Category: Medicaid News and Analysis

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Monday Morning Medicaid Must Reads: October 1st, 2018

Helping you consider differing viewpoints. Before it’s illegal. 

 

Article 1:  

Jersey Community Hospital receives Small and Rural Award for quality improvement, RiverBender.com, 9/27/2018

Clay’s summary: Sometimes we forget that healthcare happens on the ground. Here’s an example of an IL hospital improving readmission rates.

Key Passage from the Article

Jersey Community Hospital’s all-cause readmission rate dropped from 16% to 7% with an estimated 63 readmissions prevented over a 12-month period and a total cost savings of $455,600.

“I’m happy that the high quality of care provided at JCH is being recognized for its consistency and reliability. I’m proud of the team here and they are deserving of this recognition” stated Jon Wade, CEO.

IHA President and CEO A.J. Wilhelmi recognized Jersey Community Hospital’s project team at the association’s annual Leadership Summit. Michael McNear, MD, Chief Medical Officer and Medical Group President, accepted the award on the team’s behalf.

IHA’s Institute for Innovations in Care and Quality spearheaded this effort to highlight the quality improvement work of IHA-member hospitals and health systems. The Institute is a strategic center actively engaged in implementing evidence-based quality and safety initiatives while creating innovative member programs to measurably strengthen the quality of healthcare across Illinois.

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Read it here 

Article 2:   

NURSING HOME QUALITY: Continued Improvements Needed in CMS’s Data and Oversight, GAO, 9/6/2018

Clay’s summary: When was the last time you were in a nursing home? There is a wide spectrum of quality out there…

Key Passage from the Article

About 15,600 nursing homes participate in Medicare and Medicaid. To help ensure that residents receive quality care, the Centers for Medicare & Medicaid Services (CMS) collect data (such as nurse staffing levels) on these nursing homes.

We testified that CMS’s data showed mixed results—they showed an increase in consumer complaints along with improvements in the quality of care. We found that data issues (e.g., different states using different data collection methods) complicated CMS’s ability to assess whether the results reflected actual changes. We made recommendations to address these issues in the report on which this testimony is based.

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Read it here 

 

 

 

Article 3:   

Amerigroup Ranked Among Top Medicaid Plans in Texas by NCQA, BusinessWire, 9/28/2018

Clay’s summary: It’s easy to forget that plans are staffed by people who care about people. They work hard to improve the quality of care delivered, and should get props when they do well. Yay, Amerigroup Texas!

Key Passage from the Article

“Amerigroup is pleased to be recognized by the NCQA as one of the highest performing Medicaid health plans in the state,” said Tisch Scott, plan president, Amerigroup Texas. “These ratings demonstrate that our consumers have timely access to care, and they’re receiving the right care at the right time. Quality is foundational to everything we do at Amerigroup, and we’re committed to building on our accomplishments to provide a better healthcare experience for all consumers.”

In recognizing Amerigroup, the NCQA evaluated the plan’s performance based on three areas — consumer satisfaction, prevention and treatment. Amerigroup received an overall score of 3.5 out of 5.

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Read it here 

 

 

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Monday Morning Medicaid Must Reads: September 24th, 2018

Helping you consider differing viewpoints. Before it’s illegal. 

 

Article 1:  

Details of federal health care fraud probe show how massive the problem is, Bethany Blankley, The Hayride, July 24th, 2018

Clay’s summary: 601 defendants. $2B stolen. All from your paycheck. Work hard!

Key Passage from the Article

Less than a month after the largest federal health care fraud sting in American history, details of the operation show how massive the problem is. As part of the operation, more than 600 people were charged with committing more than $2 billion in fraud and taxpayer theft. “Health care fraud is a betrayal of vulnerable patients, and often it is theft from the taxpayer,” Attorney General Jeff Sessions said. “In many cases, doctors, nurses, and pharmacists take advantage of people suffering from drug addiction in order to line their pockets. These are despicable crimes.” The investigation was led by the Department of Justice (DOJ) and the Department of Health and Human Services (HHS). The joint action involved more than 1,000 federal, state, local, and tribal law enforcement officers. The 601 defendants include 165 doctors, nurses, pharmacists, and medical professionals in 29 states and the District of Columbia, who are accused of financially profiting from more than $2 billion in false health care billings. In addition to criminal charges, HHS announced that 2,700 individuals were excluded from government health care programs since July 2017. The multi-agency investigation targeted fraudulent schemes that billed Medicare, Medicaid, TRICARE (a health insurance program for U.S. military members, their families, and veterans), and private insurance companies for “medically unnecessary” services or services that were never rendered. Bills were submitted for payment for prescription drugs and compounded medications that were rarely or never purchased or distributed to beneficiaries. Some doctors and medical professionals also distributed opioids and other prescription narcotics unlawfully, according to DOJ.

 

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Read it here 

Article 2:   

CMS Needs to Better Target Risks to Improve Oversight of Expenditures, GAO, August 6th, 2018

Clay’s summary: No one really cares. Just keep the money flowing or else we will call you bad names.

Key Passage from the Article

What GAO Found

The Centers for Medicare & Medicaid Services (CMS), which oversees Medicaid, has various review processes in place to assure that expenditures reported by states are supported and consistent with Medicaid requirements. The agency also has processes to review that the correct federal matching rates were applied to expenditures receiving a higher than standard federal matching rate, which can include certain types of services and populations. These processes collectively have had a considerable federal financial benefit, with CMS resolving errors that reduced federal spending by over $5.1 billion in fiscal years 2014 through 2017.

However, GAO identified weaknesses in how CMS targets its resources to address risks when reviewing whether expenditures are supported and consistent with requirements. CMS devotes similar levels of staff resources to review expenditures despite differing levels of risk across states. For example, the number of staff reviewing California’s expenditures—which represent 15 percent of federal Medicaid spending—is similar to the number reviewing Arkansas’ expenditures, which represents 1 percent of federal Medicaid spending. CMS cancelled in-depth financial management reviews in 17 out of 51 instances over the last 5 years. These reviews target expenditures considered by CMS to be at risk of not meeting program requirements. CMS told GAO that resource constraints contributed to both weaknesses. However, the agency has not completed a comprehensive assessment of risk to (1) determine whether oversight resources are adequate and (2) focus on the most significant areas of risk. Absent such an assessment, CMS is missing an opportunity to identify errors in reported expenditures that could result in substantial savings to the Medicaid program.

GAO also found limitations in CMS’s processes for reviewing expenditures that receive a higher federal matching rate. Internal guidance for examining variances in these expenditures was unclear, and not all reviewers in the three CMS regional offices GAO reviewed were investigating significant variances in quarter-to-quarter expenditures. Review procedures for expenditures for individuals newly eligible for Medicaid under the Patient Protection and Affordable Care Act were not tailored to different risk levels among states. For example, in its reviews of a sample of claims for this population, CMS reviewed claims for the same number of enrollees—30—in California as for Arkansas, even though California had 10 times the number of newly eligible enrollees as Arkansas. Without clear internal guidance and better targeting of risks in its review procedures for expenditures receiving higher matching rates, CMS may overpay states.

   

Read it here

 

 

 

Article 3:   

Research: Medicaid expansion serves as employment incentive for people with disabilities, Tim Carpenter, The Garden City Telegram, July 24, 2018

Correcting an injustice: HHS moves to stop unions from skimming from Medicaid, Chantal Lovell  & Vincent Vernuccio, Washington Examiner,  August 07, 2018

Clay’s summary: So more healthcare means people will be healthier to work? And its also evil to expect them to do so if they can? I’m confused…

Key Passage from the Article

Research involving the University of Kansas and partner organizations showed individuals who reported not working because of a disability declined in Medicaid expansion states. In 2013, data showed 41.3 percent of individuals with disabilities in expansion states were employed or self-employed. That number escalated to 47 percent in 2017. In the same period, the percentage of the population that reported not working because of disability dropped from 32 percent to 27 percent. Those trends weren’t present in non-expansion states. In effect, the KU Institute for Health and Disability Policy Studies viewed Medicaid expansion as an employment incentive for people with disabilities.

“The takeaway is that, over time, these changes are becoming more robust,” said Jean Hall, professor of applied behavioral science and director of the KU institute. “Our argument is that, over time, those who are better able to manage their health would have a better ability to be employed.” Thirty-two states and the District of Columbia have expanded Medicaid eligibility under a law obligating the federal government to pay no less than 90 percent of the cost of expanded services. In the five-state region that includes Kansas, only Colorado has expanded. Nebraska, Oklahoma, Missouri and Kansas have not. Colyer, who took over for Brownback in January and is seeking the GOP nomination for governor in the Aug. 7 primary, said he supported work requirements within the state’s Medicaid system and opposed expansion of eligibility for Medicaid coverage under the 2010 federal law.

“I’ve been fighting Obamacare and its skyrocketing premiums with shrinking benefits since before it passed,” Colyer said. “Medicaid expansion is not financially sustainable and it focuses on the wrong people.” Sheldon Weisgrau, with the pro-Medicaid expansion group Alliance for a Healthy Kansas, said research showed Ohio’s expanded system improved the health of participants so they could be part of the workforce. “The main reason people on Medicaid don’t work is they’re not healthy enough to work,” said Weisgrau, who disputed the idea expanded Medicaid was unsustainable. “In fact, it is helping the state budgets of most of the states that are participating.”..

 

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Monday Morning Medicaid Must Reads: September 17th, 2018

Helping you consider differing viewpoints. Before it’s illegal. 

 

Article 1:  

NC Medicaid guidelines limit what drugs doctors can use to fight opioid addiction, Nick Oshner, WBTV3, August 30th, 2018

Clay’s summary: Generic vs brand becomes an issue in the opioid crisis.

Key Passage from the Article

In North Carolina, doctors must prescribe either Suboxone or Sublocade to treat opioid addiction in new patients who are using Medicaid insurance. The requirements are listed on the state’s Medicaid formulary, which sets out preferred drugs and non-preferred drugs. Under the formulary for drugs to treat opioid addiction, doctors must first prescribe Suboxone or Sublocade before trying any other generic or pill form of the drug. But, doctors like Manos say there is no medical difference between the name brand drugs and the generic alternatives.

“If you have the active ingredient of buprenorphine in a product and it’s FDA regulated, then the generic is the equivalent to the name brand,” Manos explained.

The only real difference in the name brand and generic versions is price. Manos said the generic alternatives to Suboxone and Sublocation could be one-third to one-fourth of the cost of the name brand drug without rebates. “Does that tie your hands as a physician?” a WBTV reporter asked Manos of the requirement to prescribe only the name brand sublingual strip or injectable. “Well, of course, if they’re saying that you must use what’s on the formulary,” Manos said. “It’s just the way of medicine today.”

But the head of North Carolina’s Medicaid takes a different view. Dave Richard, Deputy Secretary for North Carolina Department of Health and Human Services, said the limits imposed by the state’s formulary is the best for patients and for taxpayers who fund the Medicaid program. Specifically, Richard told WBTV, the state uses a preferred drug list that is administered by the federal government that gives the state rebates on certain drugs. In the case of drugs that treat opioid addiction, the state gets a rebate on name brand drugs manufactured by Indivior. “Through the rebate process, we try to get the best deal for North Carolina for those drugs, which are appropriate for the use of the individuals,” Richard said…

 

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Read it here 

Article 2:   

The Man Who Used To Run Medicaid Has A New Idea To Make It Better, Michela Tindera, Forbes, August 22, 2018

Clay’s summary: Wonder Andy he can do for these startups what he did for Optum?

Key Passage from the Article

Slavitt is back in the private sector and again focused on fixing America’s healthcare system, this time from outside the government. In the past year he’s founded and launched both a nonprofit (United States of Care) and a venture capital firm (Town Hall Ventures). Next up? The Medicaid Transformation Project, a plan to improve the way the 75 million Americans on Medicaid receive treatment at some of the country’s largest hospital systems. “When I left CMS, I launched an initiative in three critical areas to basically say, we want to change the way healthcare works in a decade,” says Slavitt. “I was 50 when I left. The question I ask myself is by the time I’m 60, what do I want to be different?” Slavitt is pulling together the CEOs of 17 hospital systems around the country to commit to improving care for their Medicaid patients over the next two years in at least four areas: behavioral health, women and infant care, substance use disorder as well as aiming to reduce the number of preventable emergency department visits. The participating hospital systems serve over half of the country’s Medicaid population across 21 states…

   

Read it here

 

 

 

Article 3:   

Medicaid Administrator Verma Blames Ballooning Costs on Structural Problems, Holly Kellum, The Epoch Times, August 24, 2018

Correcting an injustice: HHS moves to stop unions from skimming from Medicaid, Chantal Lovell  & Vincent Vernuccio, Washington Examiner,  August 07, 2018

Clay’s summary: You don’t say.

Key Passage from the Article

For “expansion” states, the federal government agreed to cover 100 percent of newly eligible patient costs from 2014 through 2016. In 2017, it agreed to cover 95 percent of their costs, and this year, will cover 94 percent. The match rate will decline to 90 percent starting in 2020, where it will remain indefinitely. There is no limit on how many people can enroll, so the government, both state and federal, will be left to pick up the tab, no matter how large. Verma said these new enrollees alone are estimated to cost the government $806 billion between 2016 and 2025. “I think that diverts the program from the most vulnerable populations,” she said. “We’ve always had program integrity efforts with the Medicaid program. Given the change with the match rate, and it’s not only the 90 percent, but it’s a completely open-ended entitlement, the incentives aren’t necessarily in place for states to focus on program integrity.” She said it’s also possible that states are taking advantage of this higher match rate. The federal government pays at least 50 percent of the cost for traditional Medicaid patients, but with a minimum 90 percent match rate for “expansion” enrollees, she said this creates an incentive for states to shift traditional Medicaid patients into the “expansion” population…

 

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Monday Morning Medicaid Must Reads:September 10th, 2018

Helping you consider differing viewpoints. Before it’s illegal. 

 

Article 1:  

HHS Secretary Alex Azar warns drug makers to pay full Medicaid rebate amount, Susan Morse, Healthcare Finance, August 10, 2018

Clay’s summary: Who the heck let them get away with this between the years 2008 and 2016?

Key Passage from the Article

“In fact, I am pleased to announce here, to all of you, that HHS is issuing a guidance today to drug manufacturers that will ensure they are paying the full Medicaid rebates they owe on certain prescription drugs,” HHS Secretary Alex Azar said Thursday during the 45th American Legislative Exchange Council Annual Meeting in New Orleans. The Medicaid drug rebate program requires prescription drug companies to pay rebates to states on drugs purchased by Medicaid, where about 10 percent of drug spending occurs. Sometimes, drug manufacturers roll out what’s called a “line extension” for a drug, such as an extended release, once-daily form of a pill they already sell and some of them have used it to reset the price that’s used to calculate the inflation rebates they have to pay, Azar said. This means they could pay less than they would otherwise owe, just by introducing a new drug formulation. “This is the kind of abusive behavior from drug companies that this administration will not tolerate,” Azar said. “Starting today, we’ve made clear that manufacturers must pay the full amount of rebates that they owe under the law.”…

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Read it here 

Article 2:   

Texas Tightens Disclosure Rules Following Medicaid Investigation, Liz Whyte, NPR, August 17, 2018

Clay’s summary: How is this even a thing?

Key Passage from the Article

A Medicaid committee in Texas is requiring those who comment at its meetings to disclose more details about their ties to pharmaceutical companies after a Center for Public Integrity and NPR investigation into the drug industry’s influence on such boards. The state is one of the latest to respond to the findings of the Medicaid, Under the Influence project. Officials in Arizona, Colorado and New York have already taken action. The Texas committee, which helps decide which medicines are best for patients and should therefore be preferred by Medicaid, will now ask speakers to disclose verbally and in writing if they have “directly or indirectly received payments or gifts” from any pharmaceutical companies and to identify those firms, Texas Health and Human Services Commission spokeswoman Kelli Weldon said in an email. The changes come in response to the July investigation that detailed, among other things, how doctors who came before the Texas committee praised drugs without acknowledging their financial ties to the drugmakers that market them. One physician did not disclose more than $181,000 he had been paid to speak about certain drugs that he then recommended to the committee…

   

Read it here

 

 

 

Article 3:   

3 things you need to know about drug pricing to understand this week’s Medicaid changes, Katie Weddel, Dayton Daily News, August 16, 2018

Correcting an injustice: HHS moves to stop unions from skimming from Medicaid, Chantal Lovell  & Vincent Vernuccio, Washington Examiner,  August 07, 2018

Clay’s summary: Ohio got tired of all the reports showing them paying stupid money to CVS.

Key Passage from the Article

 

The change was announced as Auditor of State Dave Yost prepared to release a report, out today, that shows PBMs charged Ohio a 31 percent markup on some drugs or more than $224.8 million in a one-year period through a controversial “spread” pricing model. This news can be difficult to understand if you don’t know how Medicaid prescription benefits currently work. The Dayton Daily News has been covering the complex system of drug pricing and efforts to make it more transparent for more than a year. 

1. What is a PBM?

Pharmacy benefit managers — or PBMs — are the middlemen between the pharmacy and your health plan and they have influence on many aspects of the consumer prescription experience. They determine which drugs are covered or excluded by health plans, which pharmacies patients can use, and play a major role in determining the price everyone along the supply chain will pay.

Health plan sponsors have been contracting with pharmacy benefit managers since the 1970s to run their prescription benefits. They started out as just claims processors, but now wield much more power…

Read it here

 

 

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Monday Morning Medicaid Must Reads:September 3rd, 2018

Helping you consider differing viewpoints. Before it’s illegal. 

 

Article 1:  

California Eyes Medicaid Reimbursement for Telehealth Counseling, Eric Wicklund, mHealth Intelligence, August 28, 2018

Clay’s summary: The opioid crisis is driver broader acceptance of telehealth. CA is the 2nd state in as many months to approve more telehealth reimbursement to deal with the crisis.

Key Passage from the Article

With passage of the bill, which was unanimously approved by state legislators, California joins a growing list of states who are enabling reimbursement for connected care services that address substance abuse addiction disorders. Telehealth and telemedicine experts say a telemental health platform can improve access to care for underserved communities, giving more people with substance abuse issues the ability to access virtual treatment. They also have the support of the Centers for Medicare & Medicaid Services. Earlier this year, CMS sent a letter to state Medicaid directors urging them to consider telehealth and mHealth in new programs addressing the nation’s opioid abuse crisis. Medi-Cal currently offers telehealth as part of the Drug Medi-Cal Organized Delivery System, but that coverage doesn’t extend across the entire state. This bill would enable providers across California to quality for reimbursement. “The opioid epidemic has ravaged communities and ruined the lives of too many families,” the bill’s sponsor, State Assemblyman Rudy Salas, D-Bakersfield, said in a press release. “For those seeking treatment, we need to ensure that they can access help when they need it most. Telehealth is an innovative way to remove barriers for people seeking help in rural areas so that they can get treatment from specialists and get on the road to recovery.”

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Read it here 

Article 2:   

Don’t Blame Older Adults For Big Increases In Medicaid Spending, Howard Gleckman, Forbes, August 23, 2018

Clay’s summary: Looks like I will have to get some new charts that aren’t as simplified as the old KFF ones we’ve all been cribbing in our slides for the last 20 years..

Key Passage from the Article

Is the growing need for long-term supports and services (LTSS) by older adults driving big increases in Medicaid spending? Not according to a new study by Don Redfoot and my Urban Institute colleague Melissa Favreault. Indeed, they found that while Medicaid enrollment and expenditures for older adults grew in recent decades, it had far less effect on the program than increases in other Medicaid populations, especially younger people with disabilities. Older adults accounted for only about 13% of Medicaid spending increases from 1975 to 2011. Their paper, published in the Gerontological Society of America’s Public Policy and Aging Report, found that over that period the number of Medicaid beneficiaries tripled from about 22 million to 68 million and program spending increased four-fold from $90 billion to $365 billion (in 2011 dollars)…

  

Read it here

 

 

 

Article 3:   

 Humana Bold Goal Targets Members’ Social Determinants of Health, Thomas Beaton, Health Payer Intelligence, March 27, 2018

Correcting an injustice: HHS moves to stop unions from skimming from Medicaid, Chantal Lovell  & Vincent Vernuccio, Washington Examiner,  August 07, 2018

Clay’s summary: We need more studies of actual SDOH projects like this. The time for research on SDOH from an academic perspective is over (sorry researchers).  Go do stuff.

Key Passage from the Article

The Bold Goal 2018 Progress Report reveals that implementing community-level changes has led to positive health outcomes for elderly beneficiaries with diabetes, heart disease, respiratory conditions, mental health issues, and other chronic diseases. Humana looked for patterns of key social determinants within senior citizen populations such as food insecurity, housing instability, limited English proficiency, social isolation, and inadequate emotional support. The payer found these social determinants had a strong correlation with poor beneficiary health. Older beneficiaries that had limited access to healthy food options were 50 percent more likely to develop diabetes, 14 percent more likely to experience higher blood pressure, and had a 60 percent higher chance of having a heart attack.Social isolation was cited as a significant social determinant of health for elderly beneficiaries. Humana Medicare members living in social isolation had a 26 percent higher likelihood of dying prematurely than members who lived with friends or family. These socially isolated members also had double the risk of Alzheimer’s disease. “As the nation’s senior population grows, they’ll play a larger and more vital role in all of our communities,” said Bruce D. Broussard, Humana’s President and CEO…

 

Read it here

 

 

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Monday Morning Medicaid Must Reads: August 27th, 2018

Helping you consider differing viewpoints. Before it’s illegal. 

 

Article 1:  

NTU Leads Coalition Letter to Combat Fraud in Federal Health Care Programs, Pete Seep, July 19, 2018

Clay’s summary: Makes a strong case for using “smart cards” for the Medicaid benefit… Worth a read.

Key Passage from the Article

 

Federal health care programs have long been plagued by improper payments, one component of which is attributable to fraudulent activities such as identity theft, billing for services never rendered, or falsifying patient records to obtain prescription drugs illicitly. A 2012 study led by former Director of the Centers for Medicare and Medicaid Services Donald Berwick pegged the fraud rate alone (as opposed to other types of improper payments) in Medicare and Medicaid at between 3 percent and 10 percent of all dollars spent. Taxpayers may be forgiven for thinking that the higher figure might be the more plausible one.

Furthermore, although the extent of such fraud is not precisely known, existing research suggests that policymakers seem likelier to understate rather than overstate its prevalence. For example, the Government Accountability Office (GAO) recently concluded that existing improper payment identification methods failed to find some $200 million in misspent funds within Medicaid’s Managed Care Organizations.

A variety of responses are required to reduce improper payments in federal programs, but one of the more promising — and least controversial — remedies should be smart card technology. HR 4554 aims to create a pilot program within Medicare employing “secure, electronic authentication of the identity of a Medicare beneficiary at the point of service through a combination of the smart card and a personal identification number known by or associated with such beneficiary.” The result would be a system highly resistant to ID theft, with sufficient data capacity on each beneficiary’s card to significantly reduce other undesirable outcomes such as prescription abuse. The latter concern is especially timely, given the need to deploy as many policy assets as possible in reducing the severity of opioid addiction (and therefore additional taxpayer burdens associated with treatment and emergency responses).

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Read it here 

Article 2:   

California Medicaid shows Obamacare failure, Oklahoman Editorial Board, August 23, 2018

Clay’s summary: That’s a mean headline. Must not be true. Phew! Almost had to challenge my own strongly held beliefs there for a minute!

Key Passage from the Article

 Among other things, passage of the Affordable Care Act was supposed to dramatically reduce non-emergency use of ERs. Because more people would have coverage, fewer would delay routine care and they would be less likely to use an ER to get cold medicine or similar treatments. A recent study in California illustrates there was a huge gap between that theory and reality. California’s Democrat-dominated state government eagerly embraced the ACA by expanding the Medicaid program, which is the main method the law used to reduce the uninsured rate. A new report by the California Health Care Almanac, an online clearinghouse for data and analysis, shows Medicaid expansion resulted in no obvious reduction in unnecessary ER visits. In fact, a slight acceleration in the use of ERs occurred. In 2006, there were 10.1 ER visits per 1,000 people in California. By 2016, that rate had increased to 14.6. Contrary to activists’ predictions, the steady increase in ER use observed before Medicaid expansion did not turn into a decline after expansion. The report notes the number of ER visits by Medicaid patients “almost doubled between 2006 and 2016,” rising from 23 percent of patients in 2006 to 43 percent by 2016. That increase is far larger than the reduction in self-pay/uninsured visits, which declined from 16 percent of patients to 7 percent.

   

Read it here

 

 

 

Article 3:   

Exploring the Growth of Medicaid Managed Care

Correcting an injustice: HHS moves to stop unions from skimming from Medicaid, Chantal Lovell  & Vincent Vernuccio, Washington Examiner,  August 07, 2018

Clay’s summary: Had no idea CBO did these reports. Great charts that I will be using in my next conference talks for sure.

Key Passage from the Article

In this case its a chart. Note the enrollment line slowing in recent years, but the spending line turning up..

Lots of good discussion possible as to why: increase in federal spending incentives more spending per bennie (ACA), sicker / more vulnerable bennies being put into managed care, plans getting better at cap negotiation, etc..

Read it here

 

 

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Monday Morning Medicaid Must Reads: August 20th, 2018

Helping you consider differing viewpoints. Before it’s illegal. 

 

Article 1:  

Behavioral health workforce faces critical challenges in meeting population needs, Elsevier, May 2018

Clay’s summary: This one has a map. Everybody loves a map!

Key Passage from the Article

 

A 2016 report by the Health Resources and Services Administration (HRSA) on the projected supply and demand for behavioral health practitioners through 2025 indicated significant shortages of psychiatrists, psychologists, social workers, mental health counselors, and marriage and family therapists. The magnitude of provider shortages, however, is not the only issue when considering access to behavioral health services. Another major concern is maldistribution, since parts of the US have few or no behavioral health providers available, and access to mental health services is especially critical in areas of poverty.

“It is imperative that a plan be developed to address the resource limitations inhibiting the delivery of behavioral health services,” says Angela J. Beck, PhD, MPH, of the University of Michigan School of Public Health, Behavioral Health Workforce Research Center, Ann Arbor, MI, USA, one of the supplement’s Guest Editors. “This set of articles collectively proposes strategies and best practices to guide success of the current and future behavioral health workforce.”

 

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Read it here 

Article 2: 

HEALTHCARE TRANSPORTATION ‘DISRUPTERS’ MAKE BIG DRIVE IN NEW JERSEY, Lilo Stanton, NJ Spotlight, July 13, 2018

Clay’s summary: Another transport vendor enters the competition to solve NEMT challenges.

Key Passage from the Article

 

Roundtrip, which said it transports hundreds of New Jersey residents every week, also enables individuals anywhere in the state to book medical transportation for themselves, to any provider — by phone, through its website, or via free mobile apps. People can also use the system to arrange a ride for friends or family, regardless of where the patients live or the doctor’s location.

Founded in 2016, Roundtrip is now operating in more than 15 states, including New Jersey, and officials said business has tripled since January. The company wants to make it easier for people to access medical care, reduce the number of missed appointments and improve clinical outcomes — changes that can also reduce the cost of care. It can be particularly useful for patients who need regular and potentially debilitating treatments, like chemotherapy and dialysis, and helps hospitals free up beds when someone is ready to be discharged but lacks safe transportation to get home.

   

Read it here

 

 

 

Article 3:   

Long-term nursing care turnover linked to low Medicaid payments

Correcting an injustice: HHS moves to stop unions from skimming from Medicaid, Chantal Lovell  & Vincent Vernuccio, Washington Examiner,  August 07, 2018

Clay’s summary: The answer is clearly more money. Done! What complex problem is next? Bet we can fix that one with more money, too!

Key Passage from the Article

 

A study by the Texas Health Care Association, a nonprofit trade group representing nursing homes, says the annual turnover rate for certified nursing assistants is 97 percent. The churn rate for registered nurses and licensed vocational nurses is almost as high, coming in at 90 percent, according to a THCA study released this year. Kevin Warren, president and CEO of Austin-based THCA, said one of the primary issues is the state’s low Medicaid reimbursement rate of $143.48 per day. Only South Dakota provides a lower payment at $133.74. “When you look across the state, roughly two-thirds of the residents that reside in nursing facilities in the state, their care is paid for through Medicaid,” he said. “And we see that today’s Medicaid rate in skilled nursing is roughly about $27 a day less than what the cost of care is to deliver.” There are about three dozen long-term care facilities located in the Rio Grande Valley. Statewide, there are about 1,200 such facilities and they are caring for 90,000 residents. Warren said the low Texas Medicaid reimbursement means a long-term care facility is only paid about $6 per hour per patient for care, which hampers a nursing home company’s ability to compensate and retain nurses.

Read it here

 

 

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Reader’s Write-In: Bracker & Marcus LLC: Beaumont Hospital to Pay $84.5 Million False Claims Act Settlement

RoundUp Reader Jason Marcus sent this in- impressive story of how a massive fraud at William Beaumont Hospital in Detroit was uncovered and successfully prosecuted. Jason’s law firm specializes in False Claims Acts cases, and this one is one example of their success.

 

Related links

Full story / original article

Related press release

 

From the original story –

 

Detroit Area Hospital System to Pay $84.5 Million to Settle False Claims Act Allegations Arising From Improper Payments to Referring Physicians

WASHINGTON – William Beaumont Hospital, a regional hospital system based in the Detroit, Michigan area, will pay $84.5 million to resolve allegations under the False Claims Act of improper relationships with eight referring physicians, resulting in the submission of false claims to the Medicare, Medicaid and TRICARE programs, the Justice Department announced today.    

The Anti-Kickback Statute prohibits offering, paying, soliciting, or receiving remuneration to induce referrals of items or services covered by Medicare, Medicaid, and other federally funded programs.  The Physician Self-Referral Law, commonly known as the Stark Law, prohibits a hospital from billing Medicare for certain services referred by physicians with whom the hospital has an improper financial arrangement, including the payment of compensation that exceeds the fair market value of the services actually provided by the physician and the provision of free or below-market rent and office staff.  Both the Anti-Kickback Statute and the Stark Law are intended to ensure that physicians’ medical judgments are not compromised by improper financial incentives and instead are based on the best interests of their patients.

“Offering financial incentives to physicians in return for patient referrals undermines the integrity of our health care system,” said Acting Assistant Attorney General Chad A. Readler of the Justice Department’s Civil Division.  “Patients deserve the unfettered, independent judgment of their health care professionals.”

“We are very pleased with the outcome of this case.  This result should impress on the medical community the fact that we will aggressively take action to recover monies wrongfully billed to Medicare, through the remedies provided in the federal False Claims Act,” said U.S. Attorney Matthew Schneider for the Eastern District of Michigan.  “I would like to commend the new leadership at Beaumont Hospital for making things right once its past wrongdoing was brought to its attention by federal investigators.”

The settlement resolves allegations that between 2004 and 2012, Beaumont provided compensation substantially in excess of fair market value and free or below-fair market value office space and employees to certain physicians to secure their referrals of patients in violation of the Anti-Kickback Statute and the Stark Law, and then submitted claims for services provided to these illegally referred patients, in violation of the False Claims Act.  The settlement also resolves claims that Beaumont allegedly misrepresented that a CT radiology center qualified as an outpatient department of Beaumont in claims to federal health care programs.  As a result of this settlement, Beaumont will pay $82.74 million to the United States and $1.76 million to the State of Michigan. 

…Read the rest @ links above

 

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Monday Morning Medicaid Must Reads: August 13th, 2018

Helping you consider differing viewpoints. Before it’s illegal. 

 

Article 1:  

165 medical professionals charged in $2B DOJ, HHS healthcare fraud investigation: 5 facts, Rachel Popa, Beckers, July 24, 2018

Clay’s summary: Good highlights list from the recent massive fraud dragnet.

Key Passage from the Article

 The federal government’s largest-ever investigation led by the DOJ and HHS into healthcare fraud in the U.S. stretched across 58 federal districts and included 165 medical professionals, physicians and nurses accused of allegedly profiting from false healthcare billings, according to the DOJ.

Over 600 people were charged in the investigation with committing more than $2 billion in fraud and taxpayer theft. The report details several incidences where physicians and healthcare providers allegedly committed fraud, received kickbacks or fraudulently prescribed medications.

Here are the key facts from the investigation: 1. The investigation focused on fraudulent

…

Read it here 

Article 2:   

CMS proposes to overhaul Medicare billing standards, pay for telehealth, Virgil Dickson, Modern Healthcare, July 12, 2018

Clay’s summary: 2018 may just be the year telehealth breaks through.

Key Passage from the Article

 In a lengthy proposed rule, the agency said it would pay doctors for their time when they reach out to beneficiaries via telephone or other telecommunications devices to decide whether an office visit or other service is needed. In addition, the CMS also proposed paying for the time it takes physicians to review a video or image sent by a patient seeking care or diagnosis for an ailment.  “This is a big issue for the elderly and disabled population for which transportation can be a barrier to care,” CMS Administrator Seema Verma said. “We’re not intending to replace office visits but rather to augment them and create new access points for patients.”  Most physicians bill Medicare for patient visits under a relatively generic set of codes that distinguish level of complexity and site of care, known as evaluation and management visit codes. 

Read it here

 

 

 

Article 3:   

Drugmakers try evasion, tougher negotiations to fight new U.S. insurer tactic, Michael Erman, Reuters, July 5, 2018

Correcting an injustice: HHS moves to stop unions from skimming from Medicaid, Chantal Lovell  & Vincent Vernuccio, Washington Examiner,  August 07, 2018

Clay’s summary: “Copay accumulator programs”- What will they think of next? My head hurts trying to keep up with the insurance-PBM fights… These are some clever folks, worthy adversaries..

Key Passage from the Article

 In recent years, insurers have tried to guide patients toward less expensive treatments by making them pay a higher portion of a drug’s costs. Drugmakers responded by dramatically raising the financial aid they offer, in the form of “copay assistance” cards – similar to a debit card – that reduce what consumers need to pay when they place their pharmacy order. Express Scripts Holding Co and CVS Health, which manage prescription drug coverage for large U.S. employers, say these payments shield consumers from drug costs, making it easier for manufacturers to raise those prices. Insurers have to make up the difference.

This year, Express Scripts and others introduced a new “copay accumulator” approach for its corporate customers. The programs prevent copay card funds from counting toward a patient’s required out-of-pocket spending before insurance kicks in on expensive specialty drugs, such as arthritis and HIV treatments.

As an example, a patient whose medicine costs $1,000 per month might be required to pay that amount until they reach a deductible of $2,000 set by their insurer. A copay card from the drugmaker would cover most, or all, of those costs for the patient and it would count towards the deductible. When the deductible is reached, the insurance begins to pay.

Read it here

 

 

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Monday Morning Medicaid Must Reads: August 6th, 2018

Helping you consider differing viewpoints. Before it’s illegal. 

 

Article 1:  

ACA Medicaid Expansion Helped Make This Doctor a Billionaire, Tom Metcalf and Zachary Tracer, ThinkAdvisor, August 06, 2018

Clay’s summary: Capitalism at its finest, amiright? I mean, this is the way its supposed to work, yeah?

Key Passage from the Article

Catering to Detroit and Chicago’s poor has made the Cottons rich. David Cotton and his family spent two decades building Meridian Health Plans into the biggest private provider of Medicaid benefits in Michigan and Illinois. It serves about 1.1 million members, with more than $4.3 billion of revenue forecast for 2018.

Now they’re cashing out. WellCare Health Plans Inc. announced in May that it’s buying Meridian for $2.5 billion, a deal that includes two state insurance businesses and a pharmacy benefits manager.
Cotton, 67, his wife Shery, and their three sons own the entire company, according to filings. The sale is expected to be completed by year-end and would leave the family with about $2 billion after taxes, according to the Bloomberg Billionaires Index. That puts them in the same wealth stratosphere as Detroit’s Dan Gilbert, owner of Quicken Loans, and Chicago’s Penny Pritzker, the Hyatt Hotels heiress.

…

Read it here 

Article 2:   

Arkansas’ Medicaid Spending Drops by $22M, AP, August 6th, 2018

Clay’s summary: First. Time. Ever.

Key Passage from the Article

The decrease came despite slightly higher spending on Arkansas Works, the state’s expanded Medicaid program, the Arkansas Democrat-Gazette reported. Arkansas Works spending rose to $1.91 billion, a less than 1 percent increase. That was offset by a $31 million decrease in spending on the traditional Medicaid program, which covers primarily low-income families and low-income people who are elderly or disabled. The state Department of Human Services said spending on both parts of the Medicaid program fell by 0.3 percent, to $7.1 billion.

   

Read it here

 

 

 

Article 3:   

Correcting an injustice: HHS moves to stop unions from skimming from Medicaid, Chantal Lovell  & Vincent Vernuccio, Washington Examiner,  August 07, 2018

Clay’s summary: This ACA rule was as slimy as it gets. Should make any Dems embarrassed and want to go take a shower.

Key Passage from the Article

A scheme by state governments that costs sick, elderly, and disabled Americans hundreds of millions of dollars each year appears to be on thin ice, thanks to the Trump administration taking action. In July, the Department of Health and Human Services published a Notice of Proposed Rulemaking that, if enacted, would prohibit states from diverting money from the Medicaid program and sending it to public-sector unions. This practice, known commonly as dues-skimming, is allowed in 11 states where governors and legislatures have wrongly classified relatives and friends who provide in-home care to their needy loved ones as public employees simply because they receive money from the taxpayer-funded Medicaid program to offset the cost of care. Each year, these caregivers lose an estimated $150 million to unions that skim off the top of their loved ones’ benefits, often without their knowledge.

Read it here