CMS Proposes Easing Medicaid Access Protections

States would have to do less to ensure access to Medicaid-covered services for their Medicaid population under a new regulation proposed by the Centers for Medicare & Medicaid Services.

In 2015, CMS required states to track their Medicaid fee-for-service payments and submit them to the federal government as part of a process to ensure that Medicaid payments were sufficient to ensure access to care for eligible individuals.  Now, CMS proposes rescinding this requirement, writing in a news release that

This proposed rule is designed to help streamline federal oversight of access to care requirements that protect Medicaid beneficiaries.  CMS anticipates that the proposed rule would, if finalized, result in overall cost savings for State partners that could be redirected to better serve the needs of their beneficiaries.

The proposed regulation itself explains that

While we believe the process described in the current regulatory text is a valuable tool for states to use to demonstrate the sufficiency of provider payment rates, we believe mandating states to collect the specific information as described excessively constrains state freedom to administer the program in the manner that is best for the state and Medicaid beneficiaries in the state.

CMS also notes that the current requirement applies only to Medicaid fee-for-service payments even though most Medicaid beneficiaries now receive care through managed care plans, the payments for which are not subject to the same process.

The agency adds that it intends to

…replace the ongoing access reviews required by current regulations with a more comprehensive and outcomes-driven approach to monitoring access across delivery systems, developed through workgroups and technical expert panels that include key State and federal stakeholders.

Because they care for so many Medicaid patients, the adequacy of the rates states pay for Medicaid services is especially important to private safety-net hospitals.

Learn more about CMS’s proposal in its news release on the subject or see the proposed regulation itself.  Learn about the process CMS intends to employ to replace its current approach to monitoring access to Medicaid services in this CMS informational bulletin.

 

Medicaid DSH Delay Advances in Energy and Commerce Committee

Medicaid disproportionate share cuts would be delayed for two years under a proposal advanced last week by the Health Subcommittee of the House Energy and Commerce Committee.

The Medicaid DSH cuts, mandated by the Affordable Care Act, have already been delayed three times by Congress and could be on their way to a fourth delay if the proposal advanced by the Health Subcommittee is endorsed by the Energy and Commerce Committee and works its way to the full House of Representatives, where such a proposal is thought to enjoy wide support.

The National Alliance of Safety-Net Hospitals has long endorsed the delay and even the repeal of cuts in Medicaid DSH payments, doing so most recently in a letter earlier this year to Senate Finance Committee chairman Charles Grassley in which it argues that those cuts would be especially harmful to private safety-net hospitals.

Learn more about the possibility of another delay of Medicaid DSH cuts in the HealthLeaders article “House Panel Advances Surprise Bill Package.”

 

The Role of Medicaid in Addressing Social Determinants of Health

Medicaid can play a major role in addressing the social determinants of health.

Or so argues a recent post on the Health Affairs Blog.

According to the post, social determinants of health – income, education, decent housing, access to food, and more – significantly influence the health and well-being of individuals – including low-income individuals who have adequate access to quality health care.  Medicaid, the post maintains, can play a major role in addressing social determinants of health.

The post outlines the role state Medicaid programs can play in addressing social determinants of health; describes tools for such action such as section 1115 Medicaid demonstration waivers; offers examples of efforts currently under way in some states; and presents suggestions for steps the federal government can take to facilitate such efforts.

Addressing social determinants of health is an especially important issue for private safety-net hospitals because they care for so many more Medicaid-covered low-income patients than the typical American hospital.

Learn more from the Health Affairs Blog post “For An Option To Address Social Determinants Of Health, Look To Medicaid.”

 

NASH Comments on Proposed Medicare Regulation (Part 3 of 3)

The National Alliance of Safety-Net Hospitals has submitted formal comments to the Centers for Medicare & Medicaid Services in response to the latter’s proposed hospital payment plan for FY 2020.

Responding to the proposed inpatient prospective payment system published by CMS in April, NASH primarily addressed a CMS proposal to change how it calculates Medicare disproportionate share (Medicare DSH) uncompensated care payments and proposed changes in the Medicare area wage index system.

On Tuesday, the NASH blog presented the alliance’s written comments about proposed changes in Medicare DSH uncompensated care payments.  Yesterday, it presented a detailed alternative proposal to CMS’s April 2019 recommendation for calculating those payments.  Today, the blog presents NASH’s response to proposed changes in the Medicare area wage index system.  The complete NASH response to the proposed CMS regulation can be found here.

Proposed Changes in the Medicare Area Wage Classification System

The “Compression Proposal”

The Medicare area wage classification system adjusts Medicare payments to hospitals based on hospitals’ labor costs relative to the average labor costs of hospitals across the country.  Parts of the country where labor costs are greater than average are assigned a higher wage index, more than 1.0, which is applied to Medicare’s standard payments; areas with lower wage costs, on the other hand, are assigned a lower wage index, less than 1.0, which is applied to the same standard Medicare payments.  The wage index assigned to each hospital is based on an objective formula that reflects hospitals’ actual incurred labor costs in different parts of the country.

CMS has proposed what is being referred to as a “compression proposal” that would inflate the wage indexes of hospitals with indexes below the 25th percentile so Medicare can direct more money to those hospitals.  To pay for this increase and make this proposal budget-neutral, CMS calls for arbitrarily cutting the wage indexes of hospitals currently above the 75th percentile for wage index values.

This wage index proposal seeks to address what CMS describes as “growing disparities between low and high wage index hospitals, including rural hospitals that may be in financial distress and facing potential closure” by providing “certain low wage index hospitals with an opportunity to increase employee compensation without the usual lag in those increases being reflected in the calculation of the wage index.”

NASH does not dispute CMS’s conclusion that some distressed hospitals may need additional financial assistance from Medicare and urges CMS to identify such hospitals.  At the same time, however, NASH believes CMS should explore means other than the proposed wage index changes for providing this additional assistance.

This wage index compression proposal raises a number of concerns.  There is, to be sure, a growing disparity in the wage indexes of hospitals because there is a growing disparity in wages in different parts of the country.  The wage index itself, however, has neither caused nor contributed to this disparity; it is, instead, a reflection of this disparity.  Previous commenters have suggested that it is possible that the lag in wage data could suppress a hospital’s ability to increase wages, but the existence of such wage suppression is undocumented and its potential impact is limited by several factors, including the presence of other hospitals in a labor market area; Medicare fee for service representing only a portion of hospital reimbursement; and probably most significantly, the FY 2005 modification of the wage index that artificially reduces the labor-related share for labor market areas with a wage index adjustment less than 1.0 that was expressly created by Congress to address this perceived issue.

The assertion that this proposal would help rural hospitals facing financial struggles is undermined by NASH’s analysis that only 26 percent of the redistributed money would even reach rural hospitals while 74 percent of the redistributed money would go to urban hospitals.  In fact, there are more than 60 rural hospitals in 20 different states that lose money under the proposal.

Finally, it is not clear from the explanation provided in the proposed rule that the Secretary has the authority to implement this change.  The rule states that the adjustment would be made under

…section 1886(d)(3)(E) of the Act, which gives the Secretary broad authority to adjust for area differences in hospital wage levels by a factor (established by the Secretary) reflecting the relative hospital wage level in the geographic area of the hospital compared to the national average hospital wage level, and requires those adjustments to be budget neutral, and our exceptions and adjustments authority under section 1886(d)(5)(I) of the Act.

Between CMS’s proposed inflation of the lowest quartile and its proposed reduction to the highest quartile, it is not reasonable to conclude that the proposed policy change would continue to reflect “…the relative hospital wage level in the geographic area of the hospital compared to the national average hospital wage level…”  CMS cannot, as the rule seems to argue, arbitrarily alter wage adjustments as long as it ensures that those above the national average are greater than 1.0 while those below the national average are below 1.0.  Inherent in the concept of an area’s relative wage is the proportionality of that relativity, which is lost under this proposal.

NASH asks CMS to withdraw this proposal.  There undoubtedly are hospitals in need of additional financial support and many are located in low-wage areas, but we do not believe the wage index is either the cause of their troubles or an appropriate means of addressing them.  NASH believes CMS should identify the true root causes of these financial challenges and then work with Congress to secure the funding needed to address this problem.

The Proposed Exclusion of the Wage Data of Some Hospitals

NASH also objects to CMS’s decision to exclude wage data from eight hospitals located in the “northern” region of a single state because the wages these providers pay are noticeably higher than the wages paid by other hospitals in the area.  In this case, one entity owns multiple hospitals and negotiates common wages with its workforce throughout the region in which its hospitals are located.  CMS has expressed concern that these common wages are not representative of the wages hospitals need to pay in the areas in question.

CMS asserts that it does not believe these wages “accurately reflect the economic conditions in their respective labor market areas during the FY 2016 cost reporting period.”  NASH believes this conclusion misses the point:  The actual wages paid in a region are not a proxy meant to reflect economic conditions.  They are the economic conditions that the wage index is meant to reflect.  In this situation, a hospital or hospitals in a region paying higher wages forces other hospitals in that region to increase their wages to compete for staff.  It is these local market conditions, and not Medicare fee-for-service payments, that dictate the wages paid to hospital staff.

NASH objects to CMS’s proposal to eliminate wage data that it acknowledges to be legitimate.  Doing so for these particular hospitals for the reasons articulated in the proposed rule would set a dangerous precedent for the future elimination of other unquestionably legitimate wage data.  We believe this is a step CMS should not take and urge the agency to restore the wage data of the excluded hospitals to the calculation of the average wages in the wage index areas in which they are being paid.

*          *          *

See NASH’s entire response to the proposed Medicare regulation here.

NASH Comments on Proposed Medicare Regulation (Part 2 of 3)

The National Alliance of Safety-Net Hospitals has submitted formal comments to the Centers for Medicare & Medicaid Services in response to the latter’s proposed hospital payment plan for FY 2020.

Responding to the proposed inpatient prospective payment system published by CMS in April, NASH primarily addressed a CMS proposal to change how it calculates Medicare disproportionate share (Medicare DSH) uncompensated care payments and proposed changes in the Medicare area wage index system.

Yesterday, the NASH blog presented the alliance’s written comments about proposed changes in Medicare DSH uncompensated care payments.  Today, it presents a detailed alternative proposal to CMS’s April 2019 recommendation for calculating those payments.  On Thursday the blog presents NASH’s response to proposed changes in the Medicare area wage index system.  The complete NASH response to the proposed CMS regulation can be found here.

Calculation of Medicare DSH Uncompensated Care Payments for FY 2020

Factor 3 represents a hospital’s share (as estimated by the Secretary) of the total uncompensated care provided by all hospitals eligible to receive DSH payments.  CMS has, in recent years, calculated UCC DSH payments using an average of three factor 3 calculations subject to a budget neutrality adjustment that modifies the average factor 3 for each hospital to spend the appropriate amount of money (i.e., factor 1 times factor 2) for the fiscal year.

For the reasons stated in the accompanying comment letter, NASH recommends that for FY 2020, CMS implement year one of a three-year transition to using a three-year average of audited post-transmittal 11 data.  The schedule for this transition would be as follows:

  • Year one (FY 2020) would consist of a blend of 2/3 of a hospital’s 2019 UCC DSH payment with 1/3 of the hospital’s UCC DSH payment based on unaudited 2017 S-10 data. During FY 2020, CMS could engage in audits of the 2017 data.
  • Year two (FY 2021) would consist of a blend of 1/3 of a hospital’s 2019 UCC DSH payment with 2/3 of the hospital’s UCC DSH payment based on the average factor 3 derived from the hospital’s audited 2017 data and unaudited 2018 data. During FY 2021, CMS could engage in audits of the 2018 data.
  • Year three (FY 2022) would consist of an equally weighted blend of the hospital’s audited 2017 and 2018 data and unaudited 2019 data.

Each year thereafter, CMS could continue to engage in audits while rolling forward the three-year average, adding a new year of data to the calculation and dropping the oldest year of data.  The result balances timeliness and accuracy while also maintaining year-over-year stability.

Specifically, for FY 2020, a hospital’s final factor 3 would be calculated by:

  • Calculating for each hospital a preliminary 2017 factor 3 by dividing the hospital’s reported line 30 uncompensated care (subject to any adjustments or trims) by the total reported line 30 uncompensated care (subject to any adjustments or trims) reported by all hospitals expected to receive DSH in FY 2020 on their 2017 cost reports.
  • Calculating for each hospital a blended FY 2020 factor 3 by summing the hospital’s preliminary 2017 factor 3 plus its FY 2019 final factor 3 plus its FY 2019 final factor 3 and dividing by 3 if the hospital received a payment in 2019 and 1 if the hospital received no payment in 2019.
  • Deriving a standardization factor by calculating the average factor 3 for all hospitals projected to receive DSH and dividing the result by 1.0.
  • Calculating each hospital’s final FY 2020 factor 3 by multiplying its blended FY 2020 factor 3 by the standardization factor.

Puerto Rico hospitals, Indian Health Service and Tribal hospitals would continue receive a factor 3 based on low-income insured days from FY 2013.

For 2021, each hospital’s factor three would be based on the three-year average of its 2019 final factor 3, its 2017 factor 3 and its 2018 factor 3.

*          *          *

Tomorrow, see NASH’s comments on CMS’s proposal for changes in the Medicare geographic wage classification system.

See NASH’s entire response to the proposed Medicare regulation here.

NASH Comments on Proposed Medicare Regulation (Part 1 of 3)

The National Alliance of Safety-Net Hospitals has submitted formal comments to the Centers for Medicare & Medicaid Services in response to the latter’s proposed hospital payment plan for FY 2020.

Responding to the proposed inpatient prospective payment system published by CMS in April, NASH primarily addressed a CMS proposal to change how it calculates Medicare disproportionate share (Medicare DSH) uncompensated care payments and proposed changes in the Medicare area wage index system.

In this first of three parts, the NASH blog presents the alliance’s written comments about proposed changes in Medicare DSH uncompensated care payments. Tomorrow the blog presents a more detailed look at NASH’s alternative proposal for calculating Medicare DSH uncompensated care payments. On Thursday the blog presents NASH’s response to proposed changes in the Medicare area wage index system. The complete NASH response to the proposed CMS regulation can be found here.

The Calculation of Medicare DSH Uncompensated Care Payments

The Present Challenge

When the Affordable Care Act divided Medicare DSH payments into two components, one of which was a Medicare DSH uncompensated care payment that was to be based entirely on how much uncompensated care hospitals provide, it created a major challenge for policy-makers: how to determine how much uncompensated care hospitals provide. Lacking a clear, credible source of uncompensated care data to use for this purpose, CMS for three years – from 2014 through 2016 – used a proxy for hospital uncompensated care based on two low-income variables: eligible hospitals’ Medicaid patients and their SSI patients.

In 2017, CMS announced that it would move away from this proxy and begin a three-year transition into a different source of data for hospital uncompensated care: line 30 of the S-10 worksheet of the Medicare cost report, where hospitals report their uncompensated care. At that time CMS also announced that it would begin calculating hospitals’ Medicare DSH uncompensated care payments based on three years worth of data. The purpose of using three years of data was to reduce undue fluctuations in hospitals’ Medicare DSH uncompensated care payments from one year to the next.

For years, NASH (previously the National Association of Urban Hospitals) and others have urged CMS to prepare for future use of S-10 data for this purpose in two ways:

  • By improving the instructions for completing the form, which have widely been viewed as confusing and have led to hospitals reporting their uncompensated care in many different ways – including ways it is virtually inconceivable that CMS ever intended. Representatives of NASH met with CMS officials on several occasions in recent years to share examples of hospitals reporting uncompensated care data that totally lacked credibility and to discuss specific aspects of the S-10’s instructions that give rise to inconsistent and inaccurate data reporting.
  • By auditing hospitals’ reported S-10 data to ensure that they are reporting this data accurately and in compliance with the S-10’s instructions. NASH has been urging CMS to audit S-10 data for nine years – ever since passage of the Affordable Care Act created the new Medicare DSH uncompensated care payment and it appeared inevitable that the S-10 would eventually be used in the calculation of that payment. Auditing is necessary because NASH’s reviews of the uncompensated care data hospitals reported on their S-10 in recent years revealed that some hospitals are reporting enormous amounts of uncompensated care that simply cannot be believed in the context of their size, their operating expenses, and their other patient revenue. NASH has shared these reviews with CMS officials on a number of occasions. If left unaddressed, this inaccurate reporting would greatly skew the distribution of the limited pool of Medicare DSH uncompensated care money, inappropriately rewarding some hospitals for their inaccurate data and unfairly penalizing others.

Now, NASH is concerned that while work on both of these tasks is under way, that work remains incomplete at this time. CMS has made progress in improving the S-10’s instructions, as can be seen by what NASH believes are improvements in the quality of the data hospitals are reporting. Despite this, further improvements may still be needed. The auditing is not nearly as far along: as described below, the very limited auditing that has been undertaken so far has been troubled and insufficient.

CMS Proposes Using Flawed Data for FY 2020

In its proposed FY 2020 Medicare inpatient prospective payment system regulation, CMS calls for using uncompensated care data from hospitals’ FY 2015 S-10 forms when calculating FY 2020 Medicare DSH uncompensated care and also asks interested parties to share their view on the possibility of using FY 2017 S-10 data instead of the 2015 data. NASH believes that neither FY 2015 data nor FY 2017 data is suitable for this purpose.

NASH opposes the use of hospitals’ FY 2015 data as the single source of data in the calculation of FY 2020 Medicare DSH uncompensated care reports because while this was the first such uncompensated care data CMS audited, that auditing so far has been not sufficient to give hospitals – and taxpayers – confidence that federal Medicare DSH uncompensated care funds will find their way to the hospitals providing the greatest verified amount of uncompensated care. Among the problems that arose during the first round of auditing were inadequate time frames for hospitals to submit data to auditors; rushed auditing; the use of different auditing methodologies in different parts of the country, between the different Medicare Administrative Contractors (MACs), and even within individual MAC regions; and the lack of comprehensive auditing, with only about 20 percent of affected hospitals actually audited. In its proposed FY 2020 Medicare inpatient prospective payment system regulation, CMS revealed that “approximately 10 percent of audited hospitals have more than a $20 million difference between their audited FY 2015 data and their unaudited FY 2016 data.” CMS also observed that some hospitals have suggested that had the S-10 instructions developed for FY 2017 – instructions that clearly represented an improvement over past instructions – been in place when they completed their FY 2015 S-10 reports, those 2015 reports would have had fewer errors and been more accurate. Together, these problems lead NASH to oppose the use of S-10 data from hospitals’ FY 2015 Medicare cost reports in calculating hospitals’ FY 2020 Medicare DSH payments, even when that data has been audited, because auditing was only undertaken for a relatively small proportion of hospitals.

NASH also opposes CMS’s suggested alternative to using FY 2015: using FY 2017 data as the single source of data in the calculation of Medicare DSH uncompensated care payments. That data remains entirely unaudited, and while the instructions that guided hospitals during completion of their S-10 forms for FY 2017 are generally thought to be clearer and better than those used in FY 2015, there is, at least at this time, little reason to believe this unaudited data as a whole is any more accurate and any more credible than FY 2015 data. Upon reviewing this data, NASH found evidence of some improved data but also numerous examples of reported uncompensated care data that simply lack credibility – generally, hospitals reporting so much uncompensated care that it seems inconceivable that their doors could remain open. In addition, while hospitals that did undergo auditing of their FY 2015 data undoubtedly learned lessons that will improve their ability to complete future S-10 reports, 80 percent of DSH-eligible hospitals have not yet undergone those audits and therefore are not better prepared to complete future S-10s worksheets.

One Year of Data is Insufficient

The proposed FY 2020 regulation also calls for another change: calculating FY 2020 payments based on one year of data instead of three, as has been the case in recent years. NASH opposes this shift in approach. With so little auditing completed and the auditing that has been done of questionable value, NASH opposes any methodology for calculating hospitals’ Medicare DSH uncompensated care payments that relies on data from just a single year. In addition to the problems specific to 2015 and 2017 data, outlined above, NASH objects to using data from just one year because the possibility of aberrant data from any one year skewing the distribution of Medicare DSH uncompensated care payments is too great.

CMS is on record expressing this same view, writing in the final FY 2017 regulation that

…because the data used to make uncompensated care payment determinations are not subject to reconciliation after the end of the fiscal year, we believe that it would be appropriate to expand the time period for the data used to calculate Factor 3 from one cost reporting period to three cost reporting periods. We stated that using data from more than one cost reporting period would mitigate undue fluctuations in the amount of uncompensated care payments to hospitals from year to year and smooth over anomalies between cost reporting periods.

Also,

We stated that we believe that computing Factor 3 using data from three cost reporting periods would best stabilize hospitals’ uncompensated care payments while maintaining the recency of the data used in the Factor 3 calculation. We indicated that we believe using data from two cost reporting periods would not be as stable while using data from more than three cost reporting periods could result in using overly dated information.

Until now, CMS had insisted on basing these payments on three years of data even after it shifted from basing payments on the low-income proxy to uncompensated care data as reported on the S-10. Now, however, it proposes changing its approach and basing the payments’ calculation on just a single year of data, leaving hospitals potentially vulnerable to precipitous declines in their Medicare DSH uncompensated care payments because of either one unusual year of their own activity or questionable reporting by other hospitals.

Accuracy in S-10 reporting is so important because Medicare DSH payments are made out of a single pool of federal funds, with hospitals drawing from that pool based on the amount of uncompensated care they provide in comparison to other DSH-eligible hospitals. As a result, every hospital’s reporting affects how much Medicare DSH uncompensated care money every other DSH-eligible hospital receives. Whether the result of misinterpreting the S-10’s instructions, placing the wrong data on the wrong line on the form, an accounting or mathematical error, or an attempt to maximize their potential Medicare DSH uncompensated care revenue, some hospitals could unfairly receive a windfall of Medicare DSH uncompensated care money – and they would do so at the expense of other hospitals, including those that reported their data exactly as CMS intended. Conversely, the same reporting mistakes could result in aberrant data in which some hospitals’ uncompensated care is under-reported, resulting in such hospitals not receiving the Medicare DSH uncompensated care payments to which they should reasonably be entitled.

An Alternative Approach: NASH’s Proposal

NASH proposes an alternative to CMS’s plan for calculating hospitals’ FY 2020 Medicare DSH uncompensated care payments: a three-year proposal that would cover FY 2020, FY 2021, and FY 2022. At the heart of this proposal is NASH’s belief – a belief CMS in the past made very clear that it shares – that these payments should be made based on more than one year of hospitals’ S-10 data. Using more than one year of data would help smooth the overall data and ensure that no single year’s aberrant data, whether the result of reporting error or just an unusual year in the life of a hospital, inappropriately skews calculations in ways that unfairly benefit or harm any hospitals or has wide-ranging effects that can be felt throughout the universe of the approximately 2,430 hospitals that will be eligible for Medicare DSH uncompensated care payments in FY 2020.

NASH has concluded that the more recent the data is, the more likely it will be reliable – or at least closer to reliable – for three reasons: first, CMS has improved the S-10’s instructions since 2015, suggesting that data reported after 2015 should be more reliable than it was that year or prior to that year; second, future auditing should uncover flaws in hospitals’ data reporting practices that hospitals will correct in the future, leading to more accurate reporting as time passes; and third, improved auditing will enable CMS to adjust hospitals’ reported uncompensated care totals, which also should make future data more accurate.

With this in mind – using more recent data, including audited data, and the value of using data from more than one year – NASH suggests that instead of adopting its proposed methodology, CMS instead use the following methodology for calculating Medicare DSH uncompensated care payments over the next three years:

For FY 2020 (year one of three):

Calculate Medicare DSH uncompensated care payments based on a blend that consists two-thirds of the Medicare DSH uncompensated care payments hospitals receive in FY 2019 and one-third on hospitals’ calculated share of the overall Medicare DSH uncompensated care pool for FY 2017.

For FY 2021 (year two of three):

Calculate Medicare DSH uncompensated care payments based on a blend that consists one-third of the Medicare DSH uncompensated care payments hospitals receive in FY 2019 and two-thirds on the average of hospitals’ calculated share of the overall Medicare DSH uncompensated care pool for FY 2017 and FY 2018.

For FY 2022 (year three of three):

Calculate Medicare DSH uncompensated care payments based on the average of hospitals’ calculated share of the overall Medicare DSH uncompensated care pool for FY 2017, FY 2018, and FY 2019.

By using this approach, CMS would reduce the importance of unreliable 2015 data in the calculation of Medicare DSH uncompensated care payments and instead use the most credible data available at the time of the calculation for each of the three years. Most important, adopting NASH’s alternative proposal would buy CMS time: time to improve its auditing, time to do more auditing, time to engage in additional provider education to ensure that hospitals understand how to comply with Medicare’s uncompensated care data reporting requirements, and time to refine the S-10’s instructions still further if the outcome of future auditing suggests that improvements are still needed. NASH’s proposed alternative also would eliminate the need for any auditing of hospitals’ FY 2016 S-10 data, which is not needed to implement this alternative approach. NASH’s proposed approach also takes advantage of the two major advances CMS has implemented in recent years: better S-10 instructions and a commitment to auditing. Together, these steps can help ensure that future uncompensated care data reporting is more accurate and can constitute an appropriate foundation for the calculation of Medicare DSH uncompensated care payments during the next three years and do so without the volatility inherent in potentially significant swings in hospitals’ annual Medicare DSH uncompensated care payments – swings that CMS made a point of expressing its concern about in the past. Until then, NASH believes our alternative approach to that calculation for the next three years would produce more appropriate payments to hospitals

*       *       *

See NASH’s entire response to the proposed Medicare regulation here.

Tomorrow:  more details about NASH’s alternative Medicare DSH uncompensated care proposal.

ACA Tied to Reduced Disparities in Cancer Care

Improved access to health insurance has led to reduced racial disparities in the diagnosis and treatment of cancer.

As reported by the Washington Post,

According to researchers involved in the racial-disparity study, before the ACA went into effect, African Americans with advanced cancer were 4.8 percentage points less likely to start treatment for their disease within 30 days of being given a diagnosis.  But today, black adults in states that expanded Medicaid under the law have almost entirely caught up with white patients in getting timely treatment, researchers said.

Another study found that since the reform law’s implementation in Medicaid expansion states, women are being diagnosed and treated earlier for ovarian cancer than they were in the past.

Many of these patients receiving more timely care are served by private safety-net hospitals, which care for more Medicaid patients than most community hospitals.

Researchers also note that disparities, so often viewed from a racial and socio-demographic perspective, are now being seen on a geographic basis depending on whether individual states expanded their Medicaid program.  As one observer explained,

We are moving from black-white disparities to Massachusetts versus Mississippi disparities.

Learn more from the Washington Post article “ACA linked to reduced racial disparities, earlier diagnosis and treatment in cancer care.”

 

Administration Ramps Up Scrutiny of Immigrants’ Use of Public Benefits

Immigrants’ sponsors could be more likely to be held financially responsible for the cost of public benefits those immigrants receive under a new memorandum issued by the White House.

The requirement itself is not new; the purpose of the memorandum is to encourage federal agencies to enforce existing laws that state that, according to the memorandum,

…when an alien applies for certain means-tested public benefits, the financial resources of the alien’s sponsor must be counted as part of the alien’s financial resources in determining both eligibility for the benefits and the amount of benefits that may be awarded.  Financial sponsors who pledge to financially support the sponsored alien in the event the alien applies for or receives public benefits will be expected to fulfill their commitment under law.

Among the means-tested public benefits programs at which this new directive is aimed are Medicaid, the Supplemental Nutrition Assistance Program (SNAP, formerly food stamps), and Temporary Assistance for Needy Families (TANF).

While the law already requires agencies to enforce immigrants sponsors’ legal financial responsibilities, the White House memorandum notes that it is not being enforced and directs the federal agencies involved to review and update their enforcement procedures.

Enforcement of this directive could result in fewer people applying for and being found eligible to receive Medicaid. If this occurs, it could be especially harmful to many private safety-net hospitals that serve large immigrant communities, potentially leaving them unpaid for care they provide to such patients.

Learn more from the administration’s “Memorandum on Enforcing the Legal Responsibilities of Sponsors of Aliens.”

Proposed Immigration Rule Discouraging Medicaid Enrollment

A proposal by the U.S. Department of Homeland Security is discouraging participation in Medicaid and other government safety-net programs.

A proposed Homeland Security regulation would establish new criteria for determining whether individuals seeking admission into the U.S. might eventually become “public charges”:  people who would depend on public resources to meet their needs rather than the resources of friends, family, sponsors, or private organizations or be able to provide for themselves or their families.  Among those criteria are past use of government aid programs and current income and health status.

Since the regulation was proposed last October, many legal immigrants, including those who already have green cards, have grown fearful of its implications and have shied away from seeking assistance from public aid programs and have even chosen to withdraw from programs in which they were already participating.  Among the survey’s findings:

  • 13.7 percent of adults in immigrant families reported family members dropping out of non-cash aid programs.
  • 17.4 percent of adults in immigrant families with children under the age of 19 were more likely to avoid public benefit programs.
  • Among those who reported avoiding public aid programs, 46 percent reported choosing not to participate in the federal Supplemental Nutrition Assistance Program (formerly food stamps), 42 percent reported someone in their household not participating in Medicaid even though they were eligible for the program, and 33.4 percent did not participate in housing subsidies.

Any withdrawal of legal residents from Medicaid or unwillingness to enroll in the program when eligible could leave hospitals with increased uncompensated care when serving low-income patients who otherwise lack the means to pay for their care.  This could pose a particular challenge for private safety-net hospitals because they serve communities with especially large numbers of low-income residents.

Learn more about the proposed public charge regulation and its apparent impact on participation in government safety-net programs among legal immigrants in the Urban Institute report “With Public Charge Rule Looming, One in Seven Adults in Immigrant Families Reported Avoiding Public Benefit Programs in 2018.”

Medicaid Waiver Process Often Lacks Transparency, GAO Finds

States’ applications for federal Medicaid waivers often lack transparency, according to a new report by the U.S. Government Accountability Office.

According to the GAO, the chief problem with the transparency of state applications for Medicaid waivers arises when states either seek to amend waivers they have already obtained or amend waiver applications currently under review by the Centers for Medicare & Medicaid Services.  Too often, the GAO found, states neither subject such amendments to public review and comment nor adequately explain to stakeholders the implications of the amendments they are proposing.

To address this problem, the GAO recommends that CMS address these shortcomings.  CMS agrees with these recommendations.

States often use section 1115 Medicaid waivers to seek exemptions from selected aspects of federal Medicaid law so they can employ new approaches to the delivery of Medicaid services and to payment for those services. Because they serve so many more Medicaid patients than most hospitals, private safety-net hospitals have a much greater stake in changes in state Medicaid programs than other hospitals.

Learn more about why the GAO undertook this analysis and what it found in its report Medicaid Demonstrations:  Approvals of Major Changes Need Increased Transparency.