Stefany Goradia’s Post

Launch of Behavioral Health and Intellectual/Developmental Disabilities Tailored Plans At a legislative committee hearing earlier this month, NC Medicaid officially announced that all Tailored Plans are ready to go live on July 1. Tailored Plans are a new kind of NC Medicaid Managed Care health plan for approximately 210,000 beneficiaries with a serious mental illness, a serious emotional disturbance, a severe substance use disorder, an intellectual/developmental disability or a traumatic brain injury in North Carolina. They will cover doctor visits, prescription drugs and services for mental health, substance use, I/DD and traumatic brain injury in one plan. Eligible North Carolinians who are covered by NC Medicaid Direct will be covered by a Tailored Plan beginning July 1. The name of their Medicaid plan will change but the services covered remain the same. A bilingual toolkit with accessible resources is now available for people impacted by the transition to Tailored Plans. The NC Medicaid Enrollment Broker will mail a letter this week to anyone moving to a Tailored Plan. Tailored Plan beneficiaries will need to choose a primary care provider between now and May 15, 2024. If you don’t choose a PCP by May 15, the Tailored Plan will assign one to you. People can change their PCP through Jan. 31, 2025. Tailored Plans will be managed by the Local Management Entities (LMEs) Alliance Health, Partners Health Management, Trillium Health Resources and Vaya Health. For more information about Tailored Plans, visit: https://buff.ly/4atFYGg. To access the toolkit, visit: https://buff.ly/3VYJHHz.

Key Takeaways (notes) from the Dept of HHS, zoom call, and webinar from CMS administrator and  team this morning. "Affordability is the Guiding Light " ; "North Star is the Consumer"; " Every American must have health care coverage" - CMS Administrator and team Reforms: * Extra help - Drug Law 1/1/24 - * High drug cost – relief – inflation reduction (www.cms.gov) * People with Medicare whole persons - access to behavioral health: Marriage and family therapy and addiction counseling. * New payments for community health integration and payments for psychotherapy - outpatient therapy * Medicare Advantage - remains strong and Thriving; no steering allowed 2024 will maintain the momentum, lower drug cost, transform care, and improve Medicare Advantage. Trust the MEdicare program solvency Increasing coverage - including improving transitions in coverage (Seamless experience) Increasing value; Drive Quality Outcomes;Finalizing consumer protection rules CMS remains committed to Improving access and quality of care to CHIP enrollees. Addressing challenges to the 4 Walls policy (Indian Health Services ) Developed LTC proposal for staffing rule Digital transformation Expanding access to mental health services includes rural health communities. Transparency TCET (Transitional Coverage for Emerging Technologies) From Innovation Center: continue working on health equity, new models include, primary, guide model (dementia), AHEAD (all-payer health equity approaches and development) , transforming maternal health outcomes (supports whole person approach to pregnancy, childbirth and care) Goal - Improve safety, and whole person and increase access to care IBH -integrated services state-based model on integrated whole person care mental health and or substance abuse care CMS cancelled over 2500 unauthorized enrollments and remains committed in 2024 Striving to work against bad actors and fraudulent COVID testing billing Ensure hospice provides quality care, and decrease bad actors AI – focus on integrity and ensure ethical application of this technology OMH (Office of minority health) – sustain the momentum built- Note: May 29 and 30th,  2024 -  Health Equity Recognize and support data, research and analysis to decrease disparities. Health Equity Assistance program continues to provide support with additional tools and resources in 2024 Final rule for prior authorizations will help patients access care in a timely manner (72 hours ; 7 days ) Payors will need to report certain prior auth metrics. Patients will be empowered with access to more of their data. #nationalstakeholdercallwithcmsadministrator#cms#medicare#medicaid#Medicarestrong https://lnkd.in/gY5XFrVj

How do you deliver better care to patients whose lives are so complicated by poverty and other social problems that routine conditions like diabetes and asthma regularly turn into $10,000 hospital visits? That’s the question the Camden Coalition — a small group of New Jersey doctors, nurses and other providers — set out to answer in 2002. They pioneered an approach that sought to address people’s medical needs and their social ones, too. Since then, the sort of patients the Coalition focuses on have attracted attention and growing investment from policymakers, hospitals and health insurers across the country. This week, we catch up with the Coalition and other experts who share what they’ve learned in two decades about one of health care’s toughest, costliest problems. A few of those lessons include: 🔵 To succeed, this combined approach to addressing medical and social needs takes more time and tailoring than originally expected. A 90-day intervention isn’t enough. “We now work with someone for as long as they need,” says Kathleen Noonan, CEO of the Camden Coalition. And they’ve learned to tailor their mix of services for each patient. 🔵 Many more health care organizations now recognize unmet social needs as a health care problem. All told, state Medicaid agencies, private Medicare plans and even health care giants like CVS are investing billions in new social programs for high-need patients, from affordable housing to meal delivery. 🔵 As the number of providers attempting to address patients’ social needs grows, so does the need for better coordination. Noonan estimates the Camden Coalition, for example, now spends just 25% of its time directly delivering services to clients — and the rest improving collaboration and reducing redundancy among other local service providers. 🔵 Cost savings are much harder to realize than people hoped. Though these programs do improve some patients’ access to care, researchers have yet to identify a particular approach that reliably reduces costly hospital visits. More studies are needed, they say. “These problems are too important to not keep working on, but they're also too important to just declare victory without evidence,” economist Amy Finkelstein, Professor of Economics at Massachusetts Institute of Technology, told us. To dive deeper into these lessons and some of the research studies informing them, check out the resources section at the bottom of the story: https://lnkd.in/dNXK5RuH

Last night I had the opportunity to participate in an event thanks to an invitation from my friend Kevin Taffe . The discussion focused on health equity, and called up for me the abysmal maternal mortality rate in Georgia. From ChatGPT: Georgia has one of the highest maternal mortality rates in the United States, ranking near the bottom compared to other states. In 2024, Georgia's maternal mortality rate was reported at 33.9 deaths per 100,000 live births, which is significantly higher than the national average [[❞]](https://lnkd.in/eF-cdmiy) [[❞]](https://lnkd.in/eRXTDRCR). This places Georgia among the states with the worst maternal health outcomes in the U.S., only surpassed by states like Louisiana and Indiana [[❞]](https://lnkd.in/epPv6aZH). Globally, Georgia's maternal mortality rate is notably higher than many developed countries. For example, in high-income countries, the maternal mortality rate is significantly lower. In countries such as the United Kingdom and Canada, rates are around 7 and 11 deaths per 100,000 live births, respectively [[❞]](https://lnkd.in/eRXTDRCR). This stark contrast highlights the severe maternal health challenges facing Georgia, despite being in a high-income country. Efforts to improve maternal health outcomes in Georgia include discussions around Medicaid expansion and improving healthcare access, especially for low-income and minority women who are disproportionately affected by these high mortality rates [[❞]](https://lnkd.in/ePe-Sp7D) [[❞]](https://lnkd.in/eg5KZQAg

Today, the Centers for Medicare and Medicaid Services (CMS) announced the release of the NOFO application for the Innovation in Behavioral Health (IBH) Model. The IBH Model is focused on improving the behavioral and physical health outcomes and quality of care for people with Medicaid and Medicare who experience moderate to severe behavioral health conditions. The model seeks to bridge the gap between behavioral and physical health by enabling specialty behavioral health practices to integrate behavioral health with physical health care and health-related social needs. The IBH Model is a state-based model, led by state Medicaid agencies (SMAs), with a goal of aligning payment between Medicaid and Medicare for integrated care. CMS will select up to eight SMAs to participate in the IBH Model, and these SMAs will use cooperative agreement funding to develop necessary infrastructure and capacity to implement the IBH Model. SMAs will recruit “Practice Participants” to deliver care, and they will receive funding to support necessary upgrades to health information technology, electronic health records, practice transformation activities, and staffing to implement the model. Award notices will be issued to selected SMAs in mid-December. https://lnkd.in/eMdXpUmp

"North Carolina’s regional managed care organizations that will administer specialized #Medicaid plans for people with complex needs say they’re ready for the plans — which have had multiple delays — to finally go live on July 1. "CEOs for the four organizations, known as LME-MCOs, appeared Tuesday before the state legislature’s Joint Legislative Oversight Committee on Medicaid. They assured lawmakers that the so-called “tailored plans,” which are expected to cover about 150,000 Medicaid participants, will launch on that schedule. "The tailored plans will serve people with intellectual or developmental disabilities, traumatic brain injuries, complex psychiatric disorders and substance use disorders — all conditions that require more extensive care and support than that for typical enrollees. The N.C. Department of Health and Human Services originally hoped to implement the plans in December 2022, but the rollout was pushed back multiple times to give the LME-MCOs more time to prepare and nail down contracts with providers. “We all feel highly confident and highly prepared about going forward,” Rhett Melton, CEO of Partners Health Management, told the committee. He added that his organization has “passed the readiness reviews” and the “re-reviews of the re-reviews of the re-reviews.” "Partners will be working with Alliance Health to administer tailored plans across a 22-county swath of central North Carolina. Vaya Health will manage 32 counties, most of them in the western part of the state. Trillium Health Resources will handle 46 counties in the east." https://lnkd.in/eUW5pj2y

Brightside Health, a company offering virtual therapy and medication management, just landed $33 million to serve more people! 🎉 They're expanding into Medicare and Medicaid, which means millions with limited access can now get the help they need. This is a huge deal considering Medicaid is the biggest payer for mental health services in the US. What about tech-powered approach, Brightside uses #AI to match patients with the right care and medications. They claim a 70% response rate in the first treatment cycle, which is apparently double the industry standard. That's impressive! #MentalHealth #Telehealth #DigitalHealthcare #HealthTech

With demand outpacing supply, an estimated 75,000 additional beds are needed across the U.S. to support patient care in the behavioral health space. During their Q3 2024 earnings calls, UHS and Acadia Healthcare shared insights on their strategies to meet this rising need nationwide. In VMG Health's latest article, co-authored by myself and Brett Nelson, we dive into each company’s capacity expansions, strategic growth in key services, and the potential impact of Medicaid supplemental payments discussed in their calls. Check out this quick read on growth strategies and industry impacts: https://lnkd.in/ejQUz5aF #BehavioralHealth #MentalHealthCare #Medicaid #UHS #AcadiaHealthcare #HealthCareStrategy #VMG #VMGHealth

Fierce Healthcare today released an exclusive HHS report: "Medicaid insurers can do more to improve maternal health access, HHS report says." "States are missing opportunities to require Medicaid managed care organizations (MCOs) to improve maternal health access, a new [Fierce Healthcare exclusive] report from the Department of Health and Human Services Office of Inspector General (HHS OIG) shows." I'm digging into this now as I finalize the content for my Ushur and Medicaid Health Plans of America (MHPA) webinar on October 9th - "Transform Care Navigation for Maternal Health Journeys and Chronic Conditions Management". Register to join the webinar here: https://hubs.la/Q02QDrn30 #medicaid #mco #medicaidengagement #medicaidmemberengagement #chronicconditions #comorbiditites #pregnancy

Value-Based Health Care (VBHC) aims to transform healthcare systems by focusing on patient outcomes and quality of care rather than the volume of services provided. This approach encourages healthcare providers to deliver the most efficient care, potentially leading to improved patient health outcomes and more sustainable healthcare systems. Abstract: Despite growing global support for value-based health care (VBHC), there is no consensus on the best approach for the identification of improvement potential nor on the selection and implementation of improvement initiatives. #unitedseniorassociation #USA #eldercare #FDA #seniorliving #ADA #AI #NIH #patientcare #compliance #hospitals #OIG #healthcare #HHSOIG #digitalhealth #HSS #CMS #assistedliving #nursinghomes #seniorcare #medicare #seniorcitizen #homehealthcare #caregiver #dementia #inhomecare #seniorhealth #kloekorby #alzheimers #mentalhealth