NAMD Submits Comments on Medicaid Outpatient Rx Rule; OMB Major Grant Reform Ideas
From the NAMD Desk
NAMD submits comments on Medicaid outpatient Rx rule. On April 2nd, NAMD submitted comments on a proposed regulation, "Medicaid Program; Covered Outpatient Drugs" (CMS 2345-P). In addition to implementing amendments to the Medicaid Drug Rebate Program (MDRP) that were enacted in the Patient Protection and Affordable Care Act ("ACAʺ), the regulation also proposes to make a number of changes to the MDRP and Medicaid drug payment that were not mandated by the ACA. NAMD's letter recommends ways to simplify implementation, improve transparency, and minimize the administrative burden of the proposed changes for state Medicaid agencies. The letter is posted on NAMD's website.
OMB Proposes Major Grant Reform Ideas. On February 28, 2012, the Office of Management and Budget (OMB) released an advanced notice of proposed guidance in the Federal Register that outlines reform ideas for federal grants and cooperative agreements involving state and local governments as well as universities and nonprofit organizations. The reforms relate to audit requirements, cost principles, and administrative requirements. The reforms are a result of several executive orders to reduce administrative burdens and increase flexibility, while at the same time targeting improper payments and improving program performance. Because of the potential magnitude of these changes, OMB issued this advanced notice to receive feedback prior to developing a proposal. Comments must be received April 30, 2012 (extended from the original deadline of March 29, 2012).
CMS Announces One-Year Delay In ICD-10 Compliance Deadline. CMS revealed plans to set the new ICD-10 compliance date at October 1, 2014, a one-year delay from the planned October 1, 2013 deadline which physician groups had complained was not viable for many physicians.
Upcoming CMCS eligibility webinars.CMCS will continue its webinar series providing information about the Medicaid and CHIP Eligibility Final Rule (CMS-2439-F), which was formally published in the Federal Register on March 23, 2012. The webinars are open to anyone who is interested and will also be posted under the Affordable Care Act section of Medicaid.gov as soon as possible after the event. More information on the Medicaid Eligibility final rule is available at http://www.medicaid.gov/AffordableCareAct/Provisions/Eligibility.html.
Register here for CMCS's upcoming webinars, which are scheduled as follows:
- April 19, 3:00 pm. EST: Application, Verification, and Accessibility for individuals with disabilities and those with limited English proficiency
- April 26, 3:00 p.m. EST: MAGI Screening & Renewals
- May 10, 3:00 p.m. EST : Eligibility & Enrollment Wrap-up
Members of Congress return from spring break. The Congress returns this week after a two week spring break, but it's unclear what they will accomplish prior to the November elections. Congressional staff will continue work on draft fiscal year 2013 appropriations measures, but Congress is not likely to complete such measures before the new fiscal year, which starts October 1, 2012. Like most in the health care community and other interested stakeholders, Members of Congress are anxiously awaiting the Supreme Court's ruling on the constitutionality of the Patient Protection and Affordable Care Act ("ACA").
In the News
AR judge fines J&J $1.2 Billion in Medicaid fraud case. Johnson & Johnson and a subsidiary have been fined about $1.2 billion by an Arkansas judge after a jury found that the companies had downplayed risks associated with Risperdal, an antipsychotic drug. In a verbal ruling, Circuit Judge Tim Fox held that Johnson & Johnson and its subsidiary Janssen Pharmaceuticals Inc. committed nearly 240,000 violations of the state's Medicaid fraud law -- one for each Risperdal prescription issued to state Medicaid patients over a 3.5-year period, each violation carrying a $5,000 fine. ("Companies belittled risks of Risperdal, slapped with huge fine," LA Times, April 11, 2012).
Arkansas law requires the fine go toward the state's Medicaid Trust Fund, which faces a shortfall of up to $400 million starting in July 2013. The state is moving forward with a proposal to change the way Medicaid pays for services, and lawmakers say they expect a debate over the program to dominate next year's session. The federal government last year gave Arkansas permission to explore changing the way it pays medical providers for services, and DHS has said it expects to begin rolling out those reforms in July in a handful of Medicaid programs. ("Arkansas not counting on $1.2B from drug trial yet," Bloomberg Businessweek, April 13, 2012).
AZ terminates high-prescribing providers. Arizona's Medicaid program terminated the contracts of seven doctors who were top prescribers of powerful pain pills and mental-health prescription drugs. Their dismissals were made public as the result of an ongoing probe by U.S. Sen. Charles Grassley, (R-IA), of drug-prescribing patterns in Medicaid programs across the country. Medicaid programs. AHCCCS Director Thomas Betlach said that the top prescribers of the mental-health drugs represented less than 2 percent of AHCCCS' total prescription costs for 2010 and 2011. ("7 Arizona doctors lose Medicaid contracts," The Arizona Republic, April 10, 2012).
CT moves away from managed care. After more than 15 years of operating a Medicaid managed care program, on January 1, 2011, Connecticut began directly reimbursing health care providers. A non-profit organization will provide care coordination and customer service for all of the state's Medicaid and CHIP beneficiaries, plus members of a state-funded health programs for low-income adults -- about 600,000 people in all. State officials say the managed care system was no longer saving the state money, and patients were not getting the care they need. ("Connecticut revisits old-school Medicaid financing," Stateline, April 9, 2012).
NJ Tapped to Participate in National PCMH Trial. New Jersey was one of seven states selected to participate in a federal pilot that aims to transform primary care practices into patient-centered medical homes that cut costs and enhance care by eliminating duplicative and unnecessary treatments. Horizon Blue Cross Blue Shield of New Jersey and AmeriHealth NJ are the commercial payers that applied for and were selected to take part in the Comprehensive Primary Care Initiative. Horizon subsidiary Horizon Healthcare Innovations has been running a PCMH pilot for the past 18 months in the state and this week released some preliminary findings. Valerie Harr, the New Jersey Medicaid director, will be working with CMS to implement the program. ("New Jersey Tapped to Participate in National PCMH Trial," NJ Spotlight, April 12, 2012).
InsideHealthPolicy compares ROI of MFCUs to MICs. According to a recent article published in the trade publication InsideHealthPolicy, data collected by HHS' Office of the Inspector General (OIG) suggest that Medicaid Fraud Control Units (MFCUs) are more financially successful than Medicaid Integrity Contractors (MICs). IHP reported that MFCUs return more than $8.00 for every dollar spent while MIC programs cost almost twice as much to run as they take in. The article notes that while both programs are tasked to look for suspected fraud, they employ different methods and their scopes also differ. IHP reporter Michelle Stein spoke with NAMD's Executive Director Matt Salo who said the programs represent a "massive coordination failure" and referenced NAMD's recent report which raised specific concerns with the Medicaid program integrity atmosphere.
NAMD's Salo spoke at Health Reform webinar. On March 27th, NAMD's Executive Director Matt Salo will spoke at a live webinar hosted by the Alliance for Health Reform, "Implementing Health Reform in the States." Salo was a panelist along with Noam Levy of the LATimesand Enrique Martinez-Vidal, vice president for state policy and technical assistance at AcademyHealth. A recording of the webinar is available at: www.allhealth.org.
NH Transitions Medicaid to Managed Care. A bill passed by the New Hampshire Legislature last year instructs the Department of Health and Human Services to transition the state's Medicaid system to a managed care model, administered by private companies, by July 1, 2012. Lawmakers are hoping to save $16 million in the first year by transitioning to managed care. Kathleen Dunn, the state's Medicaid director, said she envisions "multiple points of contact" between DHHS and Medicaid recipients during the enrollment process, which will allow DHHS to forward information about individual patients directly to the private managed care companies.
Services will be transitioned in three phases. The first, which begins when the program launches later this year, includes payment for things like routine visits to the doctor and drug services. Twelve months later, the system will expand to encompass people who receive long-term care supports, such as people with developmental disabilities and elderly people in long-term care facilities and nursing homes. The third phase, commencing in 2014, will be the expansion of the program to include some 40,000 to 50,000 Medicaid beneficiaries made newly eligible by the Affordable Care Act, extending benefits to families living at up to 138 percent of the federal poverty level. ("Health commissioner casts doubt on July launch for Medicaid overhaul," Fosters.com, March 28, 2012).
Governing Continues Profile of Rhode Island's Health Insurance Exchange Implementation. Governing magazine published the second in a series of articles about Rhode Island's implementation of its health insurance exchange. Over the last year, a call for efficiency from the federal government and stakeholder groups pushed Rhode Island officials toward creating a simpler experience for the estimated 862,000 customers that will use the exchange, where the entire infrastructure "should be invisible to the consumer," Medicaid director Elena Nicolella explained. To aid its IT decisions, Rhode Island also joined the New England States Collaborative Insurance Exchange Systems collaborative, a group of six Northeast states that are sharing ideas about how to create the technological infrastructure necessary for the insurance marketplaces. The next big step for the state is putting out requests for proposals (RFPs), which would allow IT companies to pitch their ideas for the website design and accompanying software program that will run the exchange based on Rhode Island's vision. ("Rhode Island's Health Insurance Evolution," Governing, March 23, 2012).
Florida must pay for autism therapy for poor kids, judge says. U.S. District Judge Joan Lenard, in an order signed last week, required Florida's Medicaid program to begin paying for a psychological program, called applied behavioral analysis (ABA), designed to improve the behavior, language and cognitive development of autistic children. The state already requires commercial carriers to provide the ABA therapy to Floridians with private insurance. Although the ruling impacts only Florida at the moment, it could have significant implications in the future for other states. ("Florida must pay for autism therapy for poor kids, judge says," Miami Herald, March 28, 2012).
Other Items of Interest
Improving the Use of Psychotropic Medication among Children and Youth in Foster Care: A Quality Improvement Collaborative. Recent legislation requires that plans for the oversight and coordination of health care services for children in foster care -- to be developed jointly by child welfare and state Medicaid agencies -- include protocols for the appropriate use and monitoring of psychotropic medications. To help states address this complex issue, the Center for Health Care Strategies, through support from the Annie E. Casey Foundation, is launching Improving the Use of Psychotropic Medication among Children and Youth in Foster Care: a Quality Improvement Collaborative. Through this three-year initiative, five states --llinois, New Jersey, New York, Oregon, and Vermont -- will work together to improve the appropriate prescribing and effective monitoring and oversight of psychotropic medications for children and youth in foster care.
Briefing highlights different models of multi-payer coordination. On April 13, 2012, the Alliance for Health Reform hosted a Congressional briefing on "Coping with Fragmented Payment in the Real World." The briefing featured representatives from three different models of payment and delivery reforms, including a large academic medical center in the Bronx that was recently selected as one of 32 Pioneer ACOs, an IPA that serves as a physician-led, risk-based ACO in Grand Junction, CO, which was featured in Atul Gawande's 2009 article, "the Cost Conundrum," as having the lowest health care costs in the US, and a statewide Cost Review Commission in Maryland that oversees the state's all-payer hospital rate setting system.
The Grand Junction, CO, model in particular may be of interest to SMDs, in that a contracted health plan aggregates payments from all payers, withholds 15%, then pays all providers the same PMPM rate for all patients, then supplements this annually with a share of the withholds. In this way, the IPA claims it has been able to maintain a high level of access for Medicaid patients relative to other providers. Speaker presentations as well as a wealth of resources on payment reform proposals are on the Alliance's website here.
New State Health Reform Assistance Network resources. The State Health Reform Assistance Network, a project of the Robert Wood Johnson Foundation, released a number of products, including a chart of 2012 ACA milestones with key checkpoints for states working on exchange development, the Medicaid expansion, and implementing insurance market reforms.
U.S. Medical Specialty Societies to Identify Overused or Unnecessary Tests, Procedures. Nine United States specialty societies representing 374,000 physicians developed lists of "Five Things Physicians and Patients Should Question" in recognition of how physician and patient conversations can improve care and eliminate unnecessary tests and procedures. These lists represent specific, evidence-based recommendations the groups believe physicians and patients should discuss to help make wise decisions about the most appropriate care based on their individual situation. Choosing Wisely is part of a multi-year effort of the ABIM Foundation to help physicians be better stewards of finite health care resources.
Mark Your Calendar
NAMD States-Only Spring Meeting: May 20-22, 2012, Crystal Gateway Marriott, Arlington, VA.
Save the date for NAMD's 2012 fall meeting: October 28-30, 2012, Crystal City, Marriott, Arlington, VA.