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The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 
 

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The 2nd phase of the NC managed care transition includes the full move of behavioral health members hits some challenges with issues with Cardinal Innovations (the largest behavioral healthcare provider in the state).

 
 

Clipped from: https://www.wfae.org/health/2020-11-13/will-north-carolina-be-ready-for-medicaid-transformation

North Carolina’s 2.36 million Medicaid recipients are in for a big change next July. That’s when the state’s Medicaid system will be transformed into a managed care program run by private health care companies.

 
 

Right now, only behavioral and mental health care is handled by managed care companies like Cardinal Innovations Healthcare. Cardinal serves 20 counties in the state, but that’s likely to change. Five counties, including Mecklenburg, say Cardinal has done such a poor job they want to switch to another provider.

But under the state law requiring transformation, all medical care — including doctor visits, hospital stays and prescription drugs — will be coordinated by private companies. And controversy over Cardinal Innovations could raise questions about whether North Carolina will be ready to embark on Medicaid transformation next July.

On Monday night, Stanly County joined four other counties that want to fire the managed care company for poor performance. The move came only hours after Cardinal submitted a plan to correct problems in Mecklenburg and Forsyth counties.

Department of Health and Human Services’ Deputy Secretary Dave Richard told WFAE he’s optimistic about Cardinal’s new plan to reduce wait times for treatment. And he says Cardinal has been told DHHS will impose financial penalties if it falls short. Cardinal says it has yet to learn the specifics of potential penalties.

But DHHS has been responsible for overseeing Cardinal for five years. And the department’s oversight role will increase enormously under transformation.

Under the plan, Medicaid recipients without behavioral or mental care needs will sign up with one of five managed care companies chosen by the state. So will those with mild or moderate behavioral problems. They’ll choose between plans offered by Carolina Complete Health, Wellcare, United Healthcare, Blue Cross and Blue Shield and AmeriHealth Caritas.

Those with severe mental and behavioral issues will transfer all their care a year later to one of the companies which currently provides behavioral health care — including Cardinal Innovations.

All managed care companies will be paid a set amount for each patient they serve, and they’ll get to keep any money they don’t spend. State lawmakers say that will cut the cost of unnecessary care.

The theory is that companies will have an incentive to spend more on preventative care so they don’t have to spend money on expensive treatments for avoidable illnesses. But companies will also have an incentive to cut other costs, so the need for accountability and oversight will grow.

That worries state Auditor Beth Wood. In a May 2019 audit of the DHHS oversight of the managed care companies currently providing behavioral care — like Cardinal — she found the department didn’t have formal policies and procedures for evaluating performance or for designing corrective action plans and imposing penalties when necessary.

Under Medicaid transformation, Wood noted “the risk to the state will increase exponentially.”

Managed care companies currently get about $3.2 billion annually from the state, she wrote in the audit. She projected that would jump to $13.9 billion under Medicaid transformation, “which will increase the risk that quality services are not provided, costs are unreasonable, and performance standards are not met.”

Richards says DHHS’ oversight capabilities are better today than when Wood issued her report. He points out that DHHS has added key staff with deep experience in managed care and contract oversight in anticipation of transformation. And, he says, standards in the new contracts will be tougher than those imposed on managed care companies by other states.

But Richards says DHHS has told counties that once transformation starts, it will become increasingly difficult for them to “disengage” from the managed care companies which currently handle behavioral health care. After the state decides how it will divide up its Medicaid budget, he says, making changes could “destabilize” the system.

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The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 
 

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The impact of NY DSRIP in Western New York is examined, and found to have decreased preventable hospital admissions by 35%, but the impact on ER visits was not quantified.

 
 

Clipped from: https://www.bizjournals.com/buffalo/news/2020/11/11/medicaid-costs-western-new-york.html

It’s been five years since state health officials announced New York would pump $335 million into Western New York to help area hospitals and health care providers cut Medicaid costs.

The goals were clear: reduce unnecessary emergency department visits and the number of readmissions within 30 days of discharge. Groups of providers had no choice but to work together if they wanted to reap the financial benefits of the Delivery System Reform Incentive Payment (DSRIP) program.

Statewide, health care officials called the $8 billion program a success. Preventable hospital admissions dropped by 21%, and readmissions went down by 17% through June 2018.

Though emergency department visit reductions didn’t quite reach the same threshold in Western New York, local health care leaders say hospital readmissions dropped by 34.5% over the five years. While they can’t estimate how much was saved on events that never took place, it’s clear there were savings.

“It’s hard to say, because we know there are different reimbursement models that pay at different rates, but when you’re avoiding an ER visit, you’re saving thousands of dollars,” said Amy White Storfer, director of Community Partners Western New York which is affiliated with Catholic Health and one of two provider systems that organized providers and distributed the DSRIP funds. The other is Millennium Collaborative Care, affiliated with Erie County Medical Center Corp.

Just before the Covid-19 pandemic hit New York, the federal government rejected a state request for a four-year extension. Though the program expired March 31, providers are required to continue to measure outcomes March 31, 2021.

Ann Monroe, one of two co-chairs overseeing the DSRIP program and the state’s Medicaid reform effort, said five years wasn’t enough.

“My concern now is that while collaboration was made much stronger, that was in a time of resource plenty and we are now moving into a time of resource scarcity,” Monroe said. “Maintaining the progress made between and among organizations will be much harder in the next few years. I think the temptation is to hunker down and defend one’s organization during a dark time and that would be the antithesis of what we will really need in the next few years.”

ECMC’s COO Andy Davis is interim executive director at Millennium. He said financial savings were important, but the new, strong relationships between hospitals and community-based organizations are invaluable. Many executives had never spoken to each other before the DSRIP meetings.

“We saw that particularly during the height of Covid in the spring when we were able to flow some of those dollars to testing with community partners,” he said. “If we didn’t already have that community collaboration, we wouldn’t have been able to do that.”

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 
 

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A MO audit found about $7M in managed care payments for out of state patients and another $1M for prisoners not eligible for Medicaid.

 
 

Clipped from: https://www.msn.com/en-us/news/world/audit-finds-dollar8m-in-potential-missouri-medicaid-overpayments/ar-BB1aM1Pl

Missouri overpaid as much as $8 million for Medicaid health care for out-of-state residents and prisoners in recent years, according to a state audit released this week.

 
 

© Madeline Carter/Tribune Nicole Galloway gives her concession speech after losing the Missouri Governor’s race to Governor Mike Parson at the Tiger Hotel on Tuesday evening.

State Auditor Nicole Galloway’s office found the state overspent as much as $6.6 million for 2,600 on health care for patients with out-of-state addresses through the state’s managed care system between July 2017 and June 2019.

Medicaid is a government program that provides health care coverage for low-income adults, children and people with disabilities. Missouri works with managed care companies as middlemen to provide Medicaid care at a lower cost.

The audit also identified $1.7 million in state payments for 500 patients who were incarcerated for at least some of that three-year period.

Missouri law at the time required the state to kick people off Medicaid when they were jailed or imprisoned. Current law requires Medicaid be suspended for those patients so officials can check to see if they qualify for an exemption.

“At a time when every dollar is being stretched to deliver vital services to Missourians, state government must stop wasting resources,” Galloway said in a statement. “The millions in payments for prisoners and non-Missouri residents is unacceptable.”

Missouri’s Department of Social Services, which oversees Medicaid, said problems with the state’s data system required the agency to exempt some recipients from regular eligibility checks to prevent eligible patients from improperly losing coverage. The agency said staff have been working to check those patients’ eligibility now that data system errors have been fixed and cited annual eligibility checks enacted in 2018.

“This audit confirms that the DSS’ action to implement annual renewals in 2018 and 2019 to verify continued eligibility was the correct action,” the agency wrote in a response included in the audit.

Galloway, a Democrat, on Tuesday lost a bid to unseat Republican Gov. Mike Parson. During her campaign, she frequently criticized his administration for dropping close to 90,000 children from the state’s Medicaid health insurance program.

State officials cited a drop in unemployment and improved efforts beginning in 2018 to purge Medicaid rolls of people who were not eligible. Department of Social Services Acting Director Jennifer Tidball has said that about a third of people who lost coverage didn’t answer letters to renew their eligibility.

This article originally appeared on Columbia Daily Tribune: Audit finds $8M in potential Missouri Medicaid overpayments

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 
 

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Kevin Bagley is the new Nebraska Medicaid Director.

 
 

Clipped from: https://journalstar.com/news/state-and-regional/govt-and-politics/new-nebraska-medicaid-director-named/article_0209133a-843b-58b8-83d4-a6a830d8b32a.html

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A Utah man has been named the new director of the Nebraska Division of Medicaid and Long-Term Care, Gov. Pete Ricketts announced Monday. 

Kevin Bagley, who replaces Matthew Van Patton, who left in February, has worked for the Utah Division of Medicaid since 2011 and is the director of long-term services and supports in the division.

“Kevin’s extensive expertise in Medicaid operations will be especially valuable as Nebraska enhances the Heritage Health Adult Plan and continuously improves customer service,” Ricketts said. 

 
 

Kevin Bagley, director of the Division of Medicaid and Long-Term Care at the Nebraska Department of Health and Human Services.

 
 

Bagley, 37, has collaborated in Utah with community stakeholders; federal, state, and local government agencies; and providers. He has worked with health plans and other community-based organizations to assess and review rate changes, patient access, utilization patterns, clinical standards, provider participation criteria and consumer and provider satisfaction.

He has also worked with the Utah Legislature, provider networks and consumer advocacy groups to design and implement new strategic programs.

During his Utah Division of Medicaid tenure, he has been an actuarial specialist, a process implementation manager and assistant director of authorizations.

He has a Master of Business Administration from Utah State University and a Bachelor of Arts in economics from Brigham Young University.

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 
 

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4 years in the making, the Medicaid Managed Care Rule is now fully finalized, with most of the original components in tact.

 
 

Clipped from: https://www.modernhealthcare.com/medicaid/cms-signs-medicaid-managed-care-changes

CMS on Monday wrapped up its long-awaited changes to how states can run their Medicaid and Children’s Health Insurance Program plans.

The final rule gives states more flexibility to set rates for their managed-care plans and ensure plans have adequate provider networks. The Trump administration hopes the changes will encourage private health plans within Medicaid and CHIP, slash regulations and cut federal exposure to healthcare costs.

“The era of prescriptive regulations has failed. The government should identify expected outcomes, results, and standards—not micromanage processes,” CMS Administrator Seema Verma said in a statement.

Most of the rule changes take effect next month.

Health plans sparred with provider and consumer groups over the rule’s relaxed network adequacy standards, which allow states to set their standards—like provider-to-enrollee ratios—instead of using minimum time-and-distance standards. Insurers claimed the change would help states and plans take up telehealth and other innovations. But critics argued the move could make it harder for beneficiaries to access care.

Providers and Medicaid managed-care plans also asked CMS to allow states switching to managed care to require plans to make pass-through payments to providers for up to five years instead of three years.

“We continue to view pass-through payments as problematic and not consistent with our regulatory standards for actuarially sound rates because they do not tie provider payments with the provision of services,” the final rule states. CMS claimed three years is “a reasonable amount of time to integrate pass-through payment arrangements into allowable payment structures.”

The rule doesn’t affect an Obama-era requiring insurers to spend at least 85% of their Medicaid revenue on medical care and other activities to improve quality, even though that requirement is the biggest concern for plans and states.

According to CMS, comprehensive managed-care plans covered more than 55 million people enrolled in Medicaid in 2018.

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 
 

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Oklahomans voted for Medicaid expansion, but they don’t want to pay for it using tobacco settlement funds.

 
 

Clipped from: https://www.enidnews.com/news/state/voters-reject-tapping-of-tset-for-medicaid-expansion/article_4cc44f8b-22f0-57c3-a5e6-07cca8eaf482.html

OKLAHOMA CITY — Voters decided Tuesday that they don’t want lawmakers to pay for Medicaid expansion by tapping the state’s constitutionally protected tobacco settlement funds.

Nearly 60% voted against the ballot measure. Garfield County voters rejected the measure by 61.21%.

The resounding rejection of State Question 814 dealt a blow to legislators. Lawmakers had proposed reducing the amount of the annual payment that flows into the Tobacco Settlement Endowment Trust (TSET) by 50% to offset some of the expense of the upcoming Medicaid expansion approved by voters earlier this year.

“I hate that it didn’t pass because our options on how to fund Medicaid expansion are really limited at this point, and none of the options that are left on the table are options that people are going to like,” said state Sen. Greg McCortney, R-Ada.

He said the Legislature is constitutionally mandated to balance the budget. If income is down and expenses are up, lawmakers will have to cut spending somewhere, and there are only so many options on the table.

McCortney said he’s heard some Oklahomans suggest tax increases to pay for expansion, but suspects many of Tuesday’s legislative winners ran on pledges to keep taxes low.

“So increasing taxes to pay for Medicaid expansion is clearly not what the people of Oklahoma are looking for the Legislature to do,” he said.

Had the measure passed, lawmakers would have received about $49.7 million — or 75% — of the state’s share of the annual payment from “big tobacco.” The measure required lawmakers to use the TSET funds to help pay the state’s 10% Medicaid expansion share. The federal government is responsible for paying the remaining 90%.

The voter-mandated Medicaid expansion is expected to shore up struggling hospitals and insure as many as 200,000 more Oklahomans. However, it comes amid a worsening state budget situation and doesn’t provide lawmakers any guidance on how to pay the estimated $164 million to $246 million price tag next year.

“Today’s outcome is an enormous win for Oklahomans who clearly prioritize their health,” said Matt Glanville, Oklahoma government relations director for the American Cancer Society Cancer Action Network.

He is part of the Vote No — 814 is Not OK coalition.

“We are grateful that voters recognize they don’t have to sacrifice tobacco control and cancer research grants to expand Medicaid,” Glanville said. “The Legislature knows how to fund Medicaid expansion while maintaining the integrity of the TSET trust, and they simply need to implement those measures.”

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The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 
 

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340 B covered entities are opposed to moving drugs to FFS only in NY (carving rx out of managed care).

 
 

Clipped from: https://www.nydailynews.com/news/politics/new-york-elections-government/ny-medicaid-prescription-drugs-funding-change-20201111-njbe3len6fgwbn2khxxykwxoxi-story.html

ALBANY — A growing coalition of health care groups and providers are outraged over an impending change to Medicaid funding for prescription drugs in the Empire State.

The groups are pleading with the Department of Health to not follow through on changes to the 340B drug discount program, which allows safety net hospitals catering to underserved and low-income communities to purchase deeply discounted prescription drugs.

A provision tucked into the budget this year, based on a recommendation by the state’s Medicaid Redesign Team, would “carve out” the discount and shift payment to a fee-for-service reimbursement starting next April.

That means hospitals that care for large numbers of people with Medicare, Medicaid or those without insurance would lose out on the savings and the state would instead capture the rebate, a move that could decimate essential services for communities hardest hit by the coronavirus pandemic, opponents argue.

“It’s essential to maintain the safety net for our state’s most vulnerable populations,” said Guillermo Chacon, president of the Latino Commission on AIDS and founder of the Hispanic Health Network. “The State’s budget changes to ‘carve-out’ Medicaid prescription drugs will devastate the 340B drug discount program for the poorest New Yorkers in need of health services.”

Sen. Gustavo Rivera (D-Bronx) and Assemblyman Dick Gottfried (D-Manhattan), the health chairs in both the Senate and Assembly, have proposed a bill that would delay the transition for three years.

As per the current law, the state Department of Health has convened an advisory group, which is exploring the impact of the change. The work group has met three times and is scheduled to reconvene soon, according to agency spokesman Jonah Bruno.

Bruno said the proposal “saves taxpayers millions of dollars by increasing transparency, ensuring Medicaid pays the best price for medications, and eliminating unnecessary administrative costs to health plans, all while ensuring that consumers continue to have access to needed medications.”

More than 35 groups have so far joined the Save NY’s Safety Net: 340B Saves Lives coalition, including the Drug Policy Alliance, the Alcoholism & Substance Abuse Providers of New York State, and Community Healthcare Network, a non-profit network of 14 federally-qualified health centers serving 85,000 patients annually in the five boroughs.

“We provide high-quality, affordable primary care and specialty support services, regardless of patient ability to pay,” said Robert Hayes, president and CEO of the the health care provider. “The 340B carve-out threatens our most essential programs. The carve-out is reverse Robin Hood, taking efficient, life and health preserving care from New Yorkers most in need.”

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 
 

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OH will scrap the PBMs chosen by the MCOs and replace them with a single pharmacy operational support vendor (POSV) chosen by the state.

 
 

 
 

Clipped from: https://www.dispatch.com/story/news/2020/11/06/medicaid-stepping-up-oversight-pharmacy-benefit-program-saving-taxpayers-money-due-pbm-abuses/6181248002/

 
 

The Ohio Department of Medicaid on Thursday started the process of hiring a private administrator to oversee its $3 billion pharmacy benefit program.

The department requested proposals for a pharmacy operational support vendor to help design its program and provide financial oversight once it’s up and running.

Medicaid created the new post as part of a broader overhaul of its managed care program. In addition to rebidding contracts with private managed care organizations that oversee the program, the state agency is also replacing five pharmacy benefit managers hired by those private organizations to process claims with one company hired by the state and monitored by the administrator.

“The POSV (pharmacy operational support vendor) will ensure monetary incentives are properly and fairly aligned, eliminate self-dealing and steering, and monitor and close potential pricing or rebate loopholes,” said Medicaid Director Maureen Corcoran.

“In short, the POSV ensures that the fox is no longer guarding the chicken coop.”

The administer will operate independently from the pharmacy benefit manager, providing oversight and ensuring pharmacists are paid accurately for the prescriptions they fill.

The added oversight comes after a report showed PBMs billed the state far more than they paid pharmacists and kept the difference, allowing them to receive $224 million in one year — an amount generated by PBMs charging three to six times the standard rate, according to an independent analysis.

Ohio Pharmacists Association Executive Director Ernie Boyd applauded state officials “for taking this important step in Ohio’s cleansing of the PBM problem.”

“The proposal would position Ohio as a national leader in rooting out dysfunction in the drug supply chain. With proper execution of implementation of this vision, provider access can be stabilized, incentives can become better aligned, and taxpayer dollars can be deployed more effectively and efficiently,” Boyd said.

“One thing that’s extremely noteworthy in the RFP is that ODM has effectively stripped PBMs of their price-setting capabilities. That is a major marketplace shift, and is a complete rebuke of what PBMs have been doing. Essentially, the text of the RFP is ODM’s way — through action — to completely pull the rug out from under the many shell games that PBMs were engaging in. Pretty incredible 180 from where we were.”

The tax-funded health insurance program provides coverage to more than 3 million poor and disabled Ohioans.

ccandisky@dispatch.com

@ccandisky