Feds Urge States to Do More for Dually Eligible

In a formal guidance letter to state Medicaid directors, the Centers for Medicare & Medicaid Services has outlined ten ways that states can better serve individuals who are enrolled in both Medicare and Medicaid.

Noting that such dually eligible individuals represent 20 percent of Medicare enrollees but 34 percent of Medicare spending while also constituting 15 percent of Medicaid beneficiaries but 33 percent of Medicaid spending, the letter from CMS administrator Seema Verma to state Medicaid directors explains that

This letter describes ten opportunities – none of which require complex demonstrations or Medicare waivers – to better serve individuals dually eligible for Medicare and Medicaid, including through new developments in managed care, using Medicare data to inform care coordination and program integrity initiatives, and reducing administrative burden for dually  eligible individuals and the providers who serve them. A number of these opportunities are newly available to states through Medicare rulemaking or other CMS burden reduction efforts. We are happy to engage with you and your staff on one, many, or all of the items described in this letter. The CMS Medicare-Medicaid Coordination Office (MMCO) works across CMS and with states to better serve dually eligible individuals, including through efforts to better align the Medicare and Medicaid programs and demonstrations to test new approaches to integrated service delivery and financing.

Those ten ways are:

  • state contracting with dual eligible special needs plans (D-SNPs)
  • default enrollment into a D-SNP
  • passive enrollment to preserve continuity of integrated care
  • integrating care through the Program of All-inclusive Care (PACE)
  • reducing the administrative burden in accessing Medicare data for use in care coordination
  • program integrity opportunities
  • Medicare Modernization Act of 2003 file timing
  • state buy-in file data exchange
  • improving Medicare Part A buy-in
  • opportunities to simplify eligible and enrollment

Private safety-net hospitals serve especially large numbers of dually eligible, Medicare-Medicaid patients and will be interested to see whether CMS’s recommendations translate into action at the state level.

To see the entire letter, including additional information about these ten opportunities, go here.

CBO Targets Health Care in Options for Reducing Deficit

Every year the Congressional Budget Office publishes a menu of options for reducing federal spending and the federal budget deficit.  As in the past, this year’s compendium includes a number of options to reduce federal health care spending and raises federal revenue through health care initiatives.

The cost-cutting options include:

  • establish caps on federal spending for Medicaid
  • limit states’ taxes on health care providers
  • reduce federal Medicaid matching rates
  • change the cost-sharing rules for Medicare and restrict Medigap insurance
  • raise the age of eligibility for Medicare to 67
  • reduce Medicare’s coverage of bad debt
  • consolidate and reduce federal payments for graduate medical education at teaching hospitals
  • use an alternative measure of inflation to index social security and other mandatory programs

Options to raise additional revenue include:

  • increase premiums for Parts B and D of Medicare
  • reduce tax subsidies for employment-based health insurance
  • increase the payroll tax rate for Medicare hospital insurance

Many of these proposals, if implemented, would be damaging for private safety-net hospitals.

Learn more about the CBO’s recommendations, how they might be implemented, and their potential implications in the CBO report Options for Reducing the Deficit: 2019 to 2028.

 

MedPAC Mulls Direct Billing for Nurse Practitioners, Physician Assistants

Medicare would permit nurse practitioners and physician assistants to bill directly for their services under a proposal being considered by the Medicare Payment Advisory Commission.

Currently such services are billed as “incident to” physician services, but according to a report in Becker’s Hospital Review,

MedPAC staff told commissioners there are problems with “incident to” billing because it “obscures policymakers’ knowledge of who is providing care for beneficiaries,” “inhibits accurate valuation of fee schedule services,” and “increases Medicare beneficiary spending.”  Staff also said that physician assistants and nurse practitioners increasingly practice outside of primary care.

MedPAC is an independent congressional agency that advises Congress on issues involving the Medicare program.  While its recommendations are not binding on either Congress or the administration, MedPAC is highly influential in governing circles and its recommendations often find their way into legislation, regulations, and new public policy.

MedPAC commissioners are expected to vote on the recommendation next month.

Learn more about the billing recommendation in this article in Becker’s Hospital Review.

MedPAC Meets

Last week the Medicare Payment Advisory Commission met in Washington, D.C. to discuss a number of Medicare payment issues.

The issues on MedPAC’s December agenda were:

  • Medicare payments for physician and other health professionals services
  • payments for ambulatory surgical centers
  • payments for hospital inpatient and outpatient care
  • Medicare’s hospital quality incentive program
  • payments for skilled nursing facilities
  • payments for long-term care hospitals
  • payments for inpatient rehabilitation facilities
  • the Medicare Advantage program

MedPAC is an independent congressional agency that advises Congress on issues involving the Medicare program.  While its recommendations are not binding on either Congress or the administration, MedPAC is highly influential in governing circles and its recommendations often find their way into legislation, regulations, and new public policy.

Go here for links to the policy briefs and presentations that supported MedPAC’s discussion of these issues.

Medicare Advantage to Address Social Determinants of Health

Beginning next year, the Centers for Medicare & Medicaid Services will authorize Medicare Advantage plans to pay for some health-related but non-medical benefits for their members – benefits that will help address social determinants of health that affect the health status of many Medicare beneficiaries.

As explained by Health and Human Services Secretary Alex Azar at a recent event in Salt Lake City,

These interventions can keep seniors out of the hospital, which we are increasingly realizing is not just a cost saver but actually an important way to protect their health, too.  If seniors do end up going to the hospital, making sure they can get out as soon as possible with the appropriate rehab services is crucial to good outcomes and low cost as well. If a senior can be accommodated at home rather than an inpatient rehab facility or a [skilled nursing facility], they should be.

According to Azar, HHS’s Center for Medicare and Medicaid Innovation will be looking for new ways to address social determinants of health that have an impact on Medicare beneficiaries’ health.

What if we provided more than connections and referrals?  What if we provided solutions for the whole person including addressing housing, nutrition and other social needs all together?  What if we gave organizations who work with us more flexibility so they can pay beneficiaries’ rent if they are in unstable housing or make sure that a diabetic has access to and can afford nutritious food?  If that sounds like an exciting idea, then stay tuned to what CMMI is up to.

During the gathering, Azar made similar comments about Medicaid, suggesting that in the near future, federal Medicaid funds might soon be used for non-health-related benefits as well.

Learn more about Secretary Azar’s plans for addressing social determinants of health in this Fierce Healthcare article.

House Members Protest Site-Neutral Payment Proposal

138 members of the House of Representatives have written to Centers for Medicare & Medicaid Services administrator Seema Verma to protest CMS’s proposal to extend Medicare outpatient site-neutral payment policies to off-campus, provider-based outpatient departments specifically exempted from such policies by Congress under the Bipartisan Budget Act of 2015.

In questioning CMS’s rationale for the proposed policy, the House members wrote that

It is unclear how CMS has deemed all of the OPD [outpatient department] services at the grandfathered off-campus HOPDs [hospital outpatient departments] as cause of an unnecessary increase in volume of OPD services, and we ask you to provide clarity on this when making these payment changes.

The House members also wrote that

The agency has also proposed cutting payment to 40 percent of the current HOPD rate for grandfathered off-campus HOPDs that begin to furnish a new service from a clinical facility not offered prior to November 1, 2015 which could unfairly penalize grandfathered off-campus HOPDs that expand or diversify the critical services they offer to meet the changing needs of their patients.

In a formal response to the proposed regulation, NAUH expressed much the same sentiment, maintaining that the regulation, if adopted, could detract from the ability of private safety-net hospitals to serve their communities. See that letter here.

Go here to see the House letter.

MedPAC Meets

Last week the Medicare Payment Advisory Commission met in Washington, D.C. to discuss a number of Medicare payment issues.

The issues on MedPAC’s October agenda were:

  • managing prescription opioid use in Medicare Part D
  • opioids and alternatives in hospital settings: payments, incentives, and Medicare data
  • Medicare payment policies for advanced practice registered nurses and physicians
  • Medicare’s role in the supply of primary care physicians
  • Medicare payments for services provided in inpatient psychiatric facilities
  • episode-based payments and outcome measures under a unified payment system for post-acute care
  • Medicare policy issues related to non-urgent and emergency care

Go here for links to the policy briefs and presentations that supported MedPAC’s discussion of these issues.

MedPAC is an independent congressional agency that advises Congress on issues involving the Medicare program.  While its recommendations are not binding on either Congress or the administration, MedPAC is highly influential in governing circles and its recommendations often find their way into legislation, regulations, and new public policy.

Senators Ask CMS to Back Off Medicare Outpatient Proposal

Nearly half of the members of the Senate have written to CMS asking the agency to withdraw its proposal to make more Medicare outpatient payments on a site-neutral basis.

In the letter, 48 senators note that in the 2015 Bipartisan Budget Act Congress specifically directed that CMS grandfather certain existing hospital-based off-campus outpatient facilities from CMS efforts to make more outpatient payments on a site-neutral basis.  The proposed regulation, however, would affect those very facilities.

NAUH made much the same point in its September letter to CMS expressing its opposition to this aspect of the agency’s proposed 2019 outpatient prospective payment system regulation.

Go here to see the senators’ letter to CMS.

 

New Approach to Readmissions Program Takes Effect

Medicare’s hospital readmissions reduction program is moving in a new direction beginning in FY 2019 after Congress directed the Centers of Medicare & Medicaid Services to compare hospitals’ performance on readmissions to similar hospitals instead of to all hospitals.

The policy change, driven by a belief that safety-net hospitals were harmed by the program and excessive penalties because their patients are more challenging to serve, results in all hospitals being divided into peer groups based on the proportion of low-income patients they serve.  The readmissions performance of hospitals is then compared only to other hospitals within each peer group.

As a result of this new approach, readmissions penalties against safety-net hospitals are expected to decline 25 percent in FY 2019 while the average penalty for hospitals serving the fewest low-income patients will rise.

NAUH was one of the leading proponents of this major change in how the readmissions reduction program treats hospitals.

Kaiser Health News has published a detailed story describing the policy change and its implications for hospitals, which face penalties of up to three percent of their Medicare revenue for what is considered “excessive” readmissions of Medicare patients within 30 days of their discharge from the hospital.  Included in the article is a searchable database of every hospital in the country that lists the peer group for each hospital, its FY 2018 and FY 2019 readmissions penalties by percentage of Medicare revenue, and the change in readmissions penalty expected from FY 2018 to FY 2019.  Go here to see the article “Medicare Eases Readmission Penalties Against Safety-Net Hospital.”

OIG: Medicare Advantage Plans May be Denying Access to Save Money

The Office of the Inspector General of the U.S. Department of Health and Human Services is concerned that Medicare Advantage plans may be denying their members access to services to save money and increase profits.

According to the OIG, those Medicare Advantage plans overturn 75 percent of their own denials of service upon appeal and independent reviewers are overturning still more denials.  In the OIG’s view, this high rate of service denials raises concerns that Medicare Advantage plans, which today serve more than 20 million seniors, are denying their members access to needed medical services so they can cut costs and make more money.

To address this problem, the OIG recommends that the Centers for Medicare & Medicaid Services increase its oversight of Medicare Advantage contracts, address problem plans it identifies, and do more to inform enrollees when their plans are performing in such a manner.

CMS agreed with these recommendations.

To learn more about how the OIG went about this work, what it found, and what it recommended, go here to see a summary of its report or go here to see the full report Medicare Advantage Appeal Outcomes and Audit Findings Raise Concerns About Service and Payment Denials Report, the complete OIG report.