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In the NAMD newsletter this week we cover Medicaid Quality Measures; the House-passed AHCA; opioids and prescription drugs.

May 9, 2017
In This Issue

2017 NAMD Fall Meeting
November 6-8, 2017
Hyatt Regency Crystal City


Reg Update


Funding Opportunity Announcement (FOA): National Institute on Drug Abuse, Expanding Medication Assisted Treatment (MAT) for Opioid Use Disorders in the Context of the SAMHSA Opioid STR Grants
There are several effective, FDA-approved medications for opioid use disorder (OUD) including methadone, buprenorphine/naloxone, buprenorphine, and naltrexone. Too often, however, these medications are not available to patients in a context that meets their clinical needs. The purpose of this FOA is to solicit applications/proposals to test approaches for expanding MAT for OUD in the general health care sector, or linking individuals to MAT in the context of states’ plans for use of the funds authorized under the 21st Century Cures Act.


For more information, please click here. Applications are due by June 20, 2017.
Presidential Executive Order Promoting Free Speech and Religious Liberty
In a broad executive order issued last Thursday, May 4th, President Trump has directed the Department of Health and Human Services (HHS), the Department of the Treasury, and the Department of Labor (DOL) to consider issuing amended regulations in order to address conscience-based objections to the Affordable Care Act (ACA) mandate regarding first-dollar preventive coverage for women’s services, including contraception. Following the order, HHS Secretary Tom Price, M.D., spoke approvingly, stating, “Religious liberty is our country’s first freedom. Americans of faith play a vital role in caring for our most vulnerable citizens, including the elderly and the poor…We welcome today’s executive order directing the Department of Health and Human Services to reexamine the previous administration’s interpretation of the Affordable Care Act’s preventive services mandate, and commend President Trump for taking a strong stand for religious liberty.”


To read the order, please click here


CMS Seeks Comments on Medicaid Quality Measure Concepts
As part of the Innovation Accelerator Program (IAP), the Centers for Medicare and Medicaid Services (CMS) started a three-year quality measure development effort. This effort is aimed at filling quality measurement gaps by developing new measures or refining existing ones for Medicaid beneficiaries. CMS will be seeking public input on three new measure concepts over the coming weeks and is posting information about them online here. The measure concepts include:
  • Use of pharmacotherapy for opioid use disorder. The comment period for this measure concept is open until May 10, 2017, and input may be submitted to
  • All-Cause Inpatient Admission Rate for Medicaid Beneficiaries with Complex Care Needs and High Costs. CMS anticipates that the comment period for this measure will be open from April 24 – May 12, 2017. Comments may be submitted to
  • Stratification for Medicaid Beneficiaries with Serious Mental Illness: Proportion of Days Covered: 3 Rates by Therapeutic Category. CMS anticipates that the comment period for this concept will be open May 18 – June 9, 2017, and comments may be submitted to

Hill Update


House Passes AHCA; Senate Begins its Work on Health Reform

Last Thursday, House Republicans held a successful floor vote on the American Health Care Act (AHCA), approving the bill ( H.R. 1628) by a narrow 217-213 margin and advancing their effort to repeal and replace the Affordable Care Act. Following the vote, the House left Washington for a week long recess.

Shortly after AHCA passed the House, it became clear that the Senate plans to chart their own path forward on healthcare reform, rather than advancing the version drafted in the lower chamber. However, it is unclear if the Senate will completely start over in writing their own bill or use the House bill as a framework and make adjustments to garner votes. Experts predict the latter scenario is most likely.

To spearhead the Senate’s effort, Majority Leader Mitch McConnell has already assembled a 13-person intra-party working group representing different factions of the caucus – and the group has already met twice. The Working Group includes:
  • Senate leadership: Majority Leader Mitch McConnell (R-KY), Majority Whip John Cornyn (R-TX), GOP Conference Chairman John Barrasso (R-WY), and GOP Policy Committee Chairman John Thune (R-SD);
  • Key committee chairman: Finance Chairman Orrin Hatch (R-UT), Budget Chairman Mike Enzi (R-WY), and HELP Chairman Alexander;
  • Other working group members: Sens. Ted Cruz (R-TX); Mike Lee (R-UT); Rob Portman (R-OH); Cory Gardner (R-CO); Tom Cotton (R-AR); and Pat Toomey (R-PA).
It is expected to take a few weeks or more before the Senate brings their own version of the healthcare bill to the floor. Two key issues likely to emerge in the Senate process include:
  • Byrd Rule – A handful of policies in the House bill are not expected to comply with the Byrd Rule, which requires reconciliation legislation to contain solely budgetary provisions rather than policy changes. Some of these provisions could include: the provision allowing plans to charge older adults up to five times more than younger Americans; the penalty for not maintaining continuous coverage; and allowing states to adjust the ACA’s EHB package. These provisions could be stripped from the bill or subject to a ruling from the Senate Parliamentarian.
  • Medicaid – The phase-out of the ACA’s enhanced FMAP for states that expanded Medicaid to childless adults is expected to be a key sticking point. Several GOP lawmakers have already expressed concerns about the phase-out in the current version of the repeal legislation, two of which sit on the Senate working group. Sen. Portman is reportedly working on an amendment that would create a more gradual phaseout of the Medicaid expansion. While the Medicaid per-capital cap proposal is likely to stay, additional tweaks could be offered around populations exempted from the caps or the growth rate for federal spending.
The AHCA faces numerous procedural and political hurdles to become law. Republicans will need to reach near-unanimous consensus to pass their own version of the bill. And similar to the process in the House, any changes made to appease one constituency may just as easily alienate another. Moreover, the House will have to approve of any changes made by the Senate or resolve their difference in a conference committee.

In the News


How Does New York’s New Prescription Drug Spending Cap Work?
New York generally covers the cost of drugs under Medicaid, but prices have been rising due to “manufacturers attempting to generate windfall profits,” says Jason Helgerson, New York’s Medicaid Director. To counter the effects of ever-rising drug costs, the state has decided to cap how much the Medicaid program can increase spending on prescription drugs each year. The limit is based – in part – on the medical portion of the Consumer Price Index (currently between eight and nine percent spending growth). If the state is projected to go over the limit, says Helgerson, a new law would give New York “enhanced powers” to negotiate with drug companies via the Drug Utilization Review Board (DURB), which identifies a rebate amount that the company should give the Medicaid program, or, if that doesn’t work, “non-preferred” or “non-covered” classifications for fee-for-service and managed care patients, respectively.  Individuals, moreover, would continue to have the ability to appeal such decisions.
To learn more, please click here.
The Opioid Epidemic May Be Underestimated, CNN Reports
Experts say the United States is in the throes of an opioid abuse epidemic, causing 91 overdose deaths each day. Yet, the total number of opioid-related deaths may still be underestimated, suggests new research from the US Centers for Disease Control and Prevention. According to Dr. Victoria Hall, a CDC field officer based in Minnesota, it is difficult to track causes of death within surveillance systems that are obsoletely based on the International Classification of Diseases, Tenth Edition, or ICD-10. Deaths involving infectious disease like pneumonia, for example, are complicated if an individual has opioids in his/her system. In addition to affecting the immune system, opioids make people breathe shallower and slower, meaning they are less likely to cough and more debris is likely to settle in their lungs. Among the 32 pneumonia cases evaluated in the CDC study, for instance, nine of the deceased had a history of drug abuse, six had chronic pain, and one was taking methadone. The findings, says Hall, are “quite concerning, because it means that the (opioid) epidemic, which is already quite severe, could potentially be even worse.”
Please read article here.


Take Note


GAO Makes MACPAC Appointments, Designates Chair
Last Thursday, May 4th, Gene L. Dodaro, Comptroller General of the United States and head of the U.S. Government Accountability Office (GAO), announced the appointment of five new members to the Medicaid and CHIP Payment and Access Commission (MACPAC): Martha Carter, Frederick Cerise, Kisha Davis, Darin Gordon, and William Scanlon. Current member Penny Thompson has been named the Commission’s Chair.
 “The men and women named to the Commission,” said Dodaro, “bring diverse professional experiences and an impressive level of knowledge and expertise that will benefit the Commission as it advises Congress on Medicaid and CHIP.”
For brief biographies of the new commission members and the Commission Chair, please click this link.
GAO, Medicaid Managed Care: Compensation of Medicaid Directors and Managed Care Organization Executives in Selected States in 2015
This GAO audit examines what is known about the 2015 compensation of Medicaid Directors and top paid MCO executives in 10 states that offered comprehensive, risk-based managed care in 2015. It finds that the average salary for Medicaid Directors in 2015 in the 10 selected states was $152,439 (ranging from $103,020 to $260,08), compared to the $236,007 average salary (ranging from $110,740 to $1,904,431) paid to MCO executives in 7 of the states. In addition to their salary, MCO executives received supplemental compensation, such as bonuses, stock awards, and option awards, adding an average of about $78,271. Overall, the Medicaid Directors’ average salary was $84,645 less than the MCO executives’ average salary; this is despite the fact that the roles and responsibilities of Medicaid Directors are reportedly more complex and time consuming than those of MCO executives.
GAO’s findings are consistent with those of NAMD’s annual Operation Survey (cited in the audit), which found that Medicaid Directors made between $105,000 and $260,000, with an average of $152,518 and a median of $142,000 in FY2016.
To read the audit, please click here.
Commonwealth Report Explores Medicaid Expansion Impact on Uncompensated Care
Last week, The Commonwealth Fund released a report exploring the impact of the ACA’s Medicaid coverage expansion on hospital uncompensated care. The report finds that uncompensated care costs fell between 2013 and 2015, from 3.9 percent to 2.3 percent of hospitals’ operating costs. The study also examines how potential federal policy changes to the Medicaid expansion could impact this trend in uncompensated care.
The report is available here.
Kaiser Family Foundation, State Variation in Medicaid Per Enrollee Spending for Seniors and People with Disabilities
This issue brief by the Kaiser Family Foundation investigates the substantial variation among state Medicaid programs in the eligibility pathways and covered services for seniors and people with disabilities compared to other populations. It finds that:
  • Per enrollee spending for seniors and people with disabilities varies substantially by state.
  • Many age and disability-related coverage pathways (i.e., increasing eligibility above the SSI level, allowing working individuals with disabilities with income above eligibility limits to buy into Medicaid, etc.) are offered at state option, contributing to the variation among states in per enrollee spending for seniors and people with disabilities.
  • Variation among states in spending per enrollee for seniors and people with disabilities is influenced by different state choices about Medicaid-covered services, as most home and community-based long-term care services are offered at state option.
This variation carries substantial implications given the American Health Care Act’s proposal to restructure Medicaid financing and reduce federal funds under a per capita cap. A per capita cap could disproportionately affect seniors and people with disabilities, argues Kaiser.  Tying Medicaid spending levels to a base year under a per capita cap, for example, does not account for future spending increases due to new drug therapies or other medical advances. Most age and disability-related coverage pathways and many important services, moreover, are provided at state option, making them subject to potential cuts if states are faced with federal funding reductions.
Please read full brief here.
NCPDP White Paper on the Proper Use of the NCPDP Telecommunication Standard Version D.0 as it Applies to the Implementation of Medicaid Reimbursement Methodologies
This white paper provides Medicaid agencies and fiscal agents guidance in implementing new acquisition cost based reimbursement rules for covered outpatient drugs. In discussing common issues experienced in implementing cost based reimbursement with professional dispensing fees, the paper highlights how to best utilize the NCPDP Telecommunication Standard Version D.0, identifying best practices for various scenarios.
Please download paper here.

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