Department of Health and Human Services – HHS administers more than 100 programs across its operating divisions. HHS programs protect the health of all Americans and provide essential human services, especially for those who are least able to help themselves.
Further reading
Health Plan Employer Data and Information Set –
HEDIS is a tool used by more than 90 percent of America’s health plans to measure performance on important dimensions of care and service. Because so many plans collect HEDIS data, and because the measures are so specifically defined, HEDIS makes it possible to compare the performance of health plans on an “apples-to-apples” basis. Health plans also use HEDIS results themselves to see where they need to focus their improvement efforts.
HEDIS measures address a broad range of important health issues. Among them are the following:
Asthma Medication Use
Persistence of Beta-Blocker Treatment after a Heart Attack
Controlling High Blood Pressure
Comprehensive Diabetes Care
Breast Cancer Screening
Antidepressant Medication Management
Childhood and Adolescent Immunization Status
Childhood and Adult Weight/BMI Assessment
Further reading
http://www.ncqa.org/hedis-quality-measurement/what-is-hedis
A lot happens in Medicaid in 30 days. We covered it all in 60 minutes. Join Cathy Huff, Craigan Gray, Ray Hanley and Clay Farris for updates and insights into the Medicaid industry you won’t find anywhere else.
Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2wO7zhZ
For optimist readers- http://bit.ly/2wOp6GQ
RED AND WHITE SMOKE SEEN ON DAY 62 FROM THE TOWERS OF THE MCO NEGOTIATION COUNCIL- After a few months of dancing around the issue of insufficient rates in the press, Iowa officials and MCO folks are in closed-door sessions to figure it out. New price negotiations were expected to conclude in July, but now its looking like mid to late August. In addition to price it looks like plans may be asking for more control over care management and utilization. You know, the things they are on the hook for. The number 1 complaint I hear from plan clients is they are held accountable for things they are not allowed the tools to impact. Hear, here.
PLANS BICKERING IN THE MAGNOLIA STATE- Amerigroup and Mississippi True are protesting the late-June MCO awards. United, Magnolia Health and Molina all won another round on the MS Medicaid ride. Mississippi True is a new provider-sponsored plan arguing that the RFP requirements around experience were designed to lock out any bidders besides the incumbents. Three state lawmakers are petitioning the Governor to instruct the Caid agency to take another look. Its nice to see lawmakers take such an interest in the Medicaid procurement process. I am sure they are Medicaid experts with a lot of insight into who the Medicaid agency should select and how they should evaluate proposals.
TARHEEL STATE SUBMITS REVISED MANAGED CARE PROPOSAL- This one is from the new Guv (Cooper), updating the one from 14 months ago by the old Guv (McCrory). Right now its shaping up to be focused on integrating physical and behavioral health (makes absolute since given the efforts in the NC market in recent years), telemedicine (a bit of a surprise), opioids and care management. No word yet on whether The Good Guvnr Cooper is looking to horsetrade with CMS to expand Caid enrollment. Let’s get managed care in there first, fellas.
IOWA DID NOT COLLECT $700K IN RX REBATES. SUBTRACTS AMOUNT FROM NEXT SFY BUDGET REQUEST- Just kidding on that last part. Silly kids! Medicaid spending NEVER, EVER goes down. If it did, the pink elephants at the center of the earth’s core would stop marching and our planet would fall from its orbit and go hurtling into space and we would all die because the Republicans hate everybody and only Democrats are GoodPeople. At least that’s what General Spend-It-All in charge of the Resistance tells me.
WONDERS NEVER CEASE. NEW CLAIMS PAYMENT SYSTEM IN THE CENTENNIAL STATE BEGINS LIFE ON STATUS: SNAFU- Colorado’s new claims payment system (interChange- note the lowercase first letter, but the Capital letter in the middle of the name. That means its sophisticated.) is not a hit with providers (at least the ones being interviewed). According to them, claims that previously sailed through are now being rejected. Many providers are out a good bit of cash and have decided to stop taking any new Medicaid patients until the problems are resolved. In defense of the new system all providers had to re-enroll during implementation, and many of the problems are being seen with ones who failed to do so. Other interesting parts of this story: The vendor is DXC Technology, which I guess is maybe a new MMIS-ish vendor? And the contract is for $187M over 8 years. That has to be the cheapest claims payment system I have ever heard of – even when the price does double like we all know it will. Hear that sound? That’s the sound of change orders piling up on some project manager’s excel spreadsheet somewhere.
LOOK UP DUMPSTER FIRE IN THE DICTIONARY AND YOU WILL FIND A PICTURE OF THE ILLINOIS STATE BUDGET- Its just terrible. Terrible. The stories won’t stop. This week: 10 IL SNFs were allowed to continue their lawsuit against the state for not getting paid the correct rate for 4 years. IL NPR also ran a story about various pediatricians out hundreds of thousands of dollars as they wait for the state to pay.
AND APPARENTLY JAMES COMEY IS IN CHARGE OF THE IL MEDICAID PRESS OFFICE? I can honestly say I have never seen this: There was a news story this week letting the world know that CountyCare is a winner in the IL MCO bids. All the other winners (and losers) will have to wait until later to find out the rest of the results. Appears there’s a leaker in IL someplace.
I WILL BE AT MESC NEXT WEEK, WILL YOU? If so send me a note and let’s meet up.
I WILL BE AT MHPA 2017 IN OCT., WILL YOU? You can check it out here – http://bit.ly/2twCi5L Every 100th registrant will get a free Medicaid Foundations Course registration (our online training course).
FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph … Not enough space this week. Lots of fraudster goodies for you in the twitter feed, though.
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 (practice your eclipse poses) and keep running the race (you know who you are).
FULL, FREE newsletter@ mostlymedicaid.com . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: Viśvada uḷisalu tande maganige kaḷuhisalāgide
The Freedom of Information Act (FOIA) is a law that gives you the right to access information from the federal government. It is often described as the law that keeps citizens in the know about their government.
Further reading
We talked all things Washington Medicaid with Preston Cody, Division Director of the Division of Medicaid Program Operations and Integrity for the Washington State Health Care Authority.
The Federal Employees Health Benefits (FEHB) Program is a system of “managed competition” through which employee health benefits are provided to civilian government employees and annuitants of the United States government. The government contributes 72% of the weighted average premium of all plans, not to exceed 75% of the premium for any one plan (calculated separately for individual and family coverage).[1]
The FEHB program allows some insurance companies, employee associations, and labor unions to market health insurance plans to governmental employees. The program is administered by the United States Office of Personnel Management (OPM).
Further reading
https://en.wikipedia.org/wiki/Federal_Employees_Health_Benefits_Program
The Federal Acquisition Regulation (FAR) is the principal set of rules in the Federal Acquisition Regulations System.[1] The FAR System governs the “acquisition process” by which executive agencies of the United States federal government acquire (i.e., purchase or lease) goods and services by contract with appropriated funds.[1][2][3] The process consists of three phases:[4] Need recognition and acquisition planning; Contract formation; and Contract administration.
The FAR System regulates the activities of government personnel in carrying out that process. The FAR System is codified at Title 48, Chapter 1 of the Code of Federal Regulations. These requirements can be found in the Code of Federal Regulations at 48 C.F.R. 31.
While nearly all federal government executive agencies are required to comply with the FAR, some executive agencies are exempt (e.g., the Federal Aviation Administration[5][6] and the U.S. Mint[7][8]). In those cases, the agency promulgates its own specific procurement rules.[9][10] The remainder of the FAR System consists mostly of sets of regulations issued by executive agencies of the federal government of the United States to supplement the FAR.[1]
The purpose of the FAR is to provide “uniform policies and procedures for acquisition.”[11] Among its guiding principles is to have an acquisition system that satisfies customer’s needs in terms of cost, quality, and timeliness; minimize administrative operating costs; conduct business with integrity, fairness, and openness; and fulfill other public policy objectives.[12]
Further reading
https://en.wikipedia.org/wiki/Federal_Acquisition_Regulation
Consumer Price Index for Prescription Drugs and Medical Supplies –
The prescription drugs index is comprised of drugs one may purchase by prescription at a retail, mail order or Internet pharmacy. However, prescription drugs that are primarily consumed and paid for as part of hospital visits are not included in this sample.
Item sampling: This index employs a streamlined sampling method. At each of the pharmacies selected, the BLS field staff selects a specific item for each of the assigned number of items to be priced. To do this, the field staff obtains a list of the last 20 prescriptions dispensed. This “last 20 list” serves as a proxy for all the prescription drugs dispensed at that pharmacy, and a price is obtained for each prescription on the list. The price includes both patient and insurance payments to the pharmacy, and the sum of all 20 prices makes up total spending (by the consumer at this pharmacy). Thus, each price represents an observed share of total spending, and the probability of any one prescription being selected is proportional to its share in total spending. The more frequently a certain drug shows up in the “last 20 list” and the more expensive it is, the more likely it is to be selected for the index. This item selection procedure is done for every outlet when it is initiated for pricing.
SPECIAL PRICING PROCEDURES FOR PRESCRIPTION DRUGS
Drugs losing patent protection: When a brand-name drug in the sample loses its patent protection, generic versions of the drug receive a one-time chance to replace the original, brand-name drug even if the pharmacy continues to sell the brand name drug. Six months after a drug in the sample loses patent protection, CPI field staff selects among all drugs (including the original) that the Food and Drug Administration deems to be therapeutically-equivalent. Delaying the reselection for six months allows emerging generic drugs an opportunity to gain market share. The chance of drug selection is proportional to the number of prescriptions sold for each version of the drug over the previous 3 months. If a generic is selected, the CPI treats any price difference between the original drug and its selected substitute as a price change, and reflects this change in the index in the month when the procedure was performed.
When prescription drugs become available over-the-counter (OTC), the CPI continues to price them in the prescription drug index until they rotate out under normal rotation procedures. They are not transferred to the non-prescription drugs index. The observations remain in the prescription drug sample, and any price change is reflected in the prescription drug index. Similarly, if any over-the-counter drugs were to change so they required prescriptions, they would remain in the non-prescription drugs and medical supplies index until the next rotation and any resulting price change would occur in that index.
Further reading
The Bureau of Labor Statistics (BLS) was originally established under the Department of the Interior as the Bureau of Labor under the Bureau of Labor Act (23 Stat. 60) of June 27, 1884. After several reorganizations and transfers, the agency was renamed the Bureau of Labor Statistics and transferred to the Department of Labor in 1913.
Further reading
https://www.federalregister.gov/agencies/labor-statistics-bureau
