In a new report, CMS summarizes the results of the Medical Loss Ratio (MLR) data submitted by health insurance companies to CMS for group and individual market health insurance coverage in 2016. The MLR Provision, or 80/20 Rule, of the Patient Protection and Affordable Care Act applies to health insurance companies providing coverage to almost 75 million consumers who have health insurance coverage either through their employer (the group market) or by purchasing their own health insurance (the individual market).
Some key findings of the report include the following:
In 2016, health insurance companies paid approximately $447 million in rebates;
Employers received approximately $153 million in rebates in the small group market and $191 million in rebates in the large group market, while consumers received approximately $103 million in rebates in the individual market;
Rebates paid for 2016 will benefit approximately 3.9 million consumers across all three markets; and
The average rebate per person is $114 in the individual market, $109 in the small group market, and $116 in the large group market.
SAMHSA Publishes Final Rule Adjusting 42 CFR Part 2 Substance Use Disorder Privacy Protections
At the beginning of January, the Substance Abuse and Mental Health Services Administration (SAMHSA) published a final rule which adjusts regulations around confidentiality of substance use disorder (SUD) patient records. The changes focus on creating an option for an abbreviated notice designed for use in electronic health records, as well as circumstances under which lawful record holders and their contractors may disclose patient identifying information.
Disclosures may be used to support a number of activities focused on payment and healthcare operations. In a change from the NPRM, SAMHSA declined to codify a list of permitted activities in regulation, and instead provides an illustrative list in the preamble. However, SAMHSA explicitly states in the preamble and in regulatory text at Section 2.33(b) that disclosures to contractors, subcontractors, and legal representatives are not permitted for substance use disorder patient diagnosis, treatment, or referral for treatment.
SAMHSA also notes that while it has attempted to align Part 2 privacy rules with those under the HITECH Act and HIPAA, the statutory frameworks differ substantially enough to require different regulatory approaches. It may revisit HIPAA alignment issues in future rulemaking.
The rule is effective February 2, 2018, and contracts between legal record holders and their subcontractors must be modified within two years of that date.
Proposed Settlement Reached in Original CSR Payment Case
In December, the Trump Administration, House of Representatives, and Democratic attorneys general from 17 states and the District of Columbia filed a proposed settlement agreement with the U.S. Court of Appeals for the District of Columbia Circuit in the case regarding the legality of the Affordable Care Act’s (ACA) cost-sharing reduction (CSR) payments. As background, the case began in 2014 when the House of Representatives sued the Obama Administration asserting that it was unconstitutional for the White House to fund CSR payments without an appropriation from Congress. A federal District Court judge originally ruled in favor of the House of Representatives and the Obama administration appealed. When President Trump took office, his administration placed the appeal on hold and subsequently ceased to fund the CSR payments. In August 2017, the U.S. Court of Appeals for the District of Columbia Circuit granted a motion by Democratic attorneys general in 17 states and D.C. to intervene in the case.
The settlement proposes to vacate the previous ruling by the District Court and also would allow a separate lawsuit against the Trump Administration that was filed in October in California federal court to proceed. That lawsuit, brought by 19 Democratic attorneys general, sought to compel the Administration to continue making the CSR payments. In that case, the states’ request for a temporary injunction was denied.
The settlement has no immediate impact on what will happen to the CSR program. That will be decided by the pending lawsuit in California and/or by Congressional action that could come as early as this week if CSR funding is addressed as part of the Continuing Resolution process.
HHS Request for Information (RFI): Promoting Healthcare Choice and Competition Across the United States
The U.S. Department of Health & Human Services (HHS) is actively working to promote choice and competition, and reduce regulatory burden, throughout healthcare markets. Executive Order 13813, “Promoting Healthcare Choice and Competition Across the United States”, directs the Administration, to the extent consistent with law, to facilitate the purchase of insurance across State lines and the development and operation of a healthcare system that provides high-quality care at affordable prices for the American people, and to promote competition in healthcare markets and limit excessive consolidation throughout the healthcare system.
Executive Order 13813 also requires the Secretary of HHS, in consultation with the Secretaries of the Treasury and Labor and the Federal Trade Commission, to provide a report to the President detailing the extent to which existing State and Federal laws, regulations, guidance, requirements, and policies fail to conform to the above policies, and identify actions that states or the Federal Government could take to achieve them. Through this informal request for information, HHS seeks comment from interested parties to inform its report and lay the groundwork for future action.
CMS Approves First 10-Year Section 1115 Demonstration Extension
On December 29th, CMS approved for Mississippi the first ever 10-year extension under the Medicaid program demonstration extension to provide further coverage of family planning services in the state. This will extend eligibility for women and men ages 13 through 44, with income up to 194 percent of the federal poverty level (FPL) that are not enrolled in Medicaid, Medicare, the Children’s Health Insurance Program (CHIP) or other creditable health insurance coverage that includes family planning services. Mississippi’s waiver will be the 25th demonstration action approved by CMS since January 21, 2017.
“This is the first ten-year demonstration extension in the history of CMS, and allows Mississippi to administer its Medicaid program without the inconvenience of obtaining routine approvals from CMS,” said CMS Administrator Seema Verma. “This action shows our continuing commitment to giving states the flexibility they deserve to meet the unique needs of their people.”
CMS has instituted a series of improvements to reduce regulatory burdens, increase efficiency and promote transparency in the review and approval of Section 1115 demonstrations. In accordance with the new section 1115 policy released on November 6, 2017, Mississippi’s program meets all elements required for a 10-year approval. Other changes made to the demonstration’s Special Terms and Conditions (STCs) for this approval also align with this Administration’s priority to assure adequate federal oversight and evaluation:
On an annual basis, the state will submit monitoring reports and participate in calls with CMS.
The state will have a new streamlined template for annual monitoring and reporting while ensuring that CMS receives the appropriate information for assessing demonstration outcomes.
For more information regarding the 10-year extension of the Mississippi Family Planning Demonstration, please click here.
For more information on the new Section 1115 process improvement please click here.
CBO Revises Score for CHIP Package as Funding Negotiations Continue
Earlier yesterday, the Congressional Budget Office (CBO) issued a revised score of the CHIP policy agreed to by the Senate and passed in the House. CBO’s updated score, which accounts for the repeal of the individual mandate in the tax reform package signed into law late last year, sets the spending for the CHIP package at $0.8 billion, as opposed to the previous estimate of $8.2 billion. As a reminder, that policy framework would:
Fund CHIP through FY 2022;
Maintain the ACA’s enhanced CHIP 23 percentage point FMAP in 2018 and 2019, lower the enhanced CHIP FMAP to 11.5 percentage points in 2020, and return CHIP to its normal FMAP in FY 2021 and 2022; and
Beginning in 2020, eliminate CHIP maintenance of effort requirements for beneficiaries above 300% FPL.
While the reduced CBO score could allow an easier path forward for CHIP, it remains to be seen whether CHIP will be resolved as part of ongoing FY 2018 funding negotiations or acted upon separately. In the December 22 continuing resolution (CR) Congress passed before leaving for the holidays, $2.85 billion was appropriated to fund CHIP through the end of March 2018 – though the overall CR funding expires on January 19. Theoretically, this could allow Congress to separate CHIP from other required spending, though the appropriated amount is unlikely to be sufficient for program needs through March.
Observers currently see two scenarios for CHIP, each contingent on the status of these wider spending debates. In one scenario, CHIP is included in an omnibus spending bill that is passed either on or before January 19. This scenario would require agreement on several other issues, including immigration policies and spending caps on defense and other domestic programs. In the second scenario, an omnibus fails to emerge and Congress may pass another short-term CR, and again face a spending showdown in mid-February or March, with CHIP as a potential component of that deferred conversation.
SAVE THE DATE: January 9 SFC Confirmation Hearing for Alex Azar to Head HHS
This week, the Senate Finance Committee announced that it will hold a confirmation hearing to consider the nomination of Alex Azar to lead the U.S. Department of Health and Human Services. The hearing will take place on Tuesday, January 9, at 10:00 a.m. ET, and can be viewed live on the SFC website here.
SAVE THE DATE: January 9 Senate HELP Hearing to Examine Opioid Crisis
This week, the Senate Health, Education, Labor, and Pensions (HELP) Committee will hold a hearing titled “The Opioid Crisis: An Examination of How We Got Here and How We Move Forward.” The hearing will take place on Tuesday, January 9, at 10:00 a.m. ET, and can be viewed on the HELP website here.
In the News
The Hill: “White House – Trump Hasn’t Shifted on Cutting Entitlements” In a recent article, The Hill reported that President Trump has not changed his mind on protecting entitlement programs from funding cuts, said White House press secretary Sarah Huckabee Sanders. “The president hasn’t changed his position at this point,” she said at a White House briefing, adding that conversations with lawmakers are ongoing. Speaker Paul Ryan (R-WI), meanwhile, has said: “We’re going to have to get back next year at entitlement reform, which is how you tackle the debt and the deficit.” Medicare and Medicaid “are the big drivers of debt,” Ryan said, “so we spend more time on the health-care entitlements, because that’s really where the problem lies, fiscally speaking.”
New York Times: “‘Forget about the Stigma’: Male Nurses Explain Why Nursing is a Job of the Future for Men”
Only 13% of nurses in the United States are men, but that share has grown steadily since 1960, when the number was 2%, according to a working paper published in October by the Washington Center for Equitable Growth. The growing number of male nurses is not necessarily “a flood, but it’s a change,” said Abigail Wozniak, an economist at the University of Notre Dame, who wrote the paper with Elizabeth Munnich, an economist at the University of Louisville. The biggest drivers behind the increase in male nurses, they found, were the changing economy and expanding gender roles.
Following this working paper, the New York Times talked to a dozen male nurses, with various career paths and specialties, working in the Pacific Northwest, where recruitment efforts have focused on bringing men into nursing. The men were drawn to a variety of aspects of nursing, from the caregiving opportunities to the adrenal rush of working in a high-paced environment. In the words of the Times, “It’s a reliable, well-paying job at a time when that’s hard to come by…but also one they feel proud of.”
To learn more about these male nurses, please click here.
Stat: “Drug Makers Dodged $1.3 Billion In Payments to Medicaid, Report Finds”
According to a new report from the Health and Human Services Department’s independent inspector general (OIG), drug makers dodged more than $1.3 billion in Medicaid drug rebates between 2012 and 2016 because they inappropriately or mistakenly mis-categorized brand-name products as generics, which qualify for lower rebates. Some $1.17 billion of that figure was associated with mis-categorizations for just two drugs. Had the 10 most expensive of the drugs been classified appropriately, reveals OIG, state Medicaid programs would have saved that $1.3 billion figure. Instead, they collected just $199 million for those drug rebates.
To learn more, please click here. A writeup on the OIG report can also be found below under “Take Note.”
New York Times: “Opioid Deaths Are Spreading Rapidly into Black America”
America’s epidemic of drug overdoses, often perceived as a largely white rural problem, made striking inroads among black Americans last year, leaping by 41% in urban counties, writes the New York Times. This was particularly true in urban counties where fentanyl (including fentanyl-laced cocaine) has become widespread; African American individuals aged 45-64, moreover, were the hardest hit. The data suggest that the common perception of the epidemic as an almost entirely white problem rooted in over-prescription of painkillers is misleading and problematic.
Health experts say our evolving understanding of the crisis will likely mean slow progress, despite stepped-up efforts to address it with medication-assisted treatment and naloxone.
Los Angeles Times: “Infection Lapses are Rampant in Nursing Homes but Punishment is Rare”
Basic steps to prevent infections, such as washing hands and isolating contagious patients, writes the Los Angeles Times, are “routinely ignored in the nation’s nursing homes, endangering residents and spreading hazardous germs.” Over the past four years 74% of nursing homes have been cited for lapses in infection control – more than for any other type of health violation. Furthermore, disciplinary action is rare: Nationwide, only 1 of 75 homes found deficient in those four years has received a high-level citation that can result in a financial penalty. “The facilities are getting the message that they don’t have to do anything,” said Michael Connors of California Advocates for Nursing Home Reform, a nonprofit in San Francisco. “They’re giving them low-level warnings year after year after year and the facilities have learned to ignore them.”
Politico’s Podcast: Pulse Check with FDA Commissioner Scott Gottlieb
In a recent issue of Pulse Check, Politico sat down with FDA Commissioner Scott Gottlieb to discusses his agency’s work, why he took the job, and what lies ahead in 2018. In a follow-up panel discussion, Some of the following issues were discussed:
The FDA’s nutrition policy and its role in keeping food safe;
Whether FDA is approving too many drugs;
The ongoing crisis in Puerto Rico and the effect on medical product development; and
The FDA’s tobacco strategy.
To listen to the full conversation, please click here.
NEJM: The Public and the Opioid Abuse Epidemic
Over the past year, the U.S. opioid-abuse epidemic has gained enormous visibility. President Donald Trump has identified it as a “public health emergency,” and a national commission and a commission of state governors have issued recommendations for action. This concern stems from the fact that in 2016 more than 11 million Americans misused prescription opioids, and opioid-related deaths have more than quadrupled since 1999. To determine what the public believes should be done to address the epidemic, Robert J. Blendon, Sc.D., and John M. Benson, M.A. examined data from seven national polls conducted in 2016 and 2017. In a perspective piece in the New England Journal of Medicine, Blendon and Benson reveal several key findings, including:
A majority of the public considers addiction to prescription pain medication a major problem nationally (53%) but does not deem it a national emergency (28%).
In a list of national health problems, abuse of prescription painkillers ranks fifth in the proportion of the public that considers it an extremely serious disease or health condition facing the country.
The public is divided over which level of government bears the most responsibility generally for fighting addiction to prescription pain medicine: 36% said the federal government was most responsible, followed by state (28%) and local (21%) governments.
Only 27% believe Trump’s proposed response to the opioid crisis does too little, while 10% believe it does too much and 41% believe it’s “about right.”
Asked who is mainly responsible for the growing problem, the public placed the most blame on doctors who inappropriately prescribe painkillers (33%) and people who sell prescription painkillers illegally (28%).
MACPAC Releases 2017 Edition of Medicaid and CHIP Data Book
The Medicaid and CHIP Payment and Access Commission (MACPAC) released the 2017 edition of MACStats, a resource that compiles the most recent data on Medicaid and CHIP. It includes statistics across a wide range of Medicaid and CHIP issues. It divides the data into six key sections:
An overview of key Medicaid and CHIP statistics;
Trends in spending, enrollment and share of state budgets;
Medicaid and CHIP enrollment and spending by state, service category and eligibility group;
Medicaid and CHIP eligibility;
Measures of beneficiary health, use of services, and access; and
OIG Finds That Potential Misclassifications Reported by Drug Manufacturers May Have Led to $1 Billion in Lost Medicaid Rebates
In this report, OIG compared manufacturer-reported classifications for drugs in the Medicaid rebate program to drug information in Food and Drug Administration (FDA) files. OIG determined the Medicaid drug classifications that matched FDA’s, and those that did not match, i.e., were potentially misclassified, in 2016; estimated the rebate amounts that Medicaid may have lost from 2012 to 2016 for the 10 potentially-misclassified drugs with the highest total reimbursement in 2016; and reviewed CMS’s policies and procedures for ensuring appropriate oversight of data submitted to the Medicaid rebate program.
The vast majority of the approximately 30,000 drugs in the Medicaid rebate program, OIG found, were classified appropriately. However, they also found that manufacturers may have misclassified 885 of these drugs (3%) in 2016 and that between 2012 to 2016, Medicaid may have lost $1.3 billion in base and inflation-adjusted rebates for 10 potentially-misclassified drugs with the highest total reimbursement in 2016.
Going forward, OIG recommends that CMS:
Follow up with manufacturers associated with potentially-misclassified drugs identified in this report to determine whether current classifications are correct;
Improve its Drug Data Reporting for Medicaid System to minimize inconsistent data submissions and track potential classification errors for follow-up; and
Pursue a means to compel manufacturers to correct inaccurate classification data reported to the Medicaid rebate program. CMS concurred with all three recommendations.
New KFF Resource Tracks Developments in States’ Section 1115 Medicaid Waivers
On March 14, 2017, CMS sent a letter to state governors signaling a willingness to use Section 1115 authority to support work requirements and the alignment of Medicaid programs with private insurance policies. Later in November 2017, CMS posted revised criteria for Section 1115 waiver demonstrations. At this time, a number of states have waivers pending at CMS that include provisions not previously approved including work requirements, drug screening and testing, eligibility time limits, and premiums with disenrollment for non-payment for traditional Medicaid populations. Some of the requests are part of ACA expansion waivers, while others would apply to traditional populations.
A new map from the Kaiser Family Foundation tracks states with approved Section 1115 Medicaid waivers and pending waivers (which include new waiver applications, waiver amendments, and renewals). Visitors can use the dropdown box to view approved and pending waivers according to waiver category.
The map, as well as additional KFF waiver resources, can be found here.
Urban Institute: Work Requirements in Safety Social Net Programs
For the first time in the Medicaid program’s 50-year history, work requirements are being seriously contemplated for the program. CMS signaled its openness to considering work requirements as a condition of Medicaid eligibility in a letter to governors in March 2017. Since that time, eight states have submitted waiver requests to CMS that include work requirements, and the CMS administrator recently indicated that the agency plans to “approve proposals that promote community engagement activities,” such as “working, volunteering, going to school or obtaining job training.”
In a new report, the Urban Institute presents information on the work requirements currently in use in TANF, SNAP, and some federal housing assistance programs and discusses the available evidence on implementation experiences and impacts. It also describes Medicaid waiver requests currently under consideration at CMS that would include work requirements. It closes by highlighting key questions for consideration when assessing the use of work requirements in safety net programs.
The New England Journal of Medicine (NEJM) recently published an opinion piece in which the authors present a potential framework for evaluating whether health policies are evidence-based. The authors argue that such a framework for evidence-based health policy could focus the current health policy debate on the most promising policy approaches. They suggest that evidence-based policy has three characteristics: policies are well-specified; one can distinguish between policies and goals; and there is evidence of the magnitude of the effects of the policy.
The Integrated Care Resource Center (ICRC) helps states to develop integrated programs that coordinate medical, behavioral health, and long-term services and supports for individuals who are dually eligible for Medicare and Medicaid. Following is a list of resources produced by ICRC in 2017:
The Missouri Department of Social Services is searching for a Director for our MO HealthNet Division. The MO HealthNet Division is the division within the Medicaid single state agency that administers Missouri’s medical assistance programs that purchase and monitor health care services for low income and vulnerable citizens of Missouri.
Below is a full job description for the position, as well as information about Jefferson City. The deadline to apply is January 26, 2018.
Indiana Posting for Pharmacy and Clinical Outcomes Director
The mission of Indiana’s Family and Social Services Administration is to develop, finance, and compassionately administer programs to provide healthcare and other social services to Hoosiers in need in order to enable them to achieve healthy, self-sufficient, and productive lives. As part of the Family and Social Services Administration, the Indiana Office of Medicaid Policy and Planning (OMPP) receives around 13 percent of the state’s budget to ensure vital healthcare coverage for approximately 1 in 5 Hoosiers. This position is responsible for:
Effectively administering the state’s pharmacy benefits for 1.4 million Medicaid members;
Coordinating population health strategies and integrating novel programmatic interventions that will help contain the cost of drugs and improve member health outcomes;
Helping OMPP achieve its mission by effectively promoting population health improvements that have long-term cost containment benefits, which ensures sustainability of the program and longer, healthier lives for vulnerable Hoosiers.
The North Carolina Division of Medical Assistance (DMA) manages health care services for the most vulnerable North Carolina residents. With a budget of nearly $14 billion, DMA serves about 2 million low-income parents, children, seniors, and people with disabilities through the NC Medicaid and NC Health Choice for Children programs.
The North Carolina Division of Medical Assistance is seeking a Chief Medical Officer (CMO). This position functions as a key member of the Division Executive Team, providing input into policy decisions and medical leadership to all Medicaid sections and initiatives, with the goal of promoting the delivery of high quality services within a sustainable budget. The position will also have management responsibilities. The CMO will interact on a regular basis with Pre-Paid Health Plans (PHP) and Local Management Entities/Managed Care Organizations (LME/MCO) medical directors and clinical and non-clinical staff in other state agencies including the Division of Public Health, Division of Mental Health, Intellectual & Developmental Disabilities, and Substance Abuse, and others as needed. Other key responsibilities include analysis of proposed legislation and testimony at legislative committee meetings, input on state-related payment reform, leadership on Social Determinants, and serving as a liaison to the healthcare provider community.