Late 2024, HMA convened a panel of experts, including individuals with lived experience and state leaders, to spotlight the critical need for cross-system transformation. The discussion underscored the importance of centering youth and family voices, aligning placement and community-based services, and leveraging opportunities like the Family First Prevention Services Act, Medicaid waivers, and specialty managed care models. As states grapple with a behavioral health workforce crisis and insufficient foster care placements, the path forward requires bold, coordinated strategies grounded in flexibility, equity, and evidence. This brief includes key takeaways from the 2024 panel and outlines actionable insights to guide the transformation of the children鈥檚 behavioral health system.
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State Medicaid Non-Emergency Medical Transportation Contracts: Key Provisions, Standards, and Considerations
Federal statute requires states to provide non-emergency medical transportation (NEMT) to Medicaid beneficiaries who have no other means of getting to medically necessary healthcare facilities. Though NEMT programs must meet certain federal requirements, states have considerable flexibility in the design and operation of their NEMT program. As a result, states vary widely in their NEMT procurement and contract standards, metrics, reporting, and enforcement of requirements for NEMT brokers, MCOs, and transportation providers. 黑料网, Inc. (HMA), examined NEMT-related requests for proposals (RFPs) and contracts for five states and interviewed state Medicaid officials, transportation brokers and providers, MCOs, advocates, and subject matter experts (SMEs). The goal was to synthesize the information gathered to help inform states and other stakeholders about key NEMT standards, challenges and successes, and considerations for developing RFPs and contracts.
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Amber ground ambulance dataset reflects complexity and challenges of the industry, highlights the need to improve and continue cost data collection
The Centers for Medicare & Medicaid Services (CMS) is on the cusp of possessing the data needed to make long anticipated changes to the Medicare fee-for-service (FFS) ground ambulance payment system. It has been more than two decades since CMS revised these payment rates through a negotiated rulemaking process that was exclusive of actual cost data or inflationary considerations. Since then, the cost structure of ground ambulance entities has changed. CMS is now using the Ground Ambulance Data Collection System (GADCS) to gather ambulance cost data, as required by Congress, to offer an improved understanding of the costs of delivering ground ambulance services. Given the potential of GADCS data to improve the adequacy of Medicare FFS reimbursement rates, the American Ambulance Association developed a similar data collection device, referred to as Amber, to test these data with its membership of ground ambulance entities. Amber offers a glimpse into the current challenges of the ground ambulance industry.[i]
黑料网, Inc. (HMA) assessed the Amber dataset for response rates and data quality, along with responses containing calendar year 2022 financial data. Amber response rates were low, but sample volumes were on par with prior industry surveys conducted in the past by federal agencies. The Amber sample is representative of the industry鈥檚 wide variation in entity size and geographic service area. Amber data are reliable for calculating margins, but some aspects of these data also signal that ground ambulance entities, particularly smaller entities, may have had difficulty with variable definitions or the submission process. We observe that Amber would be improved by including information on uncompensated care and more details on medication supply costs.
The 2022 financial data from Amber suggest that Medicare FFS margins, at -6 percent, had declined since GAO鈥檚 2010 assessment and that the share of costs associated with labor has increased. Amber data also suggest that the cost structure of smaller ground ambulance entities and rural and super-rural entities differs from that of larger and more urban entities. Margins for small and rural entities are lower.
Based on our assessment of the Amber dataset and its 2022 financial, we offer several recommendations to policymakers and stakeholders. These recommendations are intended to improve future cost collection efforts that may inform payment reforms to enhance the payment accuracy of the Medicare FFS payment system for ground ambulance services.
- Provide additional educational support to respondents to improve consistency of data reporting
- Streamline and modify data collection devices to adhere to industry trends and challenges
- Develop a standardized method for assigning ground ambulance entities to geographic service area for research purposes
- Collect data on ground ambulance uncompensated care and bad debt
- Collect payer level data for cases involving treatment without transport
- Collect targeted data on top 10 medications by cost to accurately reflect costs in payment rates
- CMS should consider collecting ground ambulance cost data on a semi-regular basis
- CMS should consider phasing in the use of GADCS data to ensure that the data reflect the diversity of ambulance entities and consistent reporting of key financial variables
[i] American Ambulance Association. Ambulance Cost Collection. 2023. Available at: .
Private Equity Investment in AI in the Healthcare Sector
HMA will be offering analyses on various investor related topics in the healthcare sector. Our first report examines the growth of Artificial intelligence (AI) in the US healthcare market. AI is expected to reach projected revenues of $102 billion by 2030. Learn more in this analysis.
New Insights on Medicaid Spending: An Analysis of Disaggregated Managed Care Spending
Medicaid is a federal/state health insurance program that served more than 86 million lower-income people in fiscal year (FY) 2021. The combined federal and state spending for Medicaid totaled $717 billion that year, $420 billion of which was spent on providing care to Medicaid managed care organization (MCO) members, and $297 billion on services provided to fee-for-service enrollees.
- While the role of managed care in Medicaid has grown tremendously over the past decade, with MCOs covering nearly three-quarters of Medicaid enrollees, detailed cost information has not been estimated for the people with MCO coverage. These data historically have been available only for fee-for-service (FFS) Medicaid because of limitations on federal data sources.聽
- This lack of data blocks our understanding of the relative magnitude of the cost drivers in the program and contributes to an uninformed debate about policy reforms to control the growth of spending and improve quality of care.聽
- Obtaining and using cost data by provider type for MCOs can help answer questions such as how much funding do MCO enrollees with diabetes, asthma, and/or hypertension consume? Of these patients, how many also have behavioral health conditions? How many MCO enrollees have six or more emergency department (ED) visits during a year and/or multiple inpatient hospital stays, and what does their resource consumption look like?聽
黑料网 (HMA) has developed a reliable methodology that can be applied to all 50 states, which approximates spending for the major categories of health services that MCOs cover, including: inpatient and outpatient hospital care, physician and other professional services, skilled nursing facilities, clinics, pharmaceuticals, and other services. HMA can determine prices for these services, which, combined with data on the number of encounters, yields reliable cost figures. These cost estimates will be useful in identifying unmet medical needs, gaps in our delivery systems, and areas of high spending where efficiencies and timely care management can be added to slow the growth in total health spending.
Workforce Solutions Partnerships: Call to Action to Build a Sustainable Behavioral Health Workforce
The Workforce Solutions Partnership, a collaboration of , , and 黑料网 has worked since 2021 to create both short and long-term solutions聽 addressing the behavioral health workforce crisis. In this whitepaper, we issue a Call to Action to partners across all sectors to join us in this effort to drive pervasive change and ensure the future of behavioral health care. We need you to help us create and define the future of the workforce and envision a new system of care.聽 This paper outlines the problem and highlights the efforts developed by our partnership, and mechanisms that can help to address the problem.
HMA Prepares Health and Human Services Assessment for the City of Watertown
On Tuesday, February 25, 2025, the Watertown City Council unanimously endorsed the recommendations of a year-long health and human services assessment prepared by HMA for the City of Watertown, Massachusetts. The report, released in November 2024, included a qualitative and quantitative assessment of the community鈥檚 health and human service needs and recommended resources to fill those gaps. As part of the project, HMA facilitated extensive community outreach and data gathering efforts in 2024 to elicit a range of community perspectives including 20 interviews, 8 focus groups, and 2 community-wide meetings resulting in 9 recommendations for organizational and program efficiencies and enhancements.
Through engagement and analysis, key community priorities emerged with a focus on programs and services relating to housing security, food security, wellness promotion, disability supports, older adult supports, communications and language access, immigrant supports, veterans鈥� services, public health, physical and behavioral health, and diversity, equity, and inclusion. Health and human services were considered through an intersectional lens, recognizing their overlapping qualities and characteristics that reflect how real people experience their own unique needs and seek support from a multitude of public and private supports.
On Rare Disease Day, HMA releases new report analyzing federal spending on Orphan Drugs
Rare Disease Day is observed globally each year on February 28 to raise awareness, access, and diagnosis to therapies for people with rare diseases. Today HMA releases a report titled聽Analyzing the Impact of Policies to Exclude Certain Orphan Drugs from the Drug Price Negotiation Program of the Inflation Reduction Act, that examines how many orphan drugs the ORPHAN Cures Act might affect and the percentage of Medicare Part B and Part D spending that is attributable to these drugs. Using that information, we estimated how the legislation would affect federal spending, applying the same assumptions and methodology that the Congressional Budget Office (CBO) uses in a 10-year budget score.
State Cost Growth Benchmarking Programs: An Evaluation of Eight States鈥� Experiences and the Lessons Stakeholders Have Learned
Background
In 2024, 黑料网 (HMA) evaluated programs implemented by eight states (California, Connecticut, Delaware, Massachusetts, New Jersey, Oregon, Rhode Island, and Washington) aimed at controlling healthcare cost growth. In recent years, these states have tried to address the trend of escalating healthcare costs using an approach referred to as cost growth benchmarking (CGB). This is the act of setting a target for annual healthcare cost growth and measuring actual performance against the target. Since 2018, the Peterson-Milbank Program (PMP) for Sustainable Health Care Costs has invested in state-based CGB efforts by funding program development, implementation, and technical assistance. HMA evaluated the Peterson Center on Healthcare’s cost growth benchmarking efforts across the eight states.
Methodology
HMA鈥檚 evaluation for the Peterson Center on Healthcare included a detailed landscape review for each of the eight states and interviews with 45 state officials, providers, payers, and other stakeholders in these states. The HMA team synthesized findings from the landscape review and the key informant interviews and produced an internal evaluation report.
Analytic Approach
The landscape review captured the state鈥檚 CGB program chronology, governance structure, growth targets, enforcement authority, and performance against the target. The interviews examined the contextual factors, stakeholder influence, implementation developments, capacity to control costs, facilitators and barriers to developing cost control capabilities, and the lessons learned based on the states鈥� experience. The interview discussion guide included a scoring component which enabled quantitative analysis in addition to the qualitative findings. HMA analyzed these findings by state, category of interviewee (state officials, payers, providers, or others) and implementation stage (early vs. more recent adopters).
Findings
States鈥� efforts to engage and gather stakeholders, establish cost growth targets, collect and report data, and identify cost drivers have been successful, but states have had challenges to date in developing policies aimed at containing costs.
Utility
The findings from this analysis can be useful to the existing states in enhancing their CGB programs and to states interested in launching new CGB initiatives.
Medicare Hospital Inpatient Device-Intensive Payment Policy
Medicare鈥檚 fee-for-service (FFS) payment system includes payment policies that support providers鈥� use of innovative medical device technologies. The continued evolution of these policies is necessary to keep pace with current and future medical innovation. In this report, HMA summarizes models testing the implementation of a newly proposed policy for the hospital inpatient system which aims to eliminate systemic bias that may slow hospitals鈥� adoption of innovative technologies. HMA concludes that targeted policies that eliminate the use of the hospital wage index to standardize device costs can result in more accurate reimbursement for hospitals and increase beneficiary access to innovative technologies.
HMA helps navigate dQM to improve health outcomes
The healthcare industry is undergoing a seismic shift in how quality data are collected and reported, creating opportunities to use digital quality measures (dQM) to significantly improve health outcomes and efficiency. Starting in January 2027, new federal interoperability and prior authorization rules will promote widespread data exchange, enabling full digital quality measurement. Payers and providers must invest early to be well-positioned to undergo major strategic and operational changes to optimize healthcare data and transform their business processes.
This issue brief explains the federal policies and national changes that make digital quality measurement possible, explores challenges facing the health insurance industry, and highlights opportunities for payers and providers.
Our HMA dQM team helps health plans, providers, health & hospital systems, federal, state and local payers such as Medicare and Medicaid navigate the transformation to dQM and broader interoperability鈥攆rom early planning through strategy development, implementation, and impact evaluation.
340B Duplicate Discounts: Enforcement Inconsistent and Weak Due to Lack of Data Transparency and Despite Federal Prohibition
At the intersection of the federal 340B Drug Pricing program and the federal Medicaid Drug Rebate Program (MDRP), a potentially large set of Medicaid claims are generating duplicate discounts, which pharmaceutical manufacturers provide to eligible entities such as hospitals and health centers. These two complex federal programs were designed to reduce the costs of prescription drugs for providers that serve low-income patients, but both state Medicaid agencies and federal policymakers have been actively working to eliminate the unintended overlap of these two programs. To gain deeper insights into why duplicate discounts continue to occur, the scope of this concern, and to identify considerations of future policymaking, HMA conducted interviews with Medicaid officials and drug policy experts across several states.
Duplicate discounts occur when for a single sale a manufacturer is required to: (1) prospectively reduce the price of the product (a discount) they sell to a 340B covered entity in advance of the delivery of care to the patient; and (2) provide a retrospective payment (a rebate) to a state Medicaid program or managed care plan under the MDRP after care is delivered to a Medicaid enrollee. When duplicate discounts occur the manufacturer鈥檚 product is discounted twice for the same sale, contravening federal law, which prohibits duplicate discounts.
Despite the statutory prohibition, duplicate discounts remain a concern. Both state and federal policymakers have been actively addressing duplicate discounts but have been unable to identify clear and consistent policy solutions that neutralize this inefficiency. On the state level, Medicaid agencies and state legislatures have implemented policies to address duplicate discounts. On the federal level, the Health Resources and Services Administration (HRSA) and the Centers for Medicare & Medicaid Services (CMS) have conducted audits and published best practices for states to eliminate duplicate discounts. Nonetheless, duplicate discounts persist.
To gain deeper insights into how Medicaid agencies navigate duplicate discounts, 黑料网 (HMA) conducted semi-structured interviews with former and current Medicaid directors and pharmaceutical policy experts in 14 states. Interviewees were asked about the frequency of duplicate discounts, the extent to which Medicaid agencies devote resources to tracking them, the policies states have implemented to address them, and the extent to which state or federal authorities are working to eliminate duplicate discounts.
Based on interviews, four key themes emerged:
- Duplicate discounts remain a problem, the scope of the problem is unclear, and better data collection from covered entities is necessary.
- The opacity and complexity of duplicate discounts create a burden for state Medicaid agencies, influencing the policies they implement, resulting in variable state policy strategies.
- Contract pharmacies add an additional layer of complexity, exacerbating the burden that duplicate discounts create.
- State and federal authorities could take more decisive action to address duplicate discounts.
Policymakers should consider that the environment for addressing duplicate discounts may become more complex in the future, which may increase the need for a federally coordinated policy solution. The complexity of the environment may deepen due to the increasing presence of contract pharmacies, the increasing presence of managed care in Medicaid programs, and the implementation of the drug pricing policies of the Inflation Reduction Act of 2022. Policy action coordinated across the various stakeholders (e.g., HRSA, CMS, state Medicaid agencies, covered entities, and manufacturers) may represent the best opportunity for success in eliminating duplicate discounts.