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New Health Care Leaders Share Priorities

New leaders at the Centers for Medicare & Medicaid Services and the Center for Medicare and Medicaid Innovation are quickly making their priorities known to health care industry stakeholders.

For new CMS administrator Chiquita Brooks-LaSure, her priority is coverage.  She has declared that “Our focus is going to be on making sure regulations and policies are going to be focused on improving coverage,” and while she hopes that states that have not yet expanded their Medicaid programs will take advantage of current federal incentives to do so, there is another path to coverage:  “…the public option or other coverage certainly would be a strategy to make sure people in those states have coverage.”

For new CMMI director Liz Fowler, one of her stated objectives is to make more value-based payment models mandatory rather than voluntary, noting that “What we have learned from CMMI models over the past 20 years is that voluntary models [are] subject to risk selection, which has a negative impact on the ability to generate system-level savings.”  To that end, Fowler said she and CMMI are exploring more mandatory models.

Learn more about the directions new federal health care leaders hope to take their operations in the Kaiser Health News article “Expanding Insurance Coverage is Top Priority for New Medicare-Medicaid Chief” and the Fierce Healthcare article “CMMI director:  expect more mandatory value-based care payment models.”

Medicare Beneficiaries Happier With Their Health Insurance Than Privately Insured

People who are enrolled in Medicare are happier with their health insurance than those with private health insurance, according to a recent JAMA report.

Researchers found that the privately insured had a more difficult time finding doctors, were less likely to have a personal physician, had to deal with higher medical costs, were more likely to have medical debt, were more likely not to fill prescriptions because of their cost, and were less satisfied with their care than people insured by Medicare.

The findings were true whether people purchased their own health insurance or had employer-sponsored insurance.

Learn more about how the privately insured, Medicare beneficiaries, and Medicaid beneficiaries view their health insurance and health care experiences in the Healthcare Dive article “Privately insured face worse access, higher costs than those in public plans: JAMA report.”

MACPAC Issues Recommendations to Congress

The Medicaid and CHIP Payment and Access Commission has submitted its annual report to Congress on Medicaid and the Children’s Health Insurance Program.

The report includes recommendations for:

  • improving Medicaid’s responsiveness during economic downturns
  • addressing concerns about high rates of maternal morbidity and mortality;
  • reexamining Medicaid’s estate recovery policies
  • integrating care for people who are dually eligible for Medicaid and Medicare
  • improving hospital payment policy for the nation’s 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 array of issues affecting Medicaid and the State Children’s Health Insurance Program (CHIP).”  Its mandate calls for it to address matters such as Medicaid and CHIP payment, eligibility, enrollment and retention, coverage, access to care, quality of care, and the programs’ interaction with Medicare and the health care system generally.

Because safety-net hospitals care for so many more Medicaid and CHIP participants than the typical community hospital, MACPAC’s deliberations are especially important to them.

Learn more about MACPAC’s recommendations in its Report to Congress on Medicaid and CHIP.

NASH Calls for More COVID-19 Legislation

On Tuesday the National Alliance of Safety-Net Hospitals wrote to Senate leaders and asked them to advance legislation with five major COVID-19-related policy initiatives that private safety-net hospitals seek:

  1. An additional $100 billion for hospitals.
  2. A 14-point increase in the federal medical assistance percentage (FMAP).
  3. A 2.5 percent increase in states’ Medicaid disproportionate share (Medicaid DSH) allotments and another delay in implementation of Affordable Care Act-mandated cuts in those allotments.
  4. Reduced interest rates and a longer payback period for Medicare payments advanced to hospitals through the CARES Act’s Accelerated and Advance Payment Program.
  5. Prevention of implementation of the Medicare fiscal accountability regulation (MFAR).

Learn more from NASH’s letter to Senate majority leader Mitch McConnell and Senate minority leader Chuck Schumer.

NASH Urges CMS to Withdraw Medicaid Fiscal Accountability Regulation

CMS should withdraw its proposed Medicaid fiscal accountability regulation, NASH wrote in formal comments in response to the proposed regulation.

In its comment letter, the National Alliance of Safety-Net Hospitals wrote that

While NASH supports greater transparency in Medicaid, that support is outweighed by too many troubling aspects of the proposed regulation.

Specifically, NASH told CMS that the proposed regulation would:

  • deprive states of important, established policy-making prerogatives;
  • create major new administrative burdens for hospitals, state governments, and federal regulators;
  • inappropriately regulate how states finance their share of their Medicaid spending;
  • introduce new, unspecified standards for state Medicaid programs; and
  • violate the federal Administrative Procedures Act.

Learn more by reading NASH’s complete formal comment letter to CMS in response to the agency’s proposed Medicaid fiscal accountability regulation.

 

Feds Open Door for Exemptions from Medicaid IMD Exclusion

New federal guidelines will make it easier for state Medicaid programs to cover mental health services provided in institutions for mental diseases (IMD).

For years, Medicaid regulations greatly limited the ability of states to pay for care – generally, care related to substance abuse disorder treatment – provided in IMDs; this was generally known as the IMD exclusion.  The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act, also known as the SUPPORT for Patients and Communities Act, which was passed in 2018, opened the door for more exceptions to these limits, and last week, the Centers for Medicare & Medicaid Services approved a section 1115 waiver application submitted by the Washington, D.C. Medicaid program to circumvent the IMD exclusion for specific purposes.

At the same time that CMS approved the Washington waiver application it also issued formal guidance to state Medicaid programs outlining the circumstances and conditions under which it would consider waiver applications for similar circumvention of the IMD exclusion to facilitate the provision of care in IMDs for patients with substance abuse disorders and other serious mental health problems.  The CMS guidance memo addresses the types of care for which it might approve a waiver, the types of facilities in which waiver-authorized services can be provided, and the extent to which states could receive federal Medicaid matching funds for services provided to eligible patients through approved programs.

Learn more about the Washington waiver in the Fierce Healthcare article “CMS approves D.C. Medicaid waiver, paving way for broader mental health coverage” and read the CMS guidance memo to states here.

Immigrants Intimidated by New Public Charge Guidelines?

Immigrants served by community health centers appear less inclined than in the past to seek public aid to help them with their medical problems.

And community health center staff believes this is the result of confusion and fear as a result of changing federal immigration policies.

As stated in the Kaiser Family Foundation issue brief “Impact of Shifting Immigration Policy on Medicaid Enrollment and Utilization of Care among Health Center Patients,”

  • Health centers reported that, in recent months, immigrant patients have declined to enroll or reenroll themselves and/or their children in Medicaid for fear of public charge.
  • Health center respondents reported patients are confused about the new rule and are afraid to provide identifying information.
  • According to respondents, the public charge rule is creating a “chilling” effect, leading to decreased enrollment in other programs not subject to public charge.
  • About half of health centers reported a drop in utilization by immigrant patients, especially among pregnant women.
  • Health centers are training staff to answer questions on public charge and are working to ensure access to care for their patients.

This can pose a challenge for private safety-net hospitals:  low-income individuals who avoid public aid programs often end up receiving uncompensated care from those hospitals.

Learn more in the Kaiser Family Foundation issue brief “Impact of Shifting Immigration Policy on Medicaid Enrollment and Utilization of Care among Health Center Patients.”

Millions Eligible for Health Insurance Remain Uninsured

More than 15 million Americans who are currently entitled to free or subsidized health insurance are currently uninsured.

Among them are 11 million who are eligible for Medicaid but have not applied for benefits and 4.2 million who could afford insurance with the help of federal premium subsidies and either have decided not to take advantage of those subsidies or are unaware of the availability of such subsidies.

In addition, another two million people would be eligible for Medicaid if their states expanded their Medicaid program as authorized by the Affordable Care Act.

In light of such figures, it is not entirely surprising that the uninsured rate, according to the census bureau, rose last year for the first time since implementation of the Affordable Care Act.  That uninsured rate, 15 percent at the time the law was adopted in 2010, fell to 7.9 percent in 2017 but rose to 8.5 percent in 2018.  The uninsured rate has especially risen among Hispanics and the foreign born.

Another possible reason for the rise in the number of uninsured Americans:  the federal government has greatly reduced its outreach effort to inform people about the various options they have for obtaining insurance.

Learn more about who is uninsured and why the uninsured rate has risen in the Washington Post story “Millions of Americans aren’t getting health insurance, even though they’re eligible for free or affordable plans.”

 

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.

 

Study Finds Surprise in Sources of Medicaid, CHIP Growth

While enrollment in Medicaid and CHIP has been greatest among low-income families working full-time for small businesses, growth in Medicaid and CHIP enrollment among low-income families employed full-time by big businesses has been rising faster in recent years.

According to a new study published in the journal Health Affairs, Medicaid and CHIP enrollment among low-income families employed full-time by large companies rose from 45 percent to 69 percent between 2008 and 2016.  The driving force behind this growing reliance on public insurance appears to be the shift of health insurance costs from companies to employees:  employee share of health insurance premiums rose 57 percent during that same period, leaving many families unable to afford even employer-subsidized health insurance.

Learn more about the growing Medicaid and CHIP participation rates among different economic groups in the Health Affairs report “Growth Of Public Coverage Among Working Families In The Private Sector.”