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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.”

 

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.

End Run Around Congress for Medicaid Block Grants?

The Trump administration reportedly is considering introducing Medicaid block grants through regulations rather than legislation, according to published reports.

Those reports explain that the administration may seek to offer states an opportunity to apply to the federal government to use Medicaid block grants by obtaining section 1115 Medicaid waivers, a commonly used tool for states seeking exemptions from federal legislative or regulatory requirements.

As reported by the online publication The Hill,

…the Trump administration is now considering issuing guidance to states encouraging them to apply for caps on federal Medicaid spending in exchange for additional flexibility on how they run the program, according to people familiar with the discussions.

Proposals to implement Medicaid block grants have arisen periodically over the past decade but have never gotten beyond the discussion stage because of how difficult it would probably be to gain congressional approval for such a program.  This latest proposal would seek to circumvent that problem by making Medicaid block grants optional for states and permitting those states interested in using them to apply for a Medicaid waiver from Centers for Medicaid & Medicaid Services to do so.

It is not clear whether such an approach would be legal.

NASH has long been skeptical about Medicaid block grants, concerned that the manner in which such block grants are implemented could impose artificial limits on state Medicaid spending that could be especially harmful during economic downturns when Medicaid enrollment typically rises and the demand for Medicaid-covered services falls especially heavily on private safety-net hospitals.  NASH’s advocacy agenda for 2019 addresses this very issue, explaining 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 grants 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 this latest proposal in The Hill article “Trump officials consider allowing Medicaid block grants for states.”

MACPAC Meets

The Medicaid and CHIP Payment and Access Commission, a non-partisan legislative branch agency that advises Congress, the administration, and the states on Medicaid and CHIP issues, met publicly in Washington, D.C. last week.

The following is MACPAC’s own summary of its two days of meetings.

The April 2018 meeting began with session on social determinants of health. Panelists Jocelyn Guyer of Manatt Health Solutions, Arlene Ash of the University of Massachusetts Medical School, and Kevin Moore of UnitedHealthcare Community & State discussed state approaches to financing social interventions through Medicaid. In its second morning session, the Commission reviewed a draft chapter of the June 2018 Report to Congress on Medicaid and CHIP on the adequacy of the care delivery system for substance use disorders (SUDs) with a special focus on opioid use disorders.

In the afternoon, the Commission discussed the Centers for Medicare & Medicaid Services (CMS) March 2018 proposed rule changing the process by which states verify that Medicaid fee-for-service provider payment is sufficient to ensure access to care and agreed to submit comments to the agency. The first day of the meeting concluded with a review of the draft June chapter describing the status of managed long-term services and supports programs across the country. June chapters on Medicaid drug rebate policy and federal regulations governing confidentiality of SUD patient records were approved at the previous Commission meeting in March.

On Friday, the Commission heard from panelists Susan Barnidge, of the U.S. Government Accountability Office (GAO), and Judith Cash of CMS’s Center for Medicaid and CHIP Services, who discussed GAO’s report on Section 1115 demonstration evaluations and CMS’s efforts to improve the evaluation process. In the final session of the day, the Commission examined issues related to upper payment limit (UPL) hospital payments, which included findings from MACPAC’s recent review of state UPL demonstrations.

MACPAC members addressed a number of policy issues during the sessions using the following presentations to guide their discussion:

  1. State Approaches to Financing Social Interventions through Medicaid
  2. Draft Chapter: Access to Substance Use Disorder Treatment in Medicaid
  3. Proposed Rule on Exemptions to Monitoring Access in Fee for Service
  4. Draft Chapter: Managed Long-Term Services and Supports Programs
  5. Panel Discussion on Section 1115 Waiver Evaluations
  6. Uses and Oversight of Upper Payment Limit Supplemental Payments to Hospitals

MACPAC’s deliberations are especially important to private safety-net hospitals because they care for so many Medicaid and CHIP patients.

Addressing Socio-Economic Challenges Through Medicaid Payment Policies

Amid the growing awareness of the impact of social factors on health, policy-makers are increasingly interested in finding ways to address those factors through state Medicaid programs.

In a new blog post, the journal Health Affairs offers six ways for states to address social determinants of health through Medicaid managed care programs.

  1. classify certain social services as covered benefits under the state’s Medicaid plan
  2. explore additional flexibility afforded states through section 1115 waivers
  3. use value-based payments to support investment in social interventions
  4. use incentives and withholds to encourage plan investment in social interventions
  5. integrate efforts to address social issues into quality improvement activities
  6. reward plans with effective investments in social interventions with higher rates

Learn more about how states can use these approaches to empower Medicaid managed care plans to address social determinants of health in the Health Affairs Blog post “Practical Strategies for Integrating the Cost of Social Interventions Into Medicaid Managed Care Rates,” which can be found here.

 

A New Use for Section 1115 Medicaid Waivers?

Historically, states have pursued section 1115 Medicaid waivers as a means of expanding Medicaid eligibility.

But the Centers for Medicare & Medicaid Services now appears to be looking at granting 1115 waivers to help states reduce their Medicaid populations.

According to a new report published by the Commonwealth Fund, CMS is encouraging states – both Medicaid expansion and non-expansion states – to launch demonstration programs designed to reduce enrollment in “means-tested public assistance” programs such as Medicaid.  In their efforts to cut spending and reduce Medicaid enrollment, states are expected to seek section 1115 waivers to experiment with means of doing so such as:

  • establishing monthly premiums for Medicaid recipients
  • eliminating retroactive eligibility
  • imposing lifetime limits on how long individuals may participate in Medicaid
  • excluding people with substance abuse problems
  • shifting Medicaid enrollment to a single annual open-enrollment period
  • implementing more frequent eligibility determinations

And just last week CMS signaled states that it was now welcoming waiver applications to impose work requirements on some Medicaid recipients.

In a recent section 1115 waiver application, the state of Kentucky, for example, projects that the combination of establishing premiums for Medicaid participation and locking out those who do not make their payments, eliminating retroactive eligibility, and imposing a work requirement would reduce its Medicaid population 14.8 percent in the sixth year such changes were implemented.  That waiver was granted last week.

Learn more about how CMS is preparing to use section 1115 Medicaid waivers to enable states to reduce their Medicaid enrollment in the Commonwealth Fund report “State 1115 Proposals to Reduce Medicaid Eligibility: Assessing Their Scope and Projected Impact,” which can be found here.

MACPAC Meets

The non-partisan legislative branch agency that advises Congress, the administration, and the states on Medicaid and CHIP-related issues met recently in Washington, D.C.

The following is the Medicaid and CHIP Payment and Access Commission’s own summary of its meeting.

The December 2017 meeting of the Medicaid and CHIP Payment and Access Commission began with a brief update on the State Children’s Health Insurance Program (CHIP). Although federal funding for the CHIP expired at the end of September, legislation to renew funding was still pending in Congress. The Commission then heard from a panel discussing state tools to manage drug utilization and spending in Medicaid. Panelists included Renee Williams, director of clinical pharmacy services for TennCare; Doug Brown, Magellan Rx Management’s vice president for Medicaid drug rebate management; and John Coster, director of the Center for Medicaid and CHIP Services Division of Pharmacy at the Centers for Medicare & Medicaid Services. At the final morning session, Commissioners reviewed a draft March 2018 report chapter on streamlining Medicaid managed care authorities. The Commission voted to approve recommendations to Congress, but deferred action on a third recommendation for further discussion at its upcoming January 2018 meeting.

In the afternoon, MACPAC staff previewed highlights from the December 2017 MACStats: Medicaid and CHIP Data Book. MACStats pulls together Medicaid and CHIP data from multiple sources that often can be difficult to find. The collection is published annually and individual tables are updated throughout the year. The Commission then reviewed the draft March report chapter on telemedicine in Medicaid, and later in the day the Commission returned to the topic of prescription drugs, to explore potential recommendations on the Medicaid drug rebate program.

The final December sessions covered MACPAC’s annual analysis of disproportionate share hospital payments (a required element of its March reports), and findings from interviews with four states to better understand how they are implementing Section 1115 Medicaid-expansion waivers.

The following presentations, many with supporting documents, were offered during the MACPAC meeting:

  1. State Strategies for Managing Prescription Drug Spending
  2. Review of March Report Chapter: Streamlining Managed Care Authorities
  3. Highlights from MACStats
  4. Review of March Report Chapter: Telemedicine in Medicaid
  5. Potential Recommendations on Medicaid Outpatient Drug Rebates
  6. Review of Draft March Report Chapter: Analyzing Disproportionate Share Hospital Allotments to States
  7. Implementation of Section 1115 Medicaid Expansion Waivers: Findings from Structured Interviews in Four States

CMS Offers States New Medicaid Path for Opioid Treatment

The Centers for Medicare & Medicaid Services (CMS) has issued new guidance to states advising them on how they can use section 1115 Medicaid waivers to improve access to treatment for Medicaid recipients struggling with opioid abuse problems.

According to the 14-page guidance letter from CMS to state Medicaid directors,

CMS is now offering a more flexible, streamlined approach to accelerate states’ ability to respond to the national opioid crisis while enhancing states’ monitoring and reporting of the impact of any changes imsplemented through these demonstrations.  As the opioid crisis continues to raise alarm and highlight the need for better access to high quality, evidence-based treatment, CMS would like to partner with states to support ways to progressively improve outcomes for Medicaid beneficiaries struggling with addictions in the context of 5-year demonstrations.

See the CMS guidance letter here.

MACPAC Meets

The Medicaid and CHIP Payment and Access Commission met recently in Washington, D.C.

Among the issues MACPAC commissioners discussed during their two-day meeting were:

  • delivery system reform incentive payment programs
  • Medicaid enrollment and renewal processes
  • managed care oversight
  • monitoring and evaluating section 11115 demonstration waivers
  • Medicaid coverage of telemedicine services

MACPAC advises the administration, Congress, and the states on Medicaid and CHIP issues.  It is a non-partisan agency of the legislative branch of government.

Go here to find background information on these and other subjects as well as links to the presentations that MACPAC staff made to the commissioners during the meetings.

MACPAC Meets

Last week the Medicaid and CHIP Payment and Access Commission met in Washington, D.C.  The agency performs policy and data analysis and offers recommendations to Congress, the Department of Health and Human Services, and the states.

During two days of meetings, MACPAC commissioners received the following presentations:

  • Federal CHIP Funding Update: When Will States Exhaust Their Allotments?
  • Review of June Report Chapter: Program Integrity in Medicaid Managed Care
  • Review of June Report Chapter: Medicaid and the Opioid Epidemic
  • Medicare Savings Program: Eligible But Not Enrolled
  • Medicaid Reform: Implications of Proposed Legislation
  • Preliminary Findings From Evaluations of Medicaid Expansions Under Section 1115 Waivers
  • Potential Effects of Medicaid Financing Reforms on Other Health and Social Programs
  • Review of June Report Chapter: Analysis of Mandatory and Optional Populations and Benefits
  • Managed Long-Term Services and Supports: Network Adequacy for Home and Community-Based Services
  • Update on MACPAC Work on Value-Based Payment and Delivery System Reform

For links to all of these publications and a transcript of the two-day meeting go here, to the MACPAC web site.