NAMD has Moved; Fall Conference Registration; NAMD Submits MLTSS Recommendations; Hill News
From the NAMD Desk
Update your address books - NAMD has moved. NAMD moved suites within the Hall of the States building. We are now in suite #524 at 444 North Capitol Ave NW, Washington, DC 20001. The only change to our address is the new suite number.
Register today for NAMD's Fall conference! Registration is open for NAMD's Fall conference, October 28-30, 2012, in Crystal City, VA. Visit the conference page on NAMD's website for updated registration information, a draft agenda, and sponsorship and exhibiting opportunities. For more information, contact Tess Moore [email@example.com].
Tony Keck joins NAMD Board, appointed to IOM committee. NAMD welcomes Anthony "Tony" Keck to the NAMD Board representing the South Region. Tony is Director of Health and Human Services for South Carolina, which includes the Medicaid program. He has over 23 years of experience in health care management consulting, and policy. Prior to his appointment in South Carolina he served in the administration of Louisiana Governor Bobby Jindal as health and social services policy advisor to the governor, and chief of staff and deputy secretary of the Louisiana Department of Health & Hospitals.
In addition, Tony was also recently selected to serve on an ad hoc Institute of Medicine (IOM) committee to examine several aspects of Graduate Medical Education (GME). The committee is tasked to do the following: (1)assess current regulation, financing, content, governance, and organization of U.S. GME and (2) recommend how to modify GME to produce a physician workforce for a 21st century U.S. health care system that provides high quality preventive, acute, and chronic care, and meets the needs of an aging and more diverse population. Tony was selected from among several state representatives nominated by NAMD. A full list of the committee members is posted at: GME advisory committee.
NAMD submits MLTSS recommendations to CMCS. On August 6th, NAMD sent a letter to Centers for Medicaid and CHIP Services (CMCS) Director Cindy Mann putting forward recommendations for modernizing and strengthening federal policies and procedures for managed long term supports and services (MLTSS) programs. NAMD urged CMCS to apply the following four guiding principles as the federal agency reviews its MLTSS policies and business procedures for working with states
1. Streamline the structure and improve the timeliness of federal reviews of MLTSS programs.
2. Maintain existing state flexibility to design and implement MLTSS programs in coordination with national goals to ensure access to member-centered, quality-driven, efficient, cost-effective care in the most integrated setting.
3. Maintain state flexibility to define a meaningful and productive stakeholder engagement process.
4. Ensure collaboration between federal and state partners in developing a framework for ongoing quality improvement and performance measurement.
The document then goes into detail on specific recommendations under each principle. NAMD's letter and recommendations can be access by clicking here: MLTSS recommendations
NAMD comments on proposed methods for MAGI conversion. NAMD responded to the Centers for Medicare & Medicaid Services' (CMS) request for input on the proposed methodologies for converting current state Medicaid and Children's Health Insurance Program (CHIP) income eligibility standards to equivalent modified adjusted gross income (MAGI) standards. NAMD requested that CMS allow states to maintain maximum flexibility in choosing which income conversion method to adopt rather than codify only one method. NAMD also urged CMS to dedicate resources and work expeditiously to provide states the information and technical assistance they need to evaluate the conversion methodologies and make the associated changes to their information technology systems. Click here to view NAMD's letter.
NAMD weighs in on duals in Health Affairs blog. NAMD's Matt Salo and Andrea Maresca recently penned a piece for the Health Affairs Blog. In it, theydescribe the difficulties emerging as states and the federal government seek to create a system that better manages care for individuals dually eligible for Medicare and Medicaid. The NAMD team stresses that a good faith partnership between Medicare and Medicaid is necessary in order to integrate care and improve health outcomes and quality of life for members. They also profiled several individuals and the benefits they stand to gain under their state's proposal. Click here to read the blog post: "Who Stands To Benefit From The Duals Demonstration?"
NAMD comments on updated CBO score for the ACA.In a posting for the Health Affairs Blog, NAMD's Executive Director Matt Salo commented on the latest Congressional Budget Office analysis of the coverage provisions of the Affordable Care Act (ACA). Click here to read the blog post: "Back To The Future For ACA Cost And Policy Analyses."
CMCS releases new MLTSS resources. On August 6th, CMCS released two new resources on Medicaid managed long term services and supports (MLTSS). The first is a report based on the national environment scan CMCS conducted between January and June of 2012. Based on this work, CMCS projects that 26 states will have MLTSS programs by 2014. CMCS also released a long-awaited online tool intended to provide states guidance on program design, Medicaid authorities and other information relevant to the management of MLTSS. The technical assistance tool includes links to information such as sample contracts, state examples of effective organizational structure to manage MLTSS, and other useful sources of information. The guide is available here: http://www.medicaid.gov/mltss/.
Deal in the works for fiscal year 2013 funding, future of sequestration in question. Last week congressional leaders announced they had reached an agreement to extend fiscal year (FY) 2013 discretionary federal spending until March 2013. While the details are still to be written and the votes still have to be cast, leaders in the House and Senate believe Congress will avoid a spending showdown at start of the new fiscal year in October. Congressional staff will work over the August break to draft the measure. House Republicans are expected to push for some restrictions on funding for implementation of certain aspects of the Affordable Care Act.
Complicating the FY 2013 spending bills is sequestration that is scheduled to hit discretionary spending January 2013. FY 2013, which begins October 1st will be one-fourth over when the sequester takes effect. The verbal agreement dims prospects that lawmakers would pare the FY 2013 funding measure with provisions to stop the planned funding sequestration scheduled to take effect in January 2013. With the desire to wrap up must-do legislation early this fall to accommodate the campaign season, it remains unclear if, how, and for how long lawmakers will stop, delay, or modify the sequestration.
Congress Sends sequestration transparency bill to President. With strong bipartisan support the House and Senate recently approved the Sequestration Transparency Act of 2012 (H.R. 5872), which would require the Office of Management and Budget (OMB) to provide a detailed report on how the BCA sequestration process would affect domestic and defense programs. The President is expected to sign the measure into law, after which the Administration has 30 days to provide Congress the report.
In the meantime, in light of the sequestration requirement, OMB issued a memorandum to all departments and agency heads, stating "agencies should continue normal spending and operations since more than five months remain for Congress to act" to stop the cuts. The memo goes on to state that, "The President remains confident that Congress will act." However, due to Congress's lack of "progress towards enacting sufficient deficit reduction...OMB will work with agencies, as necessary, on issues raised by a sequestration of this magnitude." Once fiscal 2013 funding levels are defined, OMB will gather the necessary information from agencies to calculate the percentage reductions required under the sequestration.
CBO refines ACA cost, coverage estimates. On July 24, the Congressional Budget Office (CBO) and Joint Committee on Taxation issued an updated analysis of the coverage provisions of the Affordable Care Act (ACA) to reflect the U.S. Supreme Court's decision to revoke the financial penalty for states that do not adopt the law's Medicaid eligibility expansion. Less than a month after the Court decision, CBO and JCT's analysis seeks to account for the short-term uncertainty facing policymakers at the federal and state levels.
Compared to their March 2012 estimate, CBO and JCT project that over the next ten years (2012-2022) the ACA's coverage expansions will decrease the costs to the federal government by $84 billion. The reason, say the analysts, is largely because fewer individuals will be eligible for Medicaid. The CBO model now projects that approximately 11 million additional individuals will be enrolled in Medicaid in 2022, compared with the 17 million additional people projected to enroll prior to the Supreme Court decision. However, according to CBO's model, the relative decline is greater in the earlier years because a number of states are expected to expand coverage incrementally rather than all states expanding eligibility on a single date.
Of the six million people that now may not be eligible for Medicaid, CBO projects that about half of them will receive federal assistance to purchase coverage through health insurance Exchanges. As CBO points out, the difference in the federal government's share of the cost of Medicaid versus insurance purchased via the Exchange - approximately $3,000 dollars - mitigates the drop in the overall cost of the ACA for the federal government.
Notably, CBO also seems to assume that the Administration will permit states a certain level of flexibility with the ACA's Medicaid expansion on par with other Medicaid coverage options. That is, the analysis assumes that a state will have the authority to incrementally implement the expansion rather than simultaneously expanding to all individuals with income up to 138 percent of the federal poverty level.
Updated price tag for Medicare "doc fix." A 27 percent reduction in the Medicare physician reimbursement rate is scheduled to go into effect January 1, 2013 unless Congress takes actions to halt the cut. On July 31st, the Congressional Budget Office (CBO) released updated analysis showing that a one year patch would require offsets totaling $18.5 billion over the period 2013-2022. A fix that held rates steady for two years would require offsets totaling $48 billion over this time period.Â It's unclear how Congress plans to address the Medicare physician rate cut this year given the other costly and politically charged issues with year-end deadlines that also would require significant offsets, including tax cuts and sequestration.
In the News
FL caps ER visits. Beginning August 1st, the Florida Medicaid program will no longer pay the full cost of emergency room visits for members who visit the emergency room more than six times per year. According to Justin Senior, the state's Medicaid Director, "The hope would be that patients stop going from crisis to crisis and emergency room visit to emergency room visit, in some cases, as we analyze the data, going to the emergency room 50 to 150 times per year." Senior says only a few thousand Florida Medicaid patients are racking up those kinds of numbers. As part of the six-visit-per-year cap, Medicaid patients also can't go to the emergency room twice in the same month and have their care covered. The cap does not apply to children or pregnant women. ("Emergency Room Visits Limited for Medicaid Patients," WCTV, August 1, 2012).
GA, SC defend Makena prior authorization procedures in court briefs. The state health agencies in Georgia and South Carolina are being sued by drug maker KV Pharmaceutical for having prior authorization procedures that allegedly make it difficult for KV's preterm labor drug Makena to compete with compounded versions. The states say their policies comply with federal requirements and defend their continued coverage of the less-expensive compounded drug. Anthony Keck, director of the South Carolina health agency, said "forcing our physicians to use Makena so K-V can meet its quarterly profit objectives is not an option for us." The Georgia department says in court filings, "As Medicaid funds are not unlimited, the Department has the job of administering the program in a way that utilizes its scarce resources effectively and responsibly while providing necessary health care services to Medicaid members." The department also says the company has not shown that its dire financial situation could be cured by the court's intervention. ("Georgia, South Carolina Defend Makena Prior Authorization Procedures In Court Briefs," Health Policy Newsstand, August 2, 2012).
IA releases analysis of Medicaid expansion. According to a new report, the average cost of the new optional Medicaid expansion would cost Iowa $161 annually per person over the first eight years. However, the report also indicates the state cost could climb to several hundred dollars per person by 2020. Medicaid Director Jennifer Vermeer warned that the report gave very general estimates amid many uncertainties about how many Iowans would be added to the program. Vermeer said there could be an array of costs and savings. For example, the state would have to pay more than a third of the cost for the formerly eligible but not enrolled. On the other hand, she said, the state could save millions of dollars it now spends on IowaCare, a limited insurance plan for poor people who don't now qualify for Medicaid but would under the expansion. ("Study: Medicaid expansion could help 182,000 Iowans," Des Moines Register, July 31, 2012).
IA recovers millions in program integrity effort. While thirteen states announced cuts to Medicaid benefits in July, Iowa announced a $30 million savings. Iowa Medicaid Director Jennifer Vermeer said "Combined with first-year savings of more than $23 million, we have now saved or recovered more than $50 million without trimming essential healthcare services for 400,000 Iowans or reducing provider rates." Vermeer said the savings result from analyses of claims submitted by major Medicaid providers, with most savings or recoveries due to claiming errors. ("Iowa a model for Medicaid program, saves $30M," Examiner, July 31, 2012).
MO undecided on Medicaid expansion, considers DSH cuts. Missouri state Medicaid Director Ian McCaslin said the federal health reform law's impact on Disproportionate Share Hospital (DSH) payments will give states an additional reason to "think hard about (Medicaid expansion)...We'll continue to move forward." McCaslin said he also expects the Medicaid expansion to become a big issue for the legislature and the executive branch in the spring during the legislative session. McCaslin estimated that it could be six to nine months before Missouri has a real sense of direction. ("Missouri officials mull impact of forgoing Medicaid expansion," St Louis Post-Dispatch, August 2, 2012).
OH Medicaid to reorganize into its own agency. Ohio's $18.8 billion Medicaid program that serves two million-plus individuals will break from the Ohio Department of Job and Family Services effective July 1, 2014. "In the past 18 months, we have passed legislation and begun implementing comprehensive reforms to improve the quality of health care for individuals served in the Medicaid program, saving the state more than $1.5 billion in the process," said Medicaid Director John McCarthy. "But we have more work to do to create a Medicaid program that is easier for Ohioans to navigate, improves health outcomes and is fiscally sustainable,"' he said. ("Separate agency to handle Medicaid," Columbus Dispatch, July 28, 2012).
OH considers Medicaid expansion options. Ohio Medicaid Director John McCarthy notes that, unlike several other states, Ohio did not rule out expanding Medicaid after the Supreme Court ruling. "It's not just about costs," he said, "The governor is concerned about individuals below 100 percent of the federal poverty level. We are going through and analyzing options now that this group is optional." ("Medicaid decision could widen care gap," Toledo Blade, July 30, 2012).
SC moves to pay for value. Tony Keck, director of South Carolina's Department of Health and Human Services spoke with Governing about his state's plans to increase value-based purchasing in Medicaid. "We're spending a lot of time with providers trying to correct problems caused by the way we pay people," says Keck. "We're asking [providers and payors across the state], how do you create that shared risk so everyone is in it together? We are starting to see arrangements that mutually manage these populations and share the returns." Keck describes his goal is to have 20 percent of all payments made under a value-based model by 2020. ("Rewarding Preventive Care in South Carolina," Governing, July 24, 2012).
TN policy seeks to promote HCBS for the elderly. Tennessee is revising its Medicaid long-term care options by changing the eligibility rules to favor home and community based care settings. The focus of this endeavor, said TennCare Assistant Commissioner Patti Killingsworth, is to make sure healthier patients who currently qualify for nursing facilities are served "more appropriately" in community-based settings. "We want nursing homes to target patients who truly need their services," Killingsworth said. The system will spend less, she acknowledged, "but we will serve more people with home- and community-based care." Matt Salo, executive director of the National Association of Medicaid Directors, also commented on the effort, saying "Federal law requires that program eligibility be tied to eligibility for nursing homes. Tennessee is stepping ahead to create this new category of at-risk individuals whose benefits are not linked to nursing homes." ("Tennessee Cuts Medicaid Benefit Funding For Some Long-Term Care Patients," Kaiser Health News, July 29, 2012).
States move forward on duals demos post-SCOTUS decision. Governing magazine recently examined the status of states' proposals to integrate care for the Medicare-Medicaid dually eligible population. Patti Killingsworth, assistant commissioner at TennCare and who oversees her state's demonstration project told Governing, "what we said in our planning process is we are going to find a way to improve the coordination of care for dual-eligibles regardless of the authority that we use. The issue isn't going to go away. It's only going to increase in terms of the pressure it puts on the health-care system." NAMD's Executive Director Matt Salo also commented at a Health Affairs conference in July, that "It's a national shame that we are subjecting the poorest and sickest among us to this fragmented care." ("Dual-Eligible Demonstrations Push Forward After Court Ruling," Governing, August 1, 2012).
WV undecided on Medicaid expansion. West Virginia's Medicaid Commissioner Nancy Atkins says there is a lot to consider when it comes to the possible expansion of Medicaid. "We're taking this analysis very seriously, as the Governor says, and we need to balance a lot of key factors," Atkins told state lawmakers. Governor Earl Ray Tomblin recently sent a list of questions about details of the possible expansion to U.S. HHS Secretary Kathleen Sebelius. "I think, primarily, a big piece of it is we still don't have all the answers," says Atkins. ("Medicaid Leader: We Don't Have All the Answers," WV Metro News, July 23, 2012).
NAMD's Salo comments on flexibility in Medicaid expansion post-SCOTUS decision. During a forum sponsored by the Bipartisan Policy Center, NAMD's Matt Salo stated that, "one real positive" impact of the Supreme Court's Medicaid decision is that it "raised the awareness of and appreciation for Medicaid, what it does, and the role of the states." The expansion of Medicaid eligibility guidelines constituted nearly half of all the new health care coverage made possible by the ACA," Salo said, "But nobody talked about it."
Salo said one area for which states may ask for more flexibility in how they run their Medicaid programs in return for agreeing to participate in the expansion is demonstration projects. "The problem with Medicaid for decades has been the expectation that you always must be demonstrating something, even if it's demonstrating something that works," he said. He prodded the audience by asking, "at what point can we say you don't have to prove it's working ... and create a culture where innovation is the norm and not the exception?" ("CMS Official Voices Hope States Will Join Expansion as Panelists Outline Challenges," Bloomberg BNA, July 31, 2012).
NAMD weighs in on new HHS-DOJ fraud partnership. Under the National Fraud Prevention Partnership, claims data will be shared among major insurance companies, the federal government and other partners in a bid to pinpoint fraud schemes that may not be detectable by a single payer. NAMD's Andrea Maresca told InsideHealthPolicy that it was "baffling" that the state Medicaid agencies have not been involved. "Once again, they failed to engage or coordinate with Medicaid agencies," Maresca said. Sharing Medicaid data and best practices could potentially be helpful to the partnership, and NAMD has already asked HHS to clarify if and when any outreach to the Medicaid community might occur, Maresca said. ("HHS-Insurer Partnership Still Working out Key Details of New Anti-Fraud Initiative," Inside Health Policy, July 26, 2012)
Other Items of Interest
Medicaid health plan association examines MCOs' role in quality improvement. A new fact sheet from the Association for Community Affiliated Plans, "How States Can Leverage Medicaid Managed Care to Improve Quality," provides an overview of the managed care-related policy levers available to state policymakers to improve quality in their Medicaid programs. The paper examines the quality-related federal requirements for managed care programs that do not apply to fee-for-service, such as ongoing performance measurement, a state-level Medicaid managed care quality strategy, performance improvement projects and external quality review organizations.
UnitedHealth Group responds to concerns about duals demos. In a letter to Medicare Payment Advisory Commission Chairman Glenn Hackbarth, UnitedHealth Group discusses its strong support for the Medicare-Medicaid Coordination Office's initiatives, including the Financial Alignment Model demonstrations. The letter goes on to discuss the company's experience serving challenging populations and its focus on delivering quality care, the need to ensure that the scope and enrollment are sufficient to test the models and fund the innovations envisioned by states and plans, and the primary focus on better managing care.
A Systemic Approach to Containing Health Care Spending. The Center for American Progress convened leading health-policy experts with diverse perspectives, including Zeke Emanuel, Don Berwick, Michael Chernew, Tom Daschle, Uwe Reinhardt, and Peter Orszag, to develop innovative solutions for controlling health costs. This "Sounding Board" article presents a range of options for bending the health care cost curve. Recommendations include promoting payment rates within global targets, accelerating the use of alternatives to fee-for-service payment, using competitive bidding for all medical commodities, requiring exchanges to offer tiered products, requiring all exchanges to be active purchasers, simplifying administrative systems for all payers and providers, requiring full transparency of prices, making better use of non-physician providers, expanding the Medicare ban on physician self-referrals, leveraging the federal employees program to drive reform, and reducing the costs of defensive medicine. ("A Systemic Approach to Containing Health Care Spending," NEMJ, August 6, 2012).
Mark Your Calendar
HHS ACA implementation forums. **NOTE: THE DATES FOR THE IMPLEMENTATION FORUMS HAVE CHANGED** HHS has scheduled four regional sessions in Washington, DC (Aug 14th), Atlanta (Aug 15th), Chicago (Aug 21st), and Denver (Aug 22nd). Click here to RSVP for one of the sessions.
Save the date for NAMD's 2012 fall meeting: October 28-30, 2012, Crystal City, Marriott, Arlington, VA. Registration is open!