In the newsletter this week, NAMD names new leadership for 2017-2018. CMS releases information bulletins on core set of quality measures, advances on HIV prevention and care, blood lead tests for children, AI/AN Medicaid enrollment and SSI & spousal impoverishment standards.
NAMD is pleased to announce the results of the association’s Leadership and Board elections. These representatives were chosen by Medicaid Directors to guide NAMD’s work and represent Directors’ consensus perspectives and interests over the next two years. They will officially begin their terms of service on January 1, 2017:
CMS Publishes 2017 Updates to Medicaid Core Measure Sets
Last week, CMS issued an informational bulletin featuring 2017 updates to the core set of quality measures for children enrolled in Medicaid and CHIP (Child Core Set), and for adults enrolled in Medicaid (Adult Core Set). The twofold aim of this effort is to: 1) promote national reporting by states on a uniform set of adult and child health quality measures (currently voluntary under statute); and 2) support states in using these measures to drive quality improvement. The 2017 updates to the Core Sets will take effect in the FFY 2017 reporting cycle, which will begin no later than fall 2017. To support states in making these changes, CMCS will release updated technical specifications for both Core Sets in Spring 2017 and will make them available at this link.
The link to CMS informational bulletin can be found here.
HHS OIG Releases Rule on Civil Monetary Penalties
Last week, the Department of Health and Human Services (HHS) released a final regulation amending its policy around the civil monetary penalties (CMPs) that may be imposed by the HHS Office of the Inspector General (OIG). It implements statutory changes under the Affordable Care Act (ACA) and Medicare Prescription Drug, Improvement, and Modernization Act by: updating authorities for imposing CMPs, assessments, and exclusions; adding new violations and penalties that apply to contracting organizations; and reorganizing existing CMP regulations for clarity. Notably for states, the rule adds new violations and penalties under the ACA that HHS OIG may apply to Medicaid contractors.
Federal Agencies Issue Joint IB on HIV Prevention and Care in Medicaid
On December 1, the Department of Health and Human Services, Center for Medicaid and CHIP Services (CMCS), Health Resources and Services Administration, and Centers for Disease Control issued a joint informational bulletin (IB) on advances in HIV prevention, care, and treatment. The letter provides Medicaid Directors with information on advances that have occurred since CMCS’s 2011 letter to Directors on the same issue.
The IB notes that the science of HIV prevention and care has advanced rapidly, with several landmark studies demonstrating the role of early treatment in improving life expectancy, quality of life, delay in average time until onset of AIDS, and fewer transmissions. Moreover, advances in HIV surveillance systems and methods have improved federal, state, and local efforts to evaluate and improve outcomes along the HIV care continuum.
In addition to background information, this IB highlights specific opportunities for state Medicaid programs to drive improvements in HIV prevention and treatment. It does this by examining:
HIV testing and diagnosis;
Pre-exposure prophylaxis for HIV prevention;
Linkage and retention in care;
Effective antiretroviral treatment;
Monitoring and improving viral load suppression; and
CMS IB Addresses Coverage of Blood Lead Tests for Children
Responding to the recent water crisis in Flint, Michigan, this CMS IB discusses the required provision of blood screening tests for all children enrolled in Medicaid to identify elevated blood lead levels (EBLLs). It notes that the goal of such lead screening is to “assist children before they are harmed,” ensuring that lead-poisoned infants and children receive medical and environmental follow-up as soon as possible. It provides an overview of the screening requirements for children enrolled in Medicaid and CHIP, and identifies specific steps states can take to improve lead screening efforts and reach children at risk of EBLLs.
CMCS IB Explores Strategies to Enhance AI/AN Medicaid Enrollment
This CMCS IB addresses opportunities to enroll additional AI/AN individuals in Medicaid and CHIP. It notes that Medicaid and CHIP-eligible AI/ANs encounter significant enrollment challenges due to remote geographic locations, lack of access to reliable internet and phone service, distrust of government programs, language and health literacy barriers, and cultural differences. This IB identifies strategies states can employ, in concert with Tribes and Indian health care providers, and outlines outreach and enrollment best practices for those working in or with Tribal communities. Some of the state enrollment strategies explored in the bulletin include:
Providing tribal access to the state Medicaid eligibility portal;
Leveraging outstationing in federally qualified health centers;
Maximizing the tribal Medicaid administrative match;
Using express lane and/or presumptive eligibility; and
Establishing 12-month continuous eligibility for children.
CMS recently released its bulletin that updates the 2017 Supplemental Security Income (SSI) and Spousal Impoverishment Standards. Included with this bulletin is a chart that visually captures the new standards.
Beginning each January, certain Medicaid income and resource standards are adjusted in accordance with changes in the SSI federal benefit rate (FBR) and the Consumer Price Index (CPI). These changing standards underpin several factors of Medicaid, such as the offer of categorical eligibility to individuals who are not receiving SSI but who meet the financial eligibility requirements of the program, or CPI-contingent coverage for long-term services and supports.
In its National Health Expenditures 2015 Assessment, CMS finds U.S. health care spending increased by 5.8% to reach $3.2 trillion (or $9,990 per person) in 2015. This amounted to 17.8% of the U.S. economy, up from 17.4% in 2014. CMS attributes the growth in spending to coverage increases from the ACA; stronger growth in spending for private health insurance, hospital care, and physician and clinical services; and continued growth in Medicaid and retail prescription drug spending. For the Medicaid program, total spending slowed slightly in 2015 to 9.7%, with state and local Medicaid expenditures growing by 4.9% and federal Medicaid expenditures increasing by 12.6%.
The 114th Congress adjourned early after passing of a short-term continuing resolution (CR) to fund the federal government through April 28. The measure passed the House easily, 326 – 96, though it had a rockier path in the Senate, passing 63 – 36. The bill, which adheres to the 2017 fiscal cap of $1.07 trillion outlined in previous budget legislation, was signed into law by President Obama on Saturday. The short-term funding approach means the next Congress will have to address federal budget questions, including potential repeal of the Affordable Care Act, early next year.
House Republicans Vote in New E&C Chair; Democrats Tap New W&M Ranking Member
Earlier this month, both parties shuffled Committee postings in the House in the aftermath of the November elections. In the House Energy and Commerce Committee (E&C), Republicans confirmed Rep. Greg Walden (R-OR) to the chairmanship. In the House Ways and Means Committee (W&M), Democrats confirmed Richard Neal (D-MA) as ranking member.
Senate Passes 21st Century Cures; Bill Awaits President’s Signature
On December 7, the Senate voted 94 – 5 to pass the 21st Century Cures Act, clearing the final congressional hurdle for the legislation to be signed into law by the President. President Obama, who last week announced the Administration’s support for the bill, is expected to sign it promptly.
The legislation represents the most significant healthcare reform since the passage of the Affordable Care Act, and aims to speed the discovery and approval of new drugs and medical devices. It also makes investments in research and provides funding for addressing the opioid abuse epidemic. As we have noted in previous newsletters, several provisions of the legislation – including a few cost offsets – will impact the Medicaid program. Those provisions include:
Accelerating by one year the policy that would limit Medicaid reimbursement for DME to Medicare reimbursement rates. The policy would take effect on January 1, 2018.
Addressing state efforts to identify Medicaid providers terminated by Medicare or other states’ Medicaid programs.
Requiring provider directors in fee-for-service and PCCM programs.
Directing HHS to complete studies on the “in lieu of” provision of the managed care regulation related to IMDs and on the Medicaid Emergency Psychiatric Demonstration.
Requiring CMS to issue a state Medicaid Director letter on opportunities for improvements in care delivery for individuals with serious mental illness.
Specifying that children receiving Medicaid-covered inpatient psychiatric hospital services are eligible for EPSDT.
Requiring the use of electronic visit verification systems for Medicaid personal care and home health services beginning January 1, 2019.
Directing the HHS to clarify when providers can disclose information on substance use disorder treatment.
Senate Finance Chronic Care Working Group Releases Proposal
On December 6, the Senate Finance Committee’s Chronic Care Working Group released legislation reflecting its years-long engagement with chronic care issues. The legislation, called the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act, is primarily oriented towards Medicare, though certain provisions would also impact Medicaid.
Notably, Section 201 of the Act would permanently authorize the Medicare Advantage Duals Special Needs Plans (D-SNPs), direct the Medicare-Medicaid Coordination Office to be the dedicated federal point of contact for states to work on Medicare integration, require D-SNPs to have unified grievances and appeals procedures by 2020, and require D-SNPs to integrate Medicare and Medicaid long-term services and supports and/or behavioral health services by 2021. The Act would also give the HHS Secretary discretion to implement the Medicare quality Star rating system to SNPs.
The CHRONIC Care Act also contains several proposals to enhance the care coordination and telehealth services available under Medicare ACOs and calls on the Government Accountability Office to study several aspects of chronic care.
A section-by-section breakdown of the legislation is available here. Prospects for this legislation to advance in the 115th Congress remain unclear at this time.
CBO Releases Options for Federal Deficit Reduction
On December 8, the Congressional Budget Office (CBO) published a report detailing 115 policy options for reducing the federal deficit over the course of the next decade. Included in the report are changes to mandatory and discretionary federal health spending, inclusive of Medicaid reforms. Notable deficit reduction options that impact Medicaid include:
Repeal all insurance coverage provisions of the Affordable Care Act, including the Medicaid expansion;
Cap federal spending on Medicaid, with options to cap either overall spending or per-enrollee spending based on inflation;
Limiting state provider taxes by reducing the safe harbor threshold to five or four percent;
Increasing Medicare Part B premiums, which would impact Medicaid’s obligation to pay Part B premiums for certain dually eligible beneficiaries; and
Modifying the inflation measure used to update mandatory federal program spending.
A recent Kaiser Health News article explores President-elect Donald Trump’s selection of Rep. Tom Price as the new Secretary of the Department of Health and Human Services (HHS). The selection of Price, a Georgia Republican who currently chairs the House Budget Committee, signals the new administration’s commitment to repealing the Affordable Care Act (ACA) and restructuring Medicaid and Medicare. As the article points out, proposals to restructure Medicaid as a block grant date back to the Reagan administration.
While advocates purport that these proposals would decelerate rising health spending and provide states with flexibility, opponents argue that such changes would shift financial burden to states and consumers, as well as impact coverage.
In a related article, Kaiser Health News highlighted the President-elect’s choice of Seema Verma to run CMS. Verma, a health care consultant, is the founder of consulting firm, SVC, Inc. Verma has extensive experience in Medicaid, working closely with Indiana Gov. Mike Pence to design Indiana’s alternative Medicaid expansion, known as the Healthy Indiana Plan or HIP 2.0. The article notes that with Verma at the helm of CMS, states with expansion proposals similar to Indiana’s (i.e., Iowa, Ohio, Kentucky) may be more likely to receive approval.
HHS Secretary Discusses Future of Health Care in Health Affairs
In this blog post, Health and Human Services Secretary Sylvia Matthews Burwell presents her thoughts on health care in the U.S., reflecting on how HHS’s work to reframe medical payments, encourage coordination, and leverage health care data will continue to shape a patient-centered system of care in the coming years. Positioning fee-for-service as one of the main drivers of health care costs, Burwell emphasizes the importance of delivery system and payment reform. She underscores the need to chart a path forward for more active patient participation, electronic medical records, value-based purchasing, and enhanced primary care. As she looks to the next administration, Burwell hinges future success on state-based innovation and inter-state discourse, focusing on the role of states to unlock a more efficient, outcome-based, and collaborative approach to reform.
In recent years, two of the largest suppliers of the drug naloxone have dramatically increased their prices, threatening access to a drug that can reverse fatal opioid overdoses. The article notes that since 2012, Hospira’s 10-pack of naloxone has doubled in price from $62.29 to $142.49, while Kaleo’s naloxone auto-injector now costs $4,500 for two injections (a 500% increase from the 2014 price). Defending these increases, a Pfizer spokeswoman maintains that Hospira’s price “reflects the sensitivity to the need for the product,” while also taking into account “the reality and necessary investments needed to produce high-quality generic drugs.” Other experts note that price increases are not sustainable. In the article, an expert at Yale University Medical School recommends the federal government purchase naloxone products in bulk to create a stable demand that might encourage other companies to compete and keep costs low.
Washington Post Covers New Research on Impact of Medicaid Coverage
In this piece, the Washington Post reports on the National Bureau of Economic Research’s most recent working paper, which reveals that Medicaid-covered children tend to live healthier, longer, and more productive lives. Returning at least a 2 percent annual return on investment, it notes that Medicaid coverage empowers children to pay more in taxes and rely less on welfare as they get older, enabling the federal government to recoup much of its upfront insurance costs. While some gaps in research remain, the articlenotes that the paper substantively shapes public understanding of how Medicaid affects recipients.
Medicaid and CHIP Payment and Access Commission (MACPAC) released its December 2016 edition of the MACStats: Medicaid and CHIP Data Book, which is the Commission’s annual update of national and state-specific data for Medicaid and CHIP. The Data Book addresses enrollment and spending, eligibility levels across states, and beneficiaries’ health, service use, and access to care. This resource aims to help policymakers comprehend how Medicaid and CHIP operate at the federal and state levels. Notably, it finds that:
Medicaid and CHIP together accounted for 16.8% of national health expenditures in 2014;
States spent roughly 15.3% of their state budgets on Medicaid in state fiscal year 2014;
Medicaid and CHIP enrollment grew less than 1% in 2016; and
Nearly half of all individuals enrolled in Medicaid in 2015 had family incomes below 100% of the federal poverty level (FPL), and nearly two-thirds had incomes below 138% FPL.
Please find a link to the December 2016 Data Book here.
GWU Publishes Paper on Hospital Community Benefit Reform
A new report from George Washington University recommends that the incoming Trump Administration adopt a more flexible regulatory standard on what constitutes hospital community benefit, which they posit will facilitate greater hospital involvement in community health advancement. The authors suggest this change would comport with hospitals’ community health needs assessments (CHNAs), which look beyond clinical care to social determinants, such as affordable housing, economic development, and food security. Taking this into consideration, the report outlines three policy opportunities that would align U.S. tax policy with the growing focus on community health improvement. The IRS could:
Issue guidance to hospitals reframing population health efforts as community benefit spending;
Bring greater transparency to community benefit reporting by creating a link between the community health needs assessment process and community-benefit spending allocations; and
Issue tax guidance on effective community-wide health improvement activities.
SHVS Publishes Brief on Integration of Health Care and Social Services
In this report, the Robert Wood Johnson Foundation’s State Health and Value Strategies (SHVS) explores how to create operational linkages between social services and health care delivery. Developed by Bailit Health, the report highlights the experiences of states that have already developed innovative approaches toward this integration, positioning them as valuable archetypes for other states. The report delves into six approaches: 1) shared governance; 2) blended financing; 3) integrated assessments and care teams; 4) data linkages; 5) integrated procurement and grant funding efforts; and 6) coordinated performance metrics.