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

 

Article 1:  

Insurers Are Using AI to Boost Risk Management, Jared Kaltwasser, Healthcare Analytics News, 10/2/2018

Clay’s summary: Pretty blatant press-release dressed up as “news,” but interesting read nonetheless.

Key Passage from the Article

“The growth of value-based care is driving the need for deeper healthcare insights, for key activities such as risk adjustment, quality reporting, care and utilization management,” Apixio CEO Darren Schulte, M.D., told Healthcare Analytics News™.

The company’s pitch looks something like this: The Centers for Medicare & Medicaid Services is increasing audits of health plans offering Medicaid Advantage (MA), to ensure correct payments. That means health plans have to keep careful tabs on coding and payments. But unless the health plan owns the clinic, providers don’t share the same financial risks as insurers.

Apixio says about 85-95 percent of MA risk-adjustment payments are based on diagnosis codes from clinics and hospitals. The remaining payments are from chart coding. Diagnosis codes are backed up by patient notes and physician codes, but those records aren’t often reviewed prior to payment by the health plans. Thus, any errors may go undiscovered, which could cause regulatory headaches for health plans — but usually not clinics.

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Article 2:   

Enhanced Patient Matching Is Critical to Achieving Full Promise of Digital Health Records, Pew Trusts, 10/2/2018

Clay’s summary: Care management only works if you are treating the right patient.. kind of makes me think about how they write “not this one” on the leg that is not to be cut off going into surgery..

Key Passage from the Article

This report focuses on the last problem—patient matching—while also recognizing that many other challenges remain for effective and robust interoperability.

Patient matching helps address interoperability by determining whether records—both those held within a single facility and those in different health care organizations—correctly refer to a specific individual. Unfortunately, patient matching rates vary widely, with health care facilities failing to link records for the same patient as often as half the time. Deficiencies in matching patients to their records can lead to safety problems: For example, if an allergy listed in one record is not documented in another, or if records for two different individuals are incorrectly merged, patient harm can occur. In a 2012 survey conducted by the College of Healthcare Information Management Executives (CHIME), 1 in 5 hospital chief information officers indicated that patients had been harmed in the previous year due to mismatches.

Failures to effectively match patients can also be costly, leading to repeat tests and delays in care. In an extreme example, the care for an 11-month-old twin was documented in her sister’s record, resulting in the failure of the health system to recoup $43,000 in costs from the insurer.

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Article 3:   

Patient-Centered Medical Home Evidence Increases With Time, Paul Cotton, Health Affairs, 9/10/2018

Clay’s summary: Still losing money in year 7 of your health home? Don’t give up just yet- Health Affairs says they work, so they must work!

Key Passage from the Article

There are clear differences between studies that do and do not find benefits. Positive evaluations assess PCMHs on advanced standards, after up to five years of transformation and with financial incentives to improve quality and efficiency, or—like the HIV study above, the impact with high-cost, high-needs patients. Studies showing little benefit assessed practices with no financial incentives to reward improvement. They also looked at PCMHs using our initial 2008 standards that we updated in 2011, 2014, and 2017. The 2011 updates further emphasize pediatrics, health information technology, and clinician-patient collaboration. We made 2014 updates to emphasize more behavioral health care integration, team-based care, focus on high-need populations care management, and patient and family involvement. We made 2017 updates to streamline our recognition process and better support practices. And we will continue making updates in the future as we continuously listen to stakeholder feedback on how to improve this powerful program. 

PCMHs do, in fact, work. That is why the Medicare Access and CHIP Reauthorization Act (MACRA), which rewards clinicians for value instead of volume, gives PCMHs automatic credit. That is why 27 public-sector initiatives across 23 states and many private insurers use the NCQA PCMH model. That is why key medical boards provide PCMH credit for Maintenance of Certification. And that is why approximately 20 percent of all primary care physicians in the US are in the NCQA-recognized PCMH practices.

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

 

Article 1:  

National Quality Forum identifies set of quality measures for rural providers, Paige Minemyer, FierceHealthcare, 9/18/2018

Clay’s summary: The specific needs of Rural Americans- finally a focus of pop health?

Key Passage from the Article

The set includes nine measures intended for a hospital setting—such as scores on the Hospital Consumer Assessment of Healthcare Providers (HCAHPS) survey and Cesarean section rates—and 11 for ambulatory care settings, such as medication reconciliation postdischarge and preventive screenings for diabetes, behavioral health issues and tobacco use.

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Article 2:   

Health Care Quality: It’s Motherhood and Apple Pie. Until You Start To Measure It. Lola Butcher, Managed Care, 9/3/2018

Clay’s summary: You mean the government can’t write a reg to improve quality of care? And actually focuses on minutia that can be counted versus outcomes that matter? Egads! #Resist!

Key Passage from the Article

When he’s using microsurgical techniques to treat unbearable facial pain, neurosurgeon Richard Zimmerman, MD, values precision above all. But as the chair of quality outcomes at Mayo Clinic in Arizona, he has come to accept that the government’s system for measuring health care quality is less than precise.

“If you’re a hematologist–oncologist, the survival rate of cancer patients might be a better indication of quality than how often you document that you have screened for depression,” he says.

But screening a patient for depression—or, more accurately, documenting that you have screened for depression, regardless of whether you actually remembered to do so—leads to higher pay from the Medicare program. Nobody’s paying more for high cancer-survival rates.

Welcome to health care’s pay-for-value movement, in which public and private payers want to reward—and penalize—physicians based on the quality of care they provide.

It’s a good idea with a big problem: Physicians don’t believe in it.

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Read it here 

 

 

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Article 3:   

CMS: Better Data Analytics, Quality Measures will Modernize Medicaid

Clay’s summary: Looking forward to seeing the creativity of haters in coming up with a way this is a bad thing.

Key Passage from the Article

Modernizing the Medicaid program environment will require investments in data analytics and a greater reliance on meaningful quality measures, says CMS Administrator Seema Verma in a new blog post. As spending on healthcare in general – and Medicaid in particular – continues to rise, providers and regulators will need to continue to create more effective partnerships around raising quality and cutting costs, Verma stated. “As program costs have continued to rise, we have failed to deliver a level of transparency and accountability for achieving positive outcomes commiserate with our significant investment,” she wrote. “But this is finally beginning to change. Over the last several years, CMS has collaborated with states to improve how we collect and use data to modernize and measure the Medicaid and CHIP program.”

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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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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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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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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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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.

   

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Article 3:   

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

   

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Article 3:   

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

   

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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

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…

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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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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)…

  

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Article 3:   

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

 

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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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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.

   

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Article 3:   

Exploring the Growth of Medicaid Managed Care

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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