Posts

New Report Looks at Medicaid and Social Determinants of Health

A new report outlines how state Medicaid programs can improve the health of Medicaid beneficiaries through a more concerted approach to addressing social determinants of health.

The report, from the Institute for Medicaid Innovation, focuses on how state Medicaid programs, through alternative payment models and especially through managed care organizations, have implemented new programs designed to address social determinants of health such as inadequate social supports and housing, food insecurity, lack of transportation, and others.  It also highlights federal regulations that facilitate the implementation of new ways to address social determinants of health and presents brief case studies in which states, state Medicaid programs, and Medicaid managed care organizations tackle social determinants of health.

Such approaches are especially relevant to private safety-net hospitals because they care for so many more Medicaid patients than the typical community hospital.

Learn more from the Institute for Medicaid Innovation report “Innovation and Opportunities to Address Social Determinants of Health in Medicaid Managed Care.”

NASH Comments Proposed Medicaid Managed Care Reg

 

The National Alliance of Safety-Net Hospitals has submitted formal comments to the Centers for Medicare & Medicaid Services in response to CMS’s proposed changes in federal Medicaid managed care regulations.

NASH’s letter addressed three aspects of the proposed regulation:  payment rate ranges, directed Medicaid payments, and Medicaid pass-through payments.  The overall theme underlying NASH’s comments was that the proposed changes represent positive steps but could be taken further to provide additional flexibility for state Medicaid programs to take stronger steps to ensure the ability of private safety-net hospitals to serve their communities.

NASH expressed support for CMS’s restoration of the use of actuarial rate ranges in setting Medicaid managed care rates but urged CMS to make those rate ranges even broader or even eliminate them provided that negotiated rates still meet formal criteria for actuarial soundness.

NASH endorsed CMS’s expanded parameters for the use of Medicaid directed payments through managed care but encouraged CMS to expand those parameters even further than it has proposed.

And NASH called on CMS to restore the ability of states to use pass-through payments in Medicaid managed care programs, as they can do through Medicaid fee-for-service programs, so long as those payments remain actuarially sound.  In 2016 a new Medicaid managed care regulation called for the phase-out of such payments over a period of ten years but NASH asked CMS to suspend that phase-out.

Learn more about NASH’s perspective by reading NASH’s comment letter to CMS in response to the proposed Medicaid managed care regulation.

Medicaid MCOs Skimping on Care?

Medicaid MCOs may be skimping on care, according to a recent Kaiser Health News report.

According to Kaiser, for-profit companies that sub-contract with Medicaid managed care organizations to review requests for services often deny care to Medicaid patients to save money for the MCOs that employ them and to benefit themselves financially.

The Kaiser article presents examples of companies that have been identified engaging in such practices, explains how they go about their work, and outlines the dangers to Medicaid recipients posed by such practices.

Because they serve so many more Medicaid patients than the typical hospital, private safety-net hospitals, their patients, and the communities they serve can be greatly affected by such practices.

Learn more in the Kaiser Health News article “Coverage Denied: Medicaid Patients Suffer As Layers Of Private Companies Profit.”

CMS Proposes New Medicaid Managed Care Regulation

Just two years after a major overhaul of Medicaid managed care regulations, the Centers for Medicare & Medicaid Services is again proposing changes in how the federal government regulates the delivery of managed care services to Medicaid beneficiaries.

Under the newly proposed regulation, states would:

  • be free to implement more changes in their managed care programs without seeking federal permission;
  • have slightly more flexibility in how supplemental payments are made to hospitals through managed care plans and implement some such changes without federal approval;
  • be permitted to redefine what constitutes an adequate provider network for managed care plans; and
  • not be required to publicize beneficiary grievance and appeals processes as prominently as they currently do.

Overall, the proposed regulation appears to help managed care insurers a great deal, states a little, and hospitals barely at all.  It also could have serious implications for private safety-net hospitals, most of which are located in states that employ managed care in their Medicaid programs.

Stakeholders have until January 14 to submit formal comments about the proposal to CMS.

To learn more about the proposed Medicaid managed care regulation, go here to see CMS’s news release presenting the regulation, go here to see a more detailed CMS fact sheet, and go here to see the proposed regulation itself.

States Pursuing Medicaid Reforms

A new Commonwealth Fund report looks at some of the changes states are pursuing in how they deliver and pay for care for their Medicaid recipients.

The review groups the reforms into three categories:

  • Managed care reforms – demanding more data to support bids for Medicaid managed care contracts and favoring bidders that include strong value components in their bids and that seek to address recipients’ social needs.
  • Focusing on beneficiaries with complex health and social needs – working with Medicaid managed care plans to address both the medical problems of members with complex medical conditions and the social determinants of health that cause, contribute to, or impede the treatment of those problems.
  • Integrating behavioral and physical health – expanding prevention and treatment of substance abuse disorders by restructuring delivery and payment systems.

Learn more about what states are doing to improve their Medicaid programs in the Commonwealth Fund report “Considering Federal Medicaid Policy Changes in Light of State-Level Delivery System Reforms,” which can be found here.

MACPAC Meets

The Medicaid and CHIP Payment and Access Commission met recently in Washington, D.C. to review a number of Medicaid- and CHIP-related issues.

MACPAC members heard presentations on and discussed the following issues:

Find outlines of these subjects and additional materials by clicking the links above and go here for a transcript of the two days of public meetings.

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 array of issues affecting Medicaid and the State Children’s Health Insurance Program.  While its recommendations are binding on neither the administration nor Congress, MACPAC’s work is highly influential and often finds its way into future Medicaid and CHIP policy.  Because private safety-net hospitals serve so many Medicaid and CHIP patients, they have an especially major stake in MACPAC deliberations and recommendations.

 

GAO Looks at Medicaid Managed Care Spending

The federal government should do more to help states ensure the accuracy and integrity of their payments to Medicaid managed care organizations and the payments those Medicaid managed care organizations make to health care providers.

This is the conclusion reached in a new study of Medicaid managed care performed by the U.S. Government Accountability Office at the request of the Permanent Subcommittee on Investigations of the Senate Committee on Homeland Security and Government Affairs.

The GAO study identified six payment risks among various transactions between state governments, Medicaid managed care organizations, and health care providers.  The two biggest risks, the GAO concluded, were:

  1. incorrect fee-for-service payments from MCOs, where the MCO paid providers for improper claims, such as claims for services not provided; and
  2. inaccurate state payments to MCOs resulting from using data that are not accurate or including costs that should be excluded in setting payment rates.

The GAO traces some of these problems to a delay in the Centers for Medicare & Medicaid Services’ planned Medicaid managed care guidance to states; limited implementation of new auditing practices CMS introduced in 2016; and CMS’s failure to account for overpayments to providers when it reviews state capitation rates for Medicaid managed care plans.

To address these shortcomings, the GAO report recommends that CMS:

  1. expedite issuing planned guidance on Medicaid managed care program integrity;
  2. address impediments to managed care audits; and
  3. ensure states account for overpayments in setting future MCO payments.

CMS agrees with these recommendations.

Learn more about the study – why it was undertaken, how it was conducted, what it found, and what it recommended – by going here to see the GAO report Medicaid Managed Care:  Improvements Needed to Better Oversee Payment Risks.

New Policy Threatens Provider Medicaid Payments

Health care providers that fail to join the provider networks of Missouri Medicaid managed care plans will see their Medicaid payments cut 10 percent by the state under a new state policy.

The purpose of the policy, according to the state, is to encourage hospitals and physicians to join the provider networks of three managed care plans that serve more than 700,000 residents of the state.  Providers, on the other hand, say this policy will discourage them from serving Medicaid patients at all and will detract from their ability to negotiate reasonable rates with the state’s three Medicaid managed care plans.

Learn more about this new Missouri policy and its potential implications for providers, Medicaid beneficiaries, the insurers, and the state in this article in the St. Louis Post-Dispatch.

Medicaid Managed Care Plans Suffer High Physician Turnover

The physician networks developed by Medicaid managed care plans suffer from a degree of turnover that threatens continuity of care for their members.

While the number of Medicaid managed care plans using so-called narrow networks of providers declined by more than a third between 2010 and 2015, physician turnover is higher in those narrow network plans:  three percentage points higher after one year and 20 percentage points higher after five years than the networks of plans that do not employ narrow networks.

Collectively, Medicaid managed care plans experienced physician turnover of 12 percent a year from 2010 to 2015.

Learn more about physician turnover in Medicaid managed care plans in the Health Affairs study “Network Optimization And The Continuity Of Physicians In Medicaid Managed Care,” which can be found here.

 

Do “Narrow Networks” Jeopardize Care?

They may if they serve Medicaid patients.

Or so suggests a new Health Affairs report.

As growing numbers of Medicaid managed care plans reduce their provider networks as a means of managing costs, provider turnover appears to be growing.  According to the report, narrow networks tracked during a five-year period experienced a 20 percentage point greater rate of physician turnover than non-narrow plans.

Such turnover is thought to be a potential problem for Medicaid patients who are socially or clinically vulnerable and present complex medical needs.  The loss of a physician can disrupt and complicate the care of such patients – and disrupt it in ways that may not necessarily be detected by current quality measures.

This could pose a problem for the communities served by private safety-net hospitals, which generally have large numbers of Medicaid patients who are enrolled in managed care plans.

Learn more about the challenges poses by narrow networks operated by Medicaid managed care plans in the study “Network Optimization And The Continuity Of Physicians In Medicaid Managed Care,” found here, on the Health Affairs web site, or go here to see a Healthcare Dive summary of the study.