MACPAC Posts Meeting Transcript

The Medicaid and CHIP Payment and Access Commission met in Washington, D.C. earlier this month.  The issues on MACPAC’s agenda were:

  • state readiness to report mandatory core set measures
  • analysis of buprenorphine prescribing patterns among advanced practitioners in Medicaid
  • Medicaid’s statistical information system (T-MSIS)
  • Medicaid disproportionate share hospital payment (Medicaid DSH) allotments
  • Medicaid policies related to third-party liability
  • Medicaid and maternal health

A transcript of the MACPAC meeting is now available.  Find it here.

Feds Open Door for Exemptions from Medicaid IMD Exclusion

New federal guidelines will make it easier for state Medicaid programs to cover mental health services provided in institutions for mental diseases (IMD).

For years, Medicaid regulations greatly limited the ability of states to pay for care – generally, care related to substance abuse disorder treatment – provided in IMDs; this was generally known as the IMD exclusion.  The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act, also known as the SUPPORT for Patients and Communities Act, which was passed in 2018, opened the door for more exceptions to these limits, and last week, the Centers for Medicare & Medicaid Services approved a section 1115 waiver application submitted by the Washington, D.C. Medicaid program to circumvent the IMD exclusion for specific purposes.

At the same time that CMS approved the Washington waiver application it also issued formal guidance to state Medicaid programs outlining the circumstances and conditions under which it would consider waiver applications for similar circumvention of the IMD exclusion to facilitate the provision of care in IMDs for patients with substance abuse disorders and other serious mental health problems.  The CMS guidance memo addresses the types of care for which it might approve a waiver, the types of facilities in which waiver-authorized services can be provided, and the extent to which states could receive federal Medicaid matching funds for services provided to eligible patients through approved programs.

Learn more about the Washington waiver in the Fierce Healthcare article “CMS approves D.C. Medicaid waiver, paving way for broader mental health coverage” and read the CMS guidance memo to states here.

Verma Addresses Medicaid Issues

Yesterday, Centers for Medicare & Medicaid Services administrator Seema Verma spoke at a conference of the National Association of Medicaid Directors.

In addition to discussing a proposed regulation posted earlier in the day that would introduce changes in the regulation of state financing of their Medicaid programs, Verma also addressed:

  • Medicaid demonstration programs
  • Medicaid work requirements
  • a shift toward value-based payments
  • better coordination of care for the dually eligible (individuals serve by both Medicaid and Medicare)
  • enrollment issues
  • improvements in the efficiency of the federal Medicaid bureaucracy

Because private safety-net hospitals care for so many more Medicaid patients than the typical hospital, these issues are especially important to them.

Read Verma’s complete remarks here.

MACPAC Meets

The Medicaid and CHIP Payment and Access Commission met for two days last week in Washington, D.C.

The following is MACPAC’s own summary of the sessions.

The Commission devoted its Thursday morning discussion to integration of care for beneficiaries who are dually eligible for Medicaid and Medicare. Panelists Amber Christ, directing attorney at Justice in Aging; Griffin Myers, chief medical officer at Oak Street Health; and Michael Monson, senior vice president for Medicaid and complex care at Centene, presented beneficiary, provider, and health plan perspectives and a question and answer session followed.

After lunch, MACPAC staff briefed the Commission on challenges states face as they prepare for mandatory reporting of quality measures for children enrolled in Medicaid and the State Children’s Health Insurance Program (CHIP) and behavioral health measures for adults enrolled in Medicaid. Immediately following that session, the Commission reviewed a new MACPAC-commissioned study on the effects of federal legislation that provided new buprenorphine prescribing authority for nurse practitioners and physician assistants.

After a brief break, MACPAC staff updated the Commission on the status of the Transformed Medicaid Statistical Information System (T-MSIS). The final Thursday session discussed disproportionate share hospital (DSH) allotments as required in MACPAC’s annual March reports to Congress.

MACPAC’s Friday agenda opened with a session on improving Medicaid policies related to third-party liability: specifically, coordination of benefits with TRICARE, the health coverage program for active duty military and their dependents. There are close to 1 million Medicaid beneficiaries with TRICARE coverage but Medicaid’s ability to collect from TRICARE is limited. The final session of the October meeting addressed Medicaid and maternal health.

Supporting the discussion were the following briefing papers:

  1. State Readiness to Report Mandatory Core Set Measures
  2. Analysis of Buprenorphine Prescribing Patterns among Advanced Practitioners in Medicaid
  3. Update on Transformed Medicaid Statistical Information System (T-MSIS)
  4. Required Analyses of Disproportionate Share Hospital (DSH) Allotments
  5. Improving Medicaid Policies Related to Third-Party Liability
  6. Medicaid and Maternal Health: Work Plan and Further Discussion

MACPAC is a non-partisan legislative branch agency that provides policy and data analysis and makes recommendations to Congress, the Secretary of the U.S. Department  of Health and Human Services, and the states on a wide variety of issues affecting Medicaid and the State Children’s Health Insurance Program.  MACPAC’s deliberations are especially important to private safety-net hospitals because those hospitals care for especially large numbers of Medicaid patients.  Find MACPAC’s web site here.

Medicaid Expansion Brings Improvements to Expansion States

States that expanded their Medicaid programs under the Affordable Care Act have experienced fewer hospital admissions, shorter lengths of stays in the hospital, and lower hospital costs, according to a new Health Affairs study.

Specifically, they experienced:

  • a 3.1 percent decline in inpatient days
  • a 3.5 percent decrease in discharges for conditions considered “ambulatory care-sensitive,” such as diabetes, chronic respiratory problems, and pneumonia
  • a reduction of nearly three percent in hospital costs.

NASH has long supported Medicaid expansion, which has enabled private safety-net hospitals to serve their communities more effectively.

Learn more about how Medicaid expansion has improved the health of the population in states that expanded their Medicaid programs in the Health Affairs study “Medicaid Expansion Associated With Reductions in Preventable Hospitalizations.”

MACPAC Looks at Medicaid Substance Abuse Treatment

The treatment of substance abuse problems with medication within the Medicaid population is the subject of a new report by the Medicaid and CHIP Payment and Access Commission.

As required by the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act, which was enacted last year, MACPAC has prepared a report on how selected states administer and regulate the use of medications used to treat opioid and alcohol use disorders.

Among its findings:

  • The frequency with which providers are prescribing medication to treat opioid and alcohol use disorders has exploded in recent years.
  • States are starting to eliminate prior authorization for such prescriptions.
  • But states still apply utilization management practices to such medications more frequently than they do for counseling for the same problems.
  • States are becoming more likely to limit the quantities and doses that providers can prescribe at one time.
  • More states are requiring providers to check prescription drug monitoring programs before prescribing medications to treat opioid and alcohol use disorders.

Private safety-net hospitals typically care for especially large numbers of  patients with opioid and alcohol use disorders who are insured by Medicaid.

Learn more about MACPAC’s findings in its new report “MACPAC Examines Access to Medication-Assisted Treatment under Medicaid.”

 

Verma Hints at More Medicaid Changes, Deregulation

Stay tuned for more Medicaid changes, Centers for Medicare & Medicaid Services administrator Seema Verma told a Las Vegas health care gathering last week.

CMS, she told her audience, will

…soon outline new opportunities for states to flip the Medicaid paradigm and free themselves from federal micromanagement.

While Verma offered few details, one idea clearly emerged:  there will be more deregulation.  She insisted, for example, that Medicaid work requirements are not dead.  While such requirements have run into trouble in the courts in recent months, she explained that CMS is developing new implementation guidelines to address some of the challenges states have faced when introducing such requirements and made it clear that CMS would continue to approve state requests to require their Medicaid population to work or engage in volunteer activities.

Because they care for more Medicaid patients than the typical hospital, private safety-net hospitals could be disproportionately affected by any changes in the Medicaid program.

Learn more about Verma’s remarks and the context in which they were offered in the Healthcare Dive article “CMS chief Verma teases more Medicaid deregulation.”

Number of Uninsured Children on the Rise

The number of children insured by Medicaid and CHIP has fallen by more than one million over the past two years after reaching an all-time low (by percentage) in 2016.

Why?  According to the New York Times,

Some state and federal officials have portrayed the drop — 3 percent of enrolled children — as a success story, arguing that more Americans are getting coverage from employers in an improving economy. But there is growing evidence that administrative changes aimed at fighting fraud and waste — and rising fears of deportation in immigrant communities — are pushing large numbers of children out of the programs, and that many of them are now going without coverage. The declines are concentrated in a minority of states; in other places, public coverage has actually increased.  The declines appear to be greatest in states like Texas and Tennessee that subject Medicaid and CHIP eligibility to a higher degree of scrutiny than other states.  Declines also appear to be greater in places with larger numbers of immigrants who are wary of applying for Medicaid and CHIP or remaining in those programs in light of changes in federal “public charge” regulations.

Any increase in the number of uninsured children poses a challenge to private safety-net hospitals because these are the very hospitals to which low-income and uninsured families turn for care – regardless of whether they have health insurance.

Learn more about the various reasons for the decline of enrollment by children in Medicaid and CHIP in the New York Times article “Medicaid Now Covers a Million Fewer Children.”

 

Immigrants Intimidated by New Public Charge Guidelines?

Immigrants served by community health centers appear less inclined than in the past to seek public aid to help them with their medical problems.

And community health center staff believes this is the result of confusion and fear as a result of changing federal immigration policies.

As stated in the Kaiser Family Foundation issue brief “Impact of Shifting Immigration Policy on Medicaid Enrollment and Utilization of Care among Health Center Patients,”

  • Health centers reported that, in recent months, immigrant patients have declined to enroll or reenroll themselves and/or their children in Medicaid for fear of public charge.
  • Health center respondents reported patients are confused about the new rule and are afraid to provide identifying information.
  • According to respondents, the public charge rule is creating a “chilling” effect, leading to decreased enrollment in other programs not subject to public charge.
  • About half of health centers reported a drop in utilization by immigrant patients, especially among pregnant women.
  • Health centers are training staff to answer questions on public charge and are working to ensure access to care for their patients.

This can pose a challenge for private safety-net hospitals:  low-income individuals who avoid public aid programs often end up receiving uncompensated care from those hospitals.

Learn more in the Kaiser Family Foundation issue brief “Impact of Shifting Immigration Policy on Medicaid Enrollment and Utilization of Care among Health Center Patients.”

New in Medicaid Medical Transportation: Uber and Lyft

State Medicaid programs focused on ensuring that beneficiaries keep their doctor appointments are increasingly looking to ride-sharing services to supplement the providers already participating in their medical transportation programs.

Today, Lyft is working with approximately 35 state Medicaid programs while Uber, at least so far, participates only in Arizona’s program.

While ride-sharing is not going to replace other medical transportation programs – for one thing, most Uber and Lyft cars are not equipped to serve individuals with serious disabilities – they can help supplement services that today typically require patients to reserve rides days ahead of time and then share van rides with other patients.

To facilitate the use of ride-sharing services, several state governments have eased regulations that require people who drive Medicaid beneficiaries to undergo first-aid training and drug testing.

Learn more about how ride-sharing is moving into the Medicaid medical transportation industry in the Kaiser Health News article “Uber And Lyft Ride-Sharing Services Hitch Onto Medicaid.”