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This week’s NAMD newsletter looks at opioid addiction; duals; Hill health reform timeline; CHIP; work requirements.

 

Update
June 13, 2017
From the NAMD Desk
NAMD Re-appointed to NQF’s Measures Application Partnership
 
Earlier this week, the National Qualify Forum announced that they have added NAMD to the preliminary roster of the NQF’s Measures Application Partnership (MAP) Coordinating Committee. Following a notice and comment period, NAMD will be confirmed as a member of this MAP Committee for another 3 years.
The MAP Coordinating Committee is charged with harmonizing HHS and private sector measures for use in public reporting and performance-based payment. Lori Coyner, Medicaid Director in Oregon, is currently NAMD’s representative on the committee and will continue to serve in this role once NAMD’s re-appointment is confirmed.

 

In This Issue

Save the Date
 
NAMD Fall Meeting
November 6-8, 2017
Hyatt Regency Crystal City
Register here.

 

Reg Update

 

HHS Announces Grant Opportunities to Address Opioid Addiction
The Department of Health and Human Services (HHS) recently announced new grant opportunities that are aimed at preventing opioid overdose deaths and delivering treatment for opioid use disorder. These grants were authorized by the Comprehensive Addiction and Recovery Act (CARA) and will be administered through the Substance Abuse and Mental Health Services Administration (SAMHSA). They include:
  • Medication-Assisted Treatment and Prescription Drugs Opioid Addiction. Up to $28 million to 5 grantees to increase access of medication-assisted treatment for opioid use disorder.
  • First Responders. Up to $41.7 million over 4 years available to approximately 30 grantees to train and provide resources for first responders and members of other key community sectors on carrying and administering emergency treatment of known or suspected opioid overdose.
  • Improving Access to Overdose Treatment. Up to $1 million over 5 years to one grantee to expand availability to overdose reversal medications in healthcare settings and to establish protocols to connect patients who have experienced a drug overdose with care.
These funding opportunities follow up the heels of two other SAMHSA grant programs authorized under the Comprehensive Addiction and Recovery Act:
  • State Pilot Grant Program for Treatment for Pregnant and Postpartum Women.Up to $3.3 million to support a range of family-based services for pregnant and postpartum women with substance use disorder.
  • Building Communities of Recovery. Up to $2.6 million to mobilize resources within and outside of the recovery community to increase the prevalence and quality of long-term recovery support from substance abuse and addiction.
More information on these grant opportunities is
available here.
CMCS Bulletin Provides Strategies for Transitioning Newly-Eligible Duals
 
On June 7, the Center for Medicaid and CHIP Services (CMCS) published an Informational Bulletin providing clarity around required redetermination processes when a Medicaid adult group beneficiary attains Medicare eligibility, as well as strategies to enhance the transition from Medicaid coverage to Medicare coverage as a dually eligible beneficiary.
The bulletin encourages states to put processes in place to identify adult group beneficiaries who may soon become eligible for Medicare, in order to begin the redetermination process early and ensure timely redeterminations. It also notes that if the redetermination results in the beneficiary being placed in a new eligibility category with reduced benefits, fair hearing rights must be provided.
Strategies the bulletin suggests for states include:
  • conducting early outreach,
  • simplifying collection of information from beneficiaries,
  • providing adequate assistance throughout the redetermination process, and
  • aligning income and asset rules between the Medicare Savings Program and the Medicaid adult group.
Read the bulletin here.
Duals Office Update
 
Here are some important updates from the Medicare-Medicaid Coordination Office (MMCO):
 
  • The FY 2016 MMCO Report to Congress: This annual fiscal year report highlights progress made by MMCO over the past five years. The report covers topics such as the Financial Alignment Initiative demonstrations, enrollment in PACE programs, the Medicare-Medicaid ACO model, and others. Of particular note is the enrollment growth in integrated care programs for duals, which increased from 161,177 in FY 2011 to 720,614 in FY 2016.
  • In late May, MMCO released final standardized contract year 2018 Annual Notice of Change and Evidence of Coverage model documents for use in all Medicare Advantage plan types, including duals special needs plans (D-SNPs). These documents included the following flexibilities for integrated plans:
    • Incorporated flexibility to integrate Medicare and Medicaid benefit descriptions
    • Provided options for D-SNPs to provide differential information about cost-sharing liability for its members subject to no cost-sharing for Parts A and B services (including QMBs) and those with cost-sharing responsibility
    • Streamlined language about maximum out-of-pocket limits (MOOP) for dually eligible beneficiaries
    • Added optional language for plans to describe changes to Medicaid benefits and provide information about Medicaid-specific resources for information
    • Added language about inappropriate billing of QMBs
HHS Issues RFI Seeking Input on Administrative Actions It Could Take in Individual and Small Group Markets
 
Last Thursday, June 8th, the Department of Health and Human Services (HHS) issued a Request for Information (RFI) seeking comments on approaches the agency could take to reduce regulatory burdens in the individual and small group markets. The RFI reveals that the agency is “actively working” to foster “a more streamlined, flexible, and less burdensome regulatory structure” consistent with current law. In particular, it solicits comments on changes to existing regulations or guidance – or other steps within existing authority – that would address the following objectives:
 
  • Empowering patients and promoting consumer choice;
  • Stabilizing the individual, small group, and non-traditional health insurance markets;
  • Enhancing affordability; and
  • Affirming the traditional regulatory authority of the States in regulating the business of health insurance.
HHS clarifies that it is only at the RFI stage – not yet proposed rulemaking – and seeks “complete but concise responses” to its questions. It also notes that respondents do not need to address every question.
Comments are due in 30 days; responses will be made publicly available at www.regulations.gov.

 

Hill Update

 

Senate Accelerates Timeline for Health Reform Passage; New Details Emerge on Policy Approaches
 
Early last week, reports from the Senate’s deliberations on health reform indicated that Senate leadership aims to expedite the timeline for a floor vote on a complete package. The new goal is for a vote to be held prior to the July 4 recess.
This revised timeline is aggressive compared to the previously-anticipated goal of a vote before the August recess. Several steps will need to be completed in the next few weeks in order for a floor vote to be held, including final agreement on policy, development of legislative language, clearance of the package’s elements for reconciliation under the Byrd rule by the Senate parliamentarian, and scoring by the Congressional Budget Office. It is possible that one or more of these steps will introduce delays in the process. However, a failure to hold a vote before the July 4 recess should not be interpreted as an overall failure of reform efforts – merely a reversion to the previously anticipated vote prior to the August recess.
Details around the policy trajectory the Senate may take with regards to Medicaid also emerged last week. On the matter of Medicaid expansion, Senate leadership proposed a three-year phaseout starting in 2020, while several moderate Republican Senators are coalescing around a seven-year phaseout. Resolving these separate timelines on the expansion remains a key issue.
On Medicaid financing reform, Senate leadership proposed keeping the same growth rate of CPI medical for the per capita cap categories (with the exception of the CPI medical plus one percentage point for the disabled) as found in the House bill. However, these growth rates would be paired with a periodic resetting of the base year for the per capita caps, potentially occurring every 2 – 3 years.
Finally, the Senate is considering a dedicated funding pool for providing opioid addiction treatment. These funds would be aimed at mitigating the impact of the Medicaid expansion phasedown.
House E&C Health Subcommittee to Hold Hearing on CHIP, FQHC Funding
 
On Wednesday, June 14, the House Energy and Commerce Committee (E&C) Subcommittee on Health is scheduled to hold a hearing titled “Examining the Extension of Safety Net Health Programs.” The hearing will focus on questions around extending funding for CHIP, likely including whether to continue its 23% enhanced FMAP and/or the maintenance of effort requirements; and funding for federally-qualified community health centers (FQHCs).
Background materials for the hearing can be accessed on E&C’s website here, and a live broadcast of the hearing will also be featured at the same location.
HHS Secretary Tom Price Testifies on FY18 Budget Proposal Before Senate Finance and House Ways & Means Committees

Last Friday, June 9th Secretary Tom Price of the Department of Health and Human Services (HHS) appeared before the Senate Committee on Finance and the House Ways & Means Committee for two hearings on the Trump Administration’s fiscal year (FY) 2018 HHS budget request. The  HHS Budget in Brief document unveiled in late May would cut an estimated $665 billion over ten years from HHS, derived mostly from cuts to the Medicaid program.

The Secretary faced scrutiny from Democrats in both chambers regarding the cuts, which, coupled with proposed cuts to Medicaid in the House-passed American Health Care Act (AHCA), would reportedly amount to a $1.4 trillion trim to the program. In response, Sec. Price denied claims that Medicaid would lose any funding due to the complex “constellation” of funding changes currently being considered for the program through other avenues in Congress and regulation.
Other points of discussion included the Secretary refusal to commit on funding the Affordable Care Act (ACA) cost sharing reduction (CSR) payments to insurers, the Department’s efforts to stem the opioid epidemic, the elimination of certain social service programs, and the potential impact of AHCA policies still under consideration in the Senate.
Joint Economic Committee Looks at Opioid Crisis
 
On Thursday, June 8th, the Joint Economic Committee held a hearing, “Economic Aspects of the Opioid Crisis.” Among the well-known experts who testified included Angus Deaton, Nobel Prize-winning economist; Richard Frank, who ran ASPE during the Obama administration; and Ohio Attorney General Mike DeWine, a former Republican senator and representative.
To read the testimonies and/or watch the hearing, please click here.
House E&C Committee Unanimously Advances User Fee Bill
 
Last Wednesday, June 7th, the House Energy and Commerce Committee voted unanimously (54-0) to advance its bill to reauthorize the US Food and Drug Administration’s (FDA) user fee programs for prescription and generic drugs, biosimilars and medical devices (FDA Reauthorization Act of 2017) to the full House. In an effort to move the bill forward with bipartisan support, a controversial proposal by Rep. Morgan Griffith (R-Va.), which would have eased restrictions on off-label promotion of medicines, was jettisoned, as was another proposal from Rep. Peter Welch (D-Vt.) which would have allowed for the reimportation of drugs from Canada.

 

In the News

 

Arizona Declares Opioid State of Emergency
 
On June 5, Arizona Governor Doug Ducey (R) issued a state of emergency targeting the rising opioid-related deaths in the state. Arizona Department of Health Services data showed that in 2016, 790 Arizonans died of opioid overdoses, representing a 74% increase from the previous four years. The order will allow enhanced state, local, and private sector collaboration and the distribution of the opioid overdose-reversal drug naloxone to community partners.
Read a statement on the Arizona order here.
Nurse practitioner demand eclipses doctors as states lift hurdles, Forbes reports
 
According to the latest snapshot into the U.S. healthcare workforce from MerrittHawkins, a subsidiary of AMN Healthcare, nurse practitioners are more in demand than most physician specialties. This trend may only escalate as momentum builds behind legislation to eliminate hurdles for patients who need primary care and as states increasingly give direct access to nurse practitioners. Indeed, “the demand for nurse practitioners has never been higher,” says American Association of Nurse Practitioners President Cindy Cooke said, with 22 states and the District of Columbia giving nurse practitioners full-practice authority. Furthermore, retail clinics like those run by CVS Health CVS and Walgreens are predominantly staffed by nurse practitioners offering quick access to treat routine maladies, while urgent care centers, outpatient clinics, and doctor’s offices continue to staff nurse practitioners in primary roles.
Increased demand for nurse practitioners, writes Forbes, reflects the broader shift away from fee-for-service medicine to value-based care, which urges a team-based approach and which nurse practitioners and physician assistants work with doctors. In the words of Travis Singleton, senior vice president of MerrittHawkins, “Nurse practitioners and other allied health professionals are going to be a major part of our healthcare delivery systems, especially with population health and team-based care.”
Please read article here.
The New York Times: America’s Hidden HIV Epidemic
 
Thanks to the success of lifesaving antiretroviral medication pioneered 20 years ago and years of research and education, most HIV-positive people today can lead long, healthy lives. In cities like New York and San Francisco, once ground zero for the AIDS epidemic, the virus is no longer a death sentence, and rates of infection have plummeted. Emboldened by this progress, public-health officials have championed the notion of an AIDS-free generation – even without a vaccine. Yet, as the New York Times reports,
HIV continues to ravage marginalized communities across the country. Perhaps nowhere is this more acute than in the South, home to 21 of the 25 metropolitan areas with the highest HIV prevalence among gay and bisexual men and 54% of total new HIV diagnoses. In the small city of Jackson, Mississippi, for instance, half a dozen black gay or bisexual men receive the shock of a diagnosis every month, and more than 3,600 people, the majority of them black men, live with the virus.
One reason why African American gay and bisexual men have been left behind, the New York Times posits, is the general absence of gay black men from the early scientific literature surrounding HIV/AIDS. Including gay black men in the literature and understanding of the origins of the disease and its treatment, the Times predicts, would have meant earlier outreach as well as more cultural, political, and financial leverage. But years of neglect, compounded by poverty and inadequate local health care infrastructure, have left too many black gay and bisexual men falling through a series of safety nets. Despite the election of Barack Obama which brought renewed attention to the domestic epidemic, resources are stagnant (the Deep South received $100 less in federal funding per person living with HIV than the United States over all in 2015), and most black gay and bisexual men are still not benefiting from lifesaving antiretroviral medication: A CDC report published in February noted that less than half of black gay and bisexual men effectively suppress the virus with consistent medication.
Read this article to learn more about what steps can be taken to address this issue. The article also contains several poignant personal stories of gay or bisexual men living with HIV/AIDS in the South.
Vox: Medical Community Beginning to Change how it Looks at Pain
As the opioid crisis continues to grow, this
Vox article examines how the medical community is starting to shift the way they think about and treat pain. Professional societies are moving away from treating pain as a fifth vital sign. And instead of eliminating pain, physicians are beginning to focus on ways to substantially reduce it. The article adds that CMS is also moving in this direction; in a recent rule, CMS updated a Medicare policy so that hospitals are no longer financially accountable for reducing patients’ pain scores.
Find the article here.
National Public Radio Highlights Medicaid’s Role for Children with Autism, Elderly
In a recent article,
NPR explored the role Medicaid played in covering two members of a Wisconsin family: a child with autism spectrum disorder and his elderly grandmother. The author examines how congressional proposals to overhaul Medicaid might impact the services this family – and others like it – receive.
The article is available here.

 

Take Note

 

Commonwealth Fund: The Potential Impact of Medicaid Work Requirements
 
The Trump administration has made work requirements a hallmark of its Medicaid policy proposals, including the idea in the just-released 2018 HHS budget proposal, and as part of its Medicaid demonstration agenda; likewise, the House-passed American Health Care Act (AHCA) allows states to make having a job a requirement for gaining Medicaid eligibility. In their new brief, the Commonwealth Fund explores what said work requirements would actually mean for Medicaid beneficiaries and the program at large. It finds that a Medicaid work requirement would affect about 22 million low-income, working-age adults, two-thirds of whom are either working or looking for work. Importantly, it reveals that the work requirement approaches across states would be “highly variable”: Some would require work only for the Medicaid expansion population (working-age adults ineligible under traditional program rules and with incomes up to 138 percent of the federal poverty level), while others, such as those proposed by Maine, Wisconsin, and Florida, would include the traditional Medicaid adult population as well. In addition, some waivers would include exemptions for disabilities like drug addiction, while others would exempt people who have “diligently” tried to comply but who face “extraordinary” barriers to employment (i.e., Florida).
For the full brief, as well as a comprehensive list state Medicaid work requirement proposals, please click
here.
Kaiser Family Foundation: State Flexibility to Address Health Insurance Challenges under the American Health Care Act, H.R. 1628
 
This brief by the Kaiser Family Foundation (KFF) outlines the provisions in the AHCA providing flexibility for states and addresses some of the issues and tradeoffs they could face. The first – the Patient and State Stability Fund – would appropriate up to $123 billion between 2018 and 2026 for a number of designated purposes related to coverage and the costs of care, such as:
 
  • Providing financial assistance to high-risk individuals not eligible for employer-based coverage who enroll in the individual market;
  • Providing incentives to entities (e.g., insurers) to enter into arrangements with the state to stabilize premiums in the individual market;
  • Reducing the cost of providing non-group or small-group coverage in markets to individuals facing high costs due to high rates of utilization or low population density;
  • Promoting participation in the non-group and small-group markets and increasing options in these markets;
  • Promoting access to preventive, dental and vision care services and to maternity coverage, newborn care, and prevention, treatment and recovery support services for people with mental health or substance disorders;
  • Providing direct payments to providers for services identified by CMS; and
  • Providing cost-sharing assistance for people enrolled in health insurance in the state.
Under AHCA, writes KFF, states also would have flexibility to modify important insurance provisions. Through waivers, for instance, states could: 1). Extend rate variation due to age; 2). Modify the essential health benefits; or 3). Permit insurers to use an applicant’s health as a rating factor for individuals applying for coverage if they have had a coverage gap in the year prior to their enrollment.
In describing these potential new flexibilities, KFF outlines several tradeoffs that may have to be made, namely decreased federal funds, reduced coverage, higher out-of-pocket costs, adverse selection against plans with more comprehensive packages.
To read the full issue brief, please click here.
Medicaid in Small Towns and Rural America: A Lifeline for Children, Families, and Communities
 
In this report, the Georgetown Center for Children and Families (CCF) and the North Carolina Rural Health Research Program (NC RHRP) examines how the role of Medicaid has changed over time in the 46 states with small-town and rural populations. Overall, it finds that:
 
  • Medicaid covers a larger share of children and families in small towns and rural areas than in large metropolitan areas;
  • Medicaid expansion under the ACA is having a disproportionately positive impact on small towns and rural areas; and
  • The rate of uninsured children in small towns and rural areas declined in the vast majority of states (43 out of 46 states) during the time period examined.
Please click here for the full report .
Health Affairs Blog: State Medicaid Lessons for Federal Health Reform
 
This post from Health Affairs investigates the experiences of states with current 1115 waivers to better contextualize and evaluate the Trump’s administration emphasis on waiver flexibility. In describing the experiences of Arkansas, Indiana, and Michigan, which have used 1115 waivers to implement health savings accounts (HSA’s), monthly contributions, and cost sharing, for example, Health Affairs underscores the effectiveness of encouraging people to be careful consumers of services and of reducing unnecessary utilization – in Indiana, enrollees who made contributions to their HSA’s were more likely to obtain primary and preventive care, have better drug adherence, and rely less on emergency room treatment. That said, Health Affairs also acknowledges how HSA’s can also be detrimental, citing research evidencing decreased enrollment and decreased access to essential and non-essential care.
To read Health Affairs’ full analysis of the opportunities and challenges accompanying these and other waivers, as well as “lessons learned” for states that wish to proceed with such waivers, please click here.
Michigan Heart Surgery Outcomes Improved After Medicaid Expansion, Study Finds
 
According to a new study published in the Annals of Thoracic Surgery, expanding Medicaid coverage is associated with better outcomes for heart surgery patients. Comparing the health outcomes of surgery patients in Michigan and Virginia, the study finds that the risk-adjusted likelihood of a serious postoperative complication dropped by 30% after Medicaid expansion in Michigan compared to no significant changes over the same time in Virginia, which did not expand. The researchers also found that in Michigan, the number of uninsured patients having cardiac surgery dropped by 60% compared to no change in Virginia. Furthermore, the Michigan patients who were still uninsured after Medicaid expansion were older, higher risk, and more likely to die in the month after their operation.
To read the study click here; for a related press release from the University of Michigan, please click here.

Jobs
Nebraska Seeking Medicaid Director
The Nebraska Division of Medicaid & Long Term Care is seeking a Director of the Division. The position is responsible for charting the agency’s path through the dynamic health industry landscape. Works directly with the Governor and the Chief Executive Officer of the Department of Health and Human Services to set policy for the division that optimizes service delivery, patient experience, and fiscal stewardship.

Full announcement and application here.

 

Arkansas Medicaid Attorney Position
The Medicaid Attorney is responsible for providing professional legal counsel and administering legal services for the Arkansas Medicaid program. This position is governed by state and federal laws and agency/institution policy. Posting closes June 21.
See full description and application  here.

 

Multiple Openings with Nevada Health Care Financing and Policy
The State of Nevada Division of Health Care Financing and Policy has number Health Care Coordinator potions.
To see all openings click  here.

 

 

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