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“The key to a winning strategy is the right information, expert insights, and an implementation plan that comes from experience.”– Monica E. Oss

News Report | June 18, 2021

The 15 states with the largest number of senior living providers will collectively incur more than $18.8 billion in uncompensated losses due to coronavirus disease 2019 (COVID-19). Nationally, losses due to COVID-19 could reach $29.8 billion through June of 2021. Provider organizations have reported significant expenses from procuring gowns, gloves, masks, and other infection prevention and control supplies required for COVID-19 mitigation, or lost revenue due to record-low occupancy rates. These expenses are long-term, compounding, and unsustainable.

The top 15 states, and their projected losses, include:

Top 15 States With Largest Losses Due To COVID-19

# Facilities Operating At A Loss

111,110

70,402

670

191,000

4,250

66,707

440

79,651

1,250

60,897

1,100

51,503

310

63,560

540

53,995

290

26,764

300

40,890

660

42,412

937

45,143

1,200

44,819

370

21,001

310

These findings were presented in “COVID-19 Impact by State,” by Argentum. Analysts for Argentum analyzed a national representative sample of senior living providers. Estimates are based on a per-resident impact by state for 2020 and the first and second quarter estimates for 2021. The goal was to evaluate losses incurred by senior living facilities during COVID-19 for each state.

Argentum is asking leaders on Capitol Hill to share additional relief from the unallocated $24 billion in the Provider Relief Fund with senior living communities. Senior living providers were allocated less than 1% of provider relief funding in last year’s Coronavirus Aid, Relief, and Economic Security (CARES) Act. Argentum is also working to address immediate COVID-19-related challenges and plan for future long-term care needs through its SENIOR (Safeguarding Elderly Needs for Infrastructure and Occupational Resources) Act proposal.

The full text of “COVID-19 Impact by State” was published May 31, 2021 by Argentum. A free copy is available online at https://www.argentum.org/covid-19-impact-by-state/ (accessed June 16, 2021).

OPEN MINDS last reported on this topic in “Half Of Assisted Living Provider Organizations Are Operating At A Loss, Unable To Sustain Operations Another Year,” which published on September 1, 2020. The article may be found at https://openminds.com/market-intelligence/news/half-of-assisted-living-provider-organizations-are-operating-at-a-loss-unable-to-sustain-operations-another-year/.

For more information, contact: Maggie Elehway, Senior Vice President, Public Affairs, Argentum, 1650 King Street, Suite 602, Alexandria, Virginia 22314; 703-894-1805; Email: [email protected]; Website: https://www.argentum.org/

Market Intelligence Report | August 5, 2020

Currently, there are 27 Medicaid managed long-term services and supports (MLTSS) programs operating in 24 states – Arizona, Arkansas, California, Delaware, Florida, Hawaii, Idaho, Illinois, Iowa, Kansas, Massachusetts, Michigan, Minnesota, New Jersey, New Mexico, New York, North Carolina, Ohio, Pennsylvania, Rhode Island, Tennessee, Texas, Virginia, and Wisconsin. The remaining 28 states, and District of Columbia, do not operate a MLTSS program or offer MLTSS benefits. Additionally, three states – Nebraska, Nevada, and Oklahoma – are in the process of adopting a new MLTSS program.

As of June 2020, there were approximately 74.6 million beneficiaries enrolled in Medicaid nationwide. The total estimated enrollment in MLTSS programs was approximately 2.8 million, representing approximately 3.7% of the total Medicaid population.

The delivery of MLTSS through Medicaid varies per state. The main differences are seen in the variations in the federal approval process, service delivery, and procurement.

The Federal Approval ModelThe federal approval model can vary from state to state. Some states, such as California, provide services to the LTSS population through dual eligible demonstration. Other states, such as Delaware and/or Iowa, provide LTSS through the state’s Medicaid managed care health plans.

The Service Delivery ModelThere are three ways in which the MLTSS population receives services: integrated in full benefit health plan, through specialty freestanding full benefit health plans, or through specialty freestanding health plans with limited benefits. All Medicaid MLTSS beneficiaries are covered through a mixture of specialized programs and extensions of their managed care programs. Each state is free to develop their program to suit the individual needs of the state’s Medicaid beneficiaries. This also allows each state to actively seek proposals that best fit their unique needs. Based on our analysis, 15 states select health plans to deliver LTSS services through a competitive selection process.

The Procurement ProcessSome states select health plans to deliver services to the MLTSS population through a competitive bid process. For the bid process, the state’s procurement department will develop a request for proposal for a specific health care service. After that, health plans can submit proposals to deliver health care services required under the RFP. Each state has the authorization to handle bid preparations, communications, and negotiations with contractors, vendors, and suppliers. In total, 16 states select health plans to deliver LTSS to the Medicaid population. The remaining 11 states deliver LTSS through a dual eligible demonstration or a state-specific program.

This report is a state-by-state guide to these state-level program variables. For each of the 24 states, we have a summary of the program, an analysis of MLTSS request for proposals (RFP), MLTSS RFP history, MLTSS contract awards, and MLTSS contract award winners by state.

Arizona’s MLTSS population receives long-term services and supports from the Arizona Long Term Care System (ALTC). The Arizona Department of Economic Security (DES) Division of Developmental Disabilities (DDD) contracts with managed care organizations called “DDD Health Plans” as of October 1, 2019. The DDD health plans provide comprehensive physical and behavioral health services. All other LTSS and support coordination services are provided through the Division of Development Disabilities. I, III

Request For Proposal

On June 25, 2018, Arizona’s Department of Economic Security (DES), Division of Development Disabilities (DDS) released a request for proposals to contract a managed care organization to manage, implement, and provide integrated services and supports for beneficiaries enrolled in the Arizona Long-Term Care System Developmental Disability Program. Prior to the release of the RFP, the state contracted with three health plans to provide acute care services to individuals with developmental disabilities – Care1st Health Plan of Arizona, UnitedHealthCare Community Plan, and Southwest Catholic Health Network Corporation, dba Mercy Care Plan. For individuals with behavioral health disorders, DDS coordinates with local Regional Behavioral Health Authorities (RBHAs).

The deadline for proposals and/or responses to the RFP detailing new plan explanations and how members will be enrolled were due September 17, 2018. The initial contract term was scheduled to run for three years, followed by the option to extend the contract annually for a total contracting term not to exceed 10 years. The details of the new contracts are as follows:

Additionally, the state’s RFP requires the health plans to participate in value-based purchasing initiatives. II, III

Arizona Issues RFP For Managed Care Plans For Individuals With Developmental Disabilities.

Arizona Seeks Integrated Health Care Choice Plan Services

Contract Award

On March 21, 2019, Arizona’s DES-DDD awarded the contract to two health plans – UnitedHealthcare Community Plan (incumbent) and Mercy Care (new entrant). The new contracts went live on October 1, 2019. The initial contract term will run for three years followed by the option to extend annually (not exceeding 10 years). The winning proposal has not been posted yet but can be found here when it is.

Arkansas delivers MLTSS services through the Provider-led Arkansas Share Savings Entity (PASSE) program. The PASSE is a new model of organized care that addresses the needs of Medicaid beneficiaries with complex health care issues.

Arkansas MLTSS Program Overview

Request For Proposals

On October 1, 2017, the Arkansas Department of Human Services (DHS) started implementing the Medicaid Provider-led Arkansas Shared Savings Entity (PASSE) to coordinate and deliver care for beneficiaries with developmental disabilities or serious mental illness (SMI). A PASSE is a risk-based insurance entity that delivers health care services to Medicaid beneficiaries with SMI or I/DD. The PASSE model was established under the Arkansas House Bill 1706. The Arkansas DHS implemented the new model in two phases – Phase 1 started on October 1, 2017 and Phase 2 began October 1, 2019.

During Phase 1, the Arkansas Insurance Department awarded PASSE licensures to four entities: Arkansas Total Care, Empower Healthcare Solutions, the Arkansas Provider Coalition, and Forevercare. The PASSE received a per member per month (PMPM) payment of $173.33 for case management and care coordination services. The care coordination services provided by the PASSE’s operate under the same principles as specialty health homes.

For Phase 2, the PASSEs are responsible for the beneficiaries’ total cost of care. Each PASSE receives a global PMPM payment and accepts full-risk using the managed care organization model to deliver medical services, personal care services, home- and community-based services (HCBS), and counseling services. The Phase 2 PASSEs are Arkansas Total Care, Empower Healthcare Solutions, and Summit Community Care. The Arkansas Insurance Department contracted with three PASSE’s to deliver services to beneficiaries on a tiered basis and needs are determined through an independent assessment (IA). For individuals with SMI receiving PASSE services from the DHS Division of Behavioral Health Services, the three tiers are:

For individuals with I/DD receiving PASSE services from the DHS Division of Developmental Services, the three tiers are:

The PASSEs receive a PMPM based on beneficiaries’ assignment to tier and level of need. IV, V

Arkansas Medicaid To Launch Provider-Led Shared Savings Entities For Members With Developmental Disabilities Or Mental Illness

Arkansas Medicaid To Launch Full-Risk Phase Of Medicaid Shared Savings Program In March 2019.

Contract Award

On October 1, 2017, Arkansas’s Department of Human Services (DHS) started the process of implementing the Medicaid Provider-led Arkansas Shared Savings Entity (PASSE) to coordinate care for beneficiaries with serious mental illness or developmental disabilities. Phase 1 of the PASSE started on October 1, 2017 with five entities: Empower Healthcare Solutions, Arkansas Total Care, Arkansas Total Care, Arkansas Advanced Care, Forevercare, and Arkansas Provider Coalition. Arkansas Advanced Care decided to participate in Phase 1 of the PASSE demonstration. Phase 2 of the PASSE started on October 1, 2019 with three entities: Arkansas TotalCare (Centene), Empower Healthcare Solutions, Summit Community Care (Anthem)

California operates the Cal MediConnect demonstration project through the state’s 1115 waiver proposal, the California Medi-Cal 2020 waiver. The California Medi-Cal 2020 encompasses a variety of reforms including the Whole Person Care Initiative, the Drug Medi-Cal Organized Delivery System program, Public Hospital Redesign and Incentives in Medi-Cal, and the Coordinated Care Initiative. The California Coordinated Care Initiative (CCI) is responsible for the delivery of LTSS services and has three components:

The Coordinated Care Initiative is currently operating in seven demonstration counties: Alameda, Los Angeles, Riverside, San Bernardino, San Mateo, San Diego, Orange, and Santa Clara.

Request For Proposals

In California, beneficiaries receive MLTSS through the Cal MediConnect Dual Eligible demonstration. In 2011, California received funding through CMS’ State Demonstrations to Integrated Care for Dual Eligible Individuals to operate a dual eligible program. In March 2013, California signed a memorandum of understanding (MOU) with the Centers of Medicare and Medicaid Services (CMS). The demonstration was originally scheduled to end on December 31, 2016 but has since been extended through December 1, 2022.

On September 3, 2019, California’s Department of Health Care Services announced intention to transition the Cal MediConnect health plans into a new program called the Multipurpose Senior Services Program. Under this program, beneficiaries will receive the standard Medicaid beneficiaries in addition to comprehensive MLTSS. As of June 2020, the state has not released an RFP for the Multipurpose Senior Services Program. The state anticipates releasing the RFP sometime in 2021 with an implementation date of January 2024. VI, VII, VIII

State Demonstration to Integrate Care for Dual Eligibles: California Demonstration Proposal

Announcement Pertaining to Long Term Care, Transplants, and Multipurpose Senior Services Program, Benefits.

Memorandum of Understanding: California Demonstration to Integrate Care for Dual Eligible Beneficiaries

Contract Awards

On September 3, 2019, the California Department of Health Care Services announced intentions to carve out the Multipurpose Senior Services Program (MSSP) from the existing Care Coordination Initiatives. The new MSSP will includes the Medi-Cal MLTSS managed care plans and the Cal MediConnect (CMC) plans currently operating in the seven counties (i.e., Alameda, Los Angeles, Riverside, San Bernardino, San Mateo, San Diego, Orange, and Santa Clara) of operation. Under the MSSP, the MLTSS program has access to the standard long term services and supports including in-home supportive services (IHSS) and nursing facility services. The MSSP will begin operating as a separate waiver benefit in 2021.

The Delaware Department of Health and Social Services (DHSS) Division of Medicaid & Medical Assistance (DMMA) offers long term services and supports through the Diamond State Health Plan Plus (DSHP-Plus). DSHP-Plus provides the standard Medicaid state plan benefits and LTSS to eligible Medicaid beneficiaries and all dual eligible beneficiaries, even if they do not require LTSS. The state does not limit or cap the number of beneficiaries who may receive home- and community-based services (HCBS). I, VIII

Request For Proposals

The Delaware Department of Health and Social Services (DHSS) Division of Medicaid & Medical Assistance (DMMA) provides MLTSS through the Diamond State Health Plan Plus (DSHP-Plus). Previously, the DSHP-Plus program operated under an 1115 waiver that expired December 31, 2018. Therefore, the DHSS DMMA released a request for qualifications (RFQ) on May 1, 2017 with responses due June 15, 2017 to rebid Medicaid managed care contracts for Diamond State Health Plan (DSHP) and DSHP-Plus. The new contracts had an anticipated start date of January 1, 2018. Under the new contracts, the state anticipated moving 80% of Medicaid and CHIP expenditures into value-based payment models over the next three contract years. To support this goal, the state intended to endorse value-based payment models with upside and downside risk.

Prior to the RFQ, DSHP-Plus beneficiaries received acute physical and behavioral health services for individuals in need of LTSS through two health plans: UnitedHealthcare Community Plan of Delaware and Blue Cross Blue Shield of Delaware. The following six health plans submitted responses to the RFQ: AmeriHealth Caritas of Delaware, Delaware Physicians Care, Health Partners Plans, UnitedHealthcare Community Plan of Delaware, Centene, and Amerigroup. IX, X

Delaware Rebidding Diamond State Health Plan Contracts, Planning To Move 80% Of Reimbursement To Value-Based Models.

Delaware Seeks Diamond State Health Plan Delivery System Transformation Services

Contract Award

The Delaware Department of Health and Social Services (DHSS) Division of Medicaid & Medical Assistance (DMMA) provides MLTSS through the Diamond State Health Plan Plus (DSHP-Plus). On Mary 1, 2017, the DHSS DMMA released a request for qualifications (RFQ) to rebid Medicaid managed care contracts for Diamond State Health Plan (DSHP) and DSHP-Plus. With an anticipated start date of January 2018. The DHSS DMMA awarded the contract to AmeriHealth Caritas Delaware and Highmark Blue Cross Blue Shield Delaware Highmark Health Options. The managed care contract included a requirement for the health plans to move 30% medical and service expenditures to value-based arrangements in 2019 and increase to 60% by 2022. The value-based arrangement include bundled/episodic payments, shared savings, total risk/capitation, and other innovative payment arrangements. If the health plans do not meet the requirements, they forfeit up to 1% of revenue from the state.

In 2018, the Medicaid program completed a competitive re-procurement process for the state’s Medicaid program and began implementation of the new system on December 1, 2018. On February 1, 2019, the state completed the final phase of the managed care implementation. Under the old managed care system, the state provided managed care through Managed Medical Assistance (MMA) plans, specialty, and stand-alone LTSS plans that were responsible for long-term care only. Under the new program, health plans are required to increase compensation for qualified clinical professionals based on savings achieved through effective care management. I

Request For Proposals

Florida laws require the Agency for Health Care Administration to re-procure the Statewide Medicaid Managed Care program’s health plans every five years; this is the first time that Florida has re-procured its health plans. In July 2017, the Florida Agency for Health Care Administration released announced intentions to re-procure the Statewide Medicaid Managed Care (SMMC) programs. The purpose of the managed care procurement was to reduce potentially preventable inpatient and outpatient hospital events, improving birth outcomes, and increasing the number of beneficiaries LTSS in the community. Under the old SMMC system, the state provided care through Managed Medical Assistance (MMA) plans, specialty plans, and stand-alone LTSS plans that were only responsible for long-term care services. The new program eliminates the limited benefit LTSS plans.

Florida Medicaid Contract Awards

AHCA Announces The Award of New Contracts for the Statewide Medicaid Managed Care Program

Florida Receives 43 Responses To Medicaid Managed Care RFI

Contract Awards

On April 24, 2018, the Florida Agency for Health Care Administration announced its intention to award contracts to nine health plans. The nine health plans selected include: Aetna Better Health, Community Care Plan, Florida Community Care, Humana Medical Plan, Lighthouse Health Plan, Miami Children’s, Molina Healthcare, Prestige, Simply Healthcare, Staywell, Sunshine Health, UnitedHealthcare, and Vivida Health. The health plans were implemented over three phases for 11 different regions.

Under the new contract, Medicaid beneficiaries receive comprehensive physical and behavioral health services through the health plans. The health plans will continue to offer the previously established adult preventive services such as preventative treatment and dental procedures. Additionally, the Agency for Health Care Administration added an enhanced benefit package that provides extra addiction disorder and mental health treatment services. The additional addiction disorder and mental health treatments include intensive outpatient treatment, individual/group therapy, enhanced pain management services, and additional medication assisted treatment. The state also included the Medicaid Physician Incentive Program (MPIP) to provide enhanced payments to pediatric provider organizations.

Hawaii calls its managed care program QUEST (i.e., Quality care, Universal access, Efficient utilization, Stabilizing costs, and to Transform the way health care is provided to recipients) integration. The state’s managed care program cover almost all of the Medicaid population–including the MLTSS population–and provide all physical health, behavioral health, pharmacy, and long-term services and supports through five health plans.

Request For Proposals

On August 26, 2019, Hawaii’s Department of Human Services released an RFP to procure health plans for QUEST Integration (QI) Medicaid Managed. The state anticipated awarding four contracts to provide comprehensive physical health, behavioral health, pharmacy, and long-term services and supports to Medicaid and CHIP beneficiaries. Two health plans are required to provide health care coverage to the entire state; all four health plans will provide coverage to Oahu. Additionally, health plans are required to develop dual-eligible special needs plan (D-SNPs) for dual eligible beneficiaries.

Health plan proposals were due on November 8, 2019. In January 2020, the incumbent health plans – AlohaCare, Hawaii Medical Services Association (HMSA), ‘Ohana Health Plan, and UnitedHealthCare Community Plan submitted proposals for the QUEST Integration RFP. HMSA and UnitedHealthCare are expected to deliver services statewide. The ‘Ohana Health Plan and AlohaCare contracts will provide services to the island of O’ahu only. XIV, XV

Hawaii Seeks QUEST Integration Managed Care to Cover Medicaid and Other Eligible Individuals

Hawaii Medicaid Awards QUEST Integration To Incumbents: AlohaCare, Hawaii Medical Service Association, United & Ohana Health Plan/WellCare

Contract Awards

On January 22, 2020, Hawaii’s Department of Human Services Med-QUEST division awarded contracts to the four health plans (AlohaCare, HMSA, ‘Ohana Health Plan, and UnitedHealth that submitted proposals. UnitedHealthcare and HMSA were awarded the contract to provide services statewide and ‘Ohana Health Plan and AlohaCare were awarded the contract to provide service to the island of O’ahu. Additionally, all health plans are required to develop D-SNPs in an effort to improve care coordination efforts with Medicare to provide adequate care for dual eligible beneficiaries.

The new health plans are expected to go live on July 1, 2020. However, in response to the current public health emergency (i.e., COVID-19 outbreak), MED-QUEST has postponed the new health plan implementation data. All current beneficiaries covered under the health plans will not lose their coverage. The current projected end date for the contract is December 31, 2025.

Idaho does not operate a separate program from MLTSS beneficiaries. Instead, Idaho operates a Dual Special Needs Plan (D-SNP) and the Medicare Medicaid Coordination Plan (MMCP) for dual eligible beneficiaries and individuals in need of LTSS. Additionally, Idaho operates a mandatory Medicaid-only managed care plan, known as Medicaid Plus, for dual eligible beneficiaries not enrolled in MMCP. Medicaid Plus incorporates all Medicaid services, including long-term services and supports, into the managed care program. I, X

Request For Proposals

In 2007, Idaho began operating the Medicare-Medicaid Coordinated Plan (MMCP) for full-benefit dual eligible beneficiaries. Starting 2013, the state began covering long-term supports and services for the dual eligible population. Beneficiaries in the MMCP have the option to participate and have the ability to select their health plan. Additionally, Idaho operates a mandatory Medicaid-only managed care plan, known as Medicaid Plus, for eligible beneficiaries not enrolled in MMCP. The state launched the Idaho Medicaid Plus (IMPlus) in November 2018 through a 1915 (b) waiver. IMPlus is a mandatory program for dual eligible beneficiaries residing in select counties. MMCP beneficiaries and IMPlus beneficiaries receive physical health, behavioral health, and LTSS through two health plans: Blue Cross of Idaho or Molina Healthcare of Idaho. XVI, XVII, XVIII

Managed Care In Idaho

Idaho Medicaid Dual Eligible Program Options & Worksheet

Dual Eligible Participants Medicare Medicaid Coordinated Plan & Idaho Medicaid Plus

Contract Award

Starting in 2007, Idaho began the Medicare-Medicaid Coordinated Plan (MMCP) for their dual eligible population. In 2013 this was expanded to include their LTSS services. Alongside this program, in November 2018 the state started a mandatory Medicaid-only managed care program, titled Medicaid Plus, in select counties. Beneficiaries participating in this program receive services through either Blue Cross of Idaho or Molina Healthcare. The state is currently in the process of expanding this program to the rest of the state.

As of July 1, 2019, the Illinois Department of Healthcare and Family Services began offering MLTSS services statewide for individuals residing in nursing facilities, individuals receiving 1915 (c) waiver services, and dual eligible beneficiaries. Dual eligible beneficiaries are enrolled in the HealthChoice Illinois MLTSS program unless they were previously enrolled in the Illinois Medicare-Medicaid Alignment Initiative (MMAI). I, XI, XII

Request For Proposals & Contract Awards

The Illinois Department of Healthcare and Family Services announced that their MLTSS program began on July 1, 2019 for residents in nursing homes and for those enrolled in 1915(c) waivers, and for their dually eligible individuals. Dual Eligibles are enrolled in the HealthChoice MLTSS program, except for those that are in the Medicare-Medicaid Alignment Initative. The six MCO’s, Blue Cross Blue Shield of Illinois, County Care, Illinicare health Plan, Meridian Health, Molina Healthcare of Illinois and NextLevel health serve the HealthChoice MLTSS program. XIX, XX

Request to Expand the Illinois Medicare-Medicaid Alignment Initiative Demonstration Statewide

Illinois Medicare-Medicaid Plan Quality Withhold Analysis Results

Iowa’s MLTSS population receives long-term services and supports through health plans contracted with Medicaid managed care. Iowa’s managed care program is called IA Health Link and provides beneficiaries with comprehensive physical health, behavioral health, pharmacy, and long-term services and supports.

Request For Proposals

In July 2019, the Iowa Department of Human Services announced that contracts have been signed with Amerigroup and Iowa Total Care for the state’s Fiscal Year 2020. This new contract includes quality oversight for LTSS with a focus on community-based case management. Additionally the new contract includes protections for LTSS assessments that are related to Supports Intensity Scale assessments and level of care. This will allow beneficiaries to have an individual of choice present during their assessments. Beneficiaries must be given a three-day notice prior to assessments. I, XXI

New IA Health Link Contracts Signed

Contract Award

In 2019, Iowa’s Department of Human Services announced their new managed care organization contracts. The Department of Human Services signed contracts with Amerigroup Iowa and Iowa Total Care for the state’s fiscal year 2020. These new contracts include additional quality oversight for LTSS activities, in particular community-based case management activities. Additionally, Iowa’s Department of Human Services included new protections for LTSS assessments related to level of care and Supports Intensity Scale assessments into the contract. This will allow beneficiaries to have the option to have someone else present during their assessments and will require them to have at least three day notice for their assessments.

Kansas’ managed care program is called KanCare. KanCare beneficiaries receive physical health services, behavioral health services, and long-term services and supports for a majority of the Medicaid population. In the state of Kansas, MLTSS beneficiaries receive health care coverage through the Medicaid managed care health plans. In June 2018, the state announced intentions to re-procure health plans. The new contracts went into effect on January 1, 2019. I, XV

Request For Proposals

On November 2, 2017, Kansas released an RFP to procure health plans for Kansas’s managed care program, KanCare 2.0. KanCare 2.0 provides Medicaid coverage for a majority of Medicaid and CHIP beneficiaries including comprehensive physical, behavioral, and LTSS. Additionally, health plans are responsible for developing innovative strategies to address social determinants of health, access to housing and employment, and value-based reimbursement or purchasing opportunities. There were three incumbent health plans – Sunflower State Health Plan, (Centene), UnitedHealthcare, and Amerigroup (Anthem). The health plans went live on January 1, 2019 and are expected to end December 31, 2023. XXII, XXIII

HMA Weekly Roundup Trends in State Health Policy

Kansas Managed LTSS

Contract Awards

In June 2018, The Kansas Department of Health and Environment selected three health plans for the Medicaid managed care population. The health plans are Sunflower State Health Plan (Centene) (Incumbent), UnitedHealthcare (Incumbent), and Aetna Better Health of Kansas (new entrant). Amerigroup (the incumbent health plan that submitted a bid) has stated they plan to contest their loss of contract through formal channels, and has contacted a law firm to begin inspecting the RFP process.

Massachusetts offers managed long-term services and supports through their two dual eligible programs – Senior Care Options and One Care. Senior Care Options is a dual eligible demonstration program for individuals over the age of 65 (not including those in need of chronic/rehabilitative hospitalization, with end-stage renal disease, or residing in an ICF/IDD). In June 2018, the state announced the intent for a waiver to combine One Care and Senior Care Options. I, XVI

Request For Proposals

The 1915 waivers for Senior Care Options was initially submitted in 2012. In 2016, the state submitted a 1115 waiver for their Medicaid system extension. Included in this waiver was a major goal of better integration of physical health, behavioral health, and LTSS. Within this new waiver, the health plans will take on delivery and coordination of LTSS, following the One Care model. This was approved in November 2016 through to operate until June 2022.

In August 2012, the state and CMS signed a Memorandum of Understanding for the One Care demonstration, with an initial implementation date of April 2013. However, this program was then delayed to July 2013. In December 2018, the state released a request for responses (RFR) for health plans interested in the One Care demonstration. In June 2019, the state announced the six health plans who had responded to the RFR: Boston Medical Center Health Plan, Commonwealth Care Alliance. Fallon Health, Senior Whole Health, Tufts Health Plan, and UnitedHealthcare Community Plan. XXIV, XXV

Information for Organizations Interested in Serving as One Care Plans

Massachusetts Medicare-Medicaid Plan Quality Withhold Analysis Results

Contract Awards

In December 2018, the state released a request for responses (RFR) for MCO’s interested in the One Care demonstration. In June 2019, the state announced the six health plans who had responded to the RFR: Boston Medical Center Health Plan, Commonwealth Care Alliance. Fallon Health, Senior Whole Health, Tufts Health Plan, and UnitedHealthcare Community Plan. Currently, the demonstration is planned to end in December 2020.

Michigan provides long-term services and supports through the MI Choice/MI Habilitation Waiver and the Michigan Managed Specialty Support & Services Program (MSSP). The MI Choice Waiver authorizes the state’s designated waiver agencies to provide MLTSS for individuals ages 18 or older. The MI Habilitation Supports waiver provides comprehensive long-term services and supports for individuals with developmental disabilities. In total, approximately 17% of the MLTSS population receive services through the MI Choice or Habilitation Supports waivers under limited benefit capitated health plans. I, XVIII

The Michigan’s Medicaid Managed Specialty Support & Services Program (MSSP) provides behavioral health services and LTSS services for adults with I/DD, SMI, and/or Children with I/DD or SEM. Additionally, Michigan is currently exploring new initiative to expand their MLTSS to cover more populations, focus on person-centered planning, and integrated care management systems. This is being completed over a three stage process starting in January 2019 and ending by December 2023. I, XVII

Request For Proposals

The Michigan’s Medicaid Managed Specialty Support & Services Program (MSSP) provides behavioral health services and LTSS services for adults with I/DD, SMI, and Children with I/DD or SEM. Initially, this program was started through both a 1915 (b) and a 1915 (c) waiver, which was extended for six months in December 2013, and was continued until March 2019.

Starting in 2012, Michigan offers LTSS services through their MI Health Link program. This is executed through a three-way contract between the state, CMS, and the health plans that partake in the program. In 2018, this contract was re-signed, which allowed the state to update definitions, care coordination requirements, and provider networks. XXVI, XXVII

Financial Alignment Initiative Michigan MI Health Link

Michigan Medicare-Medicaid Plan Quality Withhold Analysis Results

Contract Award

In January 2018, CMS posted the new three-way contract between the state, CMS, and the participating health plans for the state’s dual eligible demonstration – MI Health Link. The new contract allowed the state to revise the contract to reflect the changes made to the 2016 Medicaid managed care regulations, updating provider network and care coordination requirements, and add new definitions, among others. This contract was further amended in a similar fashion in January 2019.

Minnesota Senior Health Options (MSHO) and Minnesota Senior Care Plus (MSC+) are statewide manage care programs that deliver LTSS services to individuals aged 65 and older population. Beneficiaries enrolled in Minnesota Senior Care Plus offers comprehensive physical and behavioral health services.

Minnesota Senior Health Options (MSHO) is a statewide managed care program for dual eligible beneficiaries. In addition to physical and behavioral health services, MSHO covers personal care assistants, home care nursing, some physician and preventative care services, the first 180 days of nursing facility services, elderly waiver services, and Medicare Parts A, B and D. I, XIX

Request For Proposals

In February 2019, Minnesota’s Department of Human Services released a RFP to establish a Medicare-Medical Assistance integrated health care and long-term care services for the seniors enrolled in their MSHO and MSC+ programs. This is the first time that health plans operating for-profit have the potential to be awarded contracts for these programs, and applies for all 87 counties in the state. The RFPs were due by May 2019, and were set to be awarded in July 2019, with an anticipated start date in January 2020. XXVIII, XXIX

Minnesota Managed Long-Term Services and Supports

State Cancels Contracting Process For Health Care Programs

Contract Winner

In September 2019, Minnesota’s Department of Human Services announced the cancellation of it’s RFP for its Medicaid Programs. This includes the Minnesota Senior Health Options and Senior Care Plus. The cancellation is in response to an August 30 court decision in regards to health care coverage contracts that would have caused an issue for the state. As a result, this would delay the completion of the contracts within their anticipated timeline thus resulting in disruption in coverage for beneficiaries. In an effort to maintain coverage, the state has instead renewed their current contracts for a year.

In New Jersey, MLTSS beneficiaries receive long-term services and supports through the Medicaid managed care health plans. New Jersey’s managed care program is called NJ Family Care. NJ Family Care provides comprehensive physical health and long-term services and supports to a majority of beneficiaries (with the exception of partial dual eligible, individuals residing in nursing homes, and individuals residing in ICF/IDDs). Behavioral health services are provided fee-for-service by the state and through the department’s administrative services organization (ASO). The MLTSS services are rendered through the five managed care health plans offered statewide, except for one plan that is not available in one county. I, XX

This program was established using a 1115 Waiver in October 2012. A renewal letter was sent to CMS in June 2016 with the intention of renewing the program and emphasizing the advancement of MLTSS and continuity of care.

Request For Proposals & Contract Award

New Jersey offers MLTSS services through its NJ Family Care managed care program for all individuals except partial duals, individuals in nursing homes, and individuals in ICF/IDD. Established in October 2012 through a 1115 waiver, this program has continued to be renewed, with the most recent renewal in July 2017. The plans partnered with the state for their managed care program are Aetna Better Health of New Jersey, Amerigroup of New Jersey, Horizon NJ, UnitedHealthcare Community Plan, and WellCare.

New Mexico provides long-term services and supports to MLTSS beneficiaries through the state’s Medicaid managed care program. A majority of Medicaid beneficiaries, with the exception of partial duals and individuals residing in an ICF/IDD, receive comprehensive physical health, behavioral health, and LTSS through New Mexico’s Medicaid managed care program is called Centennial Care.

Request For Proposals

New Mexico delivers MLTSS services through the state’s 1115 waiver, Centennial Care. Centennial Care’s 1115 waiver was submitted to CMS in August 2012 and was approved in July 2013. In September 2017, New Mexico released a RFP for an updated version of Centennial Care, titled Centennial Care 2.0. Centennial Care 2.0 did not make major changes, and instead expanded on the current program.

New Mexico Managed LTSS Program

Medicaid HCBS Waiver for People With Disabilities Update

Contract Award

In January 2018, the state awarded new contracts to deliver managed care services. On January 1, 2019, the two incumbents – Presbyterian Health Plan and Blue Cross Blue Shield of New Mexico – and the new entrant – Western Sky – went live. The new contracts include a 1.5% quality withhold to ensure the following delivery improvements are met: at least 3% of members are served through community health workers; 10%-15% of physical or behavior services for rural, frontier, or medically underserved beneficiaries receive telehealth; increased participation in patient-centered medical homes; increase provider organization payments to value-based reimbursement (VBR); and treat 90% of individuals receiving Hepatitis C drug treatments.

New York delivers LTSS services through either the Managed Long-Term Care (MLTC) program or Medicaid Advantage Plus, a dual eligible beneficiary program.

Request For Proposals

New York’s MLTC provides limited physical health care services and LTSS to individuals in need of 120 days of more of HCBS through 27 partial capitation health plans. Any physical health services not covered by MLTC are covered FFS. Similar to the MLTC program, the Medicaid Advantage Plus is a Medicaid plan type for dual eligible beneficiaries that require more than 120 days of community-based long-term care services for nursing facility level of care. Medicaid Advantage Plus is specially designed for dual eligibles requiring LTSS and is aligned with the individual’s Medicare advantage plan.

FIDA Demonstration Phase-out Plan

Financial Alignment Initiative New York Fully Integrated Duals Advantage (FIDA) Program

Contract Awards

New York recently announced the phase out of their Fully Integrated Dual Advantage program. With the removal of this program, all individuals who were enrolled have been passively enrolled into one of New York’s Medicaid Advantage Plans or into their D-SNP program. With this, the Medicaid Advantage Plans and the D-SNP program will supply the state’s MLTSS services.

North Carolina delivers LTSS services for the I/DD population only through the NC Innovations 1915 (c) Waiver led by Local Management Entities-Managed Care Organizations (LME-MCOs). This waiver authorizes statewide, mandatory enrollment of Medicaid populations with I/DD into capitated prepaid inpatient health plans for comprehensive behavioral health services. Currently, these services are delivered through the state’s primary care case management (PCCM) program called Carolina Access, also known as CCNC or CCNC/Carolina ACCESS. Eventually, all beneficiaries in the CCNC will be transition into managed care when the budgetary issues are resolved. I, XXIII

Request For Proposals & Contract Awards

NC Innovations’ Waiver was submitted in November 2017, which was then accepted by CMS in October 2018. North Carolina released their RFP for the waiver in August 2018. In October 2018, the state announced that there were eight applications. Further, it was announced that the contracts had been awarded to AmeriHealth Caritas, WellCare, UnitedHealthcare, Blue Cross Blue Shield of North Carolina, and Carolina Complete Care. The state anticipated implementing the program through a phased roll out of the program, with half starting in November 2019 and the rest in February 2020. However, due to budgetary constraints, the initiative is currently on hold. XXXVI, XXXVII

North Carolina Managed Long-Term Services and Supports

Legislators Adjourn Without Taking Actions Required for Medicaid Managed Care

Ohio has been exploring the option of developing an MLTSS program for managed care beneficiaries. Currently, dual eligible beneficiaries receive MLTSS through the state’s dual eligible demonstration, MyCare Ohio.

Request For Proposals & Contract Awards

In Ohio, full-benefit dual eligible beneficiaries receive comprehensive MLTSS through the state’s dual eligible demonstration called MyCare Ohio. MyCare Ohio began operating in 2014, and was scheduled to end on December 31, 2017. However, the state extended the three-way contract to December 31, 2023. In June 2019, the Ohio Department of Medicaid (ODM) released a Request for Information (RFI) to prepare a new competitive managed care contract. Under the new managed care contract, the health plans will provide MLTSS for eligible managed care beneficiaries. That state is planning to release an RFP in the upcoming years.

Pennsylvania operates two managed care programs. Pennsylvania delivers LTSS services through their Community HealthChoices (CHC) program. The CHC program provides physical health care and LTSS for individuals who are dually eligible for Medicaid and Medicare, individuals over the age of 21, and individuals in needs of LTSS.

Request For Proposals

In May 2016, Pennsylvania’s DHS announced that there were 14 responses to their CHC RFP, which is estimated to cover 420,000 individuals. The submitted plans were Accenda, Aetna, AmeriHealth Caritas, Cedar Woods Care Management, Cigna-Health, Gateway Health Plan, Geisinger Health Plan, Health Partners Plus, Molina Healthcare, PA Health & Wellness, Trusted Health Plan, United Healthcare, UPMC For You, and WellCare. In August 2016, the state announced AmeriHealth Caritas, Centene, and UPMC For You as the health plans for the CHC program. The CHC has had a phased roll out and was fully implemented in the state in January 2020. XXXVII

Wolf Administration Prepares for Coordinated, Community HealthChoices Third Phase Launch

Contract Awards

In August 2016, Pennsylvania’s Department of Human Services announced which health plans were selected for the Community Health Choices MLTSS program: AmeriHealth Caritas, Centene Corp, and UPMC For You. Community HealthChoices originally began in 14 counties until being fully expanded to the rest of the state in 2019. The state currently expects for there to be 400,000 enrollees in this program, with approximately 94% of the program’s enrollment attributed to dual eligibles.

In Rhode Island, dual eligible beneficiaries and individuals in need of MLTSS services were enrolled in Rhody Health Options. Rhody Health Option served dual eligibles and LTSS until September 30, 2018. Although the state terminated the Rhody Health Options program, the state continues provide services to dual eligible beneficiaries.

Request For Proposals & Contract Awards

In an effort to provide comprehensive care, Rhode Island established the Integrated Care Initiative. The Integrated Care Initiative operated through two phases. Phase 1 began in July 2016 and provided LTSS through the RHO/UNITY program. The RHO/UNITY program ended on September 30, 2018. Phase 2 of the demonstration began on July 2016 through a three-way contract with CMS. As of March 1, 2020, the state and CMS have renewed the new three-way contract.

Tennessee is the first state to operate a Medicaid managed care only program. Tennessee delivers LTSS services, in addition to comprehensive physical and behavioral health services, through the CHOICES and Employment and Community First (ECF) Choices programs.

Request For Proposals

CHOICES is a Medicaid managed care program that provides LTSS to aged and physically disabled individuals in need of a nursing facility level of care. The 1115 waiver that established both CHOICES and ECF Choices was first submitted in July 2012. In June 2016, the program was given an extension for two months to cover individuals while a new waiver could be drafted and approved. This new waiver draft was approved in December 2016 and lasts until June 2021. I, XXXIX

Tennessee Managed LTSS

Contract Awards

In June 2016, CMS granted Tennessee a two month extension of their managed care and MLTSS section 1115 waiver. This extra time allowed the state to negotiate the details of the waiver renewal. As a result, the waiver was accepted and extended through June 2021. Included in this demonstration was an amendment for the CHOICES program, a managed long-term care program. The CHOICES program serves three groups; Group 1 is nursing facility residents, Group 2 is elderly adults and adults with physical disabilities who are in nursing facilities, and Group 3 is for elderly adults and adults with physical disabilities who do not meet the requirements for nursing facilities.

Texas operates four managed care programs that serve subsets of the Medicaid population – STAR, STAR +PLUS, STAR Kids, and STAR Health. In Texas, only beneficiaries enrolled in STAR +PLUS and STAR Kids are eligible for LTSS services; in addition to standard physical and behavioral health care services.

Request For Proposals

The 1115 waiver was originally approved in December 2011. By September 2014, STAR+PLUS was expanded to the whole state. In 2015, Texas released a RFI to gather information about health plans interest in MLTSS for individuals with I/DD. In November 2019, Texas began the reprocurement process for STAR+PLUS for an anticipated start date of January 2019. The state later changed the starting date to September 2019. The RFP for the managed care contracts was posted December 2017. In July 2018, this RFP was cancelled. Proposals were then sought again and accepted in November 2018.

Medicaid STAR + Plus Procurement Announcement

Texas Cancels Controversial Medicaid Contracts After Complaints of Subjective Scoring

Contract Awards

In October 2019, contracts were awarded to Aetna, Amerigroup, UnitedHealthcare, Molina, Superior, UnitedHealthcare and El Paso Health. In March 2020, the state announced these contracts were being thrown out and the whole process was being restarted.

Virginia operates two managed care programs: Medallion 4.0 and Commonwealth Coordinated Care Plus (CCC Plus). Virginia delivers LTSS services for non-I/DD individuals through the Commonwealth Coordinated Care Plus Program. The CCC Plus program operates full-risk, capitated health plans that provide physical health, behavioral health, and LTSS for the aged, blind, and disabled (ABD) and dual eligible populations. The CCC Plus program began in April 2017. These services are delivered through six full-risk capitated health plans. The health plans are responsible for implementing person-centered individualized care plans (ICPs) for each member, except those stratified as “minimal” health risk. Additional care coordination, including face-to-face interactions, are required for high-risk members. I

Request For Proposals

In June 2015, the state announced their intention to move MLTSS services to managed care. By January 2016, the state submitted the waiver to accomplish this to CMS. In April 2016, the state released a RFP for health plans to deliver service to the MLTSS population. In September 2016, the state selected Optima Health, Humana, Magellan Complete Care of Virginia, Anthem HealthKeepers Plus, Virginia Premier Health Plan, Aetna Better Health of Virginia, and UnitedHealthcare for MLTSS services through the state’s waiver. In February 2017, the state announced that they selected Aetna Better Health of Virginia, Anthem HealthKeepers Plus, Magellan Complete Care of Virginia, Optima Health, UnitedHealthcare, and Virginia Premier Health Plan for the Coordinated Care Plus Program. These programs went live in August 2017. XLII

Virginia Medicaid Updates

Contract Award

In February 2017, the state announced that they selected Aetna Better Health of Virginia, Anthem HealthKeepers Plus, Magellan Complete Care of Virginia, Optima Health, UnitedHealthcare, and Virginia Premier Health Plan for the Coordinated Care Plus Program. These programs went live in August 2017. XLII

Wisconsin offers MLTSS services through the Family Care and Family Care Partnership programs. Family Care is a voluntary program that provides MLTSS to dual eligible beneficiaries and Medicaid aged, blind, and disabled (ABD) individuals ages 18 or older. Family Care plans operate as prepaid inpatient health plans (PIHPs) because they provide a limited set of benefit of benefits on a capitated basis. Family Care provides services through six prepaid inpatient health plans which offer a limited set of benefits on a capitated basis on a regional basis. The state also operates a related program called Family Care Partnership, which provides Medicaid state plan benefits and LTSS through health plans for dual eligible beneficiaries. Both Family Care and Family Care Partnership, the state has implemented pay-for-performance (P4P) mechanism in 2019. The P4P withhold payment are based on the result from the member satisfaction survey, competitive integrated employment activities, and assisted living quality improvement. XXVI

Request For Proposals & Contract Award

In February 2019, Wisconsin’s Department of Health Services issued an RFP for their Family Care Program and The Family Care Partnership Program’s managed care organizations. Proposals were due in April 2019, with a planned implementation of January 2020. The contract awardees have not been released yet.

Managed Care Organizations for the Delivery of Managed Long-Term Care in Selected Service Areas in GS

Wisconsin Managed LTSS Program

I OPEN MINDS. (2020). State Profile Series. Retrieved June 29, 2020 from https://www.openminds.com/resource-type/state-profiles/

II OPEN MINDS. (2018, July 22). Arizona Issues RFP For Managed Care Plans For Individuals With Developmental Disabilities. Retrieved June 29, 2020 from https://www.openminds.com/market-intelligence/news/arizona-to-implement-new-integrated-managed-care-plans-for-individuals-with-developmental-disabilities/

III OPEN MINDS. (2018, June 26). Arizona Seeks Integrated Health Care Choice Plan Services. Retrieved June 29, 2020 from https://www.openminds.com/rfp/arizona-seeks-integrated-health-care-choice-plan-services/

IV OPEN MINDS. (2017, October 15). Arkansas Medicaid To Launch Provider-Led Shared Savings Entities For Members With Developmental Disabilities Or Mental Illness. Retrieved June 29, 2020 from https://www.openminds.com/market-intelligence/news/arkansas-medicaid-launch-new-provider-led-shared-savings-entities-coordinate-care-beneficiaries-developmental-disability-mental-illness/

V OPEN MINDS. (2018, December 2). Arkansas Medicaid To Launch Full-Risk Phase Of Medicaid Shared Savings Program In March 2019. Retrieved June 29, 2020 from https://www.openminds.com/market-intelligence/news/arkansas-medicaid-delays-medicaid-shared-savings-program-until-march-2019/

VI Centers for Medicare & Medicaid Services. (2012). State Demonstration to Integrate Care for Dual Eligibles: California Demonstration Proposal. Retrieved June 29, 2020 from https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/Downloads/CAProposal.pdf

VII California Department of Health Care Services. (2019, September 3). Announcement Pertaining to Long Term Care, Transplants, and Multipurpose Senior Services Program, Benefits. Retrieved June 29, 2020 from https://www.calhospital.org/sites/main/files/file-attachments/calaim_ltc_transplant_mssp_announcement.pdf

VIII Centers for Medicare and Medicaid Services. (2017). Memorandum of Understanding: California Demonstration to Integrate Care for Dual Eligible Beneficiaries. Retrieved June 29, 2020 from https://www.cms.gov/files/document/camou.pdf

IX OPEN MINDS. (2017, July 9). Delaware Rebidding Diamond State Health Plan Contracts, Planning To Move 80% Of Reimbursement To Value-Based Models. Retrieved June 29, 2020 from https://www.openminds.com/market-intelligence/news/delaware-rebidding-diamond-state-health-plan-contracts-planning-move-80-reimbursement-value-based-models/

X OPEN MINDS. (2017, May 1). Delaware Seeks Diamond State Health Plan Delivery System Transformation Services. Retrieved June 29, 2020 from https://www.openminds.com/rfp/delaware-seeks-diamond-state-health-plan-delivery-system-transformation-services/

XI Wolfe Research. (2018, April 24). Florida Medicaid Contract Awards. Retrieved June 29, 2020 from https://wolferesearch.com/sites/default/files/attachments/x20170424_JL_Florida_Medicaid_Contracts_0.pdf

XII Florida Agency For Health Care Administration. (2018, April 24). AHCA Announces The Award of New Contracts for the Statewide Medicaid Managed Care Program. Retrieved June 29, 2020 from https://ahca.myflorida.com/Executive/Communications/Press_Releases/pdf/PressReleaseSMMCReprocurement4242018.pdf

XIII OPEN MINDS. (2017, January 22). Florida Receives 43 Responses To Medicaid Managed Care RFI. Retrieved June 22, 2017 from https://www.openminds.com/market-intelligence/news/florida-receives-43-responses-medicaid-managed-care-rfi/

XIV OPEN MINDS. (2019, August 27). Hawaii Seeks QUEST Integration Managed Care to Cover Medicaid and Other Eligible Individuals. Retrieved June 29, 2020 from https://www.openminds.com/rfp/hawaii-seeks-quest-integration-managed-care-to-cover-medicaid-and-other-eligible-individuals/

XV OPEN MINDS. (2020, February 16). Hawaii Medicaid Awards QUEST Integration To Incumbents: AlohaCare, Hawaii Medical Service Association, United & Ohana Health Plan/WellCare. Retrieved June 29, 2020 from https://www.openminds.com/market-intelligence/news/hawaii-medicaid-awards-quest-integration-to-incumbents-alohacare-hawaii-medical-service-association-united-ohana-health-plan-wellcare/

XVI Centers for Medicare & Medicaid Services. Managed Care In Idaho. Retrieved June 29, 2020 from https://www.medicaid.gov/medicaid-chip-program-information/by-topics/delivery-systems/managed-care/downloads/idaho-mcp.pdf

XVII Idaho Department of Health and Welfare. (2020). Idaho Medicaid Dual Eligible Program Options & Worksheet. Retrieved June 29, 2020 from https://healthandwelfare.idaho.gov/Portals/0/Medical/MedicaidCHIP/MMCP/DualEligibleMedicaidProgramOptionsAndWorksheet.pdf

XVIII Idaho Department of Health and Welfare. Dual Eligible Participants Medicare Medicaid Coordinated Plan & Idaho Medicaid Plus. Retrieved June 29, 2020 from https://healthandwelfare.idaho.gov/Medical/Medicaid/DualEligibleParticipants/tabid/2538/Default.aspx

XIX Illinois Department of Healthcare & Family Services. (2019, September 17). Request to Expand the Illinois Medicare-Medicaid Alignment Initiative Demonstration Statewide. Retrieved June 29, 2020 from https://www.illinois.gov/hfs/SiteCollectionDocuments/091719RequesttoExpandtheIllinoisMedicareMedicaidAlignmentInitiativeDemonstrationStatewide.pdf

XX Centers for Medicare & Medicaid Services. (2019, August 14). Illinois Medicare-Medicaid Plan Quality Withhold Analysis Results. Retrieved June 29, 2020 from https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/Downloads/QualityWithholdResultsReportILDY3.pdf

XXI Iowa Department of Human Services. (2019, July 10). New IA Health Link Contracts Signed. Retrieved June 29, 2020 from https://dhs.iowa.gov/sites/default/files/IAHealthLink_SignedContracts_July2019.pdf?092420191954

XXII Health Management Associates. (2017, November 8). HMA Weekly Roundup Trends in State Health Policy. Retrieved June 29, 2020 from https://www.healthmanagement.com/wp-content/uploads/110817-HMA-Roundup.pdf

XXIII Advancing States. (2019, July 10). Kansas Managed LTSS. Retrieved June 29, 2020 from http://www.advancingstates.org/initiatives/tracking-state-activity/state-medicaid-integration-tracker/kansas

XXIV Massachusetts Executive Office of Health and Human Services. (2020, January 7). Information for Organizations Interested in Serving as One Care Plans. Retrieved June 29, 2020 from https://www.mass.gov/service-details/information-for-organizations-interested-in-serving-as-one-care-plans

XXV Centers for Medicare & Medicaid Services. (2017). Massachusetts Medicare-Medicaid Plan Quality Withhold Analysis Results. Retrieved June 29, 2020 from https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/Downloads/QualityWithholdResultsReportMADY4.pdf

XXVI Centers for Medicare & Medicaid Services. (2019, August 14). Financial Alignment Initiative Michigan MI Health Link. Retrieved June 29, 2020 from https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/Downloads/MIEvalReport1.pdf

XXVII Centers for Medicare & Medicaid Services. (2019, September 24). Michigan Medicare-Medicaid Plan Quality Withhold Analysis Results. Retrieved June 29, 2020 from https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/Downloads/QualityWithholdResultsReportMIDY2.pdf

XXVIII Advancing States. (2019, December 2). Minnesota Managed Long-Term Services and Supports. Retrieved June 29, 2020 from http://www.advancingstates.org/initiatives/tracking-state-activity/state-medicaid-integration-tracker/minnesota

XXIX Minnesota Department of Human Services. (2019, September 3). State Cancels Contracting Process For Health Care Programs. Retrieved June 29, 2020 from https://mn.gov/dhs/media/news/#/detail/appId/1/id/401411

XXX Advancing States. (2019, December 2). New Jersey Managed Long-Term Services & Supports. Retrieved June 29, 2020 from http://www.advancingstates.org/initiatives/tracking-state-activity/state-medicaid-integration-tracker/new-jersey

XXXI Health Management Associates. (2019, September 4). HMA Weekly Roundup Trends in State Health Policy. Retrieved June 29, 2020 from https://www.healthmanagement.com/wp-content/uploads/090419-HMA-Roundup.pdf#nameddest=hma-roundup

XXXII Advancing States. (2019, May 7). New Mexico Managed LTSS Program. Retrieved June 29, 2020 from http://www.advancingstates.org/initiatives/tracking-state-activity/state-medicaid-integration-tracker/new-mexico

XXXIII New Mexico Department of Health. (2019, March 22). Medicaid HCBS Waiver for People With Disabilities Update. Retrieved June 29, 2020 from https://www.hsd.state.nm.us/uploads/PressRelease/2f473c14ee654f868b5a25b3cfd15a6d/DOH_HSD_SupportsWaiver_Release.pdf

XXXIV New York Department of Health. (2019, September 23). FIDA Demonstration Phase-out Plan. Retrieved June 29, 2020 from https://www.health.ny.gov/health_care/medicaid/redesign/fida/mrt101/docs/phase_out.pdf

XXXV Centers for Medicare & Medicaid. (2019, August). Financial Alignment Initiative New York Fully Integrated Duals Advantage (FIDA) Program. Retrieved June 29, 2020 from https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/Downloads/NYFIDAEvalReport1.pdf

XXXVI Advancing States. (2019, December 2). North Carolina Managed Long-Term Services and Supports. Retrieved June 29, 2020 from http://www.advancingstates.org/initiatives/tracking-state-activity/state-medicaid-integration-tracker/north-carolina

XXXVII North Carolina Department Of Health and Human Services. (2019, November 19). Legislators Adjourn Without Taking Actions Required for Medicaid Managed Care. Retrieved June 29, 2020 from https://www.ncdhhs.gov/news/press-releases/legislators-adjourn-without-taking-actions-required-medicaid-managed-care-dhhs

XXXVIII Pennsylvania Pressroom. (2019, May 23). Wolf Administration Prepares for Coordinated, Community HealthChoices Third Phase Launch. Retrieved June 29, 2020 from https://www.media.pa.gov/Pages/DHS_details.aspx?newsid=379

XXXIX Advancing States. (2019, May 7). Tennessee Managed LTSS. Retrieved June 29, 2020 from http://www.advancingstates.org/initiatives/tracking-state-activity/state-medicaid-integration-tracker/tennessee

XL Texas Health and Human Services. (2019, October 29). Medicaid STAR + Plus Procurement Announcement. Retrieved June 29, 2020 from https://hhs.texas.gov/about-hhs/communications-events/news/2019/10/medicaid-starplus-procurement-announcement

XLI The Texas Tribune. (2020, March 25). Texas Cancels Controversial Medicaid Contracts After Complaints of Subjective Scoring. Retrieved June 29, 2020 from https://www.texastribune.org/2020/03/25/texas-cancels-problem-plagued-medicaid-contracts/

XLII Advancing States. (2019, December 2). Virginia Medicaid Updates. Retrieved June 29, 2020 from http://www.advancingstates.org/initiatives/tracking-state-activity/state-medicaid-integration-tracker/virginia

XLIII Wisconsin Department of Administration. (2019, April 17). Managed Care Organizations for the Delivery of Managed Long-Term Care in Selected Service Areas in GS. Retrieved June 29, 2020 from https://esupplier.wi.gov/psp/esupplier/SUPPLIER/ERP/c/WI_SS_SELF_SERVICE.WI_SS_BIDDER_PAGE.?&Page=WI_SS_BIDDER_PAGE&Action=U&WI_SS_EVENT_NBR=10654

XLIV Advancing States. (2019, May 7). Wisconsin Managed LTSS Program. Retrieved June 29, 2020 from http://www.advancingstates.org/initiatives/tracking-state-activity/state-medicaid-integration-tracker/wisconsin

Industry Resource | June 22, 2023

Published in May 2023, this highly-detailed report explains how the California health and human service system works, and provides all the market data, analysis, and “insider” insights executive teams need to build a successful strategic plan for both operating and marketing in the state. This report includes:

Health Care Coverage Map – A chart illustrating state health care coverage by the Medicaid, Medicare, dual eligibles, commercial insurance, and health insurance marketplace populations.

Largest Health Plans By Enrollment – A list of the largest operating health plans and the largest health plans by SMI enrollment in the state.

Medicaid System Overview – An easy-to-read snapshot of the Medicaid finance delivery system and risk-based arrangements.

Medicaid Governance – A chart showing how the Medicaid system is organized, as well as the key players at the Medicaid department.

Medicaid Financing & Service Delivery – A close look at the Medicaid financing system, including the populations and services covered.

Pending Changes To Medicaid System – A clear timeline of proposed state changes for the next five years, as well as any long-term initiatives.

New Initiatives For Dual Eligible Population – A review of any new or planned programs for the state’s dual eligible population, including state-specific programs and the federal dual demonstration program.

New Initiatives For The Long-Term Services and Supports (LTSS) Population – A review of any new or planned programs for the LTSS population, including state-specific programs and specific home- and community-based services (HCBS) for the LTSS population.

State Mental Health & Addiction Treatment Department Organization Chart – A chart showing how the state’s mental health and addiction treatment system is organized and the key players at the mental health department.

Health Care Reform Initiatives – A summary of how the state has implemented the Medicaid expansion and health insurance marketplace.

Organizational Profile | April 30, 2021

Founded in 1969, Spectrum Health Systems is a private, non-profit organization that offers a continuum of addiction treatment services throughout Massachusetts, including inpatient detoxification, residential rehabilitation, medication-assisted treatment, outpatient counseling, and peer recovery support. Spectrum also operates a Correctional Division, which was established in 1993, and serves the justice-involved population with co-occurring mental health and addiction disorders in Massachusetts, Georgia, Tennessee, and Virginia. Their mission is to “provide the highest quality of services to individuals seeking treatment for substance abuse and/or mental health issues. We assist our clients in achieving sobriety, sustaining recovery, and fulfilling personal goals in order that they may lead healthier, more productive lives.”

Headquartered in Worcester, Massachusetts, Spectrum serves the greater Boston area, including Leominster, Marlborough, Milford, Millbury, North Adams, Pittsfield, Saugus, Southbridge, Waltham, Westborough, and Weymouth, and also provides services through state contracts with Georgia, Tennessee, and Virginia. The organization employs over 1,660 staff and serves 40,000 individuals annually.

As of fiscal year (FY) 2019, Spectrum had $75.3 million in revenue. This was an approximately 12% increase from the year prior when the organization ended the year with $67.2 million in revenue. Over the past five years, Spectrum’s annual revenues have increased by more than 20%, from $61.8 million in FY 2015 to $75.3 million in FY 2019. Services are performed under contracts with a wide variety of private and public sector clients, including federal, state, and local governments, major insurance carriers, employee assistance programs, private corporations, philanthropies, and the United Way.

Spectrum offers over 100 residential and community-based programs, many of which are accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF). Services include inpatient detoxification, residential rehabilitation, medication-assisted treatment, outpatient counseling, and peer recovery support. Spectrum also operates several residential programs for the Massachusetts Department of Youth Services and holds state contracts throughout the United States to provide specialized programming for criminal offenders with histories of substance abuse.

The service lines that comprised the majority of Spectrum’s revenue in FY 2019 included outpatient substance abuse services (approximately 38% of total annual revenue), corrections services (approximately 31% of total annual revenue), and inpatient substance abuse services (approximately 19% of total annual revenue). Spectrum’s adolescent services and additional programs accounted for approximately 11% of total annual revenue. The remaining approximate 1% of revenue was comprised of income from fundraising events and all other contributions.

Outpatient Substance Abuse Spectrum provides several outpatient programs for adults and adolescents with substance abuse and co-occurring mental health disorders. After conducting a comprehensive intake evaluation, an individualized treatment plan is developed for each client with services focusing on skill development, family education, peer recovery, medication-assisted treatment, mental health services, clinical assessment, treatment planning, counseling, and medication management. Spectrum also operates a three-week minimum intensive outpatient program involving two group and one brief individual session each day, in addition to family groups and more in depth individual sessions on a weekly basis. Serving an average of 2,500 individuals daily, this service line accounted for $28.7 million of the organization’s total annual revenue in 2019.

Corrections Spectrum’s correctional division provides substance abuse counseling to justice-involved individuals in correctional facilities or individuals on parole in community-based settings. The programs assist offenders in understanding and assessing their own treatment readiness, learning pro-social skills, addressing individual risks of relapse and recidivism, and preparing for successful community reintegration. In the outpatient program, clients receive individualized assessment, treatment planning, and discharge planning services. In prison-based programs, offenders typically attend three 90-minute group sessions per week, for a period of 12 weeks.

Spectrum also operates a reentry program to help prepare individuals for community reintegration. The reentry plan addresses each individual’s needs including housing, substance abuse, family, employment, education, physical and mental health, and well-being. Following release, the counselor provides support to the client and maintains contact with community service providers and probation/parole, as needed. For high-risk offenders, Spectrum’s Correctional Recovery Academy provides an advanced form of therapeutic community programming to address various contributors of substance abuse and criminal behavior such as dysfunctional interpersonal relations, poor impulse control, and inappropriate responses to authority. Serving about 6,600 individuals daily across seven states, this service line accounted for $23.5 million of the organization’s total annual revenue in 2019.

Inpatient Substance Abuse Spectrum offers three levels of inpatient care, including detoxification, clinical stabilization services, and residential treatment. The detoxification program provides 24-hour medical supervision to ensure safe withdrawal from alcohol, opioids, and other substances. Clinical-stabilization services, which is a short-term residential program, provides support between the detoxification and aftercare stages, includes comprehensive assessment, treatment planning, individual and group counseling, health education, continuing care planning, and follow up. Spectrum’s residential program provides individual, group, and family counseling; recovery groups; relapse prevention training; recreational activities; continuing care planning; and post-discharge support. Serving an average of 220 individuals daily, this service line accounted for $14.6 million of the organization’s total annual revenue in 2019.

Additional Programs Spectrum operates several additional programs, including adolescent services for at-risk youth with funding provided by the Massachusetts Department of Youth Services (DYS). Spectrum operates a 12-bed residential program for adolescent males aged 11 through 20, as well as a 10-bed program for adolescent and young adult males aged 13 through 21. Programming includes individual and family counseling, recovery-focused group meetings, life skills training, academic instruction, and recreational activities. The organization also operates a 15-bed detention program for females aged 13 to 20 years with charges ranging from misdemeanors to felony. The goal is to provide a highly structured and supportive environment, combined with a short-term program to reduce delinquent behaviors and facilitate positive change. Spectrum’s additional services accounted for approximately $8.2 million of total annual revenue in 2019.

In November 2020, Spectrum Health was awarded a first-of-its-kind contract by the Massachusetts Department of Correction (MADOC) to provide in-prison medication-assisted treatment to offenders with opioid use disorders statewide. The estimated $43.5 million, four-year contract will allow the organization to extend services throughout the state using a phased approach over the next year. During 2020, Spectrum also expanded into several county correctional systems in Massachusetts and was awarded contracts by the Essex County Sheriff’s Department and Suffolk County Sheriff’s Department to provide a range of substance use disorder treatment programming for inmates and detainees under the County’s supervision.

Industry Resource | June 24, 2021

This presentation was delivered June 16, 2021 by Paul Duck, Senior Associate, OPEN MINDS and Katherine Egan Bennett, Senior Associate, OPEN MINDS. In this presentation, Paul and Katherine discussed the relevant discoveries that were learned during the survey, research, and writing of the soon to be released 2021 Market Access Trends In Behavioral Health Guidebook (The Guide) – highlighting the major strategic shifts in the national behavioral health landscape.

https://vimeo.com/562110528/cfcff83430

Please fill out the fields below to let us know if you are interested in receiving a link to download a free digital copy of The 2021 Trends In Behavioral Health Guide.

Executive Briefing | June 22, 2021

It’s no surprise that COVID-19 took its toll on businesses and organizations of every shape and hue, forcing an unprecedented number of organizations and programs to close. During the pandemic, 17%, or more than 110,000 restaurants in the United States closed, of which most had been in business, on average, for 16 years, and 16% had been open for at least 30 years (see More Than 110,000 Eating And Drinking Establishments Closed In 2020). More than 12,200 retail stores downed their shutters for good—compared to 10,000 store closings in 2019—as the pandemic sent many businesses that were already struggling over the edge (see A Record 12,200 U.S. Stores Closed In 2020 As E-Commerce, Pandemic Changed Retail Forever). Overall, 200,000 more businesses than usual closed—and the closures in recent years have been about 600,000 establishments (see Covid-19’s Toll On U.S. Business? 200,000 Extra Closures In Pandemic’s First Year).

Of the 300,000 nonprofits in the nation, a study estimates that in a worst-case scenario, 38% (more than 119,000 entities) could close their doors in the next two years (see 1 In 3 Nonprofits In Danger Of Closing Due To Pandemic: Study). And 58% of non-profits reported closing at least one program in 2020 (see Persevering Through Crisis: The State Of Nonprofits). During the same year, 47+ hospitals closed or filed for bankruptcy in 2020 (see 47 Hospitals Closed, Filed For Bankruptcy This Year).

Right now, closures of service lines and program locations are a “necessary evil” of keeping organizations financially sustainable. But every executive will tell you it’s a difficult decision—changing lives of employees and consumers and altering the service delivery system in communities. The question is how to approach the decisions around your service line portfolio. And, if you decide a service line or program location needs to be closed, what is the best way to proceed? We learned best practices around this difficult issue from two executives who have made those tough choices—Peggy Terhune, Ph.D., MBA, OT/L, President and Chief Executive Officer at Monarch and Howard Snyder, Director Of Business Development at Active Day. In their session, Making The Tough Decisions: Knowing When & How To Close A Service Line at last week’s 2021 OPEN MINDS Strategy & Innovation Institute, they shared their process along with advice for their colleagues.

Monarch is an $89 million non-profit in North Carolina serving 30,000 consumers through 32 behavioral health locations and 96 long-term services and supports locations, including 19 day programs for consumers with intellectual and developmental disabilities (I/DD). Active Day is a private investor-backed entity with just over 100 adult day centers and home care services in 10 states, serving more than 8,000 seniors as well as consumers with I/DD. The executives from both organizations shared ‘lessons learned’ based on their experience in closing day programs – why to close a program, how to evaluate the options, and how to implement those decisions.

What drives the decisions to close a service line? Decisions to close a service line or program location should always be made in the context of an organization’s overall service line portfolio. Some of the drivers of a shifting portfolio include changes in service demand, reduced reimbursement rates, changing regulatory or licensure requirements, more competition, higher operating costs, or the inability of the organization to provide financial support if the service line is not breaking even.

Regulatory changes and funding cuts have been Monarch’s key reasons for deciding to close programs, according to Dr. Terhune. In her four decades in the field, she has led day programs for consumers with I/DD through many iterations—from sheltered workshops to community volunteering to micro enterprises to small group activities in the community. During COVID, the day programs transitioned to one-on-one activities with consumers in their homes and virtually. About two years ago, the Centers for Medicare and Medicaid (CMS) said that day programs are congregate care and so Medicaid funding would eventually be phased out. In addition, many consumers did not come back to day programs that reopened after the pandemic. Dr. Terhune said, “The decision was made partly because of CMS, partly because of finances. But primarily because it made sense for the people we support. I’ll never forget one of the people I met who said to me, ‘Peggy, I don’t want programs, I just want to have a life.’…”

She continued, “I’m always trying to be ahead of the game, I don’t want someone to come to me and say, ‘close your day programs’ and try to figure it out then. Based on the CMS mandate, we realized that we are going to have to close every single congregate day program within the next couple of years. So that’s what we’ve set out to do over a period of time and COVID was our unexpected trial run for how to transition.”

Economic issues have been a big driver for program closure considerations at Active Day. Mr. Snyder spoke about the threat of rate cuts—in New Jersey for example, managed care organizations were proposing a 25% rate cut for day programs. Rate fluctuations are not uncommon. But when things are going well, there is a tendency to become complacent about portfolio management. He observed that when an organization is growing, everybody likes to support a winner to open up a new center or find a new business line. He said, “Executives tend to work on things that are fun and exciting—and our marginal performing business lines sit along the side. We’ve been a relatively strong-performing organization financially. And that has exacerbated the tendency to not deal with difficult units and locations. But putting it off to the side and backburnering it is not how you fix a troubled unit.”

Evaluating the options requires an objective rather than subjective process. When it comes to closing services, the decisionmaking challenge for most health and human service managers is to separate the rational from the emotional. Even when a service line or program is a clear loss leader and drain on resources, there is often a strong inclination to keep a program open simply because it has been around “forever” and core team members cannot conceive closing it. The best way to overcome this challenge is to have clear criteria and a consistent process for portfolio analysis.

Mr. Snyder explained, “If you think you can just have a straightforward conversation with the leadership team or board about closing a service line, know that you can get sidetracked very quickly. Challenges we faced on these lines led us to develop a set of objective criteria to evaluate each program and come to a conclusion without some of the beliefs and biases that we all bring to the table.” While there are many frameworks to apply objective criteria, Mr. Snyder advised that it’s best to keep it simple and do what works for your organization. At Active Day, a simple strengths-weaknesses-opportunities-threats (SWOT) analysis turned out to be the best approach as it was not intimidating and everyone could easily understand it. And it’s a best practice to regularly examine all business lines—not just those that are struggling—against the framework. The leadership team at Active Day reviews programs annually. In a typical year, 20 out of their 100+ programs might be “in the gray and require some extra tlc” to become solid performers, failing which tough decisions have to be made.

It’s also important to plan around outliers and COVID was obviously a big one. In June 2020, the Active Day team did a comprehensive review of all its centers, and they identified 21 locations whose long-term viability was at risk. The team performed a SWOT analysis and financial review on each of these locations, looking at pre-COVID performance and potential scenarios after reopening—if consumers came back at 25% 50% and 75%, of the pre-COVID census. They examined why the programs were struggling or failing pre-COVID, whether they could recover, what resources were required for recovery, and what the margins would be like if the program recovered.

Be prepared to answer non-financial questions—such as what will happen to consumers and staff, and how the organization’s reputation will be affected—from the leadership team and board. And as Mr. Snyder said, “If you’re going to keep something operating, there’s significant costs to supporting a money-losing service line or location. If it’s related to the other things that your service lines are providing, you may want to stay in that line of service and you need to look at things holistically. So while the service line you want to keep may be losing money, consider if other service lines are making enough to compensate for those losses so the net impact on the organization’s bottom line is not negative.”

Closing a service line entails a significant risk to the organization’s reputation, community goodwill, and staff trust. When Active Day decided to close a struggling center in Wabash Valley, Indiana, they heard concerns from stakeholders at their other Indiana locations. Mr. Snyder said, “They wanted to know what was wrong and whether we were going to close their center next. So it was very important that we were proactive and communicated to all staff members about what happened. But we also used it to set expectations that other programs need to be successful.”

Executing the decision to close requires time and effort. Once the decision is made to close a service line, it’s not a cakewalk. There are costs to plan for and consequences to manage. Communicating with consumers and families, staff, and payers has to be an intentional and structured exercise.

Don’t underestimate the “exit costs” Mr. Snyder cautioned. In the case of some location closures, for example, it was a challenge to figure out what to do when they were only six months into a five-year lease—pay a lump sum to exit the agreement or find someone to sublease the space. Dr. Terhune said they monitor leases well before they are up for renewal to align with their planning for the future of programs. And where feasible, they add a clause in the property lease that allows them to get out of the lease if they lose funding, which has been very helpful.

Dr. Terhune said that at Monarch, they are investing considerable thought into alternatives for consumers as day programs in their current form are phased out. They’ve been creative with virtual activities and are also getting ready to open a coffee shop in the community where consumers have expressed interest in working. Monarch also plans to offer small group activities so consumers can spend time with their friends, which they’ve said is really important to them.

Communication is critical. Dr. Terhune said you have to start with consumers and staff involved in the program that is closing and help them see where things are going. Then you have to inform funders and the community—explain the decision and be available to answer questions. Active Day has hosted town halls and invited community members to come in with questions about the program closure.

Managing payer relationships and engaging them early in the process is also critical. You have to update your website and collateral materials. Sometimes, when you’re providing a service to a Medicaid or waiver community, there is a notice period (usually 30 to 60 days) before you can exit a service line. So consider the requirements to keep the service operating until then. Mr. Snyder shared, “We’ve used retention bonuses for leaders and key employees to keep them on board. The other thing you need to think about is severance—not every organization has a severance policy in their handbook. The way you treat staff on the way out is going to be known by the rest of the organization. And don’t underestimate the management team time and effort required to manage the closure.”

The decisions, and the processes, to close a service line are never easy. But specialty provider organization executive teams must recognize that many current service lines will likely become obsolete at some point. And in a demanding environment that requires continuous market repositioning, the need to close a service line may not be driven by obsolescence alone. It may be that the service line is no longer a “fit” in the organization’s long-term strategic direction. As Mr. Snyder summed up, “If you’re investing resources and time to keep a struggling program going, you’re spending a lot of time and effort that could be spent on your successful service lines, and you’re diverting resources from units that could be growing faster, or from expansion or diversification that could be helping your organization.”

The discussion at last week’s session reminded me that closing services lines needs to be a deliberate and directed process. And it’s better not to wait until the next crisis—external or internal—forces the tough decisions.

For more on portfolio analysis and making tough decisions, check out these resources in The OPEN MINDS Circle Library:

And for even more, join us on July 21 for the free web briefing, Diversify Your Service Lines Or Bust: Your Path To Growth. Maria Warren, Senior Director of Clinical Consulting Services, McBee Associates and Neal Tilghman, MPA, General Manager, Integrated Care, Netsmart, will discuss what it takes to successfully expand your service offerings and increase your revenue stream from a people, process, and technology perspective.

Management Newsletter Article | June 11, 2021

Making the tough decisions is the responsibility of an organization’s executive team, with the “final call” resting with the chief executive officer. And times of crisis (like the past 14 months) and recovery mean many more critical strategic decisions need to be made—quickly.

The challenge is that with the current state of market turbulence, experience alone is not adequate for making those key decisions. “Going with your gut” is not a great rationale for portfolio management decisions and transformational strategy. Executives of health and human service organizations need data—internal performance data, market landscape data, competitive information, and customer data—to make better decisions. But most of those executives do not have the data they need, on a timely basis, to make those critical strategic decisions. And whatever the available data, many executives delay making the tough decisions for a host of reasons.

Having a metrics-based management framework makes decisionmaking easier. The first step in effective decisionmaking is having a structured plan, and we’ve written a lot about the framework needed to move a management team to a metrics-based management approach (see 12 Steps To Creating Your Data-Driven Organization). There is a best practice for developing and perfecting the process for infusing a metrics-based approach across an organization—deciding what to measure, how data is analyzed and shared, and how metrics inform strategy and action.

Why invest in this framework? A recent study found that only 2% of managers regularly apply best practices when making decisions, and few organizations have systems in place to measure and improve decisionmaking processes. Yet, managers who made decisions using best practices achieved their expected results 90% of the time, while 40% exceeded expectations. Effective decisionmaking practices led to a sixfold increase in the number of good business decisions and cut failure rates by 50% (see A Checklist For Making Faster, Better Decisions).

Data-informed decisionmaking is the best practice (see Right Now, Experience Alone Is Not Enough For Decisionmaking). We’re in a period of massive disruption where executive experience matters less. The data systems supporting decisionmaking need to serve up internal performance data, market landscape data, competitive information, and customer data—in a way that facilitates decisionmaking.

Delaying decisionmaking is making a decision. The expression “timing is everything” is particularly relevant for executive decisionmaking right now—as we hurdle our way to the “next normal.” There are many reasons for lack of action on data—analysis paralysis, conflict avoidance, and lack of scenario planning are most common.

Analysis paralysis is defined as a process when overanalyzing or overthinking a situation can cause decisionmaking to become “paralyzed,” so no course of action is decided upon. It happens when executives fail to make decisions because they are waiting for more and better information. When it comes to data for decisionmaking, my advice is, don’t let the perfect be the enemy of the good. How to prevent analysis paralysis? Understand your objectives, limit the amount of information you consume and use, and set deadlines for making decisions (see Is Analysis Paralysis Holding You Back?). The only good data is the data that results in decisions and improvement.

Conflict avoidance—avoiding confronting the issue at hand—is another problem in executive decisionmaking. The tendency for many management teams is to delay the inevitable even when supported by data, particularly strategically necessary decisions that are unpopular with the community, the board, or team members. But failing to decide and act is making a decision.

Finally, time-sensitive and essential decisions can be delayed when executive teams have no alternative plans for organizational structure, operations, or business models. This is where scenario planning comes in (see How To Do Scenario Planning & Modify Business Units To Support Strategy). Building alternative models for organizational sustainability as part of your strategic plan is an exercise in helping executive teams “rehearse” for future market events.

In this issue of the OPEN MINDS Management Newsletter, “From Data To Action: The Keys To Executive Decisionmaking,” we focus on how executive decisions are made. (For more on developing a metrics-based organizational framework, see our previous OPEN MINDS Management Newsletter, Best Practices In Data Collection, Analysis & Data-Driven Executive Decision Making.) We bring you expert advice and tips on the how-tos of executive decisionmaking in Decisions! Decisions! Five Big Decisions Every Executive Team Needs To Make For The Next Normal and Watch Out For The Six Decisionmaking Traps. We take a look at how provider organizations are operationalizing data-driven decisionmaking in How to Use Your EHR To Become A Data-Informed Organization. And we move from the theory of decisionmaking to practice in six great case studies:

We hope these best practices and field experiences in this issue will guide your executive team through the tough decisions that lie ahead as the health care market continues to see seismic shifts. Read the articles online (see From Data To Action: The Keys To Executive Decisionmaking) or download a PDF of the entire issue here.

Page | April 30, 2020

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