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COVID-
19 and opportunities to reboot managed care

09.16.20

Read this if you are a state Medicaid agency, state managed care office, or managed care organization (MCO). 

The COVID-19 pandemic and resulting economic downturn has led to increased Medicaid member enrollment and has placed a strain on state budgets to support Medicaid and other health and human services programs. It has also impacted traditional Medicaid utilization patterns and has challenged provider reimbursement models, forcing managed care programs and supporting MCOs to:

  • rethink the control of program costs, 
  • seek MCO program flexibilities to expand coverage such as telehealth, and 
  • make operational changes to support their growing member populations.

Managed care opportunities

While COVID-19 has created many challenges, at the same time it has given managed care programs the opportunity to restructure their delivery of services not only during the public health emergency, but for the longer term. Flexibilities sought this year from the Centers of Medicare & Medicaid Services (CMS) put in place through waivers and state plan amendments have helped expand services in areas such as the delivery of COVID-19 testing, medical supplies, and behavioral health services via telehealth. 

These flexibilities have relieved the administrative burden on Medicaid programs, such as performance and reporting requirements outlined under federal law and 42 CFR §438. Although these flexibilities have helped managed care programs expand services during the pandemic, the benefits are temporary and will require MCOs to make programmatic changes to meet the demands of its population during and after the public health emergency.

A recent study by Families USA cited 38 states reporting 7% growth in member enrollment since February. As the Medicaid population continues to grow in 2020 and beyond, managed care programs have numerous opportunities to consider: 

Managing care coordination and establishing efficiencies with home- and community-based services (HCBS)

The increased risk of adverse health outcomes from COVID-19 due to older age and chronic illness, and the demands on providers and medical supplies, has forced Medicaid programs to seek waiver flexibilities to expand HCBS. As part of HCBS delivery, MCOs may focus on the sickest and most costly of their member populations to control costs and preserve quality. 

MCOs will most likely monitor cost drivers such as chronic conditions, catastrophic health events, and frequent visits to primary care providers and hospitals. MCOs have the opportunity to establish efficiencies and improve transitions across different providers and multiple conditions to better manage the over-utilization of services for members in skilled nursing facilities, and for those who receive HCBS and outpatient services.

Adjusting and monitoring Value-Based Payment (VBP) models

With the continued transition to VBP models, Medicaid programs face the challenge of added costs and adapting plan operations and services to address pandemic-related needs, chronic conditions, and comorbidities. 

Building on the latest guidance to state Medicaid directors from CMS on value-based care, Medicaid programs can look at COVID-19 impacts on provider reimbursement prior to the rollout of VBP models. Medicaid programs can continue establishing payment models that improve health outcomes, quality, and member experience. States can adjust contracts and adherence to local and state public health priorities and national quality measures to advance their VBP strategy. Managed care programs may need to consider a phased rollout of their VBP models to build buy-in from providers transitioning from traditional fee-for-services payment models, and to allow for refinements to current VBP models.

Continued stratification and the assessment of risk

By analyzing COVID-19’s impact on the quality of care and member experience, improved outcomes, and member and program costs, managed care programs can improve their population stratification methodologies factoring as population demographic analysis, social determinants of health, and health status. Adjustments to risk stratification during and after the COVID-19 pandemic will inform the development of provider networks, provider payment models, and services. Taking into account new patterns of utilization across its member population, managed care programs may need to refine their risk adjustment models to determine the sickest and most costly of their populations to project costs and improve the delivery of services and coordination of care for Medicaid members.

Telehealth

As providers transition back to their traditional structures, MCOs can continue to expand telehealth to improve service delivery and to control costs. Part of this expansion will require MCOs to balance the mentioned benefits of the telehealth model with the risk of over-utilization of telehealth services that can lead to inefficiencies and increased managed care program costs. In addition, because of the loosening of federal restrictions on telehealth, managed care programs will most likely want to update program integrity safeguards to reduce the risk of fraud, waste, and abuse in areas such as provider credentialing, personal identifiable information (PII), privacy and security protocols, member consent, patient examinations, and remote prescriptions. 

Continued focus on data improvement and encounter data quality

Encounter data quality and data improvement initiatives will be critical to successfully administer a managed care program. As encounter data drives capitation rates for MCOs, a continued focus on encounter data quality will likely enable Medicaid programs to better leverage actuarial services to establish sound and adequate managed care program rates, better aligning financial incentives and payments to their MCOs. 

States have pursued a number of flexibilities to establish a short-term framework to support their managed care programs during the COVID-19 pandemic. However, the current expansion of services and the need for MCOs to rapidly identify additional areas for operational improvements during the pandemic have allowed Medicaid programs to further analyze longer-term needs of the populations they serve. These developments have also helped programs increase their range of services, to expand and manage their provider networks, and to mature their provider payment models. 

If you would like more information or have questions about opportunities for adjustments to your managed care program, please contact MedicaidConsulting@BerryDunn.com. We’re here to help.
 

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Read this if you are a state Medicaid agency, state managed care office, or managed care organization (MCO).

The November 9, 2020 announcement by the Centers for Medicare & Medicaid Services (CMS) outlines updates to the 2016 Medicaid & Children's Insurance Program (CHIP) Managed Care Final Rule (Final Rule), which present new challenges to state Medicaid and CHIP managed care programs to interpret the latest CMS guidance that attempts to relieve current administrative burdens and federal regulatory barriers.

Although the latest guidance by CMS attempts to provide potential relief to states to administer their managed care programs, states will need to coordinate with federal and state partners to further understand the latest updates to federal regulations that are presented by the updated Final Rule.

By providing relief for current reporting requirements for program costs, provider rates, network adequacy, and encounter data, this latest change by the administration enables state managed care programs to reassess current operations to update and improve their current service delivery. The updated Final Rule continues CMS’ efforts to transition state managed care and CHIP programs from a fee-for-service delivery system, and to urge state Medicaid and CHIP agencies to continue to implement payment models to improve quality, control costs, and promote innovation.  

Impacts on Medicaid managed care operations 

Changes for states to consider that impact their Medicaid managed care operations based on the latest Final Rule include:

  • Coordination of benefits agreements (COBA): States will have the option to leverage different methodologies for crossover claim distribution to managed care plans, and the updated Final Rule indicates that managed care plans do not have to enter into COBA directly with Medicare.
  • Rate setting and ranges, and development practices: CMS provides the option for states to develop and certify a rate range and has provided clarification and different options for rate setting and development practices.
  • Network adequacy: CMS will allow for states to set quantitative network standards, such as provider to enrollee ratios, to account for increases in telehealth providers and to provide flexibilities in rural areas.
  • Provider directory updates: CMS will allow for less than monthly updates to provider directories due to the increased utilization of digital media by enrollees, emphasizing decreased administrative burden and the costs for state managed care plans. This update also indicates that completion of cultural competency training by providers will no longer be required.
  • Provider termination notices: The latest update increases the length of provider termination notice requirements to 30 calendar days (previously 15 calendar days).
  • Member information requirements: The latest update outlines flexibilities for enrollee materials as it relates to font size and formatting.
  • Quality Rating System (QRS): CMS will be developing a QRS framework in which states must align with, but will be able to develop uniquely tailored approaches for their state.
  • External quality review: States that exempt managed care plans from external quality review activities must post this information on their websites for public access on an annual basis.
  • Grievance and appeal clarifications: The latest update provides clarification that the denial of non-clean claims does not require adverse benefit determination notices and procedures; adjustments and clarification to State Fair Hearing enrollee request timeframes to align with recent Medicaid fee-for-service requirements

CHIP to Medicaid regulatory cross-references

CMS clarifies several CHIP to Medicaid regulatory cross-references. These cross-references include the continuation of benefits during State Fair Hearings, changes to encounter data submission requirements, changes to Medicaid Care Advisory Council (MCAC) requirements, grievance and appeals requirements, and program integrity standards.

Changing demand on managed care programs

The November 9 announcement follows a series of efforts by CMS during the past few years to modify the Final Rule in an attempt to help states meet the changing demands on their managed care programs. For the 2016 Final Rule, CMS formed a working group with the National Association of Medicaid Directors (NAMD) and state Medicaid directors to review current managed care regulations. The recommendations from the group led to public comment in November 2018 with state Medicaid and CHIP agencies, advocacy groups, health care providers and associations, health insurers, managed care plans, health care associations, and the general public. As a result of this public comment effort, the latest Final Rule seeks to streamline current managed care regulations.

The new Final Rule announcement comes after a series of efforts by CMS to offer guidance and make changes to their provider payment models, including its recent September 15 letter to state Medicaid directors that further promotes a strategic shift towards value based payments to transform the alignment of quality and cost of care for Medicaid beneficiaries.

The effective date for the new regulations will be 30 days after publication of the new Final Rule in the Federal Register (target date November 13, 2020), except for additions §§ 438.4(c) and 438.6(d)(6) for Medicaid managed care rating setting periods, which are effective July 1, 2021.

If you would like more information or have questions about interpreting the Final Rule for changes to your managed care program, please contact us.

Article
The 2020 Final Rule—Understanding new flexibilities to control costs and deliver care

Read this if you are in the senior living industry.

Happy New Year! While it may be a new calendar year, the uncertainties facing senior living facilities are still the same, and the question remains: When will the Public Health Emergency end, and how will it impact operations? Federal and state relief programs ended in 2022, and facilities are trying to find ways to fund operations as they face low occupancy levels. Inflation was at 7.1% in November and staffing remains a significant challenge. So, what can the industry expect for 2023?

Occupancy

Through the pandemic, occupancy losses were greater in nursing facilities than in assisted living (AL) and independent living (IL) facilities. This trend of care shifting away from nursing facilities had started before the onset of the pandemic. From 2018-2020, nursing facility volume decreased by over 5% while AL facilities occupancy increased by 1.1%.

Nursing facility occupancy nationwide was 80.2% in January of 2020 and declined to as low as 67.5% in January 2021. In 2022, nursing facility occupancy began to recover. As of December 18, 2022, nationwide occupancy had rebounded to 75.8%.

The assisted living and independent living markets were certainly impacted by the pandemic but not to the extent of the nursing facilities. AL and IL occupancy was reported at 80.9% in March 2021, a record low occupancy for the industry. Through the third quarter of 2022, NIC reported IL occupancy at 84.7%, which was up from 83.8% in the second quarter of 2022. AL occupancy was at 79.7%. in the third quarter of 2022. 

Providers are starting to see some positive signs with occupancy, but are reporting the recovery has been slowed by staffing shortages.

Cost of capital

The lending market is tightening for senior living providers and occupancy issues are negatively impacting facilities bottom lines. In addition, there has been significant consolidation in the banking industry. As a result, interest and related financing costs have risen. For those facilities that aren’t able to sustain their bottom lines and are failing financial covenants, lenders are being less lenient on waivers and in some cases, lenders are imposing default lending rates. 

Ziegler reports in their Winter 2022 report the lending market for senior housing is beginning to pick up. The majority of the lenders surveyed were regional banks, and reported they are offering both fixed and floating rate loans. Lenders are also reporting an increased scrutiny on labor costs coupled with looking at a facility’s ability to increase occupancy. 

Despite these challenges, analysts are still optimistic for 2023 as inflation seems to be tapering, which will hopefully lead to a stabilization of interest rates.

Staffing

Changes to five-star rating
In July 2022, the Centers for Medicare and Medicaid Services (CMS) modified the five-star rating to include Registered Nurse (RN) and administrator turnover. The new staffing rating adds new measures, including total nurse staffing hours per resident day on the weekends, the percentage of turnover for total nursing staff and RNs, and the number of administrators who have left the nursing home over a 12-month period.

Short-term this could have a negative impact on facilities ratings as they are still struggling to recruit and retain nursing staff. The American Healthcare Association has performed an analysis, and on a nationwide basis these changes resulted in the number of one-star staffed facilities rising from 17.71% to 30.89%, and the percentage of one-star overall facilities increasing from 17.70% to 22.08%.

Staffing shortages 
Much like the occupancy trend, nursing facilities faced staffing issues even before the pandemic. From 2018 to 2020, the average number of full-time employees dropped at a higher rate, 37.1%, than admissions, 15.7%. Data from the Bureau of Labor and Statistics and CMS Payroll Based Journal reporting shows nursing facilities lost 14.5% of their employees from 2019-2021 and assisted living facilities lost 7.7% over the same time period. This unprecedented loss of employment across the industry is leading to burnout and will contribute to future turnover.

This loss of full-time employees has created a ripple effect across the healthcare sector. Nursing facilities are unable to fully staff beds and have had to decline new admissions. This is causing strain on hospital systems as they are unable to place patients in post-acute facilities, creating a back log in hospitals and driving up the cost of care.

While the industry continues to experience challenges recruiting and retaining employees, the labor market is starting to swing in the favor of providers. Some healthcare sectors have recovered to pre-pandemic staffing levels. Providers are also starting to report lower utilization of contract labor.

While the industry continues to experience challenges recruiting and retaining employees, the labor market is starting to swing in the favor of providers. 

Minimum staffing requirement
CMS is expected to propose a new minimum staffing rule by early spring 2023. Federal law currently requires Medicare and Medicaid certified nursing homes provide 24-hour licensed nursing services, which are “sufficient to meet nursing needs of their residents”. CMS issued a request for information (RFI) as part of the Fiscal Year 2023 Skilled Nursing Facility Prospective Payment System Proposed Rule. CMS received over 3,000 comments with differing points of view but prevailing themes from patient advocacy groups regarded care of residents, factors impacting facilities' ability to recruit and retain staff, differing Medicaid reimbursement models, and the cost of implementing a minimum staffing requirement. In addition to the RFI, CMS launched a study that includes analysis of historical data and site visits to 75 nursing homes. 

In a study conducted by the American Healthcare Association, it is estimated an additional 58,000 to 191,000 FTEs will be needed (at a cost of approximately $11.3 billion) to meet the previously recommended 4.1 hours per patient day minimum staffing requirements.

One potential consequence of the minimum staffing requirement is higher utilization of agency staffing. Nursing facilities saw a 14.5% decrease in staffing through the pandemic and are still struggling to recruit and retain full-time staff. To meet the minimum staffing requirements, providers may need to fill open positions with temporary staffing. 

Provider Relief Funds (PRF) 

Don’t forget if you received PRF funds in excess of $10,000 between July 1 and December 31, 2021, Phase 4 reporting period opened January 1, 2023, and will close March 31, 2023.
Many of the changes to the industry brought on by the pandemic are likely to remain. Facilities who are putting a focus on their staff and working to create a positive work environment are likely to keep employees for longer.

While there are many challenges in the current environment, they were made to be met, and we are here to help. If you have any questions or would like to talk about your specific needs, please contact our senior living team. Wishing you a successful 2023.
 

Article
Status of the senior living industry: The good, the bad, and the uncertain

Read this if you are a part of the gaming industry.

The gaming industry has bounced back during 2021 and 2022 following pandemic-related declines, but a potential economic downturn will likely impact consumer behavior and have effects for gaming businesses. Though recessionary concerns may prompt some consumers to rein in spending, several factors point to resilience in the gaming industry, including customer retention initiatives, the growth of digital gaming and sports betting, and the continued allure of experiences offered by casino resorts.

Instead of merely weathering a potential recession, gaming companies can position for sustained success by reviewing strategic plans and focusing on key business objectives. Financial discipline will be another priority, particularly if changes in consumer spending affect revenue growth during 2023.

Retention has a big payoff in a recessionary environment

Despite the rate of inflation in the US reaching levels not seen in more than 40 years during 2022, consumer spending has remained relatively strong. According to data from the Bureau of Economic Analysis (BEA), disposable personal income and personal consumption expenditures both increased slightly more than expected during September. Interest rates have continued to rise, however, and there are indications that some consumers are delaying the purchase of big-ticket items, which suggests a slowdown in some areas of spending.

To help mitigate the effects of a potential recession, gaming companies may consider shifting more attention to customer retention in addition to customer acquisition. That strategy could be especially important for sports betting, a subsector that has invested heavily in customer acquisition in recent years—and may not be as recession-proof as some had predicted. According to a TransUnion study, 54% of US sports bettors earn at least $100,000 per year, but even high-income earners show signs of cutting back on discretionary spending like gambling. Nevertheless, many sportsbooks have seen relatively low rates of customer churn this year despite inflation, which could be due partly to the growth in popularity of unique multi-leg wagers such as same-game parlays.

High costs for customer acquisition due to digital competition can pose challenges for companies trying to grow their consumer base, and recessionary pressures make it even more important to keep existing customers engaged. Fragmentation and evolving competition also complicate predictions for the lifetime value of a new customer. The longer a customer stays, however, the bigger the return on initial acquisition costs.

Retention strategies

Strategies that focus on retention can help reduce churn amid growing recessionary pressures. These strategies vary for different types of companies, such as online gambling (iGaming), land-based casinos, or a hybrid of online and on-premises gaming. Taking steps to improve customer experience and leverage data analytics can both help increase engagement. Such initiatives can include customized loyalty and reward programs based on a customer’s unique habits, as well as data insights about the most popular types of games and bets that enable cross-promotion. Reload bonuses, referral bonuses, free bets, and percentage back on losses are examples of other strategies to help keep existing players engaged. Critically, even small improvements in retention can have a significant impact on margins and profitability.

Growth potential remains, but a downturn would impact industry subsectors differently

If recessionary pressures prove to be a drag on consumer spending in the months ahead, it may affect some gaming sectors differently than others. Even if consumers reduce discretionary spending, casino resorts could still fare well because of their diversified offerings, but they also have much higher operating costs than dedicated iGaming companies. Land-based casinos in particular should practice financial discipline and manage labor costs. They can achieve this by maintaining balanced staffing levels, expanding electronic casino games, and adopting cashless gaming and digital payments.

Overall, casino resorts can provide a relatively affordable range of unique leisure experiences. People remain eager to travel after dealing with pandemic-related restrictions, and recent TSA checkpoint data indicates airport activity has been near or above 2019 levels. BEA data also indicates that consumer spending on services, such as travel and dining, has outpaced spending on goods in recent months.

Although research has shown flat levels of growth for casino gambling during previous recessions, the industry has seen several notable changes in recent years. Digital gaming remains a convenient option for consumers and has experienced a spike in adoption in recent years, which aids both digital-only operators and land-based casinos that offer a digital component. Casino resorts can also use data-backed insights to help convert their online customers into on-premises customers through targeted offers and other marketing initiatives.

Sports betting has also grown rapidly during the past five years, which provides an accessible platform for a much larger population of customers than previously. Before the US Supreme Court’s 2018 decision in Murphy v. National Collegiate Athletic Association, only a few states could claim partial exemption to the 1992 federal ban on sports betting. As of November 2022, more than 30 states and the District of Columbia allow sports betting, and additional states are considering similar legislation.

Recession-related shifts in discretionary spending may not impact gaming as much as other consumer sectors. A May 2022 YouGov poll of 16 countries shows that while monthly gamblers may cut back on betting, they are more likely to reduce spending in other areas to maintain their monthly budget. A recession would still likely impact growth, so it is critical for gaming companies to protect revenue during a downturn.

Other developments also hold promise for the gaming industry. Casino stocks recently surged following China’s announcement of eased travel restrictions that would allow tour groups into Macau, the world's largest gambling jurisdiction. Overall, publicly traded gaming companies have enjoyed relatively strong earnings during 2022 despite market volatility, and many analysts have maintained “buy” ratings. A downturn could also give well-capitalized companies an opportunity to gain market share through acquisitions and partnerships.

Looking ahead: A sure thing

To help guard against the impact of recessionary pressures, managing costs and finding efficiencies will continue to be priorities. However, cutting back spending across the board can constrain growth and exacerbate customer churn. By combining financial discipline with a business strategy tailored to the effects of a potential downturn, gaming companies can continue the pandemic recovery and even thrive during volatility.

Article
Beyond weathering the storm: How the gaming industry can succeed during economically challenging times 

Read this if you use QuickBooks Online.

Let's talk about where records for products and services are used in QuickBooks Online.

To create a product or service record, you hover your mouse over Sales in the left vertical pane on the main page and click Products and services. Click New in the upper right corner and open a blank record for an Inventory or Non-inventory part, a Service, or a Bundle (assembly). Once you complete a record and save it, it will appear in the list back on the Product and services page.

Working with products and services

That’s where we’ll start today, on the Products and services screen. This is a comprehensive table, a dashboard (or home page) for your products and services. It displays real-time information about your items’ pricing and inventory levels, as well as their type and tax status. At the top of the page, you’ll see big, colorful buttons that provide a total of the number of items that are low on stock or out of stock. When you click on one, a list of those products appears.

QuickBooks Online’s Products and services page displays inventory levels and warns you when your stock is low and at zero.

Each row on this screen contains details about the item listed there, like Description, Sales Price and Cost, and Qty On Hand. If you look down at the end of the row, you’ll see options for several types of Actions: Edit, Make inactive, Run report, and Duplicate. Click the gear icon above the table to modify the columns in the table. 

The More menu at the top of the screen contains more options: Manage categories, Run reports, and Price rules. If you want to know what actions you can take on multiple items simultaneously, check the box in front of each and click the Batch actions menu, over to the right (Adjust quantity, Reorder, etc.).

Warning: Be very careful using the Adjust quantity option. There are legitimate reasons for employing it, but you need to make very sure that you understand how this will affect other areas of your accounting. Please ask us if you’re unsure.

Using products and services in transactions

Once you start using product and service records in transactions, you’ll see why we suggested that you create those early on and make them as comprehensive as possible. While you can add products and services in the process of creating an invoice, for example, it’s much easier if you have them ready to go.

Let’s look at a sales receipt to see how this works. Click +New in the upper right corner and select Sales receipt. Select a Customer in the first field and verify that the related fields on the form were filled out correctly. Check and make any changes necessary in the Sales receipt date, Payment method, and Deposit to fields. 

Once you’ve built up a list of products and services, they’ll be available when you create transactions.

Enter the Service Date, and then click the down arrow in the field under Product/Service. The top of the list has an entry labeled +Add new. Click it if you need to add a product or service on the fly, or just select the existing one that you want. QuickBooks Online will fill in the Rate, Amount, and Tax (status). You only have to enter the Qty (quantity) that you’re selling. 

If you have more items or services to add, you can do so on the next line(s). When you’re done, check the numbers in the lower right and save the transaction. QuickBooks Online will adjust your inventory to account for any items you just sold. You can see this change by going back to the Products and Services screen. Or you can run reports, including:

  • Sales by Product/Service
  • Product/Service List
  • Inventory Valuation Detail
  • Physical Inventory Worksheet

Supply chain woes?

It seems that the serious supply chain problems we were experiencing in previous months have eased up some, but you may still be having trouble stocking some items. We hope this isn’t affecting you too much. 

QuickBooks Online, though, can help ensure that you know ahead of time when you must reorder. Its inventory-tracking capabilities can also alert you to items that aren’t selling well, so you don’t get overstocked on anything. And the ability to pull up product and service records when you’re creating transactions saves time and keeps your inventory levels accurate. Please let the Outsourced Accounting team know if you need assistance with this element of your accounting or any of QuickBooks Online’s other tools.

Article
How QuickBooks Online tracks products and services

Read this if you are responsible for cybersecurity at your organization.

Cybersecurity threats aren’t just increasing in number—they’re also becoming more dangerous and expensive. Cyberattacks affect organizations around the globe, but the most expensive attacks occur in the US, where the average cost of a data breach is $9.44 million, according to IBM’s 2022 Cost of a Data Breach Report. The same report shows that the cost of a breach is $10.10 million in the healthcare industry, $5.97 million in the financial industry, $5.01 million in the pharmaceuticals industry, and $4.97 million in the technology industry.

Cyber threat actors are a serious danger to your company, and your customers, stakeholders, and shareholders know this. They expect you to be prepared to defend against and manage cybersecurity threats. How can you demonstrate your cybersecurity controls are up to par? By obtaining a SOC for cybersecurity report.

What is a SOC for cybersecurity report?

It provides an independent assessment of an organization’s cybersecurity risk management program. Specifically, it determines how effectively the organization’s internal controls monitor, prevent, and address cybersecurity threats.

What’s included in a SOC for cybersecurity report?

The report is made up of three key components:

  1. Management’s description of their cybersecurity risk management program, aligned with a control framework (more on that below) and 19 description criteria laid out by the AICPA.
  2. Management’s assertion that controls are effective to achieve cybersecurity objectives.
  3. Service auditor’s opinion on both management’s description and management’s assertion.

Why should you consider a SOC for cybersecurity report?

A SOC for cybersecurity report offers several important benefits for your organization, which include:

  • Align with evolving regulatory requirements. The cybersecurity regulatory environment is constantly evolving. In particular, the SEC’s cybersecurity guidelines are becoming stricter over time. A SOC for cybersecurity report can demonstrate you’re aligned with these guidelines. If you’re a public company or are considering going public in the future, you need to be prepared to meet not just the SEC’s guidelines of today, but their evolved guidelines in the future.
  • Keep your board of directors informed. Your board is responsible for ensuring the business is effectively addressing and mitigating risks—and that includes cyber risk. A SOC for cybersecurity report offers your board a clear and practical illustration of your organization’s cybersecurity risk management controls.
  • Attract and retain more customers. It’s becoming increasingly common for companies to require that their vendors have a SOC for cybersecurity report. Even for companies that don’t require such a report, it’s important to know their vendors are keeping their data safe. Having this report differentiates you from vendors who have not prepared one.
  • Improve your cybersecurity posture. A SOC for cybersecurity report can identify current gaps in your cybersecurity risk management program. Once you’ve addressed these gaps, you can show your customers, stakeholders, and shareholders that you’re continuously improving and evolving your cybersecurity risk management approach.

How do I prepare for my SOC for cybersecurity assessment?

There are several steps you should take to prepare for your assessment.

  1. Choose your control framework. You have several options, including the NIST Cybersecurity Framework, ISO 27002, and the Secure Controls Framework (SCF). There are multiple online resources to help you choose the framework that’s right for your organization.
  2. Determine who your key internal stakeholders are for your cybersecurity risk management program. You’ll need to select a point person to be responsible for ensuring the independent services auditor has all the documentation they need to complete their assessment and act as liaison across internal and external stakeholders.
  3. Collect all cybersecurity-related documentation in one location. Make sure you have an organizational system that makes sense to your point person so it’s easy for them to pull the appropriate materials to give to the independent services auditor.
  4. Conduct a readiness assessment. You can work with an independent services auditor to conduct such an assessment which will identify gaps you can address before performing the attestation.
  5. Select an independent services auditor to perform the attestation. SOC for cybersecurity services are provided by independent CPAs approved by the AICPA. Ideally, you’ll want to select a firm that is experienced in your industry, has a diverse and robust team of cybersecurity professionals, and is accessible when and where you need them.

As always, if you have questions about your specific situation or would like more information about SOC for cybersecurity services, please contact our IT security experts. We’re here to help.

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Yes, you need a SOC for cybersecurity report—here's why

Read this if you are at a Medicaid agency.

After attending this year’s NASHP Conference, I realized Seattle wasn’t the only gem I found. The city welcomed a record number of NASHP attendees, including many first timers, who brought with them a passion for the vital work they do to support Medicaid and health and human services agencies across the nation. Executive Director Tewarson led her first conference with finesse, and the entire conference exemplified her team’s passion and dedication to state health policy. 
 
The 35th annual conference was full of fresh ideas and a collaborative spirit. As I reflect over the three days of the conference, some ideas I am taking back to my team include:

  • Workforce challenges are here to stay—and are only becoming more severe, requiring states to rethink hiring, training, and staffing among healthcare providers at all levels. Actions to consider:
    • Work to help ensure we allocate appropriate funding for behavioral health and clinical staff. 
    • Encourage more diversity in the field. This means having more representation in the workforce for new hires to identify with, including recruiting and training staff, so they feel welcome and encouraged to join.
    • Increase support for highly skilled jobs like CNAs and childcare workers. Our system cannot work without these staff, and the skills they bring to the table are crucial to the field, developed over time, and indispensable.
    • Start planning now to address the potential loss of childcare dollars to avoid exacerbating the workforce shortage challenges.
    • Identify other ways to help the workforce with benefits and support that can go a long way toward recruiting and retaining experienced caregivers. 
  • Disparities in health equity were always there, and the pandemic laid them bare. 
    • We need to assess the impact of all initiatives to help ensure they aren’t creating additional health inequities and develop strategies to rectify existing barriers.
    • We should bring those experiencing health inequities to the table, listen to their struggles, and let them lead us to solutions.
    • We need to build a diverse workforce that will bring more voices and ideas into the room in this arena.
  • There is a lot of innovative work going on in child behavioral health that can impact outcomes:
    • Providing youth mental health first-aid training and trauma-informed training to school-based, nonclinical staff is crucial to addressing the children’s behavioral health crisis. Children spend so much time at school and build trust in teachers, bus drivers, custodians, and administrative staff.
    • Training school staff on the use of mobile crisis units to avoid children inappropriately becoming involved in the juvenile justice system or being treated in emergency rooms.
    • Putting clinical staff in schools, even via telehealth or part-time, has shown positive outcomes for child behavioral health.
  • We may not know when the Public Health Emergency will end. Still, we can spend this time developing and improving our plans for unwinding, setting consistent expectations with our members and meeting them where they are, developing strategies to make successful emergency provisions permanent, and engaging our legislatures now to prepare for the upcoming federal funding gap.
  • The most significant success factor in every session I attended was breaking down silos across health and human services agencies. We need to continue working across programs, agencies, and states to help ensure we are innovating, growing, and providing the best care for those our policies and programs serve.
  • Lastly, as a foster-adopt mom, I was heartened to hear the speakers consistently bring the topic back to focus on some of our most vulnerable youth: children in foster and kinship care and our justice-involved youth. The call to collaboration and partnerships across child welfare, juvenile justice, public health, county health departments, and Medicaid agencies to impact change was not lost on me, and I found my passion for improving our foster care system invigorated by the passion of those around me.

I am thankful for organizations like NASHP that help us come together to innovate and collaborate on the biggest problems facing our industry today. NASHP’s mission to support the development of policies that promote and sustain healthy people and communities, advance high-quality and affordable health care, and address health equity is needed now more than ever. The 2022 conference allowed us to collaborate and share innovations that can be used to help propel us in our essential work to improve the health and lives of the individuals we serve.
 
My biggest takeaway was that we are stronger when we work together. I’m excited to hear what your biggest takeaways were this year. It has energized me to continue this critical work to help Medicaid agencies improve the health and lives of our residents. I do not doubt that this group will take back all the lessons and work to improve the lives of the residents of their states, and we will all gather in Boston next year, excited to hear of all the new successes. See you next year!

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NASHP meets the Emerald City

Read this if you are at a state agency looking to implement or improve your 988 Suicide & Crisis Lifeline. 

Between 2015 and 2020, one in four fatal police shootings involved a person with a mental illness, and an estimated 44% of people incarcerated in jail and 37% of people incarcerated in prison had a mental health condition. In addition, the recent COVID-19 pandemic has adversely impacted the mental health situation in the country. 

Many people experiencing mental health distress call 911 because it is a widely known emergency number and easy to use. Recent data has shown that people using 911 to get help with serious mental illness do not get the right care at the right time and some even end up in law enforcement custody, rather than being seen by a mental health professional.

The 988 Suicide & Crisis Lifeline (formerly known as the National Suicide Prevention Lifeline) is the new three-digit, nationwide phone number that is locally operated and offers 24/7 access via call, text, and chat to trained crisis counselors who can help individuals experiencing mental health-related distress. Mental health-related distress can include substance use crisis, suicidal thoughts, depression, or any emotional distress. The 988 Suicide & Crisis Lifeline is also available for individuals worried about a loved one who might need crisis support services. Its goal is to provide accessible and immediate crisis intervention and support to every individual in need. 

988 state implementation and top challenges

As of August 2022, 23 states have passed legislation to facilitate the implementation of the 988 Suicide & Crisis Lifeline. Colorado, Nevada, and Washington enacted legislation with user fees to support 988 operations and provide financial sustainability for the system. Several states have established advisory groups or planning committees with representatives from state agencies, health providers, law enforcement, emergency medical services, and other partners to better coordinate the system and identify policy levers. 

Implementing a three-digit number for behavioral health emergencies in every state and providing 24/7 primary coverage through in-state call centers have presented certain challenges to states across the nation. As states prepare to launch the 988 hotlines, they have encountered key issues around infrastructure, workforce, 911 integration, readiness of the crisis care continuum, cultural competence, and performance management.  

Solutions for state agencies

To address these key issues, states should consider the following to aid in the successful implementation of the 988 Suicide & Crisis Lifeline:

Assess the states’ needs to successfully implement the 988 Suicide & Crisis Lifeline

Despite meeting baseline requirements for the implementation of the 988 Suicide & Crisis Lifeline, state agencies are struggling to implement the 988 Suicide & Crisis Lifeline. 

By performing a structured needs assessment, state agencies can evaluate their infrastructure, policies and procedures, funding, and workforce needs to better understand their readiness to implement and capability to sustain the 988 Suicide & Crisis Lifeline. This assessment provides insight for state agencies to understand their strengths, challenges, and areas of opportunity, and it should evaluate: 

  • State infrastructure
    Behavioral health leaders acknowledge that infrastructure supports are necessary to make the 988 Suicide & Crisis Lifeline work across the continuum of care. It is important to assess the infrastructure across the crisis care continuum to help ensure a smooth transition for individuals who need care quickly. Successful implementation should take certain considerations into account during the planning process, such as including all the interested parties representing diverse populations.
  • Workforce
    In the current labor market, workforce availability and retention are top concerns for sustainable and effective 988 Suicide & Crisis Lifeline operations. States are struggling to hire the extra staff needed to launch the 988 Suicide & Crisis Lifeline as well as to recruit qualified persons. To realistically implement the system, innovative workforce development and supporting wages to recruit and retain a specialized workforce are critical considerations for the states. Critical components to include in the assessment should include, but are not limited to:
    • Training
      Staff training and proper supervision will be crucial to effectively manage the 988 Suicide & Crisis Lifeline, and states need best practices models for how to best train crisis responders and the call center staff. States should assess the existing training infrastructure to identify ways early on to support the mental health of their 988 Suicide & Crisis Lifeline counselors to reduce the risk for burnout and post-traumatic stress disorder. 
    • Capacity
      Adequate capacity is a key factor to workforce. The assessment should identify the number of qualified workforce available for in-person staffing. In the current labor market, it will also be important to consider including the identification of the number of qualified staff able to work remotely. If states would like to consider remote capabilities for the call centers, it will also be important to assess the available technology necessary, as well as the development of standards and expectations, including strong communication. 
  • Readiness of the crisis care continuum
    Apprehension about the readiness of the crisis care continuum (e.g., mobile crisis teams through diversion services and lower levels of care) exist. Federal officials have stated they expect up to 12 million calls/texts/chats in the first year of the 988 Suicide & Crisis Lifeline, and research suggests approximately 20% of those calls/texts/chats will require some level of in-person response. States are questioning whether mobile crisis teams are prepared for the increased demand while also identifying connections and access to upstream services. In addition, states can consider the needs and experiences of the system’s end users to help address equity. The assessment can help to assess the readiness of the various components across the crisis care continuum.

Establish a strategic plan of action to implement the 988 Suicide & Crisis Lifeline 

With the implementation of the 988 Suicide & Crisis Lifeline, state agencies have an opportunity to strengthen crisis care. The best way to begin strengthening crisis care is to develop and implement strategic plans that optimize the 988 Suicide & Crisis Lifeline and the following services. Building on the strengths and opportunities identified in the needs assessment and the associated recommendations, strategic plans can establish priorities and identify sustainable solutions that build capacity, promote equitable access to care, and promote continuous quality improvement. Collaborating with key stakeholders to develop a strategic plan can help identify a roadmap for how the state should approach the implementation, maintenance, and sustainability of the 988 Suicide & Crisis Lifeline, including, but not limited to, the following areas:

  • Data and performance management
  • Stakeholder engagement
  • Health equity
  • Voice of the customer
  • Financial sustainability

Maximize available funding streams

Historically, behavioral health has not had sufficient funding to adequately address mental health and substance use disorder prevention, treatment, and recovery services across the continuum of care. The COVID-19 pandemic exacerbated behavioral health challenges for many individuals struggling and highlighted the challenges with the infrastructure and workforce. In the last couple of years, the federal administration has continued to allocate additional funding to supplement existing and ongoing federal funding. States should begin by evaluating the existing federal funding opportunities to support the implementation of the 988 Suicide & Crisis Lifeline. According to the Substance Abuse and Mental Health Services Administration’s (SAMHSA) 988 Convening Playbook for States, Territories, and Tribes, below are a few examples of funding sources that can be leveraged for the implementation of the 988 Suicide & Crisis Lifeline. 

  • SAMHSA 
    • Transformation Transfer Initiative
    • Community Mental Health Services Block Grant
    • Substance Abuse and Treatment Block Grant
    • Mental Health Block Grant Set-aside
    • State Opioid Response Grant
    • Tribal Opioid Response Grants
  • American Rescue Plan Act (ARPA) of 2021—for Mobile Crisis and Crisis Line Services
  • Medicaid
    • Early, Periodic, Screening, Diagnosis, and Treatment (known as EPSDT)
    • 1915(a) waivers
    • 1915(b) waivers
    • 1115 SMI/SED Service Delivery Waiver

The implementation of the 988 Suicide & Crisis Lifeline is critical to supporting the community and meeting their needs at a time where they need community support the most. If you have any questions, please contact BerryDunn’s behavioral health consulting team. We’re here to help.

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Components of successful implementation of the 988 Suicide and Crisis Lifeline

Read this if you are at a state Medicaid agency.

The uncertainty surrounding the end date of the COVID-19 Public Health Emergency (PHE) has made it difficult for state Medicaid agencies to plan and prepare to transition to pre-pandemic operations. Upon the federal declaration of the PHE, states and territories were forced to react quickly to reduce the impact on the Medicaid program and its enrollees. Many states and territories took advantage of the emergency authorities through the Centers for Medicare and Medicaid Services (CMS) to implement temporary policy changes such as the removal of prior authorization requirements, increased payments to providers, removal of cost-sharing, and the expansion of telehealth services. 

While many of the emergency authorities will terminate on or around the end of the PHE, states and territories may elect to make those temporary changes permanent due to the positive impact for both enrollees and providers. Take telehealth, for example. The broad flexibilities allowed during the PHE permitted providers to meet the healthcare needs of enrollees in a time where in-person visits were not recommended, nor available. To increase access to testing and vaccinations in pharmacies, pharmacy technicians and interns were permitted to administer COVID-19 vaccinations when supervised by an immunizing pharmacist.

So what comes next for states and territories once the PHE ends? Taking a proactive approach to plan out next steps will assist states and territories to be better prepared upon conclusion of the PHE. The US Department of Health and Human Services (HHS) has committed to providing at least a 60-day notice prior to the official end date of the PHE. CMS encourages states and territories to communicate changes to enrollees, managed care plans, counties, providers, and other stakeholders.

As we await the declared end date of the PHE or notification of another extension, states and territories can begin taking actions to prepare for the resumption of normal operations. We have learned new ways to prevent disruptions in meeting the needs of enrollees, developed enhanced methods of communication to stay in touch, and used technology to its fullest capacity. While our new normal is very different than pre-pandemic times, we can all use what we have learned to strengthen our tactics for any future PHEs. BerryDunn is here to assist and support states and territories as they prepare for the eventual end of the PHE.

If you have questions or would like to discuss further, please contact the Medicaid consulting team. We're here to help. You can also read more BerryDunn articles on the PHE unwinding here.

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Looking beyond the Public Health Emergency: What's next for states