Tag: State News

[MM Curator Summary]: Medicaid expansion does not help rural OB providers.

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.

Although Medicaid expansion decreased hospital closures, it has had little effect on obstetric service closures, an April Health Affairs study found.

The researchers used data from American Hospital Association surveys and information on obstetric service provision from CMS to track obstetric service closures from 2010 and 2017.

Rural obstetric units were less likely to close immediately after Medicaid expansion, but this effect tapered off within two years, according to the study.

The decrease in overall hospital closures was mostly found in hospitals that did not have obstetric units.

Obstetric services have decreased in the last decade because they are often unprofitable, according to the study. Medicaid expansion has been introduced as a possible solution because it diminishes uncompensated care and improves hospital finances.

“Policies aiming to address obstetric closure may need to tailor solutions to the challenges facing this particular service line — for example, low Medicaid reimbursement rates,” the study suggested.

Read more here.

Clipped from: https://www.beckershospitalreview.com/care-coordination/medicaid-expansion-had-little-effect-on-obstetric-service-closures-study-finds.html

[MM Curator Summary]: The timeline of the failed single pbm rollout in CA is chronicled.

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.

(LightRocket / Getty Images)

SACRAMENTO — Prescription drug costs for California’s massive Medicaid program were draining the state budget, so in 2019 Gov. Gavin Newsom asked the private sector for help. 

The new Medicaid drug program debuted this January, with a private company in charge. But it was woefully unprepared, and thousands of low-income Californians were left without critical medications for weeks, some waiting on hold for hours when they called to get help.

What happened in the two years between the contract award and the start of the program is a case study in what can go wrong when government outsources core functions to the private sector.

California awarded the Medi-Cal Rx program to a unit of Magellan Health, a company with expertise in pharmacy benefits and mental health. But Magellan was then gobbled up by industry giant Centene, worth roughly $50 billion, which was looking to expand its mental health portfolio. 

Centene was already a big player in state Medicaid drug programs — but one with a questionable record. The company was accused by six states of overbilling their Medicaid programs for prescription drugs and pharmacy services and settled to the tune of $264.4 million. Three other states made similar allegations and have settled with the company, but the amounts have not been disclosed. Centene, in resolving the civil actions, denied any wrongdoing.

KHN has learned California health officials also are investigating Centene.

Handing Over Control

In his 2019 inauguration speech, Newsom vowed to use California’s “market power and our moral power to demand fairer prices” from the “drug companies that gouge Californians with sky-high prices.”

Drug spending by the state for its Medicaid, prison, state hospital, and other programs had been climbing 20% a year since 2012, so the first-term Democrat issued an executive order requiring California to make its own generic drugs and forge partnerships with counties and other states to buy drugs in bulk. He also directed the state to buy prescription drugs for Californians enrolled in Medi-Cal, the state’s Medicaid program, which covers roughly 14 million people.

Newsom no longer wanted to allow the state’s two dozen Medi-Cal managed-care health plans to provide prescription drug coverage to their enrollees, arguing the state would get a better deal from drug companies by harnessing its purchasing power.

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That December, California awarded a competitive $302 million contract to Magellan Medicaid Administration, a subsidiary of Magellan Health, to make sure Medi-Cal enrollees get the medications that California would buy in bulk. Magellan provides pharmacy services to public health plans in 28 states and the District of Columbia.

Even though Magellan’s biggest money maker is mental health insurance, it met a key requirement of the state’s call for bids: It didn’t provide health insurance to any Medicaid enrollees in California.

Magellan was supposed to take over the drug program in April 2021. But on Jan. 4 of that year, Centene — which was seeking a greater role in the lucrative behavioral health market — announced plans to buy Magellan. 

St. Louis-based Centene, however, is one of the largest Medi-Cal insurers in the state, a factor that would have disqualified it from bidding for the original contract. Centene provides health coverage for about 1.7 million low-income Californians in 26 counties through its subsidiaries Health Net and California Health & Wellness. It earned 11% of its revenue from California businesses in 2019, according to its 2021 annual report to the U.S. Securities and Exchange Commission.

But the state bent over backward to make it work, delaying implementation of the program while Magellan set up firewalls, sectioned off its business operations from Centene, and paid for a third-party monitor.

State regulators reviewed the merger in a 30-minute public hearing in October 2021. They didn’t mention Centene’s legal settlements with other states.

The state Department of Managed Health Care approved the merger Dec. 30. Two days later, the state launched its new prescription drug program with Magellan at the controls.

Centene’s Legal Troubles

In the past 10 months, Centene has settled with nine states over accusations that it and its pharmacy business, Envolve, overbilled their Medicaid programs for prescription drugs and services: It settled with Arkansas, Illinois, Kansas, Mississippi, New Hampshire, and Ohio, according to news releases from attorneys general in those states. The three other states have not been identified by Centene or the states themselves.

The company has set aside $1.25 billion for those settlements and future lawsuits, according to its 2021 report to the SEC.

Centene, which has denied wrongdoing in public statements, did not respond to multiple requests by KHN for interviews, nor did it respond to emailed questions. Magellan also did not respond to interview requests.

From the start, other California health insurers opposed the state takeover of the Medi-Cal drug program, partly because it took away a line of business. They were even more furious when the state allowed one of their biggest competitors to seize the reins — especially given its legal entanglements.

The state Department of Health Care Services, which administers Medi-Cal, acknowledged to KHN in March that it’s investigating the company but declined to provide specifics. The state is investigating Centene’s role in providing pharmacy benefits before the state took the job from managed-care insurers.

“DHCS takes all allegations of fraud, waste, and abuse seriously and investigates allegations when warranted,” department spokesperson Anthony Cava said in a statement.

A Sale in the Offing?

When Medi-Cal Rx debuted Jan. 1, thousands of Californians couldn’t refill critical — sometimes lifesaving — medications for days or weeks. Doctors, pharmacists, and patients calling for help often languished on hold for as many as eight hours.

Magellan blamed the problems on staff shortages during the covid-19 omicron surge and missing patient data from insurance plans. State health officials went to great lengths to fix the problems and appeared before legislative committees to provide lawmakers with assurances that the contractor wouldn’t be paid in full.

But Medi-Cal patients still face uncertainty.

Not long after Magellan took over California’s Medi-Cal drug program, reports surfaced in Axios and other publications that Centene might sell Magellan’s pharmacy business.

Centene officials have not confirmed a sale. But it would align with the company’s recent moves to restructure its pharmacy operations in the face of state investigations — such as seeking an outside company to begin managing its drug spending.

“Once you tell a PBM they actually have to behave, that’s when there’s no more money in it. It’s time to go,” said Antonio Ciaccia, president of drug-pricing watchdog 3 Axis Advisors, referring to businesses known as pharmacy benefit managers.

Yet another ownership change in California’s drug program could bring more disruption to the state’s most vulnerable residents, some of whom are still having trouble getting their drugs and specialty medical supplies after Magellan’s rocky takeover.

“I don’t know what kind of instability that creates internally when there’s a change of this magnitude,” said Linnea Koopmans, CEO of Local Health Plans of California, which represents the state’s publicly run Medicaid insurers that compete against Centene. “It’s just an open question.”

Koopmans and other Centene critics acknowledge that California has long relied on private insurance plans to offer medical and prescription drug coverage to Medi-Cal enrollees and that the state shouldn’t be surprised by ownership changes that come with consolidation in the health care industry. For example, Centene has a history of taking over California contracts after an acquisition — it did so when it purchased Health Net in 2016.

But consumer advocates say the Centene fiasco makes it clear that the state must improve oversight of corporate mergers if it chooses to hand over responsibility for public programs.

“In an ideal world, this is all backroom machinations that people don’t notice — until they do, until there is a problem,” said Anthony Wright, executive director of Health Access California, a consumer advocacy group. “It just increases the need to make sure that that oversight is there, that accountability is there.”

Clipped from: https://californiahealthline.org/news/article/california-medicaid-centene-magellan-drug-program-overbilling-states/

[MM Curator Summary]: Abortion opponents in AK may get a win.

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.

Rep. Sarah Vance, R-Homer, listens as Rep. Liz Snyder, D-Anchorage, speaks against a budget amendment on Wednesday, April 6, 2022 in the Alaska House of Representatives. The amendment attempts to de-fund state funding for abortion services, and Vance had just finished delivering a speech in favor of the amendment. (James Brooks / ADN)

JUNEAU — Defying court rulings, the Alaska House of Representatives voted 21-18 on Wednesday to cut Alaska’s Medicaid budget by $350,000 in an attempt to eliminate state funding for abortion services.

The vote is the latest in a yearslong series of attempts by Alaska legislators to cancel public funding for abortion services. Prior votes have had little effect. The state has shifted Medicaid funding from other sources and continued to provide abortions. In 2021, according to the latest available figures, Medicaid funded 537 of 1,226 abortions in Alaska.

Despite the limited effects of prior amendments, this year’s proposal could have significant effects if signed into law. Last year, as they considered a similar amendment, lawmakers were warned that the language of the restriction could endanger all state funding for Medicaid if it were challenged in court. They ultimately decided to use different wording proposed by the state Senate.

The Alaska Supreme Court has repeatedly ruled that the right to an abortion is protected by the state’s constitutional right to privacy, and the court ruled in 2001 that the state would violate the constitution’s equal protection clause and discriminate against poor women if it denied abortion services under Medicaid.

Speaking Wednesday, several legislators said they believe strongly enough on the topic to vote in favor of the budget amendment, even if it is unconstitutional.

“I don’t really care if we have to run it through the courts a hundred times,” said Rep. Kevin McCabe, R-Big Lake.

Rose O’Hara-Jolley, Alaska state director of Planned Parenthood Alliance Advocates, which advocates for abortion access, said the anti-abortion measure “is unethical, unconstitutional, and puts cruel and inequitable restrictions on abortion access for people with low incomes. The bottom line is that everyone — no matter how much money they make, how much wealth they have, or who provides their insurance — should be able to access the full range of reproductive health care, including abortion.”

The electronic voting board in the Alaska House of Representatives shows the votes for and against an amendment on Wednesday, April 6, 2022 attempting to de-fund state-paid abortion services. (James Brooks / ADN)

The amendment came from Rep. Christopher Kurka, R-Wasilla. It was supported by all 18 members of the House’s Republican minority as well as independent Republican Rep. Sara Rasmussen, R-Anchorage. Majority Reps. Kelly Merrick, R-Anchorage and Josiah Patkotak, I-Utqiagvik, provided the 20th and 21st votes.

Access to abortion — state-paid or not — is legally protected in Alaska by several rulings of the Alaska Constitution and would not be immediately affected if the U.S. Supreme Court overturns its landmark 1972 decision in Roe v. Wade.

A decision on that issue is expected this summer, and Rep. George Rauscher, R-Sutton said he expects Roe to be overturned one day.

“People are going to realize that when there’s a heartbeat, this child is a person,” he said.

Rep. Ron Gillham, R-Kenai, said he believes life begins at conception and cited the language of the state constitution in saying that legislators have an obligation to protect unborn residents.

Rep. Sarah Vance, R-Homer, argued in support of the amendment, saying she unexpectedly became pregnant at 23 and lived in denial until she heard her daughter’s heartbeat.

“This is more than just dollars or just court orders. This is the very lives of our future,” she said.

Rep. Sara Hannan, D-Juneau, opposed the amendment, calling abortion “fundamental health care for women,” and Rep. Liz Snyder, D-Anchorage, shared the story of her own difficult pregnancy. She said her doctor told her that without modern medical care, she might have died.

“Don’t put women in that position,” she said.

The House is expected to consider further budget amendments through the end of the week. If the abortion-funding amendment remains, it and the rest of the budget will advance to the Senate, which is at work on a competing proposal.

That proposal, now in the Senate Finance Committee, contains a $180,000 cut to Medicaid services and language saying the state should not pay for non-mandatory abortions.

If House and Senate approve different proposals, the differences will be ironed out by a conference committee intended to write a compromise.

Clipped from: https://www.adn.com/politics/alaska-legislature/2022/04/06/alaska-house-votes-to-defund-medicaid-abortion-services-despite-court-rulings-requiring-it/

[MM Curator Summary]: The state will add up to $169M to try and get more dentists to accept Medicaid payments.

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.

More than 600,000 additional Medicaid patients in Tennessee may soon be covered with comprehensive dental benefits under a proposal by Republican Gov. Bill Lee. But the state, one of the last to extend dental coverage to adults, is also trying to make sure those Medicaid enrollees can find dentists willing to treat them.

Along with $75 million to extend Medicaid dental benefits to adults, Tennessee is considering $94 million to help its two dental schools expand. About a third of the money would help pay off the student loans of graduates who agree to work in high-need areas, with the idea that they would treat more Medicaid patients.

“It’s sometimes a chicken-and-egg phenomenon,” said Dr. Lisa Piercey, who leads the Tennessee Department of Health. “If you bring a bunch of people into coverage but don’t have the providers to do it, then that’s a real problem.”

The lack of dentists in some areas has bedeviled a number of states expanding Medicaid coverage in recent years, including Missouri and Oklahoma. Complicating matters is the unwillingness of many dentists to accept Medicaid insurance rates, which vary by state but typically pay less than half of what commercial insurance pays. A 2019 analysis from the Milliman consulting firm found some states paying less than a third of commercial rates for dental work on Medicaid patients.

In Tennessee, fewer than a third of dentists are even enrolled to treat Medicaid patients. American Dental Association data finds at least a dozen states have similar participation levels.

And many dentists cluster within higher-payer communities, leaving gaps elsewhere. Virtually every state has a shortage of dentists in at least some areas, according to tracking by KFF. The ADA finds that the problem has worsened during the covid-19 pandemic, with an exodus of dentists and hygienists. But the greatest needs are basically everywhere but large metropolitan areas, with rural communities representing roughly 60% of the shortage areas.

“There are only a handful of counties in this state that actually have an adequate number of dentists,” Piercey said of Tennessee.

So is there an actual shortage of dentists or just a shortage of those willing to practice where needed and treat those most in need? It’s likely a combination.

In the 1980s, dental schools were shrinking for lack of qualified students applying. Some were scared off by the escalating tuition to earn a “doctor of dental surgery” degree. Practicing dentists also had concerns about an oversupply in their profession. But predictions at the time suggested that advances in dentistry and even birth control would reduce demand, the dean of Emory’s dental school told The New York Times in 1987. Emory’s school closed. So did Georgetown’s, once the nation’s largest private dental program.

Within a decade, enrollment nationwide had dropped by a third. The University of Tennessee went from graduating two classes of 80 a year to just one 80-person class. It’s now grown to more than 100. But roughly a quarter of the seats are reserved for residents of neighboring Arkansas, which doesn’t have its own dental school.

Many schools are adding seats, and the American Dental Education Association isn’t standing in the way.

“The question of the right number of dentists to serve any given population is complex, with varying considerations, but in general, we believe the potential for an overabundance is a long ways off,” American Dental Education Association CEO Dr. Karen West said in a written statement.

In recent years, UT and Tennessee’s other dental school, at Meharry Medical College in Nashville, have started to add a few slots. Nationally, enrollment has surpassed 1980 levels, with the number of graduates hitting roughly 6,500 a year, though the U.S. population has also grown since then.

“Now the pendulum has swung the other way,” said Dr. James Ragain, dean of the UT College of Dentistry in Memphis.

But to expand by more than a handful of spots, Ragain said, schools need cash to build out the physical space and purchase equipment, such as sophisticated mannequins used by first-year students.

“Dentistry is a hand-skills profession,” Ragain said, contrasting dental schools with medical schools, which start out with classwork and then lean heavily on hospitals as their training grounds. “We do the clinical training.”

Providing the hands-on training and employing full-time dentists as professors, who are demanding ever-higher salaries, are the main drivers of escalating tuition, Ragain said.

The four years of dental school usually cost more than the four years of medical school. And with an average school debt of $300,000, many dentists don’t want to practice in a small town with few patients covered by commercial insurance and many retirees on Medicare, which doesn’t pay for most dental work.

So dentists prefer to work in the suburbs, where more people have private insurance through employers.

“The first thing that comes to mind is that I have $400,000 of loans,” said Dr. Ratrice Jackson, who graduated in 2018 from Meharry, one of the few historically Black dental schools. She then completed an optional two-year residency in Florida to become a pediatric specialist and now works in a Dallas suburb. “I hate that it is that way.”

While the career can be lucrative, Jackson said, the loans scare off people who would make great dentists. “A lot of people don’t want to be $500,000 in debt,” she said, adding that her monthly student loan payment is $4,500.

The median annual salary for a dentist is roughly $160,000, though specialists and practice owners make considerably more.

The expansion of dental schools alone isn’t expected to solve the clustered shortages. So as part of Tennessee’s oral health push, the state is also proposing to pay off student loans for dentists who work in high-need areas for three years, similar to an existing state program for primary care physicians.

The ADA has been pushing Congress to provide help through several bills involving loan deferment and refinancing. And some states already have loan forgiveness programs.

Dentists helped craft the Tennessee plan and are generally supportive. But Dr. Jeannie Beauchamp, president of the American Academy of Pediatric Dentistry, said the low rates paid by Medicaid in Tennessee still must be addressed. A practice like hers in Clarksville, Tennessee, could not have more than 35% or 40% of its patients on Medicaid, she said, “because you’d go broke.”

Tennessee’s program, known as TennCare, has proposed increasing reimbursement for pediatric dental services by an average of 6.5% this year. But rates haven’t been set for the 600,000 adults who would be newly covered.

Leaders in a number of Republican-led states have been convinced in recent years that poor oral health is dragging down overall health and even holding back their state economies, aligning with Medicaid advocates who have been calling for benefit expansion for years. They, too, say payments need to increase so dentists will accept the coverage.

A report from the Tennessee Justice Center finds that just 53% of children in the state’s Medicaid program saw a dentist in 2019, despite having coverage.

“We have to figure out how we make Medicaid more attractive for more providers,” said Kinika Young, the nonprofit advocacy center’s senior director of health policy and equity. “There’s not enough to even see the children … so we need more providers to step up.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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By Blake Farmer, Nashville Public Radio
Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.

Clipped from: https://www.physiciansweekly.com/tennessee-offers-to-expand-dental-schools-as-medicaid-coverage-stretches-need/