In the NAMD newsletter, we welcome a new staff member! We also cover PACE, State Innovation Models; Hill mark-ups of the American Health Care Act; and a SHVS toolkit with data points to assess federal Medicaid proposals.
NAMD Congratulates Seema Verma on Confirmation as CMS Administrator
Today, NAMD sent a letter congratulating Seema Verma on her confirmation as Administrator of the Centers for Medicare and Medicaid Services. In the letter, we express appreciation for Ms. Verma’s extensive Medicaid experience and her rapid expression of commitment to enhancing the state-federal partnership.
STAFFING UPDATE: NAMD Welcomes Dianne Hasselman as Deputy Executive Director
NAMD is pleased to welcome Dianne Hasselman as NAMD’s new Deputy Executive Director. In this role, Dianne will be providing strategic direction and leadership to the Association’s work to serve you and your staff, including through state-to-state learning and federal policy engagement.
“I am excited to join NAMD and can’t imagine a more interesting place to be right now. Medicaid is squarely in the center of health care reform, and Medicaid directors are critical leaders in understanding how policy plays out. I look forward to working with and supporting all of the Directors and their teams,” says Dianne.
Dianne brings a wealth of knowledge and experience to the Association. Prior to joining NAMD, she served as the Executive Director of Federal Programs at the Network for Regional Healthcare Improvement. In this role, she led national programs related to multi-payer and multi-stakeholder payment and delivery system reform. Prior to that, Dianne spent over seven years with the Center for Health Care Strategies where she led a variety of technical assistance programs and worked closely with state Medicaid agencies.
NAMD, NASUAD, NASDDDS Send Joint Letter to CMS on Potential PACE Demonstration
On March 1, NAMD and our sister state associations, the National Association of States United for Aging and Disabilities (NASUAD) and the National Association of State Directors of Developmental Disabilities Services (NASDDDS), sent a joint letter to CMS calling for states to play a prominent role in the future development of any Program of All-Inclusive Care for the Elderly (PACE)-like demonstration program. The letter is a follow-on to NASUAD and NASDDDS comments on a CMS Request for Information opportunity pertaining to such a demonstration program.
Following Confirmation, CMS Administrator Seema Verma, HHS Secretary Price Issue Statement to Governors on Medicaid Flexibility Building on Previous HHS Statements
On March 13, the Senate voted 55 – 43 to confirm Seema Verma as Administrator of the Centers for Medicare and Medicaid Services (CMS). The following day, Administrator Verma issued a joint letter with U.S. Department of Health and Human Services Secretary Tom Price to the nation’s Governors, outlining a vision of enhanced flexibility for states to administer their Medicaid programs. The letter mentions several issues which align with NAMD’s 2017 regulatory priorities, including:
Streamlining the approval of State Plan Amendments and waivers, including “fast-tracking” waiver concepts which received approval in other states;
Extending the timeframe for compliance with the home and community-based services (HCBS) settings rule and including more state involvement in assessment of settings compliance;
Enhancing state options to address the opioid epidemic, including additional opportunities to provide the full continuum of care for individuals with substance use disorders (such as in Institutions for Mental Disease) and streamlining 1115 waivers targeting substance use disorder treatment.
Also articulated in the letter is the intent for CMS to provide additional flexibility in 1115 waivers to support state efforts to promote employment and design programs which more closely align with private coverage. This includes consumer direction, enrollment in employer-sponsored health insurance, premium contributions, emergency room co-pays, and waivers of non-emergency medical transportation, retroactive eligibility, and presumptive eligibility.
This letter builds upon a statement Secretary Price issued last week signaling the agency’s goal of creating additional flexibility for states to run their Medicaid programs. In particular, HHS intends to review existing waiver procedures to ensure states can use this pathway to drive innovation in Medicaid. This flexibility, the statement notes, is intended to complement Congress’ health reform efforts.
Secretary Price and the Treasury Secretary Steve Mnuchin also recently issued a letter to Governors indicating that the ACA’s Section 1332 waivers also present opportunities for flexibility and reform. The letter specifically notes Alaska’s proposal to create a high-risk pool/reinsurance program to support individuals’ payments of their Exchange plan premiums.
New Findings from RTI Evaluation of Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents
On March 6, 2017, CMS released its latest evaluation report for the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents (link). Based on experience during the third full year of the Initiative (CY 2015), the report evidenced a decline in all-cause hospitalizations and potentially avoidable hospitalizations, relative to a control group. Five of the seven initiative sites showed statistically significant reductions in at least one of the hospitalization measures, while six showed reductions in Medicare expenditures. These results provide even stronger evidence that Initiative activities can improve health outcomes and the experience of care for long-stay nursing residents.
For the report, please click here. For a Health Affairs recap of the Initiative, covering results from both 2014 and 2015, please click here.
CMMI Releases Responses to State Innovation Model RFI
Last week, the Center for Medicare and Medicaid Innovation (CMMI) published the comments it received on its request for information (RFI) on the future of the State Innovation Model (SIM) program. CMMI received 67 responses, including from 18 states and NAMD, on its September 2016 RFI. Key themes from the comments include:
Federal policymakers should continue evolving their partnership with states.
Continued federal investment in state-led payment and delivery system reform is needed.
States may accelerate the adoption of Advanced APMs through supports related to data, analytic capacity, measurement, and payment model infrastructure.
CMMI could help states adapt their existing multi-payer delivery and payment efforts in response to MACRA’s Quality Payment Program.
Targeted operational and policy changes at CMS could streamline implementation of state-focused models.
House GOP Introduces American Health Care Act; Committees of Jurisdiction Hold Markups, Additional Hearings Taking Place This Week; CBO Score Shows Cost Savings, Coverage Reductions
On March 6, the long-anticipated Republican proposal to repeal and replace the Affordable Care Act (ACA) was unveiled. The American Health Care Act (AHCA) also contained significant reforms to the Medicaid program’s financing, specifically converting to a per-capita cap structure in 2020. Section-by-section summaries from the House Committees of jurisdiction, Ways and Means (W&M) and Energy and Commerce (E&C) are available here and here.
House Committee action on the began swiftly, with W&M holding an all-night markup of the legislation on March 8 and E&C finishing its markup on March 9.
Democrats in each Committee sought to introduce a plethora of amendments to draw out the process, and conservative Republicans appeared poised to introduce their own amendments, though in the end neither Committee made any significant modifications to the legislative text. Both Committees advanced the legislation on a party line vote.
The next steps in an aggressive legislative timeline involve the House Budget Committee reconciling the W&M and E&C drafts through its own markup, scheduled for March 16. Assuming completion of that process, the text would advance to the House floor next week for a final vote. Speaker of the House Paul Ryan (R-WI) has stated his goal to move the AHCA to the Senate for a vote in that Chamber before the Easter recess in April.
Complicating that timeline is a possibly frosty reception to the AHCA in the Senate, with some prominent Republicans expressing concern at the speed of the House’s process. Some have even suggested that the House simply start over, as the AHCA’s current form may have little chance of surviving the Senate. Conservatives in the House have also expressed reservations over the AHCA’s provisions, including its delayed repeal of the Medicaid expansion and its tax credits for purchasing private health insurance. Speaker Ryan argues that the AHCA is the first step in a three-pronged strategy, which will also rely on regulatory flexibility from the Trump Administration and additional, non-reconciliation health reform legislation.
Additional complications come from the Congressional Budget Office (CBO)’s score of the legislation, which indicates both federal savings and significant losses of coverage over the next decade. Specifically, CBO projects federal savings of $337 billion over 2017 – 2026, stemming primarily from reduced Medicaid spending and elimination of the ACA’s Exchange subsidies. CBO predicts an $880 billion reduction in federal Medicaid spending over the period. On coverage, CBO estimates 14 million more individuals will be uninsured by 2018, growing to 21 million in 2020 and 24 million in 2026. By 2026, CBO projects that AHCA will result in 52 million total uninsured individuals, compared to 28 million under the ACA.
In the News
Politico Covers Obesity’s “Hefty Price Tag”
In this article, Politico brings to light the preponderance of weight-loss surgery in Memphis, Tennessee, the heaviest metropolitan center in the U.S. With an obesity rate of about 36%, Memphis is certainly the heaviest city, but it is not necessarily a national outlier, Politico notes. Across the country, obesity is rising at an alarming rate and may affect 11% of U.S. adults by 2030, leaving insurers pressured to decide whether it is worth covering weight-loss surgery (which can cost up to $25,000) to circumvent the estimated $200,000 in excess medical costs obese Americans can rack up over their lifetimes. Memphis’s extra health care costs from obesity total $538 million (more than half the budget of the city’s public school system); and in West Virginia, one of the most obese states, the preventable direct medical costs of obesity range from $1.4 billion to $1.8 billion a year, with an additional $5 billion in indirect costs from factors like lost productivity and/or unemployment. Looking to the future, these costs are only expected to continue, with significant implications for the Medicaid program. Indeed, overweight and obese baby boomers (the heaviest generation on record) will spend 1.3 billion more days in long-term care than previous generations, the effects of which will cost Medicaid at least $68 billion annually.
The Washington Post Explores West Virginians’ Efforts to Reconcile the Promises of Trump with the Benefits of the ACA
Before the implementation of the Affordable Care Act (ACA), most West Virginians without children or disabilities could not qualify for Medicaid, no matter how poor they were. Now, the program covers more than half-a-million individuals, setting up crucial protections against astronomical health care costs while rendering treatment for services like immunization, physical therapy, surgery, and mental health counseling more accessible than ever. Despite the impact of Obamacare, most parts of the state voted overwhelmingly for Donald Trump, who promised to reinvigorate the coal mining industry – a historical focal point of West Virginia’s economy. In this article, The Washington Post provides a personal look into West Virginians situated in the middle of this sociopolitical dichotomy, exploring the potential effects an ACA overhaul could have on West Virginians’ access to care and health alongside Trump’s economic pledges.
Maryland Governor Declares State of Emergency for Opioid Crisis, The Washington Post Reports
Recently, Maryland Governor Larry Hogan declared a state of emergency in light of his state’s opioid-addiction crisis, committing an additional $50 million over the next five years to beef up enforcement, prevention and treatment services. In a press announcement, Hogan lamented that the threat of opioids is “rapidly escalating” in the state of Maryland: In the first nine months of 2016, heroin and fentanyl killed 1,468 Maryland residents, up 62% from the same period in 2015. The trends are part of a nationwide opioid epidemic.
Stateline Reports on Promising Vermont Health Care Delivery Experiment
Beginning this year, Vermont will embark on an experiment in which health plans will pay doctors and hospitals based on how well they care for their patients and contain costs. While this notion of “pay for performance” is not new by any means, Vermont’s experiment will be conducted on an unprecedented scale, impacting 70% of the state’s population, encompassing beneficiaries from Medicaid, Medicare, and commercial insurance. Hospitals, clinics, medical practices, nursing homes, and home health agencies that choose to participate in the experiment will join one of two “accountable care organizations” (ACOs), which insurers will pay a per capita amount to cover the care of each patient. Participating providers will earn financial rewards for staying under budget, and for meeting standards of high-quality care (access to primary care, reducing death from suicide and drug overdose, decrease chronic disease prevalence, etc.). Re providers, the initiative also includes several features designed to enhance flexibility (services, prior authorization, etc.) and foster better communication via electronic health records.
SHVS Toolkit: Data Points to Assess Federal Medicaid Proposals
To assist states in assessing the potential implications of federal Medicaid proposals, the State Health and Value Strategies Program and Manatt Health have developed a toolkit providing state-by-state data on Medicaid enrollment and expenditure trends-factors that are central to establishing the amount each state would be allocated under various capped funding proposals.
In addition to this resource (download here), a memo explaining its content is available here. The release of these materials was also accompanied by a webinar presented by SHVS and Manatt, and this presentation is available here.
NASUAD Issues Response to American Health Care Act
On March 9, NAMD’s sister state association, the National Association of States United for Aging and Disability (NASUAD), sent a letter to Speaker of the House Paul Ryan (R-WI) and House Energy and Commerce Committee Chairman Greg Walden (R-OR) providing its response to the American Health Care Act (AHCA). The letter notes that NASUAD, while not taking a position on the legislation, does have concerns about its impact on individuals receiving Medicaid-financed long-term services and supports (LTSS). The letter walks through challenges posed for LTSS by the AHCA’s per-capita cap proposal, its lack of flexibility for states, and other LTSS-specific provisions.
Annual Report: 2017 Alzheimer’s Disease Facts and Figures
The Alzheimer’s Association recently released its annual Facts and Figures report, with sections focusing on the disease’s prevalence, mortality and morbidity, caregiving, and use and costs of health care, and long-term care and hospice. Notably, the report reveals that:
An estimated 5.5 million Americans of all ages are living with Alzheimer’s dementia in 2017, and one in 10 people age 65 and older (10%) has Alzheimer’s.
The estimated lifetime risk for Alzheimer’s at age 45 is approximately one in five (20%) for women and one in 10 (10%) for men.
Between 2000 and 2014, there was a nearly 90% in deaths due to Alzheimer’s; the CDC estimates that 93,541 people died from Alzheimer’s disease in 2014.
Total payments in 2017 (in 2017 dollars) for all individuals with Alzheimer’s or other dementias are estimated at $259 billion. Medicare covers 51% of these costs ($131 billion), while Medicaid covers 17% ($44 billion).
For more information, including state-specific data, please read the report here.
Kaiser Family Foundation: Tax Credits under the Affordable Care Act vs. the American Health Care Act – An Interactive Map
Last week, the Kaiser Family Foundation released an update of its interactive map, which compares estimates of premium tax credits under the Affordable Care Act (ACA) in 2020 with those under the new House GOP plan. The maps include 2020 premium tax credit estimates by county for current ACA marketplace enrollees at age 27, 40, or 60 with an annual income of $20,000, $30,000, $40,000, $50,000, $75,000, or $100,000.
Additional Kaiser analyses related to the new legislation and its implications are forthcoming.
LAN Whitepaper on APMs in Primary Care
The HHS Health Care Payment Learning and Action Network (LAN) released a new whitepaper on how payers can implement primary care payment models that are linked to value. The paper, “Accelerating and Aligning Primary Care Payment Models,” makes a series of recommendations on how payers can ensure the success of these models, including by driving multi-payer alignment around primary care payment.
HHS’s LAN was created to support alignment in payment approaches across the public and private sectors. As part of the LAN, the Primary Care Payment Model Workgroup is tasked with building consensus on population-based alternative payment models in primary care.
Rutgers Center for State Health Policy, Year 1 of the New Jersey Medicaid Accountable Care Organization Demonstration Project
This report provides support to the New Jersey Department of Human Services (DHS) in its annual evaluation of the state’s Medicaid Accountable Care Organization (ACO) Demonstration Project. It summarizes findings from in-depth interviews with ACO leadership, assessing ACO operations and care management tactics. In focusing on the three certified ACOs in Camden, Newark, and Trenton, it reveals the following:
Overall, the ACO construct is viewed as part of a larger community health improvement strategy with components and organizations outside of the ACO itself;
ACOs are developing strategies to engage, and prove their value to, largely skeptical MCOs;
ACOs continue to define and rethink the most important patient subgroups to target for focused intervention;
ACOs are developing precisely targeted strategies to engage providers and improve targeted subsets of quality measures; and
ACOs rely on multiple and unstable funding sources to cover costs and retain staff. Uncertain funding limits longer term planning.
On March 2-3, the Medicaid and Children’s Health Insurance Program (CHIP) Payment and Access Commission (MACPAC) held a public meeting in Washington, D.C. The following include some of the key takeaways from the meeting:
Specific, more targeted interventions are needed to target opioid abuse in rural vs. urban settings, and more data are needed to better understand the extent of addiction treatment.
There is greater comparability between the fiscal pressures in expansion vs. non-expansion states than one would expect. It is key to consider factors like state budgets, state legislative relations, etc. to put these fiscal pressures in greater context.
When looking at mandatory and optional benefits, it is necessary to make assumptions about the distribution of mandatory and optional enrollees, the distribution of service spending in managed care and fee-for-service frameworks, and spending on managed long-term services and supports (MLTSS) as a portion of overall managed care.
There are several challenges when establishing per capita caps, including uncertainty over which services and populations should be included and what savings (if any) will be yielded. State-level per capita data, it is also important to note, may not always mirror national models.
States are divided in how they think access to high-cost drugs will impact downstream costs and savings, and how effectively they can engage with manufacturers.
Looking to the future of managed care regulatory compliance, it is unclear whether it will be possible to reduce administrative burden for states and CMS, and/or whether states will be able to enroll traditionally exempted populations in managed care.
For more information on the meeting, and to access related materials, please click this link.
Nevada – Multiple Job Openings
The Division of Health Care Financing and Policy (DHCFP) is seeking qualified applicants for the a number of Health Care Coordinator positions.
The mission of DHCFP is to purchase and provide quality health care services to low-income Nevadans in the most efficient manner; promote equal access to health care at an affordable cost to the taxpayers of Nevada; restrain the growth of health care costs; and review Medicaid and other state health care programs to maximize potential federal revenue.