Category: Resource

Transforming Healthcare Negotiation: The ‘Getting to Yes’ Approach

Introduction

In the intricate dance of healthcare negotiations, achieving a win-win outcome can seem like a daunting task. Whether it’s negotiating agreements between health plans and providers, determining reimbursement rates, or collaborating on value-based care initiatives, the principles of effective negotiation remain crucial. One seminal work that sheds light on this process is “Getting to Yes: Negotiating Agreement Without Giving In” by Roger Fisher, William Ury, and Bruce Patton. This book offers timeless strategies that can transform the negotiation landscape, particularly in the healthcare business context.

Negotiation is a Fact of Life

Negotiation is ubiquitous in healthcare. Providers and payers constantly negotiate to align their interests, share risks, and enhance patient care. However, the stakes are high, and the outcomes directly impact patient access to care, provider satisfaction, and financial sustainability.

The Problem: Don’t Bargain Over Positions

Fisher, Ury, and Patton argue against bargaining over positions, which often leads to unwise agreements and strained relationships. In healthcare, this can translate into protracted disputes over contract terms, pricing, and service levels. For instance, a health plan insisting on deep discounts while a provider demands high reimbursement rates can lead to a stalemate, ultimately affecting patient care delivery.

Principled Negotiation: A Better Way

The authors propose principled negotiation, a method that focuses on merits rather than positions. This approach is particularly relevant in healthcare negotiations, where the goal is to achieve sustainable agreements that benefit all parties involved, including patients. The four key principles are:

  1. Separate the People from the Problem
  2. Focus on Interests, Not Positions
  3. Invent Options for Mutual Gain
  4. Insist on Using Objective Criteria

Separate the People from the Problem

In healthcare negotiations, emotions can run high, especially when discussing sensitive issues like reimbursement rates or care quality standards. By separating the people from the problem, negotiators can address the substantive issues without damaging professional relationships. This approach helps maintain a collaborative atmosphere, which is crucial for ongoing partnerships between health plans and providers.

Focus on Interests, Not Positions

Positions are what parties say they want; interests are why they want them. In healthcare, a provider’s position might be high reimbursement rates, but their underlying interest could be financial stability to invest in quality care. By understanding and addressing these interests, negotiators can find solutions that meet the needs of both parties. For example, a health plan might agree to higher rates if the provider implements cost-saving measures or quality improvements.

Invent Options for Mutual Gain

Healthcare negotiations often present multiple potential solutions. By brainstorming various options, negotiators can find innovative ways to meet mutual interests. For example, a health plan and provider might collaborate on a shared savings program, where both benefit from cost reductions achieved through improved care coordination.

Insist on Using Objective Criteria

Relying on objective criteria helps ensure fair and transparent negotiations. In healthcare, this could involve using benchmarks like Medicare rates, industry standards, or independent cost analyses to guide discussions. Objective criteria reduce bias and build trust, making it easier to reach a mutually acceptable agreement.

Practical Application in Healthcare

Applying these principles can lead to more effective healthcare negotiations. Here are some practical tips:

  • Build Relationships: Establishing trust and rapport with counterparts before negotiations begin can create a more positive negotiating environment.
  • Understand Interests: Invest time in understanding the underlying interests of both parties, which can lead to more creative and acceptable solutions.
  • Explore Multiple Options: Don’t settle for the first solution that comes to mind. Explore various possibilities that can address the interests of both parties.
  • Use Data and Standards: Leverage data and industry standards to support your positions and make your case more compelling.

Conclusion

Effective negotiation is essential for navigating the complexities of the healthcare business. By embracing the principles outlined in “Getting to Yes,” health plans and providers can achieve agreements that are not only efficient and fair but also conducive to long-term collaboration and improved patient outcomes. In an industry where the stakes are high, mastering the art of negotiation can make all the difference.

Unlock Financial Success with CalAIM: Budget Estimator Tool for CBOs

The CalAIM Budget Estimator Tool helps CBOs navigate the financial complexities of contracting under CalAIM. It offers an Excel-based template with built-in assumptions, cost input fields, revenue customization, and a summary tab. The tool supports informed decision-making, negotiation power, and sustainability, empowering organizations to enhance care and expand services.

Introduction

Navigating the financial complexities of contracting under the California Advancing and Innovating Medi-Cal (CalAIM) initiative can be challenging for community-based organizations (CBOs). With new Medi-Cal benefits such as Enhanced Care Management and Community Supports, understanding potential revenue and expenses is crucial. This is where the CalAIM Budget Estimator Tool comes in, offering a robust template to help CBOs project financial viability and ensure their mission’s sustainability.

Understanding the CalAIM Budget Estimator Tool

CalAIM Budget Estimator Tool: The CalAIM Budget Estimator Tool is an Excel-based template designed to help organizations estimate costs and potential revenue from providing Medi-Cal Enhanced Care Management and selected Community Support Services. These services include housing-related services and medically tailored meals.

Key Features

  • Built-in Assumptions: The tool incorporates assumptions about payment structures for these services, as outlined in the California Department of Health Care Services CALAIM Enhanced Care Management Policy Guide and Community Supports Policy Guide.
  • Cost Input: Users can enter organization-specific expenses such as staffing costs and other direct and indirect costs.
  • Revenue Customization: It includes generic rate ranges and areas for customizing expected revenue sources to calculate the program margin (ratio of revenue to expenses).
  • Summary Tab: A summary tab displays the projected margin by program year, helping users understand if their assumptions lead to a fiscally viable program.

The Importance of Financial Viability for CBOs

For CBOs, financial viability is paramount. The adage “No margin, no mission” rings true as these organizations aim to enhance services for individuals with complex health and social needs. The CalAIM Budget Estimator Tool enables organizations to model various scenarios for their programs, supporting meaningful feasibility discussions with financial officers and other decision-makers.

How the CalAIM Budget Estimator Tool Supports CBOs

The CalAIM Budget Estimator Tool is designed to facilitate informed discussions about future programming and the financial feasibility of providing new Medi-Cal services. Here’s how it supports CBOs:

  • Modeling Various Scenarios: The tool allows organizations to create multiple financial scenarios, enabling a comprehensive understanding of different potential outcomes.
  • Justifying Rate Requests: By organizing and highlighting critical financial information, the tool helps CBOs justify rate requests to MCOs during contract negotiations.
  • Enhancing Financial Confidence: With detailed projections, CBOs can confidently navigate the financial aspects of contracting with MCOs.

Step-by-Step Guide to Using the CalAIM Budget Estimator Tool

Step 1: Download the Tool

Step 2: Enter Costs

  • Input your organization-specific expenses, including staffing costs and other direct and indirect costs.

Step 3: Customize Revenue Sources

  • Use the tool to enter expected revenue sources. Customize the rates to reflect realistic projections for your organization.

Step 4: Review Summary Tab

  • Examine the summary tab to view the projected margin by program year. This will help you understand the financial viability of your program.

Benefits of Using the CalAIM Budget Estimator Tool

Informed Decision-Making: The tool provides comprehensive data to support strategic financial decisions. Enhanced Negotiation Power: With detailed financial projections, CBOs can negotiate better rates with MCOs. Sustainability: Ensuring financial viability helps CBOs sustain their mission and expand services under CalAIM.

Frequently Asked Questions

What is the CalAIM Budget Estimator Tool? The CalAIM Budget Estimator Tool is an Excel-based template designed to help organizations estimate costs and potential revenue from providing Medi-Cal Enhanced Care Management and selected Community Support Services.

How does the tool support CBOs in contracting with MCOs? The tool enables CBOs to model various financial scenarios, justify rate requests during negotiations, and make informed decisions about program viability.

What are the key features of the CalAIM Budget Estimator Tool? Key features include built-in assumptions, cost input fields, revenue customization, and a summary tab displaying projected margins.

Can the tool be customized for specific organizational needs? Yes, users can customize expense inputs and revenue projections to reflect their specific organizational needs.

How do I get started with the CalAIM Budget Estimator Tool? Download the tool, enter your organization-specific costs, customize revenue sources, and review the summary tab to understand financial projections.

Why is financial viability important for CBOs? Financial viability ensures that CBOs can sustain their mission and expand services, ultimately enhancing care for individuals with complex health and social needs.

Conclusion

The CalAIM Budget Estimator Tool is an invaluable resource for CBOs looking to contract with managed care organizations under CalAIM. By providing detailed financial projections, the tool empowers organizations to make informed decisions, justify rate requests, and ensure the sustainability of their mission. Download the tool today and take the first step towards financial success and enhanced service offerings.

Child and Family Health Policy Insights: CCF Blog Analysis

The Center for Children and Families (CCF) at Georgetown University’s McCourt School of Public Policy offers extensive insights into health policy issues affecting children and families. The CCF blog, “Say Ahhh!,” covers topics such as Medicaid, CHIP, health equity, maternal and early childhood health, and more.

One recent article discusses the positive momentum in Medicaid coverage for doula services. This coverage aims to address maternal and infant health crises by providing support during pregnancy, labor, and postpartum periods, particularly for low-income families. The article notes that as of now, 43 states and D.C. have taken steps to include doula care in Medicaid coverage​ (Center For Children and Families)​.

Another post highlights the new rule allowing Deferred Action for Childhood Arrivals (DACA) grantees to access Marketplace coverage starting in November 2024. This change will enable DACA recipients to purchase qualified health plans with financial assistance, which is expected to cover an additional 100,000 uninsured individuals. However, the rule does not extend to Medicaid and CHIP, which remains a significant gap in coverage​ (Center For Children and Families)​.

The Center for Children and Families (CCF) at Georgetown University’s McCourt School of Public Policy is a rich resource for information on health policy issues impacting children and families, especially those with low and moderate incomes. Their blog, “Say Ahhh!,” features a range of topics, from Medicaid and CHIP to maternal and early childhood health.

Key Topics and Articles:

  1. Medicaid and Doula Services:
    • Doula services are gaining momentum as states incorporate these services into Medicaid to improve maternal and infant health outcomes. Doulas provide non-clinical support during the perinatal period, which can reduce adverse birth outcomes and improve perinatal mental health. States like Washington have increased reimbursement rates for doulas to $3,500 per birth, the highest in the country, highlighting the importance of sufficient reimbursement to encourage more doulas to become Medicaid providers​ (Center For Children and Families)​.
  2. Marketplace Coverage for DACA Grantees:
    • A recent rule allows DACA grantees to access Marketplace coverage starting in November 2024. This rule enables them to purchase qualified health plans with financial help, potentially covering an additional 100,000 uninsured individuals. However, this rule does not extend to Medicaid and CHIP, maintaining a gap in coverage for DACA recipients​ (Center For Children and Families)​.
  3. State Medicaid Enrollment and Coverage:
    • Articles discuss the impact of the unwinding of continuous Medicaid coverage, with significant declines in child Medicaid enrollment. This situation underscores the need for states to take action to prevent children from losing coverage​ (Center For Children and Families)​.
  4. Behavioral Health Integration:
    • CMS has introduced new state opportunities to address behavioral, physical, and health-related social needs through the “Innovation in Behavioral Health” model. This initiative aims to integrate care for individuals covered by Medicaid and Medicare, addressing comprehensive health needs​ (Center For Children and Families)​.
  5. Child and Family Health Policy:

Additional Key Topics and Articles:

  1. Medicaid and CHIP Eligibility and Enrollment:
    • The blog discusses the variability in state performance regarding Medicaid and CHIP eligibility and enrollment, particularly during the unwinding of continuous enrollment protections put in place during the pandemic. This includes detailed analyses of state policies and their impacts on children and families​ (Center For Children and Families)​​ (Center For Children and Families)​.
  2. Behavioral Health Initiatives:
    • The CMS has introduced new opportunities for states to advance behavioral health care integration. This initiative aims to test new approaches for addressing behavioral, physical, and health-related social needs of individuals covered by Medicaid and Medicare. These models seek to improve overall health outcomes by integrating various aspects of care​ (Center For Children and Families)​.
  3. Impact of Policy Changes on Health Coverage:
    • Articles often examine how changes in federal and state policies affect health coverage for children and families. For example, discussions on the implications of the federal poverty level adjustments and how these changes impact eligibility for various health programs​ (Center For Children and Families)​.
  4. Innovations in Maternal and Child Health:
    • The blog covers innovations and state-level initiatives to improve maternal and early childhood health. This includes state efforts to expand Medicaid coverage for doula services and the outcomes associated with these initiatives, such as reduced adverse birth outcomes and improved maternal mental health​ (Center For Children and Families)​.
  5. Health Equity and Access:
    • CCF emphasizes the importance of health equity, particularly in how policies and programs are designed to ensure all children and families have access to affordable and high-quality health care. This includes addressing disparities in health outcomes among different racial and socioeconomic groups​ (Center For Children and Families)​.
  6. State-Specific Health Policy Developments:
    • The blog provides updates on state-specific health policy developments, such as new legislation, budget allocations, and innovative programs aimed at improving health coverage and care for children and families. For instance, discussions on how states like Washington are increasing doula reimbursement rates to promote better maternal health​ (Center For Children and Families)​.

Subscribe for Updates:

To stay updated with the latest posts and insights from the Center for Children and Families, you can subscribe to their updates here​ (Center For Children and Families)​.

These topics highlight the comprehensive efforts and detailed research conducted by CCF to improve health policies and outcomes for children and families in the U.S. For more in-depth articles and the latest updates, visiting the CCF blog directly is recommended.

Addressing Critical Health Needs: Partnership HealthPlan of California Strategic Response to the 2024 Population Needs Assessment

Business Brief: Addressing Critical Needs in Population Health

Partnership’s membership remained relatively stable in 2023. The member redetermination process, resulting from the winding down of the COVID-19 Public Health emergency, caused some small fluctuations. At the close of 2023, Partnership served approximately 660,800 members throughout 14 counties.

In 2024, Partnership will no longer contract with Kaiser Permanente, will fully operationalize its 10-county expansion, and the Medi-Cal redetermination process will continue.

Partnership’s membership is expected to continue to fluctuate as a result. The 2024 Population Needs Assessment draws from a broad range of data sources to identify member needs along with the overall community conditions where members live.

Executive Summary

The 2024 Population Needs Assessment (PNA) conducted by the Partnership HealthPlan of California highlights significant gaps in healthcare access, economic stability, neighborhood conditions, and social support across its 14-county service area. This brief outlines the critical needs identified and the strategic responses planned to address these issues, ensuring improved health outcomes and equity for all members.

Identified Needs and Strategic Responses

1. Healthcare Access and Quality

Identified Needs:

  • Provider Shortages: Insufficient access to primary care, dental, specialty care, mental/behavioral health, and substance use care providers.
  • Transportation Challenges: Particularly in rural areas, long distances and lack of transportation options hinder access to care.

Strategic Responses:

  • Provider Recruitment and Retention Initiatives:
    • Launching a Provider Recruitment Program to attract healthcare professionals to underserved areas with new incentives, including sign-on bonuses.
    • Implementing a Provider Retention Initiative (PRI) Pilot to incentivize primary care clinicians for long-term service, preserving institutional knowledge and clinical leadership.
    • Telehealth Expansion: Increasing the use of telemedicine to enhance access to behavioral health services, particularly in remote regions.
2. Economic Stability

Identified Needs:

  • High Poverty and Unemployment Rates: Prevalent in rural and frontier regions.
  • Severe Housing Problems: Overcrowding, high housing costs, and inadequate facilities affect many households.

Strategic Responses:

  • Leveraging State Funds:
    • Utilizing initiatives like CalAIM, Community Supports, and the Homeless and Housing Incentive Program (HHIP) to address housing instability.
    • Offering scholarships to local Community Health Worker (CHW) programs to create employment opportunities and enhance the healthcare workforce.
3. Neighborhood and Built Environment

Identified Needs:

  • Limited Access to Healthy Foods: Particularly in rural areas, contributing to poor nutrition and related health issues.
  • High Rates of Physical Inactivity: Linked to chronic health conditions in several counties.

Strategic Responses:

  • Food and Nutrition Programs:
    • Partnering with local agencies to improve access to healthy foods and provide nutrition education.
    • Conducting outreach to promote healthy eating habits and reduce food insecurity.
  • Physical Activity Promotion: Implementing community-based programs to encourage physical activity and healthy lifestyles.
4. Social and Community Support

Identified Needs:

  • High Rates of Adverse Childhood Experiences (ACEs): Leading to long-term negative health outcomes.
  • Substance Use and Smoking: High prevalence of tobacco use and substance abuse, including among adolescents.

Strategic Responses:

  • ACE Prevention and Support Programs: Developing initiatives in collaboration with schools and community organizations to address ACEs and provide support.
  • Substance Use Prevention Campaigns:
    • Conducting educational interventions to reduce tobacco use and prevent substance abuse among adolescents and adults.
    • Promoting smoke-free environments through community outreach and education.

Conclusion

The Partnership HealthPlan of California is committed to addressing the critical needs identified in the 2024 PNA through comprehensive and targeted initiatives. By enhancing healthcare access, addressing social determinants of health, improving neighborhood conditions, and strengthening community support, the organization aims to foster equitable health outcomes and ensure a higher quality of life for all its members.

PopulationNeedsAssessment2024-1Download

Population Needs Assessment

Partnership conducts an annual Population Needs Assessment (PNA), which reviews and analyzes the overall environment, specific community needs, and factors influencing the health and well-being of Partnership’s member population.

To read the 2024 report, click on the following: Population Needs Assessment

Population Needs Assessment

Partnership conducts an annual Population Needs Assessment (PNA), which reviews and analyzes the overall environment, specific community needs, and factors influencing the health and well-being of Partnership’s member population.

To read the 2024 report, click on the following: Population Needs Assessment

Archived Population Needs Assessments

​Community Health Assessments and Community Health Improvement Plan

Partnership participates in the Community Health Assessments (CHA) (sometimes called a CHNA) and Community Health Improvement Plan (CHIP) processes conducted by the local health jurisdiction in each of our 24 counties. This collaboration enhances Partnership’s ability to identify needs and assets within our members’ communities, and strengthens our relationships with community partners.

Below you will find CHAs and CHIPs for each Partnership county in addition to how Partnership participated with the county.

Butte County

Partnership staff participated in a review of the key findings and top 6 health needs identified in the CHA. Butte County released their CHA in December 2023. Click here to view the report.

Modoc County

Partnership staff participated in a review of county concerns, and discussed a tentative goal with the county. Modoc County released their CHNA in January 2024. Click here to view the report.

Napa County

Partnership staff participated in a review of county concerns, and discussed a tentative goal with the county. Napa County released their CHA in December 2023. Click here to view the report.

Shasta County

Partnership staff participated in a review of the key findings and priority areas identified in the CHIP process. Partnership and Shasta County co-developed a SMART goal focusing on increasing child well visits, aligned with DCHS’s Bold Goals 50×2025 initiative. Shasta County released their CHIP in June 2024. Click here to view the report.

Sonoma County

Partnership staff participated in a review of the county’s approach to their assessment and improvement plan, discussed the county’s 4 priority areas, and gathered ideas for a tentative shared goal with the county. Sonoma County released their combined CHA/CHIP report in December 2023. Click here to view the report.

Yuba County

Partnership staff participated in a review of CHIP health priority areas, and a discussion around how Partnership can help the county going forward. Yuba County released their CHIP in December 2023. Click here to view the report.

Introducing the Care MAP Tool: A Comprehensive Guide

Introducing the Care MAP Tool, designed to support healthcare providers in managing complex care needs. This user-friendly, Excel-based tool offers a structured framework for effective care coordination, resource allocation, and patient management. With modules for an overview and practical scenarios, plus a comprehensive resource library and FAQ section, the Care MAP Tool enhances care strategies and improves patient outcomes. Download it today and elevate your care management practices.

Effective care management is crucial in today’s complex healthcare landscape. To support healthcare professionals and organizations, we are excited to introduce the Care MAP Tool, a valuable resource designed to aid in complex care management. This blog will provide an overview of the Care MAP Tool, walk you through an example scenario, and offer access to a resource library and frequently asked questions (FAQ) section.

Module 1: Care MAP Overview

The Care MAP (Management and Planning) Tool is designed to support healthcare providers in managing and planning care for patients with complex health needs. This tool provides a structured framework to help clinics navigate the intricacies of care coordination, resource allocation, and patient management. Here’s what you can expect from the Care MAP Tool:

  • Framework for Complex Care Management: The tool offers a comprehensive structure to address the multifaceted needs of patients requiring intensive care management.
  • User-Friendly Interface: The Excel-based tool is intuitive and easy to navigate, ensuring that healthcare providers can quickly integrate it into their workflows.
  • Scalable and Adaptable: Whether you’re a small clinic or a large healthcare organization, the Care MAP Tool can be scaled and adapted to fit your unique needs.

Module 2: Example Scenario

To illustrate the practical application of the Care MAP Tool, let’s walk through an example scenario:

Scenario: Managing a Patient with Multiple Chronic Conditions

  1. Patient Overview:
    • Name: Jane Doe
    • Age: 65
    • Conditions: Diabetes, Hypertension, Chronic Obstructive Pulmonary Disease (COPD)
  2. Initial Assessment:
    • Medical History Review: Gather comprehensive information about Jane’s medical history, including past treatments, hospitalizations, and medications.
    • Social Determinants of Health: Assess factors such as living conditions, access to transportation, and social support.
  3. Care Coordination:
    • Interdisciplinary Team: Form a care team that includes primary care physicians, specialists, nurses, social workers, and community health workers.
    • Care Plan Development: Create a personalized care plan that addresses Jane’s medical and social needs, with clear goals and timelines.
  4. Monitoring and Evaluation:
    • Regular Check-ins: Schedule regular appointments and follow-ups to monitor Jane’s progress.
    • Adjustments: Modify the care plan as needed based on Jane’s response to treatment and changes in her condition.

Resource Library

The Resource Library is a curated collection of materials to further support your use of the Care MAP Tool. Here, you’ll find:

  • Guides and Manuals: Detailed instructions on how to use the Care MAP Tool effectively.
  • Case Studies: Real-world examples of the tool in action, showcasing its impact on patient outcomes.
  • Training Videos: Step-by-step video tutorials to help you and your team get up to speed quickly.

FAQ

To ensure you have all the information you need, we’ve compiled a list of frequently asked questions:

Q1: Who can use the Care MAP Tool?
A1: The tool is designed for healthcare providers, including clinicians, care coordinators, and administrative staff.

Q2: Is there a cost associated with the Care MAP Tool?
A2: No, the Care MAP Tool is available for free download.

Q3: How do I get support if I encounter issues with the tool?
A3: Support is available through our online helpdesk. You can also refer to the Resource Library for troubleshooting guides.

Care MAP Tool Download

By using the Care MAP Tool, you acknowledge that you have read and agree to the disclaimer below. If you share the tool, ensure that all individuals given access to it have reviewed and agreed to the disclaimer language before using it for any purpose.

Disclaimer: The Care MAP Tool is intended as a general framework to support considerations around complex care management in a clinic setting. It is not meant for final staffing, clinical, administrative, operational, and/or financial decision-making. Information obtained from this tool is not and should not be taken as legal or financial advice and is not a substitute for consulting a qualified professional. Community Initiatives does not accept responsibility for any loss that may arise from reliance on this tool.

Source Link:

Download Materials:

Care-MAP-Tool-Example-Scenario-3Download
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Feel free to reach out with any questions or feedback about the Care MAP Tool. Happy planning!

35 States with Any Willing Provider laws

As a provider, if your request to join a payer network in the following markets has been denied, you might have some recourse for appeals.

As a provider, if your request to join a payer network in the following markets has been denied, you might have some recourse for appeals.

Any Willing Provider and Freedom of Choice laws restrict the ability of managed care
entities, including pharmacy benefit managers, to selectively contract with providers. The
managed care entities argue this limits their ability to generate cost savings, while proponents of
the laws suggest that such selective contracts limit competition, leading to an increase in
aggregate costs.

These laws generally require health insurance companies to allow any qualified healthcare provider who is willing to meet the terms and conditions of the insurer’s contract to participate in their networks.

States listed below have some form of Any Willing Provider laws:

Alabama:

Section 27-1-19: The agreement providing coverage to an insured may not exclude assignment of benefits to any provider at the same benefit paid to a contract provider.

Section 27-45-3: Plan Beneficiaries may choose the licensed pharmacist or pharmacy of their choice. Health insurance policies and employee benefit plans may not deny licensed pharmacies or pharmacists the right to participate.

Arkansas:

Sections 23-201, 23-202, 23-203, 23-204, 23-205, 23-206, 23-207, 23-208, 23-209 : Benefit differentials are prohibited. Insurers must give qualified health care providers the opportunity to participate if providers are willing to accept the plan’s terms and conditions.

Colorado:

Section 10-16-122: Any PBM/intermediary whose contract with a carrier includes an open network must allow all area pharmacy providers to participate if they agree to the terms and conditions of the contract. PBms/Intermediaries may contract with exclusive pharmacy networks if a 60-day notice is given before the termination or the effective date of such contract by publication in a newspaper of general circulation.

Connecticut:

Section 38a-471: A prescription program administrator shall allow a pharmacy to enroll in a program absent cause for excluding it.

Delaware:

Sections 18-7301, 18-7302, 18-7303: Beneficiaries may choose any pharmacy that has agreed to participate according to the terms.  Benefit differentials are prohibited.

Florida:

Section 110.12315: The state employees’ prescription drug program requires the Department of Management services to allow prescriptions to be filled by any licensed pharmacy pursuant to contractual claims processing provisions.

Section 440.13(3) (j): The worker’s compensation statute allows for a sick or injured employee to have free, full and absolute choice in the selection of the pharmacy.

Georgia:

Section 26-2-144(a)(9): That at least 30 days prior to the date a program becomes effective, the program contract therefor shall be offered to all pharmacies located within those counties wherein reside enrollees in that program, which pharmacies shall have at least 30 days from the time they receive the offer to accept that offer and become participating pharmacies.

Section 33-30-25: Insurers may impose “reasonable limits” on the number/classes of preferred providers that meet the insurers’ standards. Insurers must give all licensed and qualified providers within a defined service are the opportunity to become a preferred provider.

Section 33-30-4.3: Beneficiaries who do not use mail-order shall not be penalized if the provider used by the insured has agreed to the same terms and conditions applicable to mail-order and has agreed to accept payment or reimbursement at no more than the same amount that would be paid for the same mail-order services.

Hawai’i:

Section 451 R-1: It shall be a violation of this section for a prescription drug benefit plan, health benefits plan under chapter 87A, or pharmacy benefit manager to refuse to accept an otherwise qualified retail community pharmacy as part of a pharmacy benefit manager’s retail pharmacy network.

Idaho:

Sections 41-2872 & 41-3927: Any insurance company or health maintenance organization issuing benefits must be willing to contract with qualified providers who meet the terms of the organization. Organizations issuing benefits must be willing to contract with qualified providers who meet the terms of the organization

Illinois:

Section 215-5/370h: Insurers/administrators must be willing to enter into agreements with any non- institutional providers who meet the established terms and conditions. The terms and conditions may not discriminate unreasonably against or among non-institutional providers.

Section 215-134/72(a) : A plan may not refuse to contract with a pharmacy provider that meets the terms and conditions established by the plan.

Indiana:

Section 27-8-11-3 : Pharmacists who agree to comply with established terms and conditions

are entitled to enter into contracts with insurers. Terms and conditions established by insurers may not discriminate unreasonably against or among providers.

Iowa:

Section 514C.5: Policies or contracts providing for third-party payment may not require a beneficiary to order prescriptions by mail if the pharmacy chosen by the beneficiary agrees to comply with the same terms and conditions as the mail-order pharmacy.

Kentucky:

Section 304.17A-270: A health insurer shall not discriminate against any provider who is located within the geographic coverage area of the plan and who is willing to meet the terms and conditions for participation established by the plan, including the Kentucky State Medicaid program and Medicaid partnerships.

Section 304.17A-505: …if the provider meets the insurer’s enrollment criteria and is willing to meet the terms and conditions for

participation, the provider has the right to become a provider for the insurer.

Louisiana:

Section: 22:1964: Policies/plans must allow beneficiaries to select the pharmacy/pharmacist of their choice as long as the chosen pharmacy agrees to meet the terms and conditions of the plan.

Pharmacies that agree to meet the established terms and conditions have the right to participate as contract providers. Renamed from Section 22:1214(15).

Section 22:2181: The Louisiana State University Health Sciences Center Health Maintenance Organization shall enter into a contract with any willing provider licensed by the Louisiana State Board of Medical Examiners or the Louisiana State Board of Dental Examiners to provide primary care services delivered in an outpatient setting including medical and surgical services.

Maine:

24-A M.R.S.A. § 4317: insurance carriers offering health plans subject to the Maine Health Plan Improvement Act that provide prescription drug benefits through a network of participating pharmacies may not refuse to contract with a pharmacy that is willing to meet the terms and conditions for participation in the health plan’s pharmacy network. If the network is a tiered network, Maine pharmacies must be offered the opportunity to participate in each tier. A pharmacy benefits manager may not require a pharmacist or pharmacy to participate in one network in order to participate in another network. The pharmacy benefits manager may not exclude an otherwise qualified pharmacist or pharmacy from participation in one network solely because the pharmacist or pharmacy declined to participate in another network managed by the pharmacy benefits manager.

Massachusetts:

Section 176D(3B): Carriers who offer restricted pharmacy networks must follow certain requirements in contracting. Carriers must neither exclude nor favor individual pharmacies and must not impose greater restrictions on non-network pharmacies than those required on in-network pharmacies.

Mississippi:

Section 83-9-6: Beneficiaries may choose any pharmacy that has agreed to participate in the plan according to the insurer’s terms. Pharmacies that accept those terms are entitled to participate.

Benefit differentials are prohibited. Plans that restrict pharmacy participation shall give 60 days notice of offer to participate to all pharmacies in the geographic area.

Missouri:

Section 354.535: Every Health maintenance organization has to apply the same coinsurance, co- payment and deductible factors to all prescriptions filled by a pharmacy provider who participates in the network if the provider meets the contact’s product cost determination. Also HMOs may not set a limit on the quantity of drugs which an enrollee may obtain at any one time with a prescription unless such limit is applied uniformly to all pharmacy providers in the network.

Montana:

Section 33-22-1704: A preferred provider agreement must provide all providers with the opportunity to participate on the basis of a competitive bid.

Nebraska:

Section 44-513.02: Beneficiaries shall not be required to obtain pharmaceutical services from mail- order in order to obtain reimbursement.

Section 44-313(2) :…an insurer may contract with a licensed pharmacist for pharmacist professional

services. Nothing in this section shall prohibit an insurer from contracting with a licensed pharmacist who is not employed or associated with a pharmacy. Nothing in this section shall require a licensed pharmacist to contract with an insurer for pharmacist professional services.

New Hampshire:

Section 420-B:12(V): HMOs seeking bids from pharmacies for agreements to be preferred providers must admit and list all pharmacies that meet the bid.

New Jersey:

Sections 17:48-6j & 26:2J-4.7: An enrollee/subscriber shall be permitted to select a pharmacy/pharmacist provided the pharmacist or pharmacy is registered. Pharmacies/pharmacists shall have the right to participate as preferred providers if the agreement provides for coverage by preferred providers, so long as the pharmacy/pharmacist complies with the terms of the agreement. Benefit differentials shall not be imposed. Enrollees/subscribers shall not be required to use a mail- order pharmacy.

New Mexico:

Section16.19.6.7(f): “Point of care vendor” means an entity contracted with a prescriber to generate or transmit electronic prescriptions authorized by a practitioner directly to a pharmacy or to a “contracted” intermediary or “network vendor”, who will ultimately transmit the prescription order to a patient’s pharmacy of choice. Vendor must provide an unbiased listing of provider pharmacies and not use

pop-ups or other paid advertisements to influence the prescriber’s choice of therapy or to interfere with patient’s freedom of choice of pharmacy. Presentation of drug formulary information, including preferred and non-preferred drugs and co-pay information if available, is allowed.

North Carolina:

Section 58-51-37: Beneficiaries may choose any pharmacy that has agreed to participate according to the insurer’s terms. Pharmacies that accept such terms are entitled to participate and must participate if offered the opportunity. Benefit differentials are prohibited. Plans that limit pharmacy participation shall give 60 days notice of an offer to participate to all pharmacies in the geographic area.

North Dakota:

Section 26.1-36-12.2: Beneficiaries may choose any licensed pharmacy/pharmacist to provide services. Benefit differentials are prohibited. Licensed pharmacists who accept the terms may participate in the plan.

Oklahoma:

Section 36-3634.3 & 36-4511: Pharmacies must be provided the right to bid on a periodic basis on any pharmacy contract to provider pharmacy services. Employers may not require employees to obtain drugs from a mail-order pharmacy as a condition for reimbursement. Employers may not impose benefit differentials if they do not use mail-order.

Title 15 § 15-788(c): No third party prescription program administrator shall deny any pharmacy the opportunity to participate in any third party prescription program offered in this state in a manner which will restrain the right of a consumer to select a pharmacy.

Rhode Island:

Sections 27-18-33, 27-19-26, 27-20-23, 27-41-38: Insurers may not require covered persons to obtain prescriptions from a mail-order pharmacy as a condition of obtaining benefits.

RI Gen. Laws 27-29-1: Unfair competition and practices.

South Carolina:

Section 38-71-147: No individual or group accident and health or health insurance policy or HMO may prohibit a participant/beneficiary from selecting pharmacies/pharmacists that agreed to participate in the plan according to the terms of the insurer, or may deny pharmacies/pharmacists the right to participate as contract providers if they agree to insurer’s terms and conditions.

South Dakota:

Section 58-18-37: Group health insurance policies may not refuse to accept licensed pharmacies/pharmacists as participating providers if they agree to the same terms and conditions offered to other providers of pharmacy services under the policy.

Tennessee:

Section 56-7-117: Group medical benefit contracts covering prescriptions may not require a covered person to obtain prescriptions from mail-order, or to pay an additional fee, or be subjected to a penalty for declining to use a designated mail-order pharmacy.

Section 56-7-2359: Licensed pharmacies may not be denied right to participate on the same terms and conditions offered other participants; benefit differentials are prohibited.

Texas:

Section 21.52B 2(a) (2): A pharmacy/pharmacist may not be denied the right to participate as a contract provider under the plan if the pharmacy/pharmacist agrees to provide pharmaceutical services that meet all terms and requirements and to include the same administrative, financial, and professional conditions that apply to pharmacies/pharmacists that have been designated as providers under plan.

Utah:

Section 31A-22-617: Insurers must allow providers to apply for and be designated as preferred providers if they agree to meet established terms and conditions. “Reasonable limitations” may be placed on the number of designated preferred providers.

Virginia:

Section 38.2-3407: Insurers shall establish terms and conditions in order to receive payment as a preferred provider. The terms and conditions shall not discriminate unreasonably against or among such health care providers and cannot exclude any provider willing to meet the terms and conditions.

Section 38.2-3407.7: Insurers shall not prohibit any person receiving pharmacy benefits from selecting, without limitation, the pharmacy of his choice.

Section 38.2-4209: Providers who are willing to accept established terms and conditions may qualify for payment under preferred provider contracts.

Section 38.2-4209.1: Corporations must allow beneficiaries to select the pharmacy of their choice if pharmacies that are non-preferred providers have previously notified the corporation of their agreement to accept reimbursement at rates applicable to preferred providers.

Section 38.2-4312.1: No Health maintenance organization shall prohibit any person receiving pharmaceutical benefits from selecting, without limitation, the pharmacy of his choice. No monetary penalty which would affect or influence any person’s choice of pharmacy shall be imposed.

Wisconsin:

Section 628.36 (2m): An annual 30-day open enrollment period during which any pharmacist may elect to participate is required.

Wyoming:

Section 26-22-503: Any provider willing to meet the established requirements has the right to enter into contracts relating to health care services.

Section 26-34-134: Providers willing to meet an HMO’s established terms shall not be denied the right to contract. An HMO may not discriminate against a provider on the basis of the provider’s academic degree.

Please note that laws can change over time, so it’s always a good idea to verify the current status of AWP laws in specific states if you need the most up-to-date information.

State Policies on Provider Market Power

The Source is a comprehensive platform that monitors and documents various state-level activities related to healthcare prices and competition. It provides valuable resources in the form of legislation and litigation databases, which are searchable and easily accessible.

The Source is a comprehensive platform that monitors and documents various state-level activities related to healthcare prices and competition. It provides valuable resources in the form of legislation and litigation databases, which are searchable and easily accessible.

The Database of State Laws Impacting Healthcare Cost and Quality focuses on legislative measures that have an impact on the cost and quality of healthcare. This database allows stakeholders at the state level to gain insights into their legal and regulatory environment. By understanding the laws in place, these stakeholders can make informed decisions and take necessary actions to enhance access, quality, and efficiency in healthcare while also striving to reduce costs.

Additionally, The Source includes a collection of maps that offer a visual representation of notable legislation and initiatives in health policy and reform across all 50 states. These maps provide a convenient way to explore the different approaches taken by each state and the progress made in addressing healthcare challenges.

If users have specific laws or cases they are interested in, they can utilize the search functionality within the database. This feature enables targeted exploration of laws and cases pertaining to a particular state, making it easier to find relevant information.

Overall, The Source serves as a valuable tool for stakeholders involved in healthcare, providing them with the necessary information to navigate the complex landscape of healthcare legislation and policy across the United States.

Through a review of state laws, CPR found a short list of states – California, Massachusetts, Montana, New Hampshire, North Carolina, Oregon, and Rhode Island – that are particularly active in their policy efforts regarding healthcare provider consolidation and market power.

Click to access State-Policies-on-Provider-Market-Power-1.pdf

State Policies on Provider Market Power Report

The Database of State Laws Impacting Healthcare Cost and Quality (SLIHCQ)

The Source on Healthcare Price & Competition

The Source tracks state activities impacting healthcare price and competition in both legislation (The Database of State Laws Impacting Healthcare Cost and Quality) and litigation in a searchable database to help stakeholders at the state level understand their legal and regulatory environment as they make efforts to improve access, quality, and efficiency, and reduce costs in healthcare.

Browse through the maps below to find out more about notable legislation and initiatives in health policy and reform across 50 states or search the database for specific laws and cases of a particular state.

ARTICLES & REPORT

  • New Mexico Enacts HB 306 – Threading the Needle on Facility Fees
    by Anna Chau
    On March 6, 2026, New Mexico enacted HB306, the “Fair Pricing for Routine Medical Care Act”, to prohibit charging of healthcare facility fees for certain services, to require the disclosure of facility fees to patients, and to require the reporting of facility fees to the all-payer claims database.  The bill prohibits hospitals and clinics from […]
  • The Source Roundup: April 2026 Edition
    by Leelah Klauber
    Antitrust and Market Competition Playing Favorites — State Protection of Academic Medical Centers from Antitrust Oversight New England Journal of Medicine Jaime S. King, Katherine L. Gudiksen, Anna D. Sinaiko The authors explore a new trend with U.S. academic medical centers (AMCs) merging with nonacademic hospitals and health care systems.  These mergers pose risks of […]
  • Department of Justice Suit Against New York Presbyterian May Be Part of a Larger Antitrust Enforcement Trend
    by Bruce Allain, Managing Editor
    On March 26, 2026, the Department of Justice (DOJ) sued New York-Presbyterian Hospital (NYP), claiming NYP used illegal anticompetitive terms in their contracts with payors.  In the related press release, the DOJ stated that “New York-Presbyterian uses its market power to protect its margins, impede competition from rival hospitals, and prevent employers and unions from […]
  • The Source Staff Co-Author New Research on the State Protection of Academic Medical Centers from Antitrust Oversight
    by Bruce Allain, Managing Editor
    The Source’s founder Jaime S. King, and executive editor Katherine L. Gudiksen, working with Harvard’s Anna D. Sinaiko, have authored a report on state antitrust exemptions for academic medical centers (AMCs) published recently by the New England Journal of Medicine.  There is a recent history of AMCs merging with nonacademic systems, with states creating "carve-outs" to exempt AMCs from antitrust oversight.  The research […]
  • California’s Antitrust Reform Recommendation Reaches the Legislature as AB 1776
    by Kassie Williams
    Background In August of last year, The Source shared information about the California Law Revision Committee's (CLRC) antitrust study, spurred by the 2022 Assembly Concurrent Resolution No. 95. At its outset, the study aimed to address the U.S. monopoly problem and the "threat of market concentration" in California.  The legislature tasked the CLRC with determining […]
  • Anticompetitive Provider Contract Terms Come Under Fire
    by Bruce Allain, Managing Editor
    Antitrust scrutiny of anticompetitive healthcare contract terms is on the rise, and the use of anticompetitive contract terms are increasingly in the crosshairs of both regulators and courts. When healthcare systems acquire a dominant market share, one method of capitalizing on this dominance is to impose anticompetitive terms on entities they contract with for financial […]
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Maryland Physicians Care (MPC) Provider Relations Representatives Maryland Physicians Care

Maryland Physicians Care (MPC) Provider Relations Representatives Maryland Physicians Care

Maryland Physicians Care (MPC) Provider Relations Representatives Maryland Physicians Care

MPC providers have designated Provider Relations Representatives based on the practice/group location. This specialist will be your primary contact with MPC and will keep you updated on any policy changes. To find your Provider Relations Representative, select a territory for the list below.

Phone: 1-800-953-8854 (follow prompts to PR dept.)
Fax: 866-333-8024

Download the Territory List

MPC Provider Relations Representatives

CMS Bundled Payments for Care Improvement (BPCI) Initiative: A Discussion on Bundled Payments

There is a large disconnect between what occurs after a patient is discharged from a hospital (acute) and what occurs thereafter. The quality of care is entirely unmanaged, uncontrolled, and unmonitored. Moreover, the patient is placed at greater risk whe

Understanding the CMS Bundled Payments for Care Improvement (BPCI) Initiative

In recent years, healthcare has been undergoing a significant transformation, driven by the need to improve care delivery and reduce costs. One of the key initiatives in this transformation is the Bundled Payments for Care Improvement (BPCI) program, introduced by the Centers for Medicare & Medicaid Services (CMS). The BPCI program is part of a broader effort to move the U.S. healthcare system towards value-based care, focusing on quality outcomes rather than the volume of services.

What is the BPCI Initiative?

The BPCI initiative was launched as part of the Affordable Care Act (ACA), which allowed the establishment of the Center for Medicare and Medicaid Innovation. The goal of this center is to pilot and expand innovative payment models that improve healthcare quality while reducing costs. BPCI is one of the many alternative payment models (APMs) being tested to align financial incentives with the quality of care provided, particularly in the post-acute care (PAC) setting.

The BPCI program focuses on bundled payments, which means that instead of paying for each service separately, healthcare providers receive a single, comprehensive payment for an entire episode of care. This “bundle” covers all services related to a patient’s treatment, including post-hospitalization care, for a specified period (e.g., 30 or 90 days). The goal is to incentivize providers to deliver coordinated, high-quality care that reduces unnecessary services and prevents avoidable readmissions.

Why Focus on Post-Acute Care?

One of the most challenging areas of healthcare to manage, particularly within the Medicare Fee-For-Service (FFS) program, is post-acute care. After patients are discharged from the hospital, they often require further care in settings such as inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), or home health agencies (HHAs). The costs and quality of care in these settings vary significantly across the country, contributing to wide regional disparities in Medicare spending. In fact, 73% of the variation in Medicare spending is attributed to differences in post-acute care settings.

The BPCI initiative specifically targets these post-acute care settings because of the high cost and the potential for improvement. For example, about 20% of Medicare patients are readmitted to the hospital within 30 days of discharge, and research suggests that 75% of these readmissions could be prevented with better care coordination.

The BPCI Models

The BPCI initiative includes four different models, each offering a different approach to bundled payments:

  1. Model 1: Retrospective Acute Care Hospital Stay Only – This model focuses on hospital costs for acute care stays.
  2. Model 2: Retrospective Acute and Post-Acute Care Episode – In this model, hospitals are financially responsible for both the acute care and all post-acute care services provided within 30 or 90 days of discharge.
  3. Model 3: Retrospective Post-Acute Care Only – This model places post-acute care providers (e.g., SNFs, HHAs) at financial risk for the services they provide after a hospital discharge.
  4. Model 4: Prospective Acute Care Hospital Stay Only – In this model, hospitals receive a single, upfront payment for an acute care stay, and they cannot bill for any additional services, even if the patient is readmitted within 30 days.

Model 2 is the most complex and widely adopted model, as it requires hospitals to manage the entire episode of care, including both acute and post-acute services. The financial risk is reconciled retrospectively, meaning that CMS reviews the total cost of care after the episode is complete and compares it to a pre-determined target price. If the costs are lower than the target, the hospital may share in the savings; if the costs are higher, the hospital is responsible for the excess.

Implementation Strategies for Success

To succeed in the BPCI initiative, hospitals and post-acute care providers need to collaborate closely. Many hospitals are implementing strategies such as narrowing their networks to include only high-performing post-acute care providers. This ensures that patients are discharged to facilities with strong track records in quality care and low readmission rates.

Hospitals are also using tools like patient choice letters, which list all available post-acute care providers but highlight those that have been vetted for quality. This approach, known as “soft steerage,” helps guide patients toward the best providers without restricting their choices.

In addition to collaboration, data sharing and technology play a crucial role in the success of BPCI. Hospitals need visibility into the patient’s care journey after discharge, which can be facilitated through electronic health records and other data integration tools. This allows for better coordination and monitoring of patient outcomes across the continuum of care.

Challenges and Opportunities

While the BPCI initiative offers significant opportunities for improving care and reducing costs, it also presents challenges. One major issue is the complexity of managing bundled payments, especially with the retrospective reconciliation process that introduces delays in financial feedback. Hospitals need to track performance in real-time and adjust their strategies based on ongoing data, rather than waiting for quarterly reconciliations from CMS.

Another challenge is managing high-risk patients and outlier cases, which can significantly skew financial outcomes. However, as bundled payment models continue to evolve and expand, hospitals that proactively adapt to these challenges will be better positioned for success in the shifting healthcare landscape.

Conclusion

The BPCI initiative is an important step towards a value-based healthcare system, particularly in managing the costly and often fragmented post-acute care segment. By aligning financial incentives with quality outcomes, the BPCI program encourages providers to deliver more coordinated, efficient care, reducing unnecessary services and preventable readmissions.

As bundled payment models continue to expand, healthcare providers who embrace this shift now will be better prepared for the future. By focusing on collaboration, data integration, and patient-centered care, hospitals can succeed in the BPCI initiative and contribute to a more sustainable healthcare system.