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Medicaid cuts on the table as states grapple with impact of pandemic on program enrollment – MarketWatch

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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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States are working on budgets that must be finalized this summer, and cuts to Medicaid and education appear likely in order to deal with a decrease in the tax revenue base.

 
 

 
 

Clipped from: https://www.marketwatch.com/story/medicaid-cuts-on-the-table-as-states-grapple-with-impact-of-pandemic-on-program-enrollment-01606494876

 
 

Administrator of the Centers for Medicare and Medicaid Services Seema Verma and Vice President Mike Pence look on as President Donald Trump speaks at a coronavirus briefing in April.

jim watson/Agence France-Presse/Getty Images

State leaders are weighing possible cuts to Medicaid services and health-care benefits to offset rising costs due to a surge of enrollees who have lost jobs and need health coverage as the coronavirus pandemic has intensified.

Congress boosted federal matching funds to states for Medicaid as part of its first coronavirus relief package, but many states are still struggling to afford the increasing pace of sign-ups in the program for low income and disabled people. Enrollment for the fiscal year ending Sept. 30, 2021, is expected to jump 8.2%, with state spending accelerating by 8.4%, compared with 6.3% growth in the previous fiscal year, based on data from 42 state Medicaid directors compiled by the Kaiser Family Foundation.

 
 

Medicaid has grown to become one of the largest portions of state budgets, from about 21% in fiscal 2008 to about 30% in fiscal 2018, according to the National Association of State Budget Officers.

State leaders working on budgets that must be finalized in July are confronting budget crises. Tax revenues have tumbled since March because of restrictions on businesses, social distancing and high unemployment related to the pandemic, economists have found. Most states have constitutional or statutory requirements that they maintain balanced budgets.

Some state leaders may try to narrow the gap between the revenues they need to balance the budget and the shortfalls they face by cutting vision and dental benefits, or payments to doctors and other providers. Cuts to other programs, such as education, could also be in the mix.

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The Trump Medicaid record: Big goals, yet few successes | Salon.com

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Most of the efforts of the outgoing administration to transform the program have failed.

 
 

 

 

 

Clipped from: https://www.salon.com/2020/11/01/the-trump-medicaid-record-big-goals-yet-few-successes_partner/

Trump entered office seeking a massive overhaul of Medicaid. Four years later, his administration has fallen short

 
 

President Donald Trump entered office seeking a massive overhaul of the Medicaid program, which had just experienced the biggest growth spurt in its 50-year history.

His administration supported repealing the Affordable Care Act’s Medicaid expansion, which has added millions of adults to the federal-state health program for lower-income Americans. He also wanted states to require certain enrollees to work. He sought to discontinue the open-ended federal funding that keeps pace with rising Medicaid enrollment and costs.

 

He has achieved none of these ambitious goals.

Although Congress and the courts blocked a Medicaid overhaul, the Trump administration has left its mark on the nation’s largest government-run health program as it has sought to make states more responsible for assessing its impact and improving the health of enrollees.

One notable achievement: The Trump administration pushed some states to be more aggressive in weeding out ineligible recipients — an initiative that led to a drop in enrollment of children in several states, including Missouri and Tennessee. About half of those enrolled in Medicaid are children.

 
 

 

A recent report from the Georgetown University Center for Children and Families found that the number of uninsured children rose by more than 700,000 to 4.4 million from 2017 through 2019. The increase of uncovered children stands out since uninsured rates typically drop during periods of economic growth, such as the one occurring from 2017 to 2019.

Advocates for the poor say the administration’s efforts contributed to an increase in the number of uninsured children, after years of decline. “The administration has not succeeded on any of its goals in any meaningful way,” said Joan Alker, executive director of the Georgetown center. “But they still have inflicted some damaging changes to the program.”

“The administration has not prioritized the health of children,” said Bruce Lesley, president of the child advocacy group First Focus on Children.

 

Alker attributes the rise in uninsured children to federal officials’ decision to slash outreach funding for the Obamacare insurance exchanges — through which families eligible for Medicaid are often identified — and the administration’s focus on the “public charge” rule. That provision allows the federal government to more easily deny permanent residency status, popularly known as green cards, or entry visas to applicants who use — or are deemed likely to use — publicly funded programs such as food stamps, housing assistance and Medicaid.

Medicaid officials said the increase is partly due to loss of health coverage by middle-income families who are not eligible for Medicaid. They say those families don’t qualify for government subsidies for the ACA’s marketplace plans and were forced to drop their plans because of high premiums.

 

But Alker said federal data suggests that families who have incomes over the 400% federal poverty level eligibility limit for subsidies (about $87,000 for a family of three) saw a slower rate of increase in the number of uninsured children as opposed to lower-income kids.

A spokesperson for the federal government’s Centers for Medicare & Medicaid Services said the agency was “committed to ensuring that eligible children are enrolled and retained in coverage” and it spent $48 million in grants for outreach and enrollment effort last year.

The Trump administration opposes the ACA’s expansion of Medicaid, which provided billions in federal dollars to cover nondisabled, low-income adults. Yet seven states adopted the expansion during the past three years, including Republican-controlled Utah, Idaho, Oklahoma, Nebraska and Missouri.

 

Despite the aim to shrink the program, about 75 million people were enrolled in Medicaid in June 2020 — roughly the same number as in January 2017, when Trump took office.

One reason is that Medicaid enrollment soared this year following the COVID-19 outbreak as unemployment spiked to historic highs and federal stimulus money forbid states to drop anyone unless they moved out of state.

But that is far from the administration’s goal of “ushering in a new day” for Medicaid, as CMS Administrator Seema Verma said when she laid out her bold vision in a 2017 speech.

 

Verma acknowledged she was stepping into a hornet’s nest of entrenched stakeholders and interest groups.

“I would like to invite everybody here today who have fought the political healthcare battles over the last decade to take a deep breath, exhale and agree to reset as a group,” she said.

They didn’t. The administration’s major Medicaid changes were met with opposition from hospitals, doctors and patient advocacy groups, who feared the efforts would lead to cuts in funding or add obstacles for enrollees seeking care.

Officials spent two years seeking to allow states to require enrollees to work or volunteer as a condition for enrollment. They approved proposals from 10 states, but only Arkansas implemented the new requirement before a federal judge ruled it illegal. Arkansas’ brief experience resulted in more than 18,000 adults losing coverage.

 

After losing in federal district and appeals courts, the Trump administration has appealed to the Supreme Court, which will decide later this year whether to take the case.

The push for work requirements and other changes have altered the culture of Medicaid so that officials are more intent on keeping people out of the program instead of welcoming more in, said Lesley, of First Focus.

Before the pandemic, he said, the administration allowed states to add hurdles for families to get enrolled and stay enrolled, such as requiring them to more frequently recertify their income eligibility.

Aaron Yelowitz, a professor of economics at the University of Kentucky, said one of the Trump administration’s biggest impacts on Medicaid was prodding states to be more active in making sure they were covering only people who met the states’ eligibility rules. He noted the ACA gave states incentives to enroll newly eligible adults over traditional groups such as children and the disabled because the federal government paid a higher share of the cost.

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Seeking flexibility for states

The administration — as well as Republicans in Congress — favored a fundamental change in how Medicaid is funded. But Congress failed to move the program to a “block grant” approach, which would have given states a set annual amount — rather than the current system that provides funding determined by how many people qualify for the program and health costs. The GOP proposal also would have allowed states more flexibility in running the operations.

Critics predicted a block grant would have cut billions in state funding and led to cuts in services and eligibility.

Once the legislative proposal was dead, the administration sought to enact the strategy via its authority to test changes in payment methods. Only one state applied — Oklahoma — and it dropped its application this year after voters passed a Medicaid expansion ballot initiative.

 

Verma promised to give states more flexibility in running their programs in other ways, while also holding them more accountable for care to Medicaid enrollees. CMS has approved dozens of Medicaid waivers since 2017, including allowing states to be more innovative in helping enrollees with substance abuse or addiction problems and serious mental illness. It granted more than 30 states waivers to enhance treatment options.

With Medicaid paying for more than half of all births in the United States, Verma also sought to improve oversight of prenatal and early childhood services.

While CMS has started a scorecard to track Medicaid outcomes, the data is missing for several states or outdated on several measures. For example, the low-birthweight measure is missing data from more than 20 states and no data is listed on children born with an addiction.

CMS officials said they are working to provide more updated information on its report card.

Changes implemented by the administration, officials added, have elicited more timely data from states, allowing them to spot problems quicker. For example, in September, CMS determined that many children were delayed from March through May in seeing a doctor and getting important vaccines as the pandemic took hold. CMS pushed states and health providers to remedy the problem but did not offer specific help.

Asked during a recent phone briefing with reporters about Medicaid’s legacy under her stewardship, Verma didn’t mention the expansion, work requirements or efforts to turn Medicaid into a block grant program for states.

“We have aimed to try to ensure the program is sustainable for generations to come and ensure better outcomes for those it serves,” she said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Mariah Carey- Merry Christmas, 2019

https://music.amazon.com/albums/B07Y414W29

Let’s work together today while we listen to the same album.

I think there are a few voices that stand atop the highest mountain of singing power.

Whitney. Celine. Tina.

And of course- and perhaps above all- Mariah.

All of us can hear her hit that high note- that only-Mariah-can-hit-it high note- in our heads on command. She does it in several songs. One of the very best instances is on track 2 of this album.

Enjoy this with me today, fellow humans. Hit the high notes today.

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Magellan Rx Management Releases Fifth Annual Medicaid Pharmacy Trend Report

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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.

Curator summary

Roughly half of Medicaid spending is on specialty drugs based on this 25-state study.

Clipped from: https://news.yahoo.com/magellan-rx-management-releases-fifth-113000880.html

Magellan Rx Management, the full-service pharmacy benefits management division of Magellan Health, Inc. (NASDAQ: MGLN), released its fifth annual Medicaid Pharmacy Trend ReportTM, the industry’s leading report exclusively detailing trends in the Medicaid pharmacy fee-for-service (FFS) space and the only detailed source examining Medicaid FFS gross and net drug spend trends.

“As a national leader in pharmacy benefit management, with more than 40 years of experience, we maintain a deep understanding of the complexities within the Medicaid space related to prescription drug costs and utilization trends,” said Meredith Delk, PhD, MSW, general manager and senior vice president, government markets, Magellan Rx Management. “The Medicaid Trend Report is one tool of many we deploy that provides value to our more than 25 government customers and Medicaid agencies across the country. We are delighted to release it for the fifth consecutive year.”

Developed through in-depth data analysis and supported by Magellan’s broad national experience managing Medicaid FFS pharmacy, the Medicaid Pharmacy Trend Report highlights the evolving landscape of Medicaid prescription drugs and anticipates the trends and challenges in the Medicaid FFS space. The report also now includes a standard in-depth analysis of the top drug classes including six additional categories that provide a superior overview of classes with significant net dollar impact.

 

Key findings in this year’s report include:

  • In 2019, specialty drugs accounted for 48.5 percent of net cost in Medicaid while making up just 1.3 percent of utilization.
  • Traditional net spending on drugs decreased 0.4 percent from 2018 to 2019.
  • Unit cost, not utilization, drove specialty trend in 2019. The net cost per claim increased by $141.12, while utilization decreased by 0.9 percent.
  • While claim volume remains virtually unchanged, the total net spend on specialty drugs increased by 2.4 percent which indicates that specialty drugs will account for 50 percent of total net spend for 2020.

“States are faced with inherent challenges related to the variability in the Medicaid program due to fluctuations in enrollment, enabling legislation and pharmacy program design,” said Chris Andrews, Pharm.D., vice president, value-based purchasing, Magellan Rx Management. “The Medicaid Trend Report clearly illustrates critical data-driven observations and helpful solutions that can assist states as they continue to explore and implement efforts to balance the growing cost of state Medicaid programs with state budget projections as they focus on achieving improved outcomes for Medicaid patients.”

The Magellan Rx Management Medicaid Pharmacy Trend Report includes data derived from Magellan Rx’s Medicaid FFS pharmacy programs in 25 states and the District of Columbia.

About Magellan Rx Management: Magellan Rx Management, a division of Magellan Health, Inc., is shaping the future of pharmacy. As a next-generation pharmacy organization, we deliver meaningful solutions to the people we serve. As pioneers in specialty drug management, industry leaders in Medicaid pharmacy programs and disruptors in pharmacy benefit management, we partner with our customers and members to deliver a best-in-class healthcare experience.

About Magellan Health: Magellan Health, Inc., a Fortune 500 company, is a leader in managing the fastest growing, most complex areas of health, including special populations, complete pharmacy benefits and other specialty areas of healthcare. Magellan supports innovative ways of accessing better health through technology, while remaining focused on the critical personal relationships that are necessary to achieve a healthy, vibrant life. Magellan’s customers include health plans and other managed care organizations, employers, labor unions, various military and governmental agencies and third-party administrators. For more information, visit MagellanHealth.com.

(MGLN-GEN)

View source version on businesswire.com: https://www.businesswire.com/news/home/20201113005178/en/

Contacts

Media Contact: Lilly Ackley, ackleyl@magellanhealth.com, (860) 507-1923

Investor Contact: Darren Lehrich, lehrichd@magellanhealth.com, (860) 507-1814

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Medicaid hemorrhaging $100B on Americans ineligible for the program

Curator, Roundtable Show, Fraud, Waste and Abuse

 

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.

 
 

 
 

Curator summary

Suspension of eligibility audits for several years has hidden $100B in spending on people who are not Medicaid eligible. The author advocates for Trump to finalize MFAR before leaving office.

 
 

Clipped from: https://nypost.com/2020/11/28/medicaid-hemorrhaging-100b-on-americans-ineligible-for-the-program/

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ObamaCare ushered in rapid Medicaid expansion, but checks on fraud were stymied, leading to record waste — which Trump can tamp down before he leaves office. NY Post photo composite

Medicaid is meant to cover health care and long-term care for lower-income Americans. But a new report reveals the government — both in Washington and in state capitols across the country — is failing to ensure that only people who are eligible for Medicaid are enrolling.

The federal government’s improper Medicaid payments now exceed $100 billion a year. This means that more than one-in-four dollars flowing out of Medicaid — our nation’s third-largest government program — do not meet program rules. This staggering failure doesn’t just reduce health-care access for the truly eligible, it also harms taxpayers who fund it.

The main problem is that states are not verifying people’s eligibility. In fact, “the required verification of eligibility data, such as income, was not done at all” in many cases, according to the report from the Centers for Medicare and Medicaid Services (CMS). The report also suggests that many people remain on Medicaid well past the time they were initially eligible.

CMS examined states each year from 2017-2019 for its 2020 report — which was entirely pre-coronavirus. The report showed an improper payment rate of 21.4 percent — a total of $86.5 billion — but the actual amount is much higher, because eligibility audits were not conducted in the year 2017. If you only count the two years where an eligibility audit was performed, the improper payment rate is actually 27 percent — and improper federal spending totals more than $100 billion.

The Obama administration canceled the eligibility audits from 2014 to 2017 — the first four years of ObamaCare’s Medicaid expansion — to build political support for its signature law by maximizing enrollment, even if it was unlawful. They were successful. Millions of ineligible people enrolled in Medicaid.

ObamaCare created a new class of Medicaid enrollees — non-disabled, childless, working-age adults — for whom the federal government reimburses no less than 90 percent of the cost. Since their coverage is financed almost entirely by federal dollars, states loosened eligibility reviews and increased payments to health insurers, who reaped massive profits from ObamaCare’s Medicaid expansion.

After Obama signed the Affordable Care Act, Americans weren’t tested for their Medicaid eligibility for four years — enabling millions to unlawfully enroll.

Because Washington pays nearly two-thirds of the total Medicaid tab, states do not spend with an eye toward value. Program integrity efforts, like ensuring only eligible people enroll, almost always get short shrift. But the primary job of executive branch agencies, like CMS, is to implement the law and ensure enrollees and taxpayers are well-served.

Before the year ends, the Trump administration can take one important and overdue step to address Medicaid’s improper payments, which have soared with ObamaCare’s expansion. CMS should finalize a fiscal accountability rule that would enhance Medicaid program integrity. This rule would require states to report to CMS where the $600 billion of Medicaid expenditures — including the $400 billion of federal tax dollars — is going. It also limits accounting gimmicks that some states use to rip off federal taxpayers.

While much more work needs to be done to reform Medicaid, including ensuring only eligible people are enrolled, greater transparency would be a good first step toward limiting widespread waste, fraud, abuse, and misspending.

Brian Blase served as a special assistant to President Trump at the National Economic Council, 2017-19. He is CEO of Blase Policy Strategies and a senior research fellow at The Galen Institute and The Foundation for Government Accountability.

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Published- Insurers’ strong financial performance continues in Q3 as they brace for a potentially rocky Q4 | FierceHealthcare

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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.

 
 

 
 

Curator summary

National health plan messaging is suggesting a slowing of the profits seen in Q2/Q3 due to COVID-utilization suppression.

 
 

Clipped from: https://www.fiercehealthcare.com/payer/insurers-strong-financial-performance-continues-third-quarter-as-they-brace-for-a-potentially

 
 

Insurers continued to turn a significant profit in the third quarter, though the results were more subdued than they were in the first half of the year.

Major national health insurers continued to largely turn a significant profit in the third quarter, though numbers didn’t quite reach the sky-high figures reported in the first half of the year.

And some warned that the fourth quarter could be ugly, with pent-up utilization and costs related to COVID-19 coming to a head.

As with the prior quarter, UnitedHealth Group led the way on profit, bringing in $3.2 billion in earnings. That’s down slightly from the third quarter of 2019, where the company earned $3.5 billion in profit, and halved from the second quarter, when UnitedHealth posted an eye-popping $6.6 billion in profit.

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Cigna came in second for profitability in the quarter, reporting $1.4 billion in profit. Humana was close behind at $1.3 billion, as was CVS Health at $1.2 billion.

RELATED: Insurers saw sky-high profits in Q2. Now, Congress wants to take a look at their finances

Those companies all saw profit declines from the second quarter as well, where CVS posted $3 billion in profit and Cigna and Humana both reported $1.8 billion in earnings.

Anthem brought in $222 million in profit and, while that represents a massive decline from its $2.3 billion in earnings for the second quarter, it still beat Wall Street estimates. Centene Corporation and Molina Healthcare also reported declines in profits from the prior quarter, bringing in $568 million and $185 million, respectively.

Across the board, insurers said that the drop in profitability compared to the beginning of 2020 reflects care utilization returning to levels near those seen before the COVID-19 pandemic. Earlier in the year, most warned that while they were hugely profitable at the time, that was likely to change as utilization ticked back up.

Some are bracing for even stormier skies in the fourth quarter, too. Humana, for instance, gave investors a heads-up about an expected loss in the quarter as use continues to rebound and COVID-19-related costs increase.

Humana Chief Financial Officer Brian Kane said the company is expecting to pay $1 billion in COVID-19 treatment and testing costs alone this year.

CVS lead the pack on revenue for the quarter, bringing in $67.1 billion, followed closely by UnitedHealth, which reported $65.1 billion in revenue.

Cigna brought in $41 billion in revenue. Anthem and Centene were neck-and-neck for the quarter, reporting $31.2 billion in revenue and $29.1 billion in revenue, respectively.

Humana brought in $20.1 billion in revenue, and Molina lands in last place for revenue with $4.8 billion reported.

RELATED: VIDEO: FierceHealthcare discusses healthcare companies’ Q1 results in the wake of COVID-19—and beyond

Here are two more trends to watch in the final quarter of 2020:

PBM subsidiaries leading the way

Both UnitedHealth and Cigna have reported substantial growth in their pharmacy benefit management subsidiaries over the course of this year. Optum has been UnitedHealth’s growth leader of late, and in the third quarter posted 21% growth.

Much of Optum’s growth has been concentrated in its OptumHealth segment, which includes the company’s large provider footprint at OptumCare. OptumHealth providers treated 98 million patients in the third quarter, an increase of 3 million year over year, with revenue per customer served up 25% compared to the third quarter of 2019.

In addition, OptumRx has invested heavily in growing its pharmacy services, including in specialty pharmacy, e-commerce and home infusion, UnitedHealth Group said.

Cigna also touted the performance of its newly rebranded Evernorth subsidiary in its earnings, a company that includes the nation’s largest PBM in Express Scripts. Evernorth’s revenues were up 20% in the third quarter compared to the second quarter, Cigna said.

Cigna is continuing to design and launch new solutions at Evernorth, CEO David Cordani said during an appearance at HLTH in October, with an eye on continued business growth.

Pandemic’s long-term impact on enrollment remains fuzzy

As shutdowns to prevent the spread of COVID-19 led to significant job losses, the healthcare industry braced for large numbers of people to become uninsured in the process.

However, insurers have found over the past several months that membership losses in the employer-sponsored segments were largely offset by growth in Medicaid and individual market enrollment.

What impact does this potentially have on the current open enrollment period for the Affordable Care Act’s exchanges? Centene CEO Michael Neidorff said enrollment has “been bouncing around a lot.”

The variability suggests we won’t have a clear picture of the pandemic’s long-term impacts on payer mix for some time.

“It is just a swinging variable and too many factors,” Neidorff said.

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Medicaid plans to offer transit | News, Sports, Jobs – Tribune Chronicle

Curator, Ohio, Managed Care, News Roundtable

 
 

 
 

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.

 
 

 
 

Curator summary

All MCOs in Ohio will provide free transportation for members to food banks.

 
 

 
 

Clipped from: https://www.tribtoday.com/news/local-news/2020/11/medicaid-plans-to-offer-transit/

WARREN — In an effort to “ensure our most vulnerable citizens maintain reliable access to food resources,” Ohio’s five Medicaid Managed Care Plans will offer free transportation services to and from food banks, food pantries, food clinics and grocery stores as part of the benefit plan.

People with Medicaid plans through Buckeye Health Plan, CareSource, Molina Healthcare, Paramount Advantage and United Heathcare Community Plan can access the benefit.

“This transportation service is essential to many of our members,” states an informational email. “By undertaking this united effort on behalf of every Ohio member, we can help get food on the table for Ohioans in need during this unprecedented health crisis.

Members of the plans can find more information by calling the Ohio Department of Medicaid Member Hotline at 1-800-324-8680.

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Molina Healthcare of California and Inland Empire Health Plan Join Forces to Provide Support for Job and Health Coverage Losses

Curator, News Roundtable, MCOs, California

 
 

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.

 
 

 
 

Curator summary

 
 

2 California MCOs are teaming up to let potential enrollees know about Medicaid and exchange coverage options after seeing a surge in unemployment in their area.

 
 

 
 

Clipped from: https://www.prnewswire.com/news-releases/molina-healthcare-of-california-and-inland-empire-health-plan-join-forces-to-provide-support-for-job-and-health-coverage-losses-301144251.html

SAN BERNARDINO, Calif., Oct. 1, 2020 /PRNewswire/ — Molina Healthcare of California (“Molina”), and Inland Empire Health Plan (IEHP) are joining forces to lead a new healthcare initiative called “Together4IE.” This collaboration will raise awareness about available coverage through Medi-Cal and the health insurance marketplace (Covered California) to support Californians affected by income or employment changes during the COVID-19 pandemic. The health plans launched a website and are offering a toll-free number (1-866-U2Apply) to learn more about securing affordable health insurance.

The California Employment Development Department reported that as of July 2020, more than 275,000 residents in the Inland Empire region were unemployed. The unemployment rates in Riverside and San Bernardino counties are both over 13%, having increased by approximately 4.7% and 4.4%, respectively, compared to the unemployment rates from 2019, which has led many to consequently lose health insurance coverage for themselves and their families.

“As many families face increased uncertainty during this time, Molina and IEHP are here to help them navigate the health care system,” said John Kotal, president of Molina Healthcare of California. “As a company with roots in this region for decades, Molina continues to advocate for quality access to health care for IE residents who need it most.”

Working together to support this population, the “Together4IE” initiative connects qualified residents to resources and works to reduce any stigma around government-sponsored health care. In addition to the resources made available, partnering organizations are actively engaging with individuals and families, as well as communities, to ensure that those interested in affordable health care are fully aware of the available options. 

Community agencies engaged in support of the initiative include: Covered California, Arrowhead Regional Medical Center, Riverside Department of Public Social Services, Riverside University Health System, San Bernardino County Transitional Assistance Department, Southern California Edison, Southern California Gas Company, and hundreds of local community organizations.

“This is about doing the right thing for the community we know and love,” said Jarrod McNaughton, IEHP chief executive officer. “Through collaboration and partnerships with agencies in the Inland Empire, we can rally around our neighbors to fill in the gaps in care, coverage and information. The health and wellness of our communities is our largest priority, and we will do all we can to ensure residents have access to the care and resources they need.”

For more information or to enroll, visit https://www.together4ie.com/ or call 1-866-U2Apply (866-822-7759).

About Molina Healthcare of California
Molina Healthcare of California has been providing government-funded care for low-income individuals for 40 years. Molina’s mission has always been to provide quality health care to people receiving government assistance. As of June 30, 2020, the company serves approximately 572,000 members through Medi-Cal, Medicare, Medicare-Medicaid (Duals) and Covered California (Marketplace). Molina’s service areas include Sacramento, Los Angeles, San Bernardino, Riverside, San Diego, Orange, and Imperial counties. For more information, visit MolinaHealthcare.com and connect with us on Facebook, Twitter, Instagram and YouTube.

About IEHP
IEHP, Inland Empire Health Plan, is one of the top 10 largest Medicaid health plans and the largest not-for-profit Medicare-Medicaid plan in the country. With a network of more than 6,400 Providers and more than 2,000 employees, IEHP serves more than 1.3 million residents in Riverside and San Bernardino counties who are enrolled in Medicaid or Cal MediConnect Plan (Medicare-Medicaid Plan). Through a dynamic partnership with Providers and Community, award-winning service and innovative products, IEHP is fully committed to advocating for our Members and providing them with quality, accessible and wellness-based health care services. For more information, https://iehp.org/

SOURCE Inland Empire Health Plan (IEHP)

 
 

Related Links

http://www.iehp.org
 

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How the Biden Administration Can Make a Public Option Work

Curator, Managed care, News Roundtable Show

 
 

 
 

Clipped from: https://hbr.org/2020/11/how-the-biden-administration-can-make-a-public-option-work

 
 

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.

 
 

 
 

Curator summary

A coupla researchers at HBR think Medicaid can be “easily folded in” to national, standardized Public Option (whose main feature is prepaid managed care).

 
 

The incoming Biden administration is expected to expand access to health care insurance coverage in the United States by adding “a public option.” In this article, the authors argue that it should be based on Medicare Advantage plans, which would accelerate the movement away from fee-for-service care to capitated payment tied to the quality of outcomes and patient satisfaction.

Under a plan proposed by President-elect Joe Biden’s camp, Obamacare would be expanded to include a “public option” health plan. Anyone without insurance could be automatically enrolled. In addition, people younger than 65 could obtain affordable coverage. Employers that decide not to offer employer-sponsored health plans could enroll their employees in the public option plan for a significantly smaller percentage of their employee salary cost (somewhere around 20%).

Rather than creating a new vehicle, we suggest a public-private option that we call the Better Care Plan (BCP), which would use as a model existing Medicare Advantage plans that provide Medicare benefits, including inpatient and outpatient coverage through a private sector health insurer. More than one-third of Medicare enrollees choose these plans today, and their satisfaction is very high.

The advantages of this approach are many, but one of the most important is to relieve the health care delivery industry of its addiction to fee for service — a payment system that encourages more visits, procedures, and services than are necessary, resulting in poor quality and high cost: in other words, low-value care. We propose a “capitated payment,” which, like Medicare Advantage plans, would prepay providers a fixed, risk-adjusted payment to care for all patients enrolled in it. This change in incentive would stop the pay-for-volume system and replace it with care for health outcomes. Under the present system, full hospitals mean higher revenue. If pay were tied to keeping people healthy, hospitals would become cost centers and the focus would be on avoiding hospitalization by better managing chronic disease.

In addition, upfront payment would encourage the development of new care models such as “hospital at home” operations like Atrius’s Care in Place and the independent Medically Home. This model allows for as many as 30% of patients who would have been hospitalized to be managed at home, reducing the cost of care by as much as 30%.

In a prepayment world, any care model that improves quality and reduces cost would be embraced much more quickly than has been the case with fee for service. Take telemedicine: clinicians seeing patients via video links. This technology has been available for more than a decade, but until insurers began to pay for virtual visits due to Covid-19, its use languished.

A third major advantage of BCP is it would provide a predictable revenue stream for providers. During the pandemic, hospitals and physician organizations across the United States have lost billions of dollars for two reasons: The amount they have been paid for their care of critically ill Covid-19  patients hasn’t covered its costs, and the postponement of elective surgeries has drastically reduced their revenues. In contrast, those provider organizations operating with upfront negotiated budgets have largely maintained their financial viability. What is more, they have been able to redeploy resources to focus on early detection and treatment of Covid-19 patients, helping them to manage the surges.

The following evidence suggests that the Better Care Plan would be better from a cost and quality standpoint than fee-for-service approaches:

  • Despite having a higher proportion of clinical and social risk factors, Medicare Advantage beneficiaries with chronic conditions experienced lower utilization of high-cost services, comparable average costs, and better outcomes.
  • Medicare Advantage enrollees with chronic conditions who were eligible for Medicare and Medicaid had better patient outcomes and lower costs compared to traditional fee-for-service Medicare members.
  • Humana recently reported that the medical cost of caring for seniors enrolled in its Medicare Advantage plans that have value-based payment contracts with physicians were 19% lower than those in traditional fee-for-service Medicare. Overall, the patients in its Medicare Advantage plans spent 211,000 fewer days in the hospital per year and had 10.3% fewer emergency department visits per year than Humana Medicare Advantage members receiving care from physicians in the traditional models.
  • Critics of Medicare Advantage plans claim that their better performance is the result of their cherry-picking the healthiest patients, but evidence suggests this is not the case.
  • Overall, the costs per patient in Medicare Advantage plans are about 40% less than fee-for-service Medicare. As a result, Medicare Advantage plan premiums are expected to decline about 11% in 2021.

We suggest the following six steps for implementing the BCP:

1. Develop standardized benefits packages. They could be similar to the Affordable Care Act’s (ACA’s) tiered set of benefit plans (bronze, silver, gold, and platinum), which would offer a range of premium and out-of-pocket-expense options. For example, the uninsured would qualify and be automatically enrolled in the equivalent of the ACA’s silver plan with low premiums and deductibles. Any out-of-pocket expense would be based on income and could be zero at certain income levels. Subsidies would be provided to limit out-of-pocket spending to 8.5% of a person’s income, which is much less than many Americans on Medicare pay today. The plans could be offered through the various existing federal or state exchanges established by the ACA or by employers through newly created private exchanges.

2. Fold Medicaid into the BCP. Many Medicaid programs today have contracts with insurers that offer Medicare Advantage plans. These plans could be easily converted to the BCP and designed to meet the needs of current Medicaid enrollees. Uniform base-eligibility rules for Medicaid enrollees could be established at some percentage (e.g., 150%) of the federal poverty level. States could increase this threshold if they deemed that necessary and could decide which BCPs to offer to Medicaid enrollees.

3. Negotiate the prepaid health budgets. One of the most difficult problems will be establishing the baseline monthly per-member payment rates to health systems. There have been several ideas floated on how to do this, but the experience in states that are offering a public option suggests that initial payments to hospitals may need to be 1.5 to 2 times the current Medicare rates or higher.

The negotiated budgets would need to consider the wide national differences in current payments to providers by Medicare, Medicaid, and commercial insurers. With a consistent and predictable cash flow not dependent on volume of care, hospitals and physician organizations would have strong incentives to redesign care to provide better value. There would be incentives to utilize staff at the highest level of their license, which would result in major productivity improvements in care delivery. The focus would be on delivering the highest quality, lowest cost care — as opposed to filling hospital beds or doing unnecessary procedures.

4. Give employers an opportunity to provide a BCP option. Employers that decide to participate would pay into a risk pool, which would cover their entire employee population. We believe that the fee would be approximately 20% of employee salary cost, which is lower than the 25% to 35% that most employers pay today. This would allow employers to access multiple competing BCPs. They still would have control over which plans were offered to their employees through the public or private exchanges of their choice. The difference is they wouldn’t be negotiating the rates with insurers every year; these rates would be established by a commission of government and private sector representatives.

5. Focus on disparities. The BCP would enroll many of the uninsured in the African American, Hispanic, Native American, and other underrepresented communities. Payments between insurers and health systems would be risk-adjusted by age, sex, and selected clinical indicators, reflecting a person’s health status. But risk adjustment should also include social determinants of health, which could be represented by the deprivation index. This would provide health systems with incentives to redesign their care model, which might include better outreach utilizing pharmacists and home care agencies to proactively address chronic diseases in the underserved population. There would be a reason to develop better integration of primary care with existing public health and mental health services and community resources such as food pantries and religious institutions. Finally, we would think about access differently, utilizing care navigators, nontraditional avenues for education — for example, hairdressers have been shown to be trusted to give advice about breast cancer screening.

6. Promote competition to improve quality and lowers cost. Insurers who chose to offer BCPs would be required to annually provide transparent and uniform cost, utilization, quality, and patient experience data to the public. The BCPs would compete on the basis of this performance information. The existing Medicare Advantage NCQA star ratings, which measure the quality of the various plans, would be expanded, utilizing more health outcomes measures such as complications from chronic disease or from elective procedures such as heart surgery.

Medicare Advantage plans have more narrow or “selective” networks of providers than traditional fee-for-service Medicare. Providers are chosen based on cost and quality, which critics argue means less consumer choice. But as discussed above, the quality of the health care obtained via Medicare Advantage is better and the costs much lower, and Medicare members are highly satisfied with plans. However, in rural areas, where providers are scarce, BCP plans may need to share providers or allow patients to travel outside of network without penalty. As virtual medical delivery continues to change, expanding broadband service to rural areas where providers are scarce will be important.

Ultimately, the United States must improve the quality and lower the cost of care delivery. The Better Care Plan’s competitive approach may be the best way to create agreement among the many disparate stakeholders in the health care system and address many of the coverage and access problems that exist today. The track record of Medicare Advantage plans proves it could work.

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Kentucky Medicaid court case heads to mediation with several hurdles – Louisville Business First

Curator, KY, Managed Care, Roundtable Show

 
 

Clipped from: https://www.bizjournals.com/louisville/news/2020/11/18/medicaid-mediation-starts-at-loggerheads-over-memb.html

 
 

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.

 
 

 
 

Curator summary

KY MCO lawsuits continue, but with a focus on mediation by early December.

Court documents show that there are hurdles just to get mediation in the case over how the state awarded its Medicaid contracts started.

 

Mediation among the eight organizations at the heart of the controversy surrounding the state’s Medicaid program has started off with conflicting visions for the process.

Court documents filed on Friday show differing views on matters such as timing, how to handle a pending motion in Franklin Circuit Court and disputes over a proposed precondition to the outcome of mediation.

On Nov. 12, Franklin Circuit Court Judge Phillip Shepherd ordered that the two government agencies and six Medicaid companies in the suit try to resolve the matter through mediation and to set a date to do so before Dec. 12.

Under dispute

The two government agencies — the Kentucky Cabinet for Health and Family Services and the Finance and Administration Cabinet — filed a joint status report with Medicaid companies: Aetna Better Health of Kentucky Insurance Co., Anthem Kentucky Managed Care Plan Inc. and Molina Healthcare of Kentucky Inc. in which they proposed a mediator: John Van Winkle of Indianapolis-based Van Winkle Baten Dispute Resolution.

They also hope to set a mediation date of no sooner than the week of Nov. 30 and no later than the court-mandated Dec. 12, the report reads. But UnitedHealthcare of Kentucky Ltd. and Humana Health Plan Inc. want to see mediation no later than or on Nov. 26, Thanksgiving, according to a joint status report that also included WellCare Health Insurance Company of Kentucky.

UnitedHealthcare brings one of the most specific demands to the table before the mediation takes place.

“[P]rior to the mediation and included with each party’s mediation statement, each [Medicaid company] must acknowledge a willingness to permit reassignment of its membership,” UnitedHealthcare states.

WellCare and Humana reject the precondition of the Medicaid companies forfeiting members, which is a major sticking point for the lawsuit that preceded the order for mediation. The two government agencies and Aetna, Molina and Anthem reject any preconditions to the mediation talks.

How we got to this point

On Oct. 23, Judge Phillip Shepherd ordered that the state must allow Anthem to remain in the Medicaid program, expanding the number of participant companies from five to six, despite Anthem’s inability to win a contract in two RFP process in the last year.

In court, UnitedHealthcare filed a motion calling for Shepherd to amend his order to release the state from providing a contract to Anthem and to eliminate Molina Healthcare from the program and assign the members of the two companies to United.

With Anthem remaining in the Medicaid program and Molina taking over Passport’s members, UnitedHealthcare contends that there won’t be enough members in the program to make it viable or enough members for the state to meet its contractual obligation to provide enough members to help new Medicaid companies get started.