Tag: Finance

MM Curator summary

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

 
 

[MM Curator Summary]: CMS invents yet another on-paper “model” to address what it thinks should be done. Cue the next 2 years of analysis, opining and vendors telling us all their 90s’ era “big data” solutions will help docs, plans, and states convert what is designed to be increased accountability into an upside-only deal. You know, value-based care. But this time with an “equity” sticker slapped on it.

 
 

Clipped from: https://www.ajmc.com/view/new-cmmi-model-supports-health-equity-in-states-shifts-care-to-the-community

The AHEAD Model will operate for 11 years and aim to shift health care to community-based settings.

CMS has unveiled a new payment model aiming to support health equity in the states by shifting health care to community-based settings. The agency is already addressing health equity in other models, such as Enhancing Oncology Model and ACO REACH.

The States Advancing All-Payer Health Equity Approaches and Development Model (AHEAD Model) aims to better address chronic disease, behavioral health, and other medical conditions by equipping states to promote health equity, increase access to primary care, encourage more sustainable health care spending, and lower costs for patients.

The new AHEAD Model aims to support health equity in states by shifting care to community-based settings, promoting primary care, and increase screening and referrals to resources to address social determinants of health.

Image credit: Bro Vector – stock.adobe.com

 
 

“Primary care is the foundation of a high-performing health system and essential to improving health outcomes for patients and lowering health care costs. For that reason, the CMS Innovation Center has invested significant time and resources over the years testing models to strengthen primary care and improve care coordination and linkages to organizations that address health-related social needs,” Elizabeth Fowler, PhD, JD, deputy CMS administrator and director of the Center for Medicare and Medicaid Innovation (CMMI), said in a statement. “Through AHEAD, more states will have the exciting opportunity to both improve the overall health of their population, support primary care, and transform health care in their communities.”

AHEAD is the next iteration of CMMI multipayer total cost of care models. States that participate will be accountable for quality and health outcomes while reducing avoidable care spending.

Through the model, CMS partners with states to redesign statewide and regionwide health care delivery with the goal of enhancing total population health. The model includes payment models for participating hospitals and primary care practices to achieve the goals of the model.

Through AHEAD, CMS is looking to not only strengthen primary care and improve care coordination, but also increase screening and referrals to resources that help address social determinants of health, such as housing and transportation.

“In our current health care system, fragmented care contributes to persistent, widening health disparities in underserved populations,” said CMS Administrator Chiquita Brooks-LaSure. “The AHEAD Model is a critical step towards addressing disparities in both health care and health equity while improving overall population health.”

Up to 8 states will be selected to participate in the AHEAD Model and each will have the opportunity to receive up to $12 million from the agency.

In late fall 2023, CMS expects to release a Notice of Funding Opportunity followed by an application period in Spring 2024. States interested in participating in the mode will have to apply during these 2 application periods.

Applying states will select 1 of 3 cohorts:

• Cohort 1: 18-month pre-implementation period tentatively starting July 2024 for states ready to apply and implement AHEAD as soon as possible. The first performance year (PY) will tentatively begin January 2026 with 9 PYs.
  
• Cohort 2: 30-month pre-implementation period tentatively starting July 2024 for states that need additional time to prepare for implementation. This time may be used for activities such as developing Medicaid components, recruiting providers to participate, and developing data infrastructure. The PY will tentatively begin January 2027 with a total of 8 PYs.
  
• Cohort 3: 24-month pre-implementation period tentatively starting January 2025 for states that need additional time to apply to the model. The first PY will tentatively begin January 2027 with a total of 8 PYs.
  

Overall, the AHEAD Model will operate for 11 years from 2024 through 2034. According to CMS, the model will build upon the work of state-based models from CMMI such as the Maryland Total Cost of Care Model, the Pennsylvania Rural Health Model, and the Vermont All-Payer Accountable Care Organization Model.

MM Curator summary

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

 
 

[MM Curator Summary]: Workforce issues, provider rate increases and continuing the accountable care collaborate experiment top the list of things included in the $15B budget ask this year.

Clipped from: https://stateofreform.com/featured/2023/01/colorado-hcpf-requests-14-8-billion-budget-plans-to-increase-provider-reimbursements-and-eliminate-medicaid-copays-in-fy-2023-2024/

 
 

Boram Kim | Jan 3, 2023 | Colorado

Led by Executive Director Kim Bimestefer, the Colorado Department of Health Care Policy and Financing (HCPF) presented its FY 2023-24 action plan while addressing questions and concerns about its budgetary requests during a Joint Budget Committee hearing on Dec. 21st. 

 
 

 
 

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The Department is requesting $14.9 billion in the upcoming fiscal year to address a declining healthcare workforce while increasing quality and affordability, which is more than $700,000 higher than the appropriation it received in FY 2022-23. 

HCPF said 96% of that request will continue to go to paying providers, $192.2 million of which will in turn go to the initiation of a 0.5% across-the-board provider rate increase and the elimination of Medicaid members’ copays in 2023. 

Other investment areas include rebalancing provider rates based on the annual rate review cycle, addressing critical needs for Nursing Home and Home and Community-Based providers, and targeted incentive payments for rural hospitals. 

An additional $8.67 million will go to support primary care medical providers’ transition to value-based payments with up-front reimbursement for care expenses. Under the Department’s value-based payment methodology, providers will have the option of receiving at least 25% of their revenue up front to allow for increased investment in care improvement.

“We can’t just keep paying as we have been, it has no future,” Bimestefer said during the hearing. “[Value-based payment] must succeed because just paying for volume is how we got to this terribly fractured system … When we increase the payments to primary care, that’s a good decision. And when we give [primary care providers] the tools to be able to better refer [to] specialty care or to refer to the right hospital systems that prescribe the right drugs, and we get to the right place with primary care, we fix a world of woes in the healthcare system.”

HCPF said this funding will help promote attribution—the process by which the department connects a Medicaid member to a provider—and strengthen the member-provider relationship through outcome-based payment flexibility. 

HCPF requested $1.1 billion for Behavioral Health Community Programs as Colorado continues to transform its behavioral health delivery system. The Behavioral Health Administration (BHA) will continue developing the state’s Hybrid Managed Care Model which aims to provide whole-person, physical and behavioral, healthcare for all Medicaid members, including prevention services, care coordination, primary, behavioral health, and specialty care. 

The Accountable Care Collaborative (ACC) has been administering that model through the state’s seven Regional Accountable Entities (RAEs) with a cost and outcome focus. RAEs will eventually administer capitation behavioral health benefits which include medical, substance-use disorder, and community-based services. 

ACC 3.0, the state’s upcoming updated value-based payment model, has already initiated community and stakeholder engagement on standardizing the processes and policies for all publicly funded behavioral health providers. HCPF plans to administer these contracts in late 2024. 

The Department is working with the BHA, providers, and community partners on establishing Certified Community Behavioral Health Clinics (CCBHC) and their roles in providing essential services.

Counties have consistently exceeded appropriated funding in conducting Medicaid eligibility determinations, forcing them to use local funds to cover the shortfall. The current budget appropriation will allow HCPF to fund counties directly through incentive payments geared around timely eligibility administration. HCPF said the direct payments should improve access and save the state money by reducing the number of inaccurate eligibility determinations. 

HCPF will focus on ensuring continuity of coverage for its Medicaid members in 2023 when the public health emergency is anticipated to end. Redeterminations for its 1.7 million Medicaid members, which Congress recently announced can begin starting April 1st, 2023, are expected to disenroll some 300,000 Coloradans from coverage.

Additionally, HCPF has requested $1 billion for the Office of Community Living, $496 million for the Indigent Care Program, and $700,000 to advance birthing equity. The legislature is expected to expand doula services in the state during the 2023 session.

“Colorado has a strong history of providing a broad array of home visitation services that complement one another,” said Adela Flores-Brennan, the state’s Medicaid Director, addressing the committee’s concerns about doula services overlapping with current midwifery services. “The Nurse Home Visitor Program, also known as the Nurse Family Partnership or NFP, provides valuable nurse services to first time parents. 

And the doula benefit complements the nurse home visitor program while improving health outcomes and equity for many of our members who may not be eligible for NFP with a support person present at their birth and may only want or be able to commit to a shorter intervention model … the NFP and doula benefit would serve slightly different populations with different models of care and different providers. Because of this, the addition of the doula benefit is not projected to undermine the sustainability or duplicate the efforts of other established home visiting models including NFP.”

Colorado Medicaid currently covers services provided by certified nurse midwives, but the push to expand both coverage and availability for doula services will be decided by lawmakers. The Medicaid benefit would be focused on improving health outcomes and reducing costs for pregnant women of color.

MM Curator summary

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

 
 

[MM Curator Summary]: Hospitals trying to deal with a reported 20% cost increase are driving the 10% Medicaid rate increase to them (on the heels of a 2% increase they got in 2021 and 2022). My costs have gone up a lot too, lately – how do I get this deal?

Clipped from: https://www.beckershospitalreview.com/finance/nebraska-hospitals-ask-for-record-medicaid-reimbursement-bump.html

The Nebraska Hospital Association is asking state lawmakers for a 9.6 percent Medicaid reimbursement rate in 2023 and a 7.7 percent rate in 2024, CBS affiliate KMTV reported Jan. 2. 

The request comes after Nebraska hospitals saw a 2 percent bump each of the last two years, according to the report.

Nebraska Hospital Association President Jeremy Nordquist said inflation has had a significant effect on hospitals in the state, according to the report. Overall costs are up more than 20 percent per patient compared to pre-pandemic levels, with most of that increase coming from labor costs. 

Mr. Nordquist said 54 percent of the state’s hospitals are operating in the red, according to the report. 

He said hospitals lose money on Medicaid and Medicare patients.

“For years a lot of that cost was shifted over to people who have private insurance,” Mr. Nordquist said, according to the report. “And everyone else has to pay more because the government’s not carrying its weight with Medicare and Medicaid. … In the past [commercial insurance] has been willing to … help with the shortfall. That negotiation is getting tougher for hospitals.”

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MM Curator summary

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

 
 

[MM Curator Summary]: Big buckets – Medicare docs magically avoid rate decreases for the 800th year in a row; Medicare adds $1B+ for mental health; states can start kicking people off their Medicaid rolls (if they want to) in April; extra Medicaid cash for maternity lives at least 1 more year; and rural health gets some stuff.

Clipped from: https://www.washingtonexaminer.com/restoring-america/courage-strength-optimism/medicaid-mental-health-omnibus-medicare

 
 

The $1.7 trillion catch-all federal spending bill, enacted by Congress and President Joe Biden just before lawmakers left town, won both praise and scorn. But supporters, most congressional Democrats, and Republican opponents, who called it a budget-buster, focused largely on spending provisions for defense, emergency assistance to Ukraine , and aid for various environmental crises.

Just as important in the 4,155-page bill, though, are spending provisions aimed at helping hospitals and healthcare systems. The law, cleared by the outgoing Democratic House on Dec. 23 and signed by Biden shortly thereafter, allots $9.2 billion for the Centers for Disease Control and Prevention for “fundamental public health activities” — coupled with a $760 million boost over the 2022 fiscal year. The appropriations bill also includes $350 million in flexible funding for public health infrastructure.

HUGE $1.7 TRILLION OMNIBUS SPENDING BILL PASSES THE HOUSE DESPITE GOP OPPOSITION

However, funding for COVID-19 prevention and mitigation measures was not included in the bill. That’s a blow to public health advocates who say new coronavirus strains could wreak havoc this winter and beyond.

Still, Senate Majority Leader Chuck Schumer (D-NY) said the bill was the most significant done in a long time.

“The omnibus is aggressive, generous, and far-reaching in healthcare, making it more affordable, more extensive,” Schumer said.

In addition to increased funding for the CDC and public health, the bill includes the following major provisions:

Public Health

The bill aims to improve public health through better data collection, vaccine development, and agency oversight.

The bill does not include a proposal that would have created a bipartisan task force, such as the 9/11 Commission, to examine the national response to COVID-19. That’s a politically touchy subject that House Republicans, soon to be in the majority, plan to tackle once they run committees. While, in theory, there’s plenty of room for a bipartisan investigation of the national response to COVID-19, it’s unlikely to go in that direction.

Physician Payments
The appropriations curb a cut of almost 4.5% to the Medicare Physician Fee Schedule, the annual regulatory rule released by the Centers for Medicare and Medicaid Services that updates the standards for physician reimbursement and policies related to the delivery of healthcare. The fee schedule cut was scheduled to go into effect in 2023. The spending law effectively tightens the cut to 2% for 2023, with another 3.25% cut in 2024.

Value-Based Care
The value-based care bonus sent to eligible physicians who participate in alternative payment models will drop from 5% to 3.5% in the next year. The health incentive aims to offset losses in revenue for physicians who move from fee-for-service to value-based care models.

Medicaid
The bill allows states in April to begin Medicaid redeterminations. That’s the process states use to ensure that Medicaid enrollees continue to be eligible for coverage by the federal and state program, which aims to limit healthcare costs for people with limited income and resources.

Now, states will have an indicator on when they should start redeterminations. States will also be allowed in April to begin removing people from pandemic-enhanced Medicaid coverage.

Telehealth
The packages ensure that flexibilities for doctors to treat patients remotely via telehealth remain in place for two years. That’s to provide regulators with the proper time to determine which flexibilities should be made permanent. Still, the provision falls short of the blanket permanence many lawmakers pushed for.

Medicare and many Medicaid programs have expanded the types of originating sites that a patient could be at while receiving services via telehealth. Other telehealth changes have included delaying certain in-person requirements and extending coverage for audio-only services.

Mental Health
The spending bill includes several policies to improve mental health across the nation, such as allowing Medicare to cover therapists and counselors, along with increases in funding for mobile healthcare units focused on mental healthcare.

Over $1 billion will also go toward the Community Mental Health Services Block Grant, in addition to increased funding for the 988 mental health hotline.

Mothers and Postpartum Care
The bill also extends a policy that allows states to offer a year of postpartum coverage for those enrolled in Medicaid and the Children’s Health Insurance Program.

Another provision, the Pregnant Workers Fairness Act, requires employers to make accommodations for medical conditions related to pregnancy. A second act, the PUMP Act, also requires employers to support mothers by providing private places, not including a bathroom, to pump breast milk.

Rural Health
The Medicare Dependent Hospital program and Low-Volume Hospitals program have been extended through 2025, which increases payments for those facilities with a large portion of Medicare patients.

The bill also includes $2 million for a rural hospital pilot program that helps to improve current hospital management.

Opioids
And $5 billion will go to efforts to reduce opioid misuse, such as easing buprenorphine prescription regulations (which previously required extra certifications.) The law includes $1.6 billion offered to states through the State Opioid Response Grant, medication-assisted treatment, and opioid overdose surveillance at the CDC.

CLICK HERE TO READ MORE FROM THE WASHINGTON EXAMINER

Increased Funding

The bill includes a 22% increase, totaling nearly $119 billion, for VA medical care. Another provision sends a 5.6% increase of almost $50 billion for the National Institutes of Health, along with $950 million for Biomedical Advanced Research and Development Authority.

It also dictates that the Advanced Research Projects Agency for Health, which receives $1.5 billion of the allotted funding, will be housed under the NIH.

[MM Curator Summary]: NC officials are warning about new monies needed to fund Medicaid spending increases, which are driven by enrollment surges and actions in response to the pandemic.

 
 

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

 
 

Another expected, but telling, ripple effect from the COVID-19 pandemic is that North Carolina’s Medicaid program is headed to a budget shortfall for 2021-22.

Kody Kinsley, the state’s health secretary, offered that projection last week to the joint legislative oversight Health and Human Services committee.

If that occurs, it would be the first non-surplus in eight fiscal years.

Medicaid currently covers 2.7 million North Carolinians with a $20.14 billion budget for 2021-22.

That represents about a 480,000 enrollment increase since the beginning of the pandemic in March 2020.

Enrollment also is up 32% from 1.84 million at the start of the 2013-14 fiscal year.

There have been Democratic-led efforts since 2014 to expand Medicaid coverage to another 450,000 and 650,000 through the federal Affordable Care Act, also known as Obamacare.

Healthinsurance.org estimates about 621,000 North Carolinians would benefit from expansion, with 212,000 of those individuals being listed as having no other realistic option for health coverage.

The nonprofit group also estimates that North Carolina is losing out on $5.9 billion in federal Medicaid funds that could gained through expansion.

Reasons for shortfall

Kinsley cited several factors for the potential shortfall, including: actual enrollment over the past nine months exceeding projections; temporary rate increases in response to the pandemic “continuing longer than planned;” additional expenses to resolve staffing shortages in skilled nursing facilities; and changes in state hospital assessment fees.

Through January, the state Medicaid program has spent 59% of its 2021-22 budget, or $11.95 billion out of $20.14 billion.

At the same time period in 2020-21, the program had spent 51%, or $9.18 billion of $18.2 billion.

Kinsley said the N.C. Department of Health and Human Services “is actively pursuing FEMA reimbursements for eligible COVID-related costs to maximize and extend support for services across North Carolina.”

For the 2009-10 through 2013-14 fiscal years, the state Medicaid program had nearly a $2.4 billion financing gap that had to be filled through additional legislative funding.

At that time, the state Medicaid program had a $14 billion budget.

The budget overrun and additional funding requirement was a key issue during the 2012 governor’s race won by Republican Pat McCrory.

The McCrory administration credited improved budgeting forecasts and more conservative spending for beginning what became eight years of Medicaid funding surpluses that has continued through the first five years of the Cooper administration.

Although Kinsley said he couldn’t project when a budget surplus would resume, he told legislators it is likely to resume in a post-pandemic period.

Kinsley said the Medicaid program’s budget priorities for 2022-23 will include:

n Expanding access to treatment and services for those most at need, including those involved in the justice system and child welfare system.

n Assisting individuals gain access “to the right level of high-quality services for their needs, including care in their community;”

n Combating the increase in behavioral health crises, including overdoses and youth suicides, with expanded crisis supports and investing in prevention and resilience initiatives;

n Increasing access to child and family well-being services;

n Sustainable pay for early childhood care workers; and

n Building “a more robust” local public-health infrastructure that “can be prepared for the next crisis.

 
 

Clipped from: https://journalnow.com/news/state-and-regional/govt-and-politics/dhhs-cautions-of-state-medicaid-funding-shortfall-for-2021-22-covid-19-expenses-biggest-impact/article_3e6f0b1e-a6da-11ec-88b3-db7bd094fbd6.html

[MM Curator Summary]: Idaho Medicaid spending has grown 100% in 10 years. The current budget requires $840M of state funds.

 
 

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

 
 

Legislators have to finish setting the state budget to adjourn 

 
 

Legislators work from the House chamber at the Idaho Capitol on Jan. 17, 2022. (Otto Kitsinger for Idaho Capital Sun)

The Idaho House of Representatives passed the state’s largest budget of the year Tuesday, the Idaho Department of Health and Welfare’s 2023 Medicaid budget.

The budget includes a total of $4 billion in funding from all sources, which is a 6.6% increase from the current budget. About 70% of the money comes from federal funds, which total almost $2.8 billion. The budget includes $830 million in state general fund money. The rest comes from dedicated funding sources, such as the Millennium Fund, which was created with money from settlements from tobacco lawsuits. 

Medicaid is a state and federal program that provides free or low-cost health care to low income individuals and children who meet eligibility criteria. 

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The budget, which is funded through House Bill 777, pays for 213 full time positions and provides $1.25 per hour per employee for merit-based pay increases. 

Rep. Paul Amador, the Coeur d’Alene Republican who sponsored the budget bill, said it is necessary to pay the state’s bills. 

“You will probably hear some debate about the unsustainability of Medicaid funding in Idaho, and I will not disagree with that,” Amador said during floor debate Tuesday. “This budget has ballooned over the last several years. But we are bound by our policies that are adopted in state statute at this time so we have to pay our bills, and this is essentially paying our bills for Medicaid for the next coming year.”

Some far-right conservatives in the House tried to kill the budget, pointing out its status as the state’s largest budget and calling it a windfall for the Idaho Department of Health and Welfare. 

“It is unsustainable at the rate we are going,” said Rep. Heather Scott, R-Blanchard. “I think we need to send a message by voting this bill down, resending it back and having it reworked.”

Rep. Ron Nate, R-Rexburg, said total funding for the Medicaid budget was just under $2 billion when he came to the Idaho Legislature in 2015. 

“The spending is clearly uncontainable. It has doubled in less than a decade,” Nate said during floor debate. “And let’s not forget that Medicaid is not sustainable without federal dollars. The federal government is on a path to financial ruin right now. What happens if the federal government can’t pay its bills?”

Since 2015, Idaho has been one of the fastest-growing states in the country, and Idaho voters voted to expand Medicaid eligibility in 2018. Medicaid expansion extended eligibility to about 100,000 additional low-income Idahoans under age 65.

Idaho began the legislative session with a projected state budget surplus of $1.9 billion.

Despite opposition by several conservatives, the Idaho House passed the budget bill by a vote of 43-27. The bill heads next to the Idaho Senate for consideration, where it will likely be taken up quickly. Legislative leaders are working to adjourn the 2022 session for the year on Friday.

Amador referenced how the Medicaid budget’s survival and passage is intertwined with the Legislature’s ability to adjourn, saying the state has to follow its laws and policies and pay the program’s bills.

“I appreciate your green light (of support); I’d like to go home this week,” Amador told legislators just before they voted Tuesday.

 
 

Clipped from: https://idahocapitalsun.com/2022/03/22/idaho-house-passes-6-6-increase-for-2023-medicaid-budget/

MM Curator summary

[ MM Curator Summary]: KY Medicaid financing maneuvers will now send an additional $2B to hospitals.

 
 

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

 
 

Kentucky hospitals that meet federal quality measures can receive up to $1.1 billion in increased Medicaid payments in 2022, Gov. Andy Beshear announced Dec. 29.

The funding is available through a federally approved, state-directed payment model, according to a news release from the governor’s office.

This is the second announcement in 2021 of additional funding after Mr. Beshear announced in January that Kentucky hospitals would receive an additional $800 million to $1 billion.

More than one-third of the state’s population is enrolled in Medicaid, according to the release.

“Health care is a basic human right, and our people deserve the best care possible,” Mr. Beshear said. “This year, our state has faced so much tragedy and heartbreak from the pandemic, tornadoes and other natural disasters, and we are thankful to our hospitals for continuing to provide quality health care to our Kentucky families in need.”

 
 

Clipped from: https://www.beckershospitalreview.com/finance/eligible-kentucky-hospitals-can-get-up-to-1-1b-more-in-medicaid-payments-in-2022.html