NASH Asks Azar to Distribute CARES Act Money Now

“Distribute as soon as possible the $100 billion designated in the [CARES] Act to assist health care providers as they deal head-on with the biggest public health crisis our country has faced in more than a century,” NASH asked Health and Human Services Secretary Alex Azar in a letter to Azar on Friday.

In the letter, the National Alliance of Safety-Net Hospitals wrote of private safety-net hospitals tackling the COVID-19 crisis that

Hospitals and other providers need these resources – and need them in a very timely manner. Hospitals invested heavily in preparations for the challenge to come and are still paying for those and continuing investments at a time when their cash flow is at an historic low because they are no longer performing elective surgery, which provides a major portion of their revenue. Thus, hospitals need this money to pay our bills, to keep the lights on and the medical supplies coming in, and to pay our courageous caregivers.

See NASH’s letter to Secretary Azar here.

NASH Asks Feds for Resources for Hospitals

Private safety-net hospitals will need federal financial support to help in the fight against COVID-19.

That was the message the National Alliance of Safety-Net Hospitals sent in a letter to Centers for Medicare & Medicaid Services administrator Seema Verma.

The letter explained that

Hospitals need consistent, reliable, adequate cash flow to support the challenge ahead.  Our private safety-net hospitals, and others like us, are already incurring significant costs preparing for the influx of patients to come.  Most of these hospitals have stopped performing elective surgeries and have lost an important source of revenue.  Now, they are concerned about their ability to pay their bills until the anticipated surge of patients and also concerned about the potential for delays in payments once those patients arrive.  This is revenue they need to pay their bills:  to keep the lights on, the water running, the staff paid, and the patient rooms supplied and equipped.  Hospitals need this reliable, consistent flow of money – and they need it sooner rather than later.

See NASH’s letter here.

NASH Seeks Assistance With COVID-19 Needs

Provide special assistance to private safety-net hospitals to help them serve their communities during the COVID-19 national health emergency, NASH has asked in a letter to Senate majority leader Mitch McConnell and minority leader Charles Schumer.

In particular, NASH asked the Senate leaders to include three things in future COVID-19/stimulus legislation:

  1. Funding to ensure cash flow for hospitals that are investing heavily in anticipation of a major influx of challenging patients while foregoing revenue from elective procedures.
  2. The permanent elimination of Affordable Care Act-mandated cuts in Medicaid disproportionate share (Medicaid DSH) funding.
  3. Protection from any new, burdensome regulations in any legislation adopted to facilitate the fight against COVID-19.

Go here to read NASH’s letter to senators McConnell and Schumer.

 

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 February 2020 MACPAC meeting opened with a continuation of MACPAC’s examination of Medicaid’s role in maternal health, when Medicaid officials from Michigan, New Jersey, and North Carolina joined the Commission to discuss how their states are addressing maternal morbidity and mortality.* The Commission plans to include a chapter on maternal health in its June 2020 report to Congress. Commissioners later turned their attention to policy options for improving enrollment in the Medicare Savings Program.

The Commission later took a deep dive into value-based payment in Medicaid managed care. This three-part session began with findings from a series of interviews with state officials, managed care organizations, and other stakeholders aimed at understanding how states use managed care to promote payment reform, conducted by MACPAC contractor Bailit Health. Then, representatives from three of these organizations shared their reactions to the findings and talked about how value-based payment models are working in practice.* The session concluded with Commissioners’ perspectives on the study’s findings and the panelists’ reactions to them, and possible next steps.

The final session of the afternoon continued a line of inquiry begun at the October 2019 meeting: third-party liability coordination between Medicaid and TRICARE. MACPAC estimates that almost 1 million Medicaid enrollees have primary coverage through TRICARE, which provides health benefits for military personnel, military retirees, and their dependents. Commissioners explored making recommendations in the June report to improve coordination between the two programs.

On Friday, the Commission returned to the theme of improving care for dually eligible beneficiaries, looking more closely at the rise of so-called dual-eligible special needs plan (D-SNP) look-alikes and how changes in the Medicare Advantage market are affecting efforts to integrate care. Commissioners also reviewed a rule proposed in February that would, among other things, restrict the growth of look-alikes.

Following that session, the Commission discussed draft recommendations to improve integration of Medicare and Medicaid benefits for dually eligible beneficiaries. The February meeting wrapped up with a discussion of a forthcoming rule expected to affect the Medicaid eligibility determination process.

Supporting the discussion were the following briefing papers:

  1. State Medicaid Initiatives to Improve Maternal Health
  2. Improving Participation in the Medicare Savings Programs: Decisions on Draft Recommendations for the June Report to Congress
  3. State Strategies to Promote the Use of Value-Based Payments in Medicaid Managed Care
  4. Medicaid and TRICARE: Third-Party Liability Coordination
  5. How Changes in the Medicare Advantage Market Are Affecting Integration of Care for Dually Eligible Beneficiaries: Analysis and Comments on Proposed Rule
  6. Improving Integrated Care for Dually Eligible Beneficiaries: Decisions on Recommendations to be Included in June Report to Congress
  7. Forthcoming Rule on Program Integrity and Eligibility Determination Processes

Because they serve so many Medicaid and CHIP patients – more than the typical hospital – MACPAC’s deliberations are especially important to private safety-net hospitals.

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.  Find its web site here.

NASH Opposes Proposed 340B Data Collection

The federal government should not require hospitals to submit new data on their acquisition costs for prescription drugs they dispense to low-income patients through the section 340B prescription drug discount program, NASH has told the Centers for Medicare & Medicaid Services.

In a formal comment letter in response to new data collection requirements proposed by CMS last month, the National Alliance of Safety-Net Hospitals wrote on behalf of private safety-net hospitals that

The 340B program was created by Congress to enable hospitals (and other providers) that serve low-income communities to maximize their resources when working to serve those communities. The program helps improve access to high-cost prescription drugs for low-income patients and helps put additional resources into the hands of qualified providers so those providers can do more for their low-income patients: provide more care that their patients might otherwise not be able to afford, offer more services that might otherwise be unavailable to such patients, and do more outreach into communities consisting primarily of low-income residents. This was the purpose of the 340B program when Congress created it in 1992 and Congress has not modified that purpose since that time. NASH believes that through this proposed data collection CMS is seeking to exert authority it does not have to demand of providers information to which the agency is not entitled.

In the letter, NASH also objected that the proposed data collection would be costly and burdensome for hospitals and is premature because the courts are still considering challenges to CMS’s authority to reduce 340B payments to providers; the latter is why CMS seeks this data.

Go here to see NASH’s formal comment letter to CMS.

MFAR Backlash Continues

Diverse health care and government interests are rallying around their opposition to the proposed Medicaid fiscal accountability rule.

The regulation, proposed by the Centers for Medicare & Medicaid Services in November would impose new limits on the ability of states to finance their share of their Medicaid spending, potentially jeopardizing provider payments and the ability of high-volume Medicaid providers to operate without suffering great losses.

In all, CMS received more than 4200 written comments in response to the proposed regulation, most of them expressing opposition.  Among those doing so were state governments, the National Governors Association, hospitals and hospital associations, nursing home operators, and health advocacy organizations.  Also among them was the National Alliance of Safety-Net Hospitals.  In summarizing its opposition, NASH wrote in a formal comment letter to CMS on behalf of private safety-net hospitals that

While NASH supports greater transparency in Medicaid, that support is outweighed by too many troubling aspects of the proposed regulation. In this letter, NASH is especially interested in commenting on five aspects of the proposed regulation: how it would deprive states of important, established policy-making prerogatives; its creation of major new administrative burdens for state governments and for hospitals; its inappropriate regulation of financing of the state share of Medicaid spending; its proposed introduction of new, unspecified standards that state Medicaid programs would be held accountable for meeting; and its violation of the Administrative Procedures Act.

See NASH’s entire letter here.

Learn more about the Medicaid fiscal accountability rule, what it seeks to do, and why so many oppose in the Stateline article “Medical Groups Slam Trump Medicaid Rule.”

Azar: Budget Proposes Reducing Medicaid Matching $

The federal government would reduce its financial commitment to state Medicaid programs under the FY 2021 budget the Trump administration proposed earlier this month.

While testifying before the Senate Appropriations Committee’s Subcommittee on Labor, Health and Human Services and Education, Health and Human Services Secretary Alex Azar acknowledged that the administration’s proposed FY 2021 would eliminate the enhanced rate at which the federal government matches state funds used to serve individuals who enrolled in Medicaid through the Affordable Care Act’s Medicaid expansion provision.  That enhanced rate calls for the federal government to pay 100 percent of the costs associated with the Medicaid population during the first year of Medicaid expansion, eventually scaling down to 90 percent after 2020.  Nationally, the federal government’s matching rate for the pre-expansion population is 57 percent; that matching rate would not be affected by this proposal.

This aspect of the administration’s proposed FY 2021 budget has mostly flown under the radar since the budget’s release and has received little public attention.

In explaining the proposal, Azar said that enhanced funding for the Affordable Care Act’s Medicaid expansion population was biased against the disabled, women, and children.

Such a policy change could be a blow to private safety-net hospitals in Medicaid expansion states.

Learn more about what Secretary Azar said about federal matching funds for state Medicaid programs in the McKnight’s Long-Term Care News article “Official confirms Trump budget proposed to eliminate enhanced Medicaid match.”

 

Supreme Court Paves Way for Public Charge Regulation

The revised public charge regulation that will make it more difficult for some immigrants to come to the U.S. will be implemented after the Supreme Court lifted preliminary injunctions issued by lower courts that delayed the regulation’s implementation.

Under revisions of the public charge regulation introduced last year, individuals seeking entry into the U.S. and green cards who do not appear to be financially independent or have employment commitments can be denied entry if they will be dependent on means-tested public aid programs such as Medicaid or food stamps or even if they, or members of their family, appear likely to become dependent on such aid in the near future.

A number of judges throughout the country blocked the administration’s implementation of revisions of the public charge rule.  The Supreme Court’s action only lifts those injunction; it does not address the constitutionality of the regulation, leaving that matter to continue to be addressed by lower courts for now.

The challenge posed to health care providers by the updated public charge regulation is as much a matter of perception as reality:  individuals already legally in the U.S. who are not subject to the regulation have withdrawn from Medicaid out of fear of deportation while others who also are in the country legally and qualify for Medicaid are choosing not to apply for benefits for the same reason.  This, in turn, may leave some providers with more uncompensated care instead of Medicaid reimbursement for the care they provide to some of their patients.

The National Alliance of Safety-Net Hospitals has conveyed its opposition to the public charge regulation to both Congress and the administration.  In a message to Congress, NASH wrote that “The new public charge regulation threatens the health of families and communities and threatens the ability of private safety-net hospitals to serve those families and those communities.”  In response to the proposed changes in the regulation, NASH wrote in a formal comment letter on behalf of private safety-net hospitals that it

…believes the proposed regulation could have a chilling effect on the willingness of many legal citizens and legal non-citizens to seek out government health care programs for which they legally qualify. This could lead to millions of low-income legal citizens and legal non-citizens choosing not to seek the care to which they are entitled by law and ignoring serious illnesses and injuries until they become a crisis. When such individuals have no choice but to turn to hospital emergency departments in search of care – something hospital emergency departments are required by law to provide regardless of a patient’s ability to pay – this could overwhelm those facilities and would do so to the detriment of other patients while also producing a surge of uncompensated care, especially for private safety-net hospitals. That, in turn, could jeopardize the jobs of thousands who work in those hospitals and the economies of the communities in which those hospitals are located. It could also jeopardize access to care for residents of these same communities – including ordinary people who receive their health care coverage from private insurers and Medicare.

See NASH’s entire comment letter here.

Learn more about the Supreme Court’s decision and how it affects implementation of the public charge regulation in the New York Times article “Supreme Court Allows Trump’s Wealth Test for Green Cards.”

 

Fitch: Medicaid Block Grants, MFAR Threaten States, Providers

Medicaid block grants and the proposed Medicaid fiscal accountability regulation (MFAR) pose new financial threats to providers and states, according to Fitch Ratings, the financial rating company.

MFAR poses the greater threat, Fitch believes, noting in a new analysis that it could

…reduce total Medicaid spending nationally by $37 billion and $44 billion annually…and by $23 billion to $30 billion for hospitals alone.  States, and to some extent providers, would respond to MFAR’s implementation with measures to mitigate the negative fiscal implications.

Block grants, through what has been named the Healthy Adult Opportunity program, also pose a threat, with Fitch explaining that

Capping federal Medicaid contributions, even for a subset of beneficiaries, poses risks to state budgets and those entities reliant on state funding, including local governments and providers.  States would need to find revenue or cost savings, either in Medicaid or elsewhere, to offset reduced federal contributions.

Because private safety-net hospitals care for more Medicaid patients than the typical hospital, both proposed policy changes have a potentially greater impact on them.

Last month NASH conveyed its opposition to the proposed MFAR regulation in a formal comment letter to the Centers for Medicare & Medicaid Services in response to the regulation’s publication late last year.  While NASH has not commented publicly about the Healthy Adult Opportunity program, it has long been concerned about a block grant approach to Medicaid funding, writing in its 2019 advocacy agenda that

Block grants, whether based on individual states’ Medicaid enrollment or on their past Medicaid spending, could impose unreasonable limits on Medicaid spending that could potentially leave private safety-net hospitals unreimbursed for care they provide to legitimately eligible individuals. NASH will work to ensure that any new approach that involves Medicaid block grant continues to give states the ability to pay safety-net hospitals adequately for the essential services they provide to the low-income residents of the communities in which those hospitals are located.

Learn more about the potential impact of the proposed Medicaid fiscal accountability regulation and Medicaid block grants in the Fitch Ratings analysis “Fitch Rtgs: Medicaid Changes Will Affect States, NFP Healthcare Providers.”

NASH Raises Concerns About Proposed Budget in News Release

Medicare and Medicaid cuts detailed in the administration’s proposed FY 2021 budget could be harmful to private safety-net hospitals, the National Alliance of Safety-Net Hospitals declared in a news release issued in response to that proposed budget.

Among those cuts:  $465 billion in Medicare payments and $920 billion in Medicaid reductions over the next ten years.

“The extent of the proposed spending cuts is daunting,” said Ellen Kugler, NASH’s executive director.  “The payments that have been targeted for the biggest cuts are the very payments that enable safety-net hospitals to provide vital services to their communities.  Without them, the capacity of private safety-net hospitals across the country to continue serving the low-income, low-income elderly, uninsured, and medically vulnerable residents of their communities could be in serious jeopardy.”

Among the payments targeted for major cuts are Medicare disproportionate share (Medicare DSH), Medicaid disproportionate share (Medicaid DSH), Medicare graduate medical education payments, Medicare bad debt reimbursement, and payments for some Medicare-covered outpatient services.

Learn more about NASH’s objections to the proposed cuts in this NASH news release.