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

Attached are the June & July 2018 edition of our 5 Slide Series. Both of these editions draw upon datasets we have developed and regularly update.  Our June 2018 edition summarizes the recent financial performance and quality performance for Georgia’s Medicaid health plans, as an example of the information we often provide our clients using these datasets.  Our July 2018 edition conveys summary data regarding the Medicaid MCO industry’s overall financial performance during CY2016 and CY2017.

Medicaid MCO Profile Report — Georgia

Medicaid MCO Profitability During 2016 and 2017

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

A few Medicare-ish ones this week, but keeping with our July them of technology.

Article 1:  

5 payers launch blockchain partnership, chronic disease tech released and more during Q2, Dave Muoio, MobiHealthNews, July 6, 2018

Clay’s summary: I still don’t really know what blockchain is. And I’d like to keep it that way I think. Seems like some big players are betting a lot on it, though.

Key Passage from the Article

 A handful of headlines from the past three months have made it clear that insurers are moving forward with novel technologies in mind.  Of note, a partnership of five healthcare organizations including insurers UnitedHealthcare and Humana, Optum, Quest Diagnostics, and MultiPlan announced plans to launch a blockchain pilot to help payers tackle mandated provider directories. The program will apply blockchain technology to improve the quality of data and reduce the administrative costs associated with insurers getting up-to-date healthcare provider demographic data, with results expected in the fall.

“I think the alliance is one of the first, if not the first, national blockchain alliances for healthcare,” Mike Jacobs, a senior distinguished engineer at Optum, who has been working on the test program for two years, said. Optum also seems to have been keeping an eye on other up-and-coming technologies, namely AI and neural networks. In a sold-out discussion hosted at Optum’s Boston office and organized by the Design Museum Foundation, Sanji Fernando, vice president and head of OptumLabs’ Center for Applied Data Science, explained at length how ongoing difficulties researchers face in explaining the decision-making process of these networks is limiting their role in healthcare. “There’s some amazing breakthroughs in AI that we expect will transform health and healthcare across the world,” Fernando said during his talk. “And while some of those breakthroughs may radically change the way you receive care, there’s a long road and journey before we accomplish that — along the way, though, there’s really valuable impact that AI can have in how we receive healthcare today.”

Earlier in the quarter Tom Beauregard, chief innovation officer at UnitedHealth Group, participated in a discussion with heads from Fitbit and Empatica on the future of health and fitness wearables in an industry becoming increasingly concerned about data privacy. Noting the increasing need to communicate with consumers about these topics, he said that the best way for insurers to keep patients on board with continuous monitoring strategies is to communicate the potential health benefits through a primary care physician.

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Read it here 

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Article 2:   

AHA ‘strongly opposes’ interoperability as a Medicare requirement, Evan Sweeney, FierceHealthcare, June 25, 2018

Clay’s summary: Hospitals don’t want any more things to slow down getting their cash, thank you very much.

Key Passage from the Article

 

The American Hospital Association (AHA) has come out against a policy floated by the Centers for Medicare & Medicaid Services (CMS) to make interoperability a requirement to bill Medicare and Medicaid.

In a proposed hospital payment rule issued in April, CMS included a request for information regarding a revision to hospital Conditions of Participation (CoP) and Medicaid Conditions for Coverage (CfC) that would require hospitals to share data electronically with other hospitals, community providers and patients “if possible.” In comments (PDF) submitted to CMS, the AHA said it “strongly opposes creating additional CoPs/CfCs to promote interoperability of health information.”

Read it here

 

 

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Article 3:   

Medicare May Soon Pay Doctors For Diagnosis Via Text Message, Bruce Japsen, Forbes, July 12, 2018

Clay’s summary: You have about 6 weeks to tell CMS you want them to move forward with the policy.

Key Passage from the Article

By allowing doctors to bill Medicare for a text, it could cut down on a more expensive trip to a hospital emergency room or help a patient save time and money by making an unnecessary trip to the doctor’s office for something that can be treated or evaluated remotely. In a conference call with reporters Thursday, Verma cited the use of Skype as one example where a physician could be paid for evaluating and consulting with a patient. The following provisions are proposed in the 2019 physician fee schedule that would allow Medicare to:

• Pay clinicians for “virtual check-ins – brief, non-face-to-face appointments via communications technology,” CMS said.
• Pay clinicians for “evaluation of patient submitted photos,” CMS said
• Expand covered telehealth services to include “prolonged preventive services,” CMS said.

Before the proposal can be implemented, it is open for public comment. But Verma believes it will go over well among physicians and their patients. “Physicians tell us they continue to struggle with excessive regulatory requirements and unnecessary paperwork that steal time from patient care,” Verma said. Public comments on the proposed rules are due by September 10, CMS said.

Read it here

 

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

 

Article 1:  

More Than 600 Charged In Historic Opioid Fraud Takedown, Beth Leipholtz, The Fix, 7/10/2018

Clay’s summary: The national fraud sweeps get cooler and cooler to watch each year. I think they should wear go pros next time so we can watch in real time as they kick in doors.

Key Passage from the Article

“This is the most fraud, the most defendants, and the most doctors ever charged in a single operation,” said Attorney General Jeff Sessions.Sessions says the DOJ’s investigation “has stopped or prevented billions of dollars’ worth of fraud.” More than 600 people within 58 federal districts have been charged by the U.S. government for their involvement in “multi-billion-dollar profit-making schemes involving opioid painkillers,” CBS News reported.

On Thursday, June 28, the U.S. Justice Department announced the charges, which have to do with billing government programs like Medicare and Medicaid, as well as private insurers, for prescription medications that have been deemed medically unnecessary. These actions resulted in more than $2 billion in losses, the Justice Department and the Department of Health and Human Services states.

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Read it here 

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Article 2:   

GAO Confirms It: 340B Hospitals and Contract Pharmacies Profit from Low-Income, Uninsured Patients, Adam J Fein, Drug Channels, July 10, 2018

Clay’s summary: 340B can be an amazing profit center for providers who choose to not pass the savings onto patients.

Key Passage from the Article

The United States Government Accountability Office (GAO) has just issued a must-read report on the 340B Drug Pricing Program: Federal Oversight of Compliance at 340B Contract Pharmacies Needs Improvement.

Some of the report’s most startling revelations confirm our worst fears about how hospitals and pharmacies are abusing the 340B program.

Here are two especially dispiriting findings from the GAO’s analysis:

16 out of 28 hospitals (57%!) did not provide discounted drug prices to low-income, uninsured patients who filled prescriptions at the hospital’s 340B contract pharmacy. Seriously?!?
Many 340B contract pharmacies can earn excessive profit margins of 15% to 20% from brand-name 340B prescriptions. As I have long suspected, large, publicly-traded pharmacies are sharing in the 340B discounts generated for covered entities.
Bottom line: Hospitals and pharmacies are making money from poor people. Are you kidding me?!? For shame!

The 340B program’s apologists will have a hard time rebutting the uncomfortable facts from this GAO report. Calling something a “drug discount program” apparently doesn’t mean that the neediest patients get access to those discounts. Read on, and prepare to be outraged.

  

Read it here

 

 

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Article 3:   

CMS suspends $10.4B in risk adjustment payments to insurers, Evan Sweeney, Fierce Healthcare, July 9, 2018

Clay’s summary: Health plans have a pretty big outstanding invoice. A smaller plan in NM is gumming up the works for the big guys with a lawsuit that says ACA calculations for the payments favor bigger plans.

Key Passage from the Article

Citing a March court ruling, the Centers for Medicare & Medicaid Services announced over the weekend that it is placing payments on hold while it resolves the litigation. Insurers on the Affordable Care Act marketplace are owed $10.4 billion in risk adjustment payments for the 2017 benefit year, which were slated to be paid in the fall. “We were disappointed by the court’s recent ruling,” CMS Administrator Seema Verma said in a statement. “As a result of this litigation, billions of dollars in risk adjustment payments and collections are now on hold.”

Verma added that CMS has asked the U.S. District Court for the District of New Mexico to reconsider its ruling and that the agency “hopes for a prompt resolution.”

The case involves New Mexico Health Connections, a consumer operated and oriented plan (CO-OP), which sued the Department of Health and Human Services (HHS) over what the insurer said was a flaw in the calculation that favored larger insurers. Judge James Browning ruled that HHS’ formula was not illegal but should be re-examined.

A separate ruling in Massachusetts in January found HHS acted within its authority in calculating risk adjustment payments. The program was created under the ACA to prevent insurers from risk selection and avoiding sicker enrollees.

Read it here

 

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

 

Article 1:  

N.J. bill would cap Medicaid ER visits at $140 for non-emergencies, Nicole Leonard, Press of Atlantic City, July 3, 2018

Clay’s summary: Great idea. Now spend 1,000 years arguing about all the exceptions to the rule. Forrest for the trees and all that.

Key Passage from the Article

  

If a Medicaid patient comes into an emergency room with what turns out to be a minor or nonemergency case, New Jersey hospitals will see a standard $140 reimbursement payment for that health care if a new bill becomes law.

Legislators who crafted the bill, which now awaits Gov. Phil Murphy’s signature, said the goal is to save the state and taxpayers money by capping payments to hospitals for these “low-acuity” cases, but some provider organizations and hospital experts fear it will do more harm than good.

“Our biggest concern is that hospitals will be penalized for treating patients who have nowhere else to go,” said Neil Eicher, vice president of government relations and policy at the New Jersey Hospital Association.

The bill, which passed the Assembly and Senate on June 21 with support and opposition within both political parties, applies specifically to Medicaid patients in the fee-for-service program.

About 1.8 million residents get coverage through Medicaid, according to state reports, and patients in the fee-for-service managed-care program account for about 5 percent of that population.

The state Office of Legislative Services estimated their collective outpatient health care services amounted to nearly $206 million in fiscal year 2017, but the amount that is related to emergency department visits is unknown.

 

 

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Read it here 

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Article 2:   

Finally, Some Answers on the Effects of Medicaid Expansion, Aaron Carrol, New York Times, July 2, 2018

Clay’s summary: If the goal was an insurance card in every pocket, we did awesome. According to lots of researchers.

Key Passage from the Article

 Since the start of Medicaid expansion, 77 studies, most of them quasi-experimental in design, have been published. They include 440 distinct analyses. More than 60 percent of them found a significant effect of the Medicaid expansion that was consistent with the goals of the Affordable Care Act.

Read it here

 

 

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Article 3:   

Kentucky cuts dental, vision coverage for nearly 500,000 Medicaid recipients, Tami Luhby, CNN, July 3, 2018

Clay’s summary: I’ve been telling you guys he’s not bluffing.

Key Passage from the Article

 Kentucky Republican Gov. Matt Bevin has suspended dental and vision benefits for nearly 500,000 Medicaid recipients after a federal judge blocked his plan to overhaul the safety net program.

Bevin’s administration was set to launch a massive reorganization of Medicaid benefits on July 1. The changes, which were approved by the Trump administration in January, included requiring certain beneficiaries to work and to pay premiums. The reorganization also would have changed dental and vision coverage for many low-income adults.
The effort was halted — at least temporarily — on Friday after US District Judge James Boasberg voided the federal approval and kicked the matter back to the Department of Health and Human Services for further review. Calling the agency’s approval “arbitrary and capricious,” Boasberg said HHS Secretary Alex Azar had neglected to analyze whether Kentucky’s plan would cause recipients to lose their health insurance coverage.
Bevin administration officials quickly warned that the state would have “no choice but to make significant benefit reductions” to offset the increasing cost of Medicaid expansion. On Sunday, they announced that dental and vision coverage would end for about 460,000 recipients until the overhaul moves forward.

Read it here

 

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