*Many healthcare providers would be compelled to make preparations for major emergencies (such as weather disasters or epidemics) as a condition for getting Medicare and Medicaid reimbursement. Current federal rules don’t require even minimal preparations for such disasters.
*Providers covered by the proposed rule would have to conduct regular disaster drills, plan for maintaining services during power failures and create systems to track and care for displaced patients.
Ashley Thompson, a senior vice president at the American Hospital Association, told The New York Timesthat the AHA generally agrees with the proposal, but wants Medicare to align its requirements with crisis-preparedness standards developed by such other bodies as the Joint Commission.
In HealthAffairs, Timothy Jost looks at the healthcare elements of President Obama’s proposed budget for 2017, which includes “new initiatives to increase access to mental-health care, expand opioid-abuse treatment, fight antibiotic resistance, address the Zika virus threat and fund a ‘cancer moonshot.”’
He writes: “To control Medicare spending, the budget proposal would reduce the target growth rate for Medicare enforced by the Independent Payment Advisory Board {IPAB} to 0.5 percentage points above per-capita GDP growth. It also contains a host of Medicare payment and delivery reform proposals.”
Regarding private insurance, one proposal “would attempt to curb surprise balance bills by out-of-network providers by requiring hospitals to take steps to match patients with in-network providers and requiring physicians who regularly provide services in a hospital to accept an appropriate in-network rate as payment in full.
“Another proposal would allow HHS {Department of Health and Human Services} to develop uniform definitions and principles for standardizing medical billing and making it more transparent. Self-insured non-federal governmental plans would be prohibited from opting out of various federal consumer protection laws, such as the Mental Health Parity Law.”
Mr. Jost notes that “{T} budget request of a president in his final year of office ….is unlikely to lead to enacted legislation. Congress in unlikely to expand the authority of the IPAB or increase funding for the Medicaid expansions. But many of the expenditures identified in the budget—for the risk adjustment, reinsurance, premium tax credit, and (subject to the court decision in House v. Burwell) cost-sharing reduction payment programs—are mandated by law and are unlikely to be changed by Congress.”
“Despite the momentum, there are still plenty of gaps and question marks when it comes to telehealth policy. The 21 states without a parity {on provider reimbursement} law aren’t uniformly liberal or conservative. Kansas, South Carolina and Utah don’t have one, but neither do Illinois or Pennsylvania. Massachusetts, a state known for progressive healthcare policies, doesn’t have a parity law. It currently only covers telemedicine under Medicaid with certain managed care plans, and not for fee-for-service payments.
“Even among states that do have parity laws, the patchwork of policies can vary widely from one state to the next. Texas, for example, requires insurers to cover telehealth, but it mandates that a patient’s first appointment with a new doctor must be an in-person visit. Within Medicaid programs, about half of the states require that a patient be in a medical facility for telehealth appointments, rather than at home. The differences among states can be frustrating for telemedicine providers. Kofi Jones, vice president of public relations and government affairs for the telehealth company American Well, says she has 30 binders in her office filled with state-by-state regulations and legislation. …”
“Traditional health-care providers can be slow to integrate new technology. After all, almost half of doctor’s offices polled in 2013 still used paper records, according to a survey from the U.S. Department of Health and Human Services. Other recent surveys have found that only 2 percent of patients nationwide have access to video visits with their primary care physician. Less than half — 45 percent — even receive a traditional phone appointment reminder.”
Arkansas Gov. Asa Hutchinson is working with federal officials in Washington to negotiate the future of the state’s Medicaid expansion program, which leading Republicans say could be killed if it’s not changed.
No state has seen its uninsured rate fall faster since the implementation of the federal health law than Arkansas, where it has fallen more than half, to 9.1 percent, from 2013 to 2015. Most of the credit goes to the state’s decision to expand eligibility for Medicaid, which has provided coverage for around 250,000 low-income Arkansans who make up to 138 percent of the federal poverty level — about $16,000 for an individual and $33,000 for a family of four.
However, in a red state like Arkansas, dominated by anti-Obamacare lawmakers, the future of the expansion is politically tenuous. In 2013, Democratic Gov. Mike Beebe worked with a Republican-controlled legislature to craft a bipartisan compromise that became known as the “private option”: The state received a waiver from federal rules to use Medicaid funds to purchase private health insurance plans for most newly eligible beneficiaries, rather than placing them in the traditional Medicaid program.
That waiver expires at the end of 2016, and Hutchinson — Beebe’s Republican successor — is now seeking additional GOP-friendly tweaks to the program. Legislators are watching closely.
“My read on the politics is that if the federal government does not consider out-of-the-box and unprecedented measures, there’s a high likelihood that it’s not going to have the political support to get through the Arkansas legislature,” warned Republican state Sen. Jim Hendren, chairman of the state’s health reform task force (and the governor’s nephew).
Haggling with federal officials over what is allowed in the Medicaid program has become a familiar dynamic in GOP-controlled states across America. Since the 2012 U.S, Supreme Court ruling that upheld the Affordable Care Act but gave individual states the choice on whether to expand Medicaid, 31 states and the District of Columbia have accepted federal money to expand the program. Nineteen states have declined, leaving an estimated 3 million people in a coverage gap because they don’t qualify for Medicaid or subsidies to buy private policies on the Obamacare exchanges.
In addition to Arkansas, leaders in Iowa, Indiana, Michigan, Montana, and New Hampshire have negotiated waivers to expand Medicaid that have included Republican-backed policy ideas, such as privatized schemes, wellness and work programs, and “skin in the game” in the form of cost-sharing or premiums.
“CMS [the federal Centers for Medicare & Medicaid Services] wants states to do the Medicaid expansion, so they have rolled up their sleeves and tried to get to yes on all these agreements, without compromising the fundamental integrity of the Medicaid program,” said Joan Alker, executive director of Georgetown University’s Center for Children and Families and an expert on Medicaid waivers.
For reasons both philosophical and political, Hutchinson hopes to negotiate further alterations. After the governor’s one-day meeting with federal officials, they will likely continue to hammer out details in the coming weeks. If an agreement is reached, Hutchinson is expected to present it to the state’s health reform task force on Feb. 17.
Hutchinson calls his proposed new policy “Arkansas Works.” He described its framework — which would continue the expansion via purchasing private health care plans for beneficiaries — in a December letter to U.S. Secretary of Health and Human Services Sylvia Burwell.
Hutchinson’s main requests are to charge small premiums or other cost-sharing for some beneficiaries, encourage employment and healthy practices, and make more use of employer-sponsored insurance plans. Medicaid-eligible beneficiaries who are employed and are offered insurance at work would be required to enroll in those plans rather than Medicaid. The governor would have Medicaid pay the difference in costs to beneficiaries as well as provide any Medicaid benefits not offered by the employer plan.
Hutchinson has made clear that he would like to establish work requirements as a condition of eligibility, but the Obama administration won’t allow states to insist that beneficiaries have a job. The federal government is more flexible on ways to encourage employment, and under Arkansas Works, the state’s Department of Human Services would refer unemployed or underemployed beneficiaries to job training programs.
Certain beneficiaries, meanwhile, would be assessed premiums, likely around 2 percent of their income (at the poverty line, that amounts to $20 a month for an individual or $40 a month for a family of four). The governor envisions carrot-and-stick incentives to encourage healthy behavior. Those who follow practices such as visiting a primary care physician upon signing up could have their premiums waived; those complying with wellness and work referral requirements might also get additional vision and dental benefits not normally included under Medicaid.
“It’s a grab bag of the kinds of ideas that are being tossed around in the handful of states that are doing expansion by waiver,” Alker said. “The risk is creating barriers to access to care for beneficiaries and creating additional bureaucracy.” Most of the governor’s requests “are in the ballpark of the kinds of things CMS has been negotiating,” she said. “I think on most of those issues, they will find a way.”
Some requests from Hutchinson may not fly with the federal government. One is a fee that would be imposed on beneficiaries with substantial assets — such as a house valued at $200,000 or cash-equivalent assets of $50,000 or more — in order to stay enrolled. “The governor feels like that’s a common sense request, but there’s going to be a lot of pushback on that,” said Arkansas Surgeon General Greg Bledsoe. “We’re hoping to get maximum flexibility.”
Asset tests for most Medicaid beneficiaries were explicitly banned by the ACA and Alker said it was unlikely that federal officials would cave on this point.
Previously, Hutchinson backed another controversial idea, a punitive “lockout” provisionthat would bar beneficiaries from regaining coverage for six months if they failed to pay required premiums. The lockout provision is unmentioned in his letter to Burwell, however, and the governor has been cagey about whether it’s still a request on the table.
“We will not be a part of any provision that says you cannot have coverage because you are poor or because you can’t make a payment,” said Democratic state Rep. Reginald Murdock, a vice chairman of the state’s health reform task force. Murdock said that Democrats in the legislature were on board with the Arkansas Works framework as described in the letter to Burwell but would seek to block any changes to the private option that “undermined the tenets of the ACA.”
Whatever the governor and the federal government agree to, if the legislature doesn’t approve of the plan this spring, that won’t just threaten health insurance for hundreds of thousands of Arkansans. It will also stop the flow of federal money paying for their health care. Under the health law, the federal government pays all the costs of Medicaid expansion for three years, with the states paying a small share in the future.
According to a state consultant, ending the expansion would cost the state budget more than $400 million between 2017 and 2021 and cost hospitals $1 billion in uncompensated care expenses over the same period.
The state constitution requires a 75 percent majority of lawmakers in both chambers to approve continuing the expansion, a tall order for a controversial program. Hendren, who said he is prepared to walk away if he’s not satisfied, acknowledged that if the expansion is not continued that would lead to “pain in the budget, and there’s going to be a lot of people who are upset if we have to make cuts. There’s no question that the stakes are high.”
With the aging of the population and Medicaid and other health-insurance expansion under the Affordable Care Act, U.S. physician assistant compensation has risen to a median of almost $100,000 on average across the U.S. amid a nationwide shortage of physicians.
This CNBC article and video suggests that Medicaid expansion under the Affordable Care Act has so many constituents now that it will be very difficult to reverse, even in states that are now run by Republicans.
As the article notes the new patients now covered by Medicaid expansion generally like it. And so do hospitals, which now don’t have to cover so much uncompensated care
As CNBC notes: “A growing number of states have signed up for that expansion of the government-run program for poor people, or are discussing doing so. Hospitals are becoming accustomed to the money that comes with expansion, and a majority of new enrollees are saying they are happy with their coverage.
“The difficulty of getting rid of Medicaid expansion, which uses federal dollars to give health benefits to previously ineligible adults, was sharply underscored this fall by the election of ardent Obamacare foe Matt Bevin as governor of Kentucky.
“The Republican Bevin originally promised to repeal expansion of Medicaid in Kentucky, where about 400,000 have joined the Medicaid rolls since the Affordable Care Act was implemented. He since has backed away from that vow. Bevin most recently has talked about redesigning the state’s Medicaid program, but has not yet offered a plan.”
“I do think we’ve reached the tipping point,” Diane Rowland, executive vice president of the Kaiser Family Foundation, told CNBC. “It’s part of the fabric of our health-care system now.”
“I think there are still states that are strongly resistant to it, but I think the tide is beginning to sweep more states in,” she added.
This Navigant study looks at the biggest challenges facing providers and payers who must deal with Medicaid, which the consulting firm calls “the least understood, most complicated and significant program in the U.S. health system.”
The study discusses:
“Securing funding for programs and services.
“Getting and keeping competent managers.
“Building and improving efficient operations.
“Building and maintaining healthcare provider participation and support.
“Innovating clinical processes and payment strategies.
Herewith an interview with Marilyn Tavenner, the former CMS administrator who last year took over the leadership of America’s Health Insurance Plans, that industry’s leading lobbyist.
She talks about such challenges as getting UnitedHealth Group, the largest health insurer in the nation, and Aetna back into AHIP, as well as expanding Medicare Advantage membership, improving Medicaid managed care, the increasingly hot issue of pharmaceuticals pricing and healthcare delivery-system reform.
In 2014, Maryland started to regulate hospital spending after nearly four decades of setting hospital prices for all payers, public and private.
“The state started setting hospital rates for private payers in 1974 and three years later won permission from the federal government to also set rates under Medicare and Medicaid. Maryland policymakers say that move has erased the cost-shifting that most U.S. hospitals rely on to make up for low rates from public payers,” Modern Healthcare reported.
“Although the all-payer model allowed Maryland to significantly reduce its costs per admission, growth in the volume of admissions undermined its broader success in holding down spending.”
“So in 2014, Maryland agreed to set a budget for each hospital for all patients. The budget includes payment from every insurer. The state also promised that the budget would not grow faster than the state economy each year. A commission tracks hospital bills, hospital prices and patient volume. It also makes complex adjustments to account for very sick patients, transfers between hospitals, flu outbreaks and other factors that can increase or decrease demand for hospital services,” the publication reported.
But do other states have the political will to make such dramatic changes?
Oregon coordinated care organizations cut admissions and emergency department use for several costly conditions, according to a new report from the Oregon Health Authority that examined the outcomes of 16 CCOs.
Oregon’s CCOs are networks of healthcare providers that work together to serve patients covered under the Oregon Health Plan (Medicaid). They focus their efforts on prevention and helping patients manage chronic conditions like diabetes.
The latest report examined outcomes between July 2014 and June 30, 2015. It found:
The all-cause readmissions rate fell to less than 10 percent from nearly 13 percent in 2011; that’s below the state’s 10.5 percent benchmark.
Use of emergency rooms fell 23 percent from 2011’s baseline.
Admissions for short-term diabetes complications fell 32 percent.
Admissions for chronic obstructive pulmonary disease in patients 40 and older plunged 68 percent.
But as FierceHealthcare noted: “Among Medicaid beneficiaries with severe mental illnesses, ED use remains far higher than the declining statewide rate of overall ED use.”
“Oregon will continue to monitor this metric to determine if additional community services made possible by recent investments lead to a decreased utilization of emergency departments for individuals with severe and persistent mental illness,” the report states.
Fierce also noted that ED use “remained higher than statewide averages for disabled patients in general, mirroring the national trend, which the report suggests can be improved through timely follow-up after hospitalization.”
