lincoln counties. Across the two counties, up to 900 families can participate. FII’s contract for the two new counties started in May 2019, and will expire on October 31, 2020.

The 12-month FII program consists of facilitated group meetings among small participant groups, and participant use of an online platform called UpTogether to support community building. The participating families can earn up to $800 over the course of the 12-month partnership. The goal is to reduce poverty in Oregon and stop the cycle of poverty for the next generation.

Funding is provided from a combination of DHS funding and grant funding procured by DHS. The total program budget is more than $1.4 million. About 65% of the pilot costs are covered by DHS SSP funds. The funds from DHS cover the cost of one full-time FII staff member who manages the pilot, and the DHS funds are used for direct cash investments in families. FII-National is contributing the remaining 35% of funding, which will be used to cover the direct project operation costs in Jefferson and Lincoln counties. FII contracted staff monitor the cohorts.

Families that are part of the DHS SSP Job Participation Incentive (JPI) will be invited to attend a FII information session. After attending the FII information session, families interested in participating in FII are asked to invite a small group of friends (up to six) to join them and form a cohort for a one-year engagement. These friends do not have to be part of the JPI, just members of the participant’s social network. In addition to in-person meetings, the cohort participants will use the UpTogether online platform to share strengths and build community so that the participants feel comfortable turning to their cohort for support and inspiration. The UpTogether platform also provides access to a journal platform for the participants to tell FII about the different initiatives the participant families are taking toward self-sufficiency to build their well-being. The journal platform also allows participants to provide mutual support to their personal cohort and to the wider FII UpTogether community. The goal is that the FII participants will serve as a resource for each other on how to manage their financial situations, health, education needs, and housing needs and challenges.

The FII program has two key objectives. Firstly, FII seeks the participants’ feedback on what does and does not work to deploy a strength-based approach to developing self-sufficiency. Secondly, FII seeks to identify trends around the initiatives families take to improve their lives, to learn how families prioritize goals for the adults and children in the household, to identify early signals in changes in the financial health of families, and to learn how families are supporting each other. FII will track these trends on a daily basis using UpTogether, and will report the trend findings to DHS quarterly. The report will discuss the collective and aggregate trends among the Jefferson and Lincoln county participants, and will discuss the participants’ progress.

More information about DHS interest in self-sufficiency programs was presented to the legislature in February 2019 in “Oregon DHS Presentation To The Human Services Subcommittee: Self-Sufficiency Programs Committed To Long-Term Success.” DHS provides a variety of programs and partnerships to build self-sufficiency. The presentation noted that, in most Oregon counties, a family of three with an income at 185% of the federal poverty level is not able to be self-sufficient.

In 2016, FII partnered with the Oregon DHS to test new ideas for self-sufficiency. The state was exploring a redesign of how it deployed Temporary Assistance for Needy Families (TANF) funds, with a long-term goal of transforming delivery of human services. FII operated a pilot during fiscal years 2017 and 2018 in Multnomah County, which encompasses the Portland metro area. The Multnomah County pilot enrolled more than 100 families across eight jurisdictions in the county. During the first project year, the participating families experienced a 26% increase in income and a 130% increase in assets.

A FII project fact sheet issued by Multnomah County noted that the implementation was supported through a public-private partnership with DHS TANF Reinvestment funds and Meyer Memorial Trust funds, totaling $456,860. The program focused on Multnomah County families who were long-term TANF participants and who were either newly employed, living at or below 37% of the federal poverty level, or at-risk of enrolling in or returning to TANF.

FII was founded in 2001 in Oakland, California. FII has also partnerships in the following cities: Austin, Texas; Albuquerque, New Mexico; Boston and Cambridge, Massachusetts; Chicago, Illinois; Cincinnati, Ohio; Detroit, Michigan; New Orleans, Louisiana; and Oakland, California. For the year ended December 31, 2018, FII reported $7.6 million in revenue and nearly $7.3 million in expenses, with $5.8 million in program expenses.

For more information, contact:

  • Ashley Conners Sherwin, Vice President of External Affairs, Family Independence Initiative, Post Office Box 301764, Jamaica Plain, Massachusetts 02130; 617-935-7566; Email:; Website:
  • Jennifer Grentz, Information Strategist, Self-Sufficiency Programs, Oregon Department of Human Services, 500 Summer Street NE, E48, Salem, Oregon 97301; 503-884-9071; Email:; Website:

There are many factors driving the increased use of value-based reimbursement. Payers are facing cost pressures and as a result are focusing on driving better value through integrated care. Competition between health plans is creating the need for better synergy with their contracted provider organizations. Finally, the volume of new technologies that allow for new treatment modalities and better administrative functions mean that reimbursement models that leverage these technologies are needed.

As the largest health care payer organization, the Center for Medicare & Medicaid Services (CMS) has set the tone for VBR and their policies are a big driver in the shift. In Medicare, there are 518 Shared Savings accountable care organizations serving 10.9 million beneficiaries.1 There is the expansion of the bundled rate program (see HHS To Launch New Mandatory Bundled Payment Models). There are pending new models for reimbursing primary care. In Medicaid, there are an increasing number of mandates for Medicaid health plans to use alternative payment methodologies (APMs)–either performance-based or value-based reimbursement models–to reimburse their provider networks.

The state-specific mandates to Medicaid health plans to use APMs in provider reimbursement the focus of recent report published by Open Minds.2 The report looks at which state Medicaid programs require the Medicaid health plans to implement APMs and what that mandate exactly means.

What did they find? The number of states with APM requirements for health plans continues to increase. When OPEN MINDS completed the report in 2017 of the 38 states with managed care, 22 required the use of APMs. In 2019, that number has increased to 28 of 40 states with managed care.

The six states that added APMs in the past year and a half include California, Colorado, District of Columbia, Kansas, Louisiana, and Wisconsin. Additionally, there are three states with active plans to add APMs in the next two to three years. Those states include Kentucky, North Carolina, and Virginia.

States with especially notable APM requirements include Washington and New York both of which have value-based roadmaps intended to drive changes in financing in delivery. New York plans to have 80-90% of payments in VBR arrangements by the end of 2020 and Washington plans to have 75% of payment in VBR by the end of 2019 and 90% in 2021. While Arizona, Pennsylvania, and New Mexico do not have requirements to move such a high percentage of payments to APMs in the near term, these states have specific requirements around the inclusion of behavioral health provider organizations in APMs.

At the state level, the implications for provider organizations varies by state like so many market factors. Typically, the mandates are not particularly prescriptive. Health plans are given the opportunity to decide the types of payment arrangements and the types of provider organizations they would like to contract with. Additionally, there is the issue of how the state is “counting” APMs. It can be the number of contracts with APMs, the percent of medical expenditures in APMs, or the number of enrollees who receive a service that is paid for using an APM.

At the macro level, the increase in the number of states offering these arrangements and the increasingly percentage of payments in APMs is indicative of the trend that VBR is reshaping the health and human services landscape. The pressure for VBR is not only coming from the state and government, but also from private sector as health plans work to implement these initiatives with or without a mandate. Provider organizations regardless of the state they operate in need to at minimum begin readying their organization for VBR. For more on this check out these resources:

  1. The Four-Part Checklist For VBR Success
  2. VBR @ Scale—Changes Required
  3. Crawl, Walk, Run To VBR
  4. Successfully Managing Bundled Rates—The Voice Of Experience
  5. Developing Case Rates? Better Find Your ‘Single Source Of Truth’

For the 2020 Medicare Part D plan year, the Centers for Medicare & Medicaid Services (CMS) will increase the total out-of-pocket (OOP) threshold to increase by 24.5%, from $5,100 in 2019 to $6,350 in 2020. The OOP threshold is the point at which the Part D catastrophic coverage for medications takes effect and the beneficiary is no longer responsible for cost sharing. Since 2007, the OOP threshold has increased 64.9% (from $3,850 in 2007). The OOP threshold does not include monthly premiums or non-formulary purchases.

CMS finalized the OOP increase in “Contract Year 2020 Medicare Advantage and Part D Flexibility Final Rule (CMS-4185-F)” on April 5, 2019. Formulas that set the OOP threshold are set by Congress, and CMS is required to implement the applicable increase. For 2020 and subsequent years, the Social Security Act requires the OOP threshold to be calculated as if the OOP threshold for years 2014 through 2019 had been subject to the respective annual percentage increase (API) values. For 2014 and 2015, the Act required that the OOP threshold be updated by the API minus 0.25 percentage points. For contract years 2016 through 2019, the Act required that the OOP threshold be updated from the previous year by the lesser of the API, or two percentage points plus the annual percentage increase in the Consumer Price Index (CPI). For 2020, the OOP threshold is increased from $5,100 in 2019 and rounded to the nearest multiple of $50.

The change in the OOP threshold for 2020 was calculated using the 2013 threshold value of $4,750 as the starting point. The calculation is as follows:

  1. The starting point is the 2013 OOP threshold of $4,750.
  2. The published API for 2014 was applied, as this is the percentage that would have been applied absent the modification.
  3. The resulting value is rounded to the nearest $50.
  4. Each of the first three steps is repeated for each subsequent year through 2019.
  5. The 2020 API is then applied, and the result rounded to the nearest $50, resulting in the $6,350 out-of-pocket threshold value for 2020.

For 2020, the total covered Part D spending at OOP threshold for applicable beneficiaries is $9,719.38. The figure is calculated given the following basic assumptions:

  1. Beneficiary cost-sharing in the deductible phase: 100%
  2. Beneficiary cost-sharing in the initial coverage phase: 25%
  3. Beneficiary cost-sharing for non-applicable drugs purchased in the coverage gap phase of the benefit: 25%
  4. Cost-sharing for the ingredient cost and sales tax for applicable drugs purchased in the coverage gap phase of the benefit: 95% (25% beneficiary coinsurance and 70% Coverage Gap Discount Program discount)
  5. Cost-sharing for the dispensing and vaccine administration fees for applicable drugs purchased in the coverage gap phase of the benefit: 25%

A line graph showing the rise in Part D OOP is posted online at (accessed September 4, 2019).

PsychU last reported on this topic in “CMS Final Rule Codifies Existing Policy On Step Therapy For Part D Protected Drug Classes,” which published on July 8, 2019. The article is available at

For more information, contact: Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore 21244; Maryland; 202-690-6145; Website:; Website:

On August 28, 2019, Nevada submitted a Medicaid state plan amendment (SPA) to transition its Certified Community Behavioral Health Centers (CCBHCs) to become a Medicaid provider organization type. On July 16, 2019, the Nevada Department of Health and Human Services (DHHS) issued the proposed SPA documents. A public hearing was scheduled for August 27, 2019.

After the Centers for Medicare & Medicaid Services (CMS) approves the SPA, Nevada’s goal is to develop a directed payment in cooperation with CMS for the CCBHCs and incorporate the directed payment into the rates and contract in or after 2021. Once this goal is achieved, the CCBHC model will again be part of the Nevada managed care system.

Nevada is one of eight states participating in the two-year grant-funded federal CCBHC demonstration program, which was recently extended through federal legislation. DHHS is currently working with CMS to find the best solution for Nevada’s program during this extension and transition. The other grant-funded states are Minnesota, Missouri, New Jersey, New York, Oklahoma, Oregon, and Pennsylvania.

Nevada has three CCBHCs: Bridge Counseling Associates in Las Vegas, New Frontier Treatment Center in Fallon, and Vitality Unlimited in Elko. DHHS seeks to have the program fully transitioned by October 1, 2019. In the interim, DHHS reached an agreement with its three CCBHCs to fund the clinics at about 75% of their average monthly billing. The CCBHC services include the following:

  1. Crisis mental health services
  2. Screening, assessment, and diagnosis
  3. Consumer-centered treatment planning
  4. Outpatient mental health and addiction treatment services
  5. Screening and monitoring of health risks and status; targeted case management
  6. Psychiatric rehabilitation
  7. Peer and family support services

Nevada is continuing to move forward with its previously announced plans to add seven more CCBHCs. The clinics will be reimbursed with a clinic-specific daily rate. Each clinic has an individual prospective payment based on the anticipated cost of their program.

For more information, contact: Sarah Dearborn, Social Services Program Specialist 3, Behavioral Health Outpatient/ Rehabilitative Services, Nevada Department of Health and Human Services, 4126 Technology Way, Suite 100, Carson City, Nevada 89706-2009; 775-684-3732; Email:; Website: ; or Shannon Litz, Public Information Officer, Director’s Office, Nevada Department of Health and Human Services, 4126 Technology Way, Carson City, Nevada 89706-2009; 775-684-4000; Email:; Website:

On August 5, 2019, the Kentucky Cabinet for Health and Family Services (CHFS) announced the launch of a new Medicaid program to help employed Medicaid beneficiaries transition from Medicaid to employer-sponsored health insurance (ESI) benefits while still retaining access to Medicaid wraparound services. The Kentucky Integrated Health Insurance Premium Payment (KI-HIPP) program will pay the employee share of premium costs for beneficiaries eligible to enroll in their ESI plan. The Medicaid individual/family will not be responsible for paying the ESI copayment and deductible amount if they see an in-ESI network and/or Medicaid provider organizations. KI-HIPP will not cover services delivered by provider organizations out-of-network with the ESI or services provided by non-Medicaid provider organizations.

Kentuckians qualify for KI-HIPP if they or a member of their household are eligible for Medicaid and have access to comprehensive and cost-effective health insurance through their job. When a member enrolls, KI-HIPP pays them for their share of the cost of the insurance premium. The premium, deductible, and copayments of the ESI plan must cost the state less than the cost to cover a member in a Kentucky Medicaid managed care organization. Members who choose to enroll in the program do not lose their Medicaid benefits. The types of insurance coverage that qualifies for KI-HIPP include the following:

  • Insurance through a comprehensive ESI plan that covers at least one benefit from each of the 10 essential health benefit categories
  • Insurance through a parent’s ESI plan
  • Coverage from United Mine Works, Retiree Health Plan, or Consolidated Omnibus Budget Reconciliation Act (COBRA)

CHFS quietly launched the KI-HIPP program on May 6, 2019 by offering enrollment to about 9,000 Medicaid beneficiaries who reported access to or enrollment in ESI. Expanded outreach started in August 2019.

On August 6, 2019, the Kentucky Hospital Association hosted a webinar about KI-HIPP. CHFS anticipates that KI-HIPP may make family coverage more affordable by reimbursing the employee’s share of a premium for more extensive coverage plans. Further, it may widen the health care network available to beneficiaries by providing access to physicians through the full traditional Medicaid network. On August 5, 2019, CHFS notified about 35,000 beneficiaries who have reported full-time employment. On September 4, 2019, another 38,000 beneficiaries with full-time work will be notified about the program. On November 4, 2019, another 10,000 non-Medicaid policy holders with at least one Medicaid beneficiary in the policy will be notified about KI-HIPP.

The Kentucky Hospital Association webinar presentation about KI-HIPP was released August 6, 2019. A copy is available online at (accessed September 4, 2019).

For more information, contact:

  • Kentucky Integrated Health Insurance Premium Payment (KI-HIPP), Kentucky Cabinet for Health and Family Services, 275 East Main Street, 6C-A, Frankfort, Kentucky 40621; 855-459-6328; Email:; Website:
  • Christina Dettman, Executive Director of Public Affairs, Office of Public Affairs, Kentucky Cabinet for Health and Family Services, 275 East Main Street, Frankfort, Kentucky 40621; 502-229-2791; Email:; Website:; or Jordan Rowe, Director of Strategic Communications, Kentucky Cabinet for Health and Family Services, 275 East Main Street, Frankfort, Kentucky 40621; 502-352-3977; Email:; Website:

Behavioral health provider organizations have long understood that biopsychosocial factors have a significant impact on behavioral health. In 1943, the humanist psychologist Abraham Maslow introduced the concept of a hierarchy of needs.1 In general, Maslow believed that in order for individuals to reach their full potential, their more basic needs must be met. Many of these needs are primarily physiological such as food, water, and sleep. Basic needs extend to safety and the need to belong. Safety needs include a safe environment, housing, and employment.2 Today these factors are referred to as social determinants of health (SDoH). The World Health Organization defines SDoH as “the conditions in which people are born, grow, live, work, and age”.3 There is a growing recognition of the impact that a lack of social determinants, such as safe affordable housing, transportation, and access to nutritional foods, has on health outcomes and health care spending. Social determinants also impact how and if individuals access health care and the quality of health care services that they receive.4

Despite Maslow’s recognition of social determinants on human growth, it is only more recently that the U.S. health system, both payers and providers, has become focused on social factors outside of direct health care services. In fact, it is estimated that medical care accounts for only 10% – 20% of the modifiable contributors to healthy outcomes.4

Medicaid, Medicare, and commercial insurers are increasingly focused on factors beyond direct medical services which impact their covered populations’ overall health. A recent survey of health plans and health plan executives that is highlighted in the Second Edition of Trends in Behavioral Health: A Population Health Manager’s Reference Guide on the U.S. Behavioral Health Financing & Delivery System (The Guide), found that all payers, to varying degrees, have developed strategies to address an array of SDoH.5

Access to safe housing, transportation, affordable childcare, and healthy and nutritious foods are social determinants significantly impacted by poverty. As the primary payer for individuals living at or below the poverty level and for individuals with serious mental illness, Medicaid is leading the way in addressing social determinants with a strong focus on coordinating with social services to help address unmet needs. Increasingly, state Medicaid programs are adding requirements around SDoH in their contracts with managed care plans and are using the flexibility under Section 1115 Medicaid Demonstration waivers (1115 waivers) to address SDoH. For example, Texas allows Medicaid health plans to cover transportation and activities to promote healthy lifestyles, Massachusetts allows Medicaid ACOs to pay for traditional non-reimbursed services to address health related social needs, and North Carolina as part of their 1115 waiver is requiring health plans to screen for social determinants.5 Under their 1115 waiver, North Carolina is launching Healthy Opportunity pilots that will require health plans to coordinate and pay community-based organizations and social service agencies to address housing, food insecurity, transportation, and interpersonal violence. Medicaid managed care contracts in California and the District of Columbia require the identification of health disparities and plans to address them, and Kansas requires that health risk assessments contain questions about domestic violence, housing, and employment.6

Resources for Human Development (RHD), a human services company that has nationwide expertise in providing innovative supportive housing programs for individuals with serious mental illness and individuals with intellectual and development disabilities, has begun to demonstrate the power of housing as a health care strategy. They have developed a model to serve high-cost Medicaid enrollees in a supported housing setting with an array of community-based supports and the goal of reducing the total cost of health care for this population. The program model leverages overall health care savings to payback social investors who provide loans to RHD which are used to cover expenses related to program enrollee housing. A pilot of this model is in development in Philadelphia, Pennsylvania where RHD will support 50 individuals who each have health care costs in excess of $80,000 annually.7 A similar project already underway in Kansas has produced a 64% decrease in emergency room use and a 38% decrease in psychiatric hospitalization for individuals housed for 6 months.8

Commercial plans are also increasingly focused on the SDoH. Over the past several years, some of the largest national payers, such as Blue Cross Blue Shield, UnitedHealthcare, Aetna, and Kaiser Permanente, have developed new partnerships and have invested hundreds of millions of dollars on various factors that impact access to health care and health outcomes. UnitedHealthcare is partnering with the American Medical Association to launch almost two dozen new International Statistical Classification of Diseases & Related Human Problems (ICD) 10th revision (ICD-10) codes to capture unmet SDoH information regarding their members.9 According to UnitedHealthcare, this work on coding allows the insurer to better track patients and their needs.9 Having this type of readily reportable information can help a payer better track the needs of their population and support referral to appropriate community support. In addition to this effort, UnitedHealthcare has invested $350 million in housing projects across 14 states since 2011.10 In 2018, Kaiser Permanente announced that they will invest up to $200 million to help address housing stability and homelessness in their communities. The initial focus of their funding is to help prevent displacement or homelessness of lower- and middle-income households in rapidly changing communities; reduce homelessness by ensuring access to supportive housing; and making affordable homes healthier and more environmentally sound.11

Payers are increasingly partnering with non-health care providers to address barriers to health care and activities that support wellness. The ridesharing company Lyft is partnering with a number of the nation’s largest health plans to provide transportation services to their members.12 Lyft began a collaboration with the Blue Cross Blue Shield Institute in 2017 to provide rides to their Medicare Advantage members to medical appointments. They have since expanded to allow members to access rides to pick up prescriptions and will be adding rides to fitness centers as a benefit. Lyft has entered in to similar partnerships with Humana and Cigna-Health Spring.12 Lyft cites that 36% of riders who have used their service to get to medical appointments report that they go to urgent care less often.12 Beyond health plans, Lyft has partnered with Allscripts to develop a feature within their EHR that allows a physician to order transportation for a patient.

It can be anticipated that as greater percentages of health care spending are tied to outcomes, health plans and health systems will continue to look to address social determinants as a strategy for improving member outcomes and reducing costs of care. While both payers and providers are finding and investing in innovative ways to address social determinants, the challenge remains of determining return-on-investment and developing long-term, sustainable solutions. For additional information and insights into how various payer are approaching SDoH and other health care trends across the nation, please see the Second Edition of Trends in Behavioral Health: A Population Health Manager’s Reference Guide on the U.S. Behavioral Health Financing & Delivery System.

About The Guide
The Second Edition of Trends in Behavioral Health: A Population Health Manager’s Reference Guide on the U.S. Behavioral Health Financing & Delivery System (The Guide) provides information and insights into the multi-layered United States behavioral health system. The Guide includes an in-depth view of current statistics, prevailing issues, and emerging trends in order to inform the discussions, debates and decision-making of policy-makers, payers, providers, advocates and consumers. The Guide addresses current behavioral healthcare trends topics, including:

• A look at the national policy that is shaping the U.S. health and human services market
• A view of the state behavioral health delivery systems that were created by a combination of historical practices, federal and state policy, and market factors over recent years
• An examination of the practices of 1,265 health plans that manage both physical and behavioral healthcare for the vast majority of the U.S. population
• A deep-dive into behavioral healthcare access and delivery of care from the consumer perspective

During a recent presentation on building partnerships with payers, which featured OPEN MIND