Year: 2017

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Clay’s Weekly Medicaid RoundUp: Week of February 20th, 2017

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2lRoz5n

Or you can click the one for optimist readers –  http://bit.ly/2lRbJno

 

THE WHEAT STATE TILTS AT WINDMILLS- Either KS and ME know something we don’t, or these 2 states are about to get approval for Medicaid expansion in the era of Trump. ME got it on the ballot and KS reps just passed it in their house. Or maybe lefty reps in both states are play-acting to look good for their base since Dems in generally are licking wounds right now? You decide. News and Weather at 10.

 

HEART OF DIXIE WANTS CAID FOR CONS- Err, sorry I meant to say “justice-involved.” Please don’t take away my snowflake card. Senator Cam Ward wants Alabama to get some help from the federalis to cover inmate costs. If his bill goes through, the feds (that translates to “taxpayers in other states”) will pay 70% of the costs of healthcare for Bama’s bad guys.

 

CONTINUED CHAOS IN UNHINGED WHITE HOUSE WITH DARK VISION OF AMERICA. DOOM! DOOM! DOOM! RUSSIANS! RESIST! Actually, yet another logical, calculated appointment was made to President Trump’s team this week. Brian Blase just joined the staff. Blase is a PhD economist who spent time as a Senate staffer and has been very open about his criticism of current Medicaid financing shenanigans. Couple this with the appointment of Price to DHS and Veerma to CMS- Mr. Trump is not joking about transforming Caid. The Resistance will have to do better than misbehaving at town halls and worshipping Michael Moore if they want to effectively shape what’s coming.

 

BEAVER STATE SEES DROP IN ENROLLMENT– There’s been about an 11% drop in Oregon Caid enrollment comparing Jan 17 to Mar 16. This translates into 133,000 less managed care members, which = 133k x 12 x the average cap rate less money for the MCOs (CCOs) in Oregon (I do fancy Medicaid math, you should sign a consulting agreement and pay me to do fancy Medicaid math for you. I also put most of my internal thought processes in parentheses [rarely in brackets] {and never in whatever these things are}). That’s a lot less cash the MCOs (CCOs) have to operate and will probably lead to some sort of horse-trading required come rate-setting time.

 

MOLINA POSTS NY CAID LOSS; RECENT SIGNALS OF EXITING EXCHANGES- Revenues for Molina in NY dropped $185M YOY, resulting in an overall $192M Q4 loss. The main culprit? Having to pay $322M into a risk adjustment pool that then got redistributed to other MCOs who showed higher risk memberships. Molina has also recently begun socializing the idea of it pulling an Aetna and exiting the exchanges.

 

XEROX (OLD ACS) ASKS JUDGE TO LIMIT THE PAIN IN THE LONESTAR STATE- The flailing MMIS giant has alleged that the state is using “a web of lawsuits” to jack up potential settlements related to that whole debacle over prior auth for orthodontics services for TX Medicaid bennies. Xerox wants to be able to designate the dentists involved as responsible 3rd parties. TX wants to be able to sue Xerox AND the dentists separately. The suit currently rings up at about $1B in potential payouts.

 

 

FARRIS’S FANTASTIC FRAUD FOLLIES– None this week dear readers. I hear you collectively, depressively sighing. But remember- I gave you an entire Roundup of Fraud Follies like 2 weeks ago. Remember that. Hold it close.

 

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (its spring. You know its spring.) and keep running the race (you know who you are).

****

FULL, FREE newsletter: http://eepurl.com/ep81Y . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: Uba ya aiko Ɗan ya ceci duniya

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Menges Group 5 Slides Series for Jan and Feb 2017

The Menges Group puts out these great analyses and insights each month. And is kind enough to let us repost them for the MM audience. Check out themengesgroup.com to learn more about the work they do. 

The January edition tabulates the distribution of Medicaid pharmacy costs by unit price cohort.  Explosive growth in the share of Medicaid prescriptions among drugs costing more than $1,000 per prescription (pre-rebate) continues to occur.  These drugs now represent 40% of all Medicaid pre-rebate prescription drug expenditures.

The February edition tabulates overall health care expenditures from 2006-2016, and shows the progression of Medicaid, Medicare, and private health spending.  A key observation from these tabulations is that health costs haven’t grown all that rapidly across the past decade – annual per capita cost increases have averaged 3.7% for the entire US population, 2.3% in Medicare, 3.2% in Medicaid, and 4.0% in the rest of the population.

 

Health Expenditures Progression 2006 – 2016 Feb. 2017

 

Price Per Script Categories Jan. 2017 (1)

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Medicaid Industry Who’s Who Series – Dr. James Bush

Dr. James Bush is the featured panelist for the upcoming Wyoming State Medicaid Spotlight Webinar on March 6th. RESERVE your seat today!

 

Medicaid Who’s Who: Dr. James Hall – Chief Medical Officer, Wyoming Medicaid

  1. What is your current position and with what organization?

A: Wyoming Medicaid Medical Director

  2. How many years have you been in the Medicaid industry?

A:  10 years

  3. What is your focus/passion? (Industry related or not)

A:  Quality improvement

  4. What is the top item on your “bucket list?”

A: A smooth transition to high-value care and revitalized primary care.

  5. What do you enjoy doing most with your personal time?

A:  Travel, hunting and music.

  6. Who is your favorite historical figure and why?

 A: Marcus Tullius Cicero. Defender of the Roman Republic.

  7. What is your favorite junk food?

A:  Pizza

  8. Of what accomplishment are you most proud?

A: 37 years of marriage and two great children.

  9. For what one thing do you wish you could get a mulligan?

A: Some ill-chosen business partners.

  10. What are the top 1-3 issues that you think will be important in Medicaid during the next 6 months? 

A:  What will stay or go from the ACA, the transition to High value high quality care, and the evolution of HIE. ​

 

To ensure that you’re in the loop on all things Mostly Medicaid, be sure to sign up to receive our free newsletter, join the discussion on LinkedIn and check out tons of great content at www.mostlymedicaid.com.

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Clay’s Weekly Medicaid RoundUp: Week of February 6th, 2017

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2lygShv

Or you can click the Special Valentine’s Day treat for optimist readers –  http://bit.ly/2lyalTX

 

It’s been a while my dearest readers. As is our custom when returning from hiatus, let’s begin with the normal ending segment…

 

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. Let’s start the ticker and see who wins this week’s award.  Maria Navarro and Judith Bench of Orlando are charged with using their special needs school to bill 21,000 bogus Medicaid therapy claims. They billed for 8 hours a day but only had staff to provide 2. Taxpayer tab – $4.5M. Pedro Garcia of Mission, TX was charged this week with submitting Medicaid claims for dead people – to the tune of $300k. John Holland of Miami was CEO of Portneuf Medical Center when he (allegedly) took bribes that facilitated $12M of Medicaid fraud. He plead not guilty this week. Michael Johnston of Broadheadsville, PA got sentenced for pilfering $100k from Medicaid using bogus mental health services claims. Mr. Johnston took the cash and used it cover trips to Jamaica. Stephen Monaco (awesome name), a podiatrist from Haverton, PA was sentenced this week for stealing $4.9M from Medicaid, Medicare and other payers. Dr. Monaco would barter opioids with patients in exchange for them letting him shoot painful (but unnecessary) injections into their feet. Eduard Zavalunov of NYC became the 9th fraudster to plead guilty in a multi-clinic racket that bribed Medicare and Medicaid bennies (with cash) to undergo unnecessary tests. Taxpayer tab – $70M. Shalonda Suggs of Oklahoma City pled guilty this week to a $200k mental health services not provided scheme. Julia Faigel of Boston, MA was ordered to pay $475k for Medicaid dental fraud. She had TWENTY ONE corporations she used to rob the taxpayers. Robert Windsor of Cumming, GA pled guilty this week of bilking GA Medicaid, KY Medicaid, Tricare and FEHBP (the healthcare federal employees get) for more than $20M. His gig? Medically unnecessary balance tests, electromyography (whatever the heck that is) and qualitative drug screens. IPC – a hospital staffing firm that provides doc labor, also goes by Team Health if you are googling for it- will cough up $60M for defrauding Medicaid and Medicare via upcoding. Dr. Oughatiyan was the whistleblower and he will get $11.4M. Bernard Greenspan of Newark, NJ got $200k in bribes for his role in a $200M fraud scheme. He’s pleading innocent (he’s also 80 years old), but 2 dozen other docs have pled out on this scheme which involved Biodiagnostic Lab Services bribing docs for referalls to Medicare and Medicaid. And now, drum roll (we have a lot of contestants this week!)… Mr. Windsor you win this week’s award for your tenacity and not settling for ripping off just one Medicaid program. Indeed – stealing from both GA and KY sets you apart. I hope you stashed some cigarette money someplace, so you can barter in the slammer.

 

Sadly, I was able to fill an entire Roundup with fraud follies (with a total of about $384M stolen by my rough count). I could do this each and every week (but that would be boring). And I left out several big ones this week, too. Nothing to see here, move along. Regardless of whether we repeal, replace or repair there will always be this wonderful gravy train for fraudsters. As I pay my taxes in the next month or so, I know that makes me feel good. How about you?

 

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (I swear we never have winter anymore here in AL. Must be global warming, or maybe the Russians?) and keep running the race (you know who you are).

****

FULL, FREE newsletter: http://eepurl.com/ep81Y . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: Papa a voye Pitit la pou konsève pou mond lan

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Obamacare / Trumpcare: Let the arguments begin

 

by Len Kirschner, MD, MPH

Dear Editor, The Affordable Care Act (aka Obamacare) became law almost seven years ago in March, 2010. The battles for and against the law have continued since Day #1. There have been many ups and downs. Trips to the Supreme Court, the initial failure of Healthcare.gov and the rancorous rhetoric in the 2016 Presidential campaign have poisoned the debate.

The positives are impressive. We now have the lowest number of people without health insurance in the history of this country. Close to 200,000 Arizonans have coverage under the Exchange and over 700,000 have received coverage under our Medicaid program better known as AHCCCS.

In Washington the debate is raging about “Repeal and Replace” with no obvious resolution to the issue. A total repeal would be damaging to Arizona and a huge hit to the state budget. Hundreds of thousands of people would lose coverage and the entire population would be impacted. Much of the debate centers on the Exchange but Medicare would also be impacted. Closing the prescription drug “doughnut hole” would be canceled and the million Arizonans on Medicare would see costs increase. Hospitals would see a rise in uncompensated care and emergency department use would increase.

The House of Representatives has voted 60 times to repeal Obamacare. It was symbolic since the bill was going nowhere. Now they have the political strength to act and truly repeal Obamacare. They look like the dog who kept chasing the car and finally caught it. What do they do now?

Change is coming and the new system will be called Trumpcare. Let the arguments begin.

 

 

Len has done so much in the healthcare space its impossible to do it justice in a simple footer. Highlights include being State President of AARP of Arizona, the former Medicaid Director for Arizona, and 22 years of active duty in the United States Air Force. He is also a physician and regular on the Medicaid conference circuit. To learn more about Len, check out this bio and this bio.

This article originally appeared in a local newspaper. Reprinted with kind permission from the author.

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Clay’s Weekly Medicaid RoundUp: Week of January 9th, 2017

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2irmSci

Or you can click the one for optimist readers –  http://bit.ly/2irnjDt

 

WAIT A MINUTE- WHO’S SURPRISED AT THE CURRENT ACA REPEAL EFFORTS? It’s been hated by millions since day 1 (and loved by millions, especially on the left), the GOP has introduced 60+ repeal bills over the last 7 years – and now everyone is floored that one of the first things the Right does once it regains control is renew repeal efforts? The Senate took step 1 of a 10-step procedure to repeal ACA early Thursday morning. Here’s the best guide I have seen so far – http://read.bi/2ipCPji

 

THE LAND OF OPPORTUNITY STATE PUTS APPLICATION BACKLOG TO REST- AR brought in about 250 temp workers, but they got it done. Back in June there were 100,000 “pieces of paperwork” overdue, including 34,000 or so apps that were 45 days old. At year end (just a few weeks ago – weird), there were no overdue apps. Hey AR – can you send those temp workers over to KS?

 

SOONER STATE MCD NEEDS ANOTHER $200M TO KEEP THE LIGHTS ON- My crystal ball says they will get it. Just look at last year- when the overall OK budget was $1.3B short, OK Mcd got $1B (which was an increase over the previous year). You silly lawmakers need to just submit to the Mcd dominance of your budgets and move on.

 

MAGNOLIA STATE NEEDS ANOTHER $75M NEXT YEAR- Backers of the bump point to cuts in prior years, as well as a recent $58M cut in September that addressed lower-than-expected state revenues. It is interesting that the request for more money is happening when MS enrollment is decreasing.

 

KUDOS TO HPP ON THE KEYSTONE WIN- Health Plan Partners was awarded new membership  in PA this week. The award will expand the HPP PA footprint into 13 more counties, home to nearly 500,000 Mcd members. Congrats HPP!

 

THE COPPER STATE ANTI-EXPANSION LAWSUIT MOVES FORWARD- Its only been four years of spending money on the 300,000 new bennies, but the AZ Court of Appeals has scheduled the hearing challenging whether the way the Good Guvn’r Brewer unilaterally expanded was legal in the first place.

 

 

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. Let’s start the ticker and see who wins this week’s award.  Family Care Nursing (such a wholesome name!) of Meriden, CT settled this week for $5.3M related to billing for 60 day assessments knowing it was not an RN doing the work. Aretha Derrico was arrested for billing Mcd for $57,000 of home health services not provided in Havana, FL. Randy Crowell of Henderson, NV plead guilty to a $100M Rx reverse-diversion scheme last week. Mr. Henderson had an impressive range – from Utah to NY. How did he do it? He was a licensed wholesale rx distributor, of course. Still wondering what “reverse-diversion” means (I made that up, I think)? Instead of the pills going from legit sources to the black market, Mr. Henderson acquired pills in the black market and sold them to pharmacies. Sort of like money laundering, but with oxycontin. Although the specific hit to Mcd is not enumerated, I am more than impressed with this one. There are wonderful details like the use of lighter fluid to remove labels from bottles. Mr. Henderson – you win this week’s award! I would be interested in acquiring the movie rights to your story, when you get out of the slammer.

 

 

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (or stay inside and order your pepper seeds. They will need 30 days to germinate, and then that’s March and you want them strong when you put them out in May, right?) and keep running the race (you know who you are).

****

FULL, FREE newsletter: http://eepurl.com/ep81Y . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: Pitā sēva dha varlḍa dīkarānī

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Truth and “Entitlements”

Dave Mosley

by Dave Mosley

For the minority of Americans that are judicious in attempting to access and digest the news relating to our economy, there is a term that is often frustrating and misleading: entitlement.

One often hears that entitlements are dooming our economy and that spending must be curbed.

However, one also hears the argument that individuals have paid into Social Security and Medicare, so, in fact, they are not entitlements, unlike Medicaid, for which those receiving the benefit, paid nothing directly toward the benefit.

Regarding Social Security each person who receives benefits has contributed to that fund throughout their working life. Moreover, if a person is self-employed the annual contribution is doubled. Thus, to classify such a program as an “entitlement” is false. Yes, there is a right to benefits specified by law, but individuals have paid for their benefits. The average person comes very close to paying for (while working) his/her Social Security benefits (while retired).

Medicare benefits are different, in that the average individual, retiring this year will likely receive more than 3x the total dollars in benefits than he/she has paid into the program. For this reason, one might argue that Medicare is an entitlement. The government receives approximately 1/3 of the amount from an individual that the government will pay out on behalf of said individual.

For Medicaid, there is zero correlation between what an individual pays in to the program, versus the benefits one receives. Yes, various taxes are used to create the funding sources from which the Federal, state, and even local governments pay for Medicaid. However, again, there is no correlation between payment and benefit. In fact, the majority of individuals on Medicaid have never paid taxes at all.

Also worth noting is the fact that across our Nation individuals believe that Medicare, Medicaid, and commercial insurance are very similar health insurance platforms. Many presume that the primary difference between these payers is that the Feds pay for old folks, employers pay for working folks, and Medicaid pays for poor folks.

In fact, while Medicaid was created as a parallel program to Medicare – – addressing care based upon medical necessity and sufficiency criteria – – nearly one-half of all Medicaid payments are made for services that Medicare does not cover and never has covered.

Medicaid’s benefit package, in every state, far exceeds the benefits available through commercial, Medicare, VA, TRICARE and any other type of health insurance. Nearly one-half of Medicaid services provided to beneficiaries are neither curative nor restorative. Unlimited nursing home days (or home-based care), occupational therapy, hearing aids, eye glasses, orthodontics, and a plethora of other services are all covered by Medicaid and only Medicaid.

As the next budget cycle comes around, let’s not only listen to those crafting and adopting both Federal and state budgets, let’s listen in an informed manner.

Perhaps it would be beneficial if neither elected officials, nor the media, endeavored to paint all “entitlements”, or all health insurance, with the same brush?

It is disingenuous, at best, when the 24/7 news lumps Medicaid coverage in with any other coverage available in the Nation. Medicaid is far more than “health insurance”. We, as a Nation, can certainly afford to care for the most fragile members of our society; however, let’s do so through in a manner that affords transparency and clarity.

Dave Mosley is a Managing Director and the State Practice Leader for Navigant’s Government Healthcare Solutions (GHS). He assists Medicaid, human services, and elected leaders to navigate regulatory channels and to apply best practices to improve organizational performance. He is a recognized public speaker, has been published in trade journals, and is frequently called upon as a resource to elected officials at the state and Federal levels.

 

For more about Dave, check out his LinkedIn profile.

 

Article reprinted with kind permission from author.

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Medicaid Industry Who’s Who Series: Shannon McMahon

Medicaid Who’s Who: Shannon M. McMahon– Deputy Secretary, Health Care Financing with Maryland Department of Health and Mental Hygiene

Shannon M. McMahon, MPA, was appointed the Deputy Secretary of Health Care Financing at the Maryland Department of Health and Mental Hygiene in February, 2015. In this role, she is responsible for the operation of the state’s Medicaid program, which serves over 1.2 million Marylanders.

Previously, Ms. McMahon was the Director of Coverage and Access at the Center for Health Care Strategies (CHCS) where she lead Medicaid eligibility, benefit design and purchasing implementation efforts and learning collaboratives for states and the federal government. Prior to CHCS, she worked in executive and management-level roles in Minnesota Medicaid, most recently as the Chief Administrative Officer, where she oversaw finance and operations for Minnesota’s three public health care programs.

Ms. McMahon also spent several years working on health policy issues as a non-partisan analyst at the Department of Legislative Services in Annapolis and also held the position of senior budget and policy adviser to the Secretary and Principal Deputy Secretary of Maryland’s Department of Health and Mental Hygiene.

Ms. McMahon has a bachelor’s degree in justice from American University, Washington, D.C. and a master’s degree in public administration from Northeastern University, Boston, Massachusetts where she was a recipient of a full tuition public policy fellowship. She is a member of the board of directors of the National Association of Medicaid Directors.

Shannon McMahon is the featured panelist in the upcoming State Spotlight Webinar on Feb. 6th at 2pm EST. Learn more and register for free here.

  1.  What is your current position and with what organization?

Deputy Secretary, Maryland Department of Health and Mental Hygiene/Medicaid Director   

  2.  How many years have you been in the Medicaid industry?

 I’ve been working in health care policy/operations and consulting for 19 years; my focus has always been on the public sector, and Medicaid in particular.

  3.  What is your focus/passion? (Industry related or not)

My passion is making the government side of health care (enrollment, access) more person-centric.  I love Lean and business process re-design.

  4.  What is the top item on your “bucket list?”

Snuba the great barrier reef

  5.  What do you enjoy doing most with your personal time?

International travel with my family; I think that foreign travel is the greatest gift you can give kids, as it imparts two key business and life skills: organization and resilience.

  6.  Who is your favorite historical figure and why?

Eleanor Roosevelt; I’ve always admired her commitment to public service and her ability to problem solve in the most politically charged environments.

  7.  What is your favorite junk food?

Snickers

8.  Of what accomplishment are you most proud?

The recent Section 1115 waiver that we secured for Maryland Medicaid is a very big step to begin addressing the social determinants of health at the local level while also expanding access to substance use disorder services in the State.  The partnership forged between the State and local governments, as well as the support from the provider and advocacy community made it possible.  The amazing team in Maryland Medicaid worked hand and glove with our federal CMS counterparts to get ‘er done.

  9.  For what one thing do you wish you could get a mulligan?

I have a knack for calling people by the wrong name, and have done so with some pretty senior people in both government and the provider community. 

  10. What are the top 1-3 issues that you think will be important in Medicaid during the next 6 months? 

In Maryland, we are coming off the recognition of the 50th anniversary of Medicaid in 2016.  Our  two big focuses for the next six months are

(1) Implementing the SUD expansion under the 1115 waiver which includes a physical health-behavioral health integration component;

(2)  Developing a new payment and delivery system for individuals dually eligible for Medicare and Medicaid.

(3) Potential changes to the ACA will be of particular interest to Maryland as well, and as a member of the NAMD board, I have had the opportunity to engage with the key executive and legislative branch leaders on potential changes.