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Last Build Date: Mon, 25 Sep 2017 16:06:20 +0000


Graham-Cassidy Continues Efforts To Bar Private Insurance Coverage of Abortion

Mon, 25 Sep 2017 16:06:20 +0000

Across all of the major House and Senate Republican proposals in 2017 to repeal and replace major portions of the Affordable Care Act (ACA), one thing that has been consistent is their inclusion of language barring federal money from being used to support private insurance plans that covers abortion. The latest proposal, from Sens. Lindsey Graham (R-SC), Bill Cassidy (R-LA), Dean Heller (R-NV) and Ron Johnson (R-WI), continues that trend. The Graham-Cassidy proposal has abortion coverage provisions in common with the American Health Care Act (AHCA), which passed the House in May, and the Better Care Reconciliation Act (BCRA), which was rejected on the Senate floor in July. (See my post from March 21 for a description of the abortion coverage restrictions in AHCA and a fuller discussion of this topic, including the history behind these restrictions, current limitations on abortion coverage in private insurance and why abortion coverage restrictions matter.) Like its predecessors, Graham-Cassidy would phase out the ACA’s subsidies to help low- and middle-income individuals purchase health plans on their own, as well as ACA subsidies to help small employers purchase health plans for their employees. During the two years (2018 and 2019) that those subsidies would still exist, the legislation would bar them from going to any plan that includes coverage for abortion, beyond those rare cases when the woman’s life is endangered or the pregnancy is the result of rape or incest. Unlike AHCA, the Graham-Cassidy proposal does not make any pretense of allowing for the purchase of abortion “riders.” Problematic Provisions As several media reports have highlighted, the timing of this proposal is especially problematic, because the deadline for insurers to participate in the ACA’s marketplaces in 2018 is on September 27. Plans that include abortion coverage could end up ineligible for purchase in 2018 by anyone receiving a premium assistance subsidy. That would include all plans in California and New York, which require abortion coverage in marketplace plans. That problem would eventually extend to Oregon, which has enacted an abortion coverage requirement that goes into effect in 2019. The Graham-Cassidy proposal also includes a provision (seen earlier in BCRA) that would allow people to use money in Health Savings Accounts (HSAs) to pay premiums for certain high-deductible health plans—but not if the plan includes coverage of abortion (except in the same limited cases). That would be the first abortion-related restriction applied to HSAs, which allow individuals to set aside money in a tax-sheltered account dedicated to medical expenses and which are in great favor among conservative lawmakers. The most distinctive feature of the Graham-Cassidy proposal is its massive block grant to the states—well over a trillion dollars over seven years—that would, starting in 2020, replace the ACA’s premium and cost sharing subsidies and its Medicaid expansion. States could use the block grant in numerous ways, including direct payments to health insurers or health care providers, funding for high-risk pools, and subsidies to help people pay premiums and cost sharing. This block grant provision is routed through an existing federal statute that bars federal funding for abortion care or for insurance coverage that includes abortion (again, except in cases of life endangerment, rape or incest). It is unclear exactly how that provision would be applied in all of the different scenarios possible under this block grant. For example, would an insurance company or health care provider receiving block grant dollars be barred from providing abortion coverage or care throughout its business? Regardless, the intention seems clear: to eliminate abortion coverage and care in as many arenas as possible. Broader Restrictions On Reproductive Health Finally, it should be made clear that the abortion coverage restrictions in Graham-Cassidy are part of a broader collection of provisions that would undermine access to reproductive health services. T[...]

New Graham-Cassidy Draft: States With Hold-Out GOP Senators Favored, Potential Higher Costs Remain For Those With Preexisting Conditions

Mon, 25 Sep 2017 14:57:15 +0000

Late on the night of Sunday, September 25, 2017—only 72 hours before a final vote on the bill is expected–a new version of the Graham-Cassidy bill was released. Although much of the bill is the same as the draft released earlier, there are significant changes. On initial review, these seem to be aimed primarily at two purposes: undergirding the argument of the bill’s sponsors that it does not exclude coverage for people with preexisting conditions and, substantially increasing funding for states represented by some of the GOP Senators who have expressed concerns about the bill. This post analyzes the non-Medicaid provisions of the new version. A post summarizing the Medicaid changes will follow. Unchanged Provisions The new draft provides full revised legislative language rather than specific amendments tied to the earlier draft. It is only slightly longer and retains many of the key provisions of the underlying bill. Like the earlier bill, it would: end the Affordable Care Act’s provision that caps the amount of premium tax credit that low-income individuals must repay when they receive excess premium tax credits because their income is higher than estimated; repeal the ACA’s premium tax credits, cost-sharing reduction payments, small business tax credits, and Medicaid expansions as of the end of 2019; bar health insurers from receiving ACA tax credits for plans that cover abortion other than when necessary to save the life of the mother or in cases of rape and incest as of the end of 2017 (this would likely make many plans illegal that have already been approved for 2018, causing headaches for state regulators); end the individual and employer mandate penalties retroactively as of the end of 2015 (presumably requiring the IRS to refund penalties already paid); terminate funding for Planned Parenthood (and any similar organizations) for one year; repeal the ACA’s Medical Device Tax, reinstate the deduction businesses can take for subsidies they offer for retiree Part D prescription drug plans; and reinstate and extend a host of subsidies for health savings accounts, but leave other ACA taxes in place; defund the ACA’s prevention and public health fund as of 2019; and increase community health center funding by $422 million for 2017. The Exchanges, Stabilization Fund, And Block Grants Unlike the earlier draft, the new draft does not repeal the ACA provisions that allow exchanges to determine eligibility for tax credits. It thus appears to fully retain the ACA’s exchanges, although their function and funding under the new bill is problematic. Like the earlier Graham-Cassidy draft, the new draft would provide a short-term individual market stabilization fund of $10 billion for 2019 and $15 billion for 2020 (but none for 2018). It would also include block grant funding available to the states for 2020 through 2026 to take the place of the ACA’s premium tax credits, cost-sharing reductions, Basic Health Program funding, and Medicaid expansions. The formula, which will be described shortly, has been changed to some extent, although its elements are similar. The uses to which states can put the block grants are also similar. These include: providing coverage for high-cost individuals, presumably through high-risk pools or special premium subsidies; subsidizing health insurers to reduce premiums, presumably through a reinsurance program; payments to health care providers for health care services; providing assistance to reduce out-of-pocket costs; providing assistance to individuals who do not have access to employer coverage to help them purchase individual market coverage; providing private market coverage for individuals who are eligible for Medicaid (only 15 percent of a state’s grant can be used for this purposes–up to 20 percent with permission from HHS); and assisting purchase of health care for individuals who are not eligible for Medicaid through arrangements with managed care companies. Under the new draft, at least 50 percent of the funds must be used to[...]

ACA Round-Up: 1332 Waiver News From Iowa And Minnesota; Big Blow To Graham Cassidy

Fri, 22 Sep 2017 21:23:40 +0000

September 24 Update CMS Approves Minnesota 1332 Waiver Application On September 22, 2017, the Centers for Medicare and Medicaid Services approved Minnesota’s application for a 1332 state innovation waiver to establish a reinsurance program. CMS estimates that Minnesota will receive $139 million in pass-through funding for the reinsurance program for 2018, and a total of $1.003 billion for 2018 through 2022. The approval letter from CMS administrator Verma states, as Governor Dayton predicted, that the federal government will only pass through the amount that it will save through reduced premium tax credits and cost-sharing reduction payments, not the amount (which the letter does not quantify) that the federal government will save because premiums for standard plans under Minnesota’s Basic Health Program will also be reduced by the reinsurance program. EEOC Sets Out Lengthy Timetable For Reconsideration Of Employer Wellness Program Surcharges In late August, a District of Columbia federal district court remanded to the Equal Employment Opportunity Commission for further consideration its rule allowing employers to impose penalties of up to 30 percent of the cost of coverage on employees who refused to disclose health information otherwise protected by the Americans with Disabilities Act and the Genetic Information Non-discrimination Act. The order was entered in a lawsuit brought by the AARP. The court held that the EEOC had failed to offer a reasonable explanation for the 30 percent rule and remanded the rule to the agency for further consideration. The judge, however, did not vacate the rule while the agency was reconsidering it, but rather ordered the agency to provide a timeframe for its reconsideration. On September 21, 2017, the EEOC filed a status report stating that it intended to issue a proposed rule addressing the issue by August of 2018 and a final rule by October of 2019. It noted, however, that the Senate is currently considering two of President Trump’s nominees to fill the chair position and one other vacancy in the EEOC and that the timetable may change under the new appointees. In any event, the EEOC noted, it would not require employers to comply with a new rule before 2021. The AARP has asked the court to reconsider its refusal to vacate the EEOC rule pending the agency’s reconsideration. (EEOC response) The leisurely schedule suggested by the EEOC would seem to support an argument that a failure to vacate the rule effectively nullifies the AARP’s victory. Original Post Iowa has submitted a supplement to its application for a state innovation waiver under section 1332 of the Affordable Care Act. One of the issues raised by its application, as noted in an earlier post, was that its proposed waiver would eliminate cost-sharing reductions for low-income enrollees.  This raised concerns as to whether the proposal satisfies a section 1332 requirement that a waiver program “will provide coverage and cost-sharing protections against excessive out-of-pocket spending that are at least as affordable” as ACA coverage. Under the supplement it submitted, Iowa offers to compensate insurers for reducing cost sharing for enrollees with incomes between 133 and 150 percent of the federal poverty level. Individuals in this income range would be offered coverage with a 94 percent actuarial value, subject to a maximum out-of-pocket of $1,000 for individuals and $2,000 for families. Iowa asserts that providing cost-sharing reductions to these individuals would cost $14 million for 2018 and might increase enrollment, but would not increase the federal deficit. The ACA extends cost sharing reductions to enrollees with incomes up to 250 percent of the federal poverty level. Enrollees with incomes between 150 and 200 percent of the federal poverty level who enroll in silver plans must be provided with 84 percent actuarial value coverage and reduced out-of-pocket limits. The Iowa supplement does not explain how enrollees with incomes between 150 and 250 perc[...]

The Graham-Cassidy Plan: Sweeping Changes In A Compressed Time Frame

Fri, 22 Sep 2017 17:21:57 +0000

Senators Lindsey Graham (R-SC) and Bill Cassidy (R-LA) have proposed a new plan for rolling back key provisions of the Affordable Care (ACA). It is possible that the Senate will vote on this plan in the coming days. The plan has many similarities to the Better Care Reconciliation Act (BCRA), which Senate Majority Leader Mitch McConnell assembled during June and July and which failed when considered in the Senate by a vote of 43 to 57. The Graham-Cassidy plan is built on the premise that the federal government should remove itself from many of the difficult policy decisions concerning how health insurance is subsidized and regulated. Those decisions would be left to the states. A key provision of the plan replaces the ACA’s premium credits and funding for the Medicaid expansion with a new block grant which would provide substantial flexibility to the states to design entirely different ways of subsidizing and regulating health insurance in the individual market. Graham-Cassidy faces many challenges, not the least of which is the difficulty of passing a coherent plan using the budget reconciliation process. Republicans would repeal the ACA’s individual mandate, but the rules of budget reconciliation (which allow the bill to pass with a simple majority instead of 60 votes) make it difficult to include an adequate replacement for the mandate in their plan. Although an important policy goal for Republicans is to lower premiums in the individual market, Graham-Cassidy, like the BCRA, is likely to have the opposite effect, at least in 2018 and 2019. Below we describe some of Graham-Cassidy’s key provisions. We then offer our thoughts on the bill’s substantive and political implications. Because Graham-Cassidy is so complex and far-reaching, we believe more time is needed to understand and debate its merits, and the legislation would benefit from a traditional mark-up in committee where serious amendments could be considered. Moving too fast risks significant unintended consequences and public resentment. Key Provisions Graham-Cassidy is a complex proposal with many provisions. The following is a brief summary of its most important features: Repeal Of The ACA’s Individual And Employer Mandates The plan repeals the penalties used to enforce the ACA’s individual and employer mandates, effective retroactively to tax year 2016. This provision would immediately relieve all Americans of any obligation to enroll in coverage because they would face no penalty for going uninsured. Short-Term Insurance Assistance Program Graham-Cassidy provides $25 billion over 2018 and 2019 to the Centers for Medicare and Medicaid Services (CMS) to directly subsidize insurers to avoid disrupting coverage in the individual market. The use of funds is flexible and could be used for reinsurance payments and similar mechanisms to stabilize markets in the short-term. Replacement Of The ACA’s Medicaid Expansion, Tax Credits, And Cost-Sharing Subsidies With A Health Care Grant Program The plan terminates the ACA’s Medicaid expansion, premium credits, and cost-sharing subsidies, effective calendar year 2020. In their place, the plan provides a new block grant to the states totaling nearly $1.2 trillion through 2026 with a complex formula for distributing the funds across states. Each state is assigned a base amount of spending for 2020, which combines federal spending for the state’s Medicaid expansion enrollees plus premium credits and cost-sharing subsidies provided through the ACA’s exchanges. The state’s base amount is adjusted to account for the number of individuals in the state with low incomes (defined as 50 to 138 percent of the federal poverty level) compared with the number of low-income individuals nationwide. Adjustments are also made to account for clinical risk factors and the actuarial value of coverage for low-income individuals. By 2026, federal funding per low-income person under the Health Care Grant Program would be equalized across all st[...]

Patient-Centered Care Starts With Patient-Provider Communication

Fri, 22 Sep 2017 16:28:22 +0000

Improving communication between patients and their providers is crucial to reforming the health care system to better meet patients’ needs and improve patient outcomes. Strategies such as shared decision making and patient-centered medical homes, which encourage patients to play an active role in their health care and rely on strong patient-provider relationships, are founded on trust and communication. Yet recent data from the Health Reform Monitoring Survey (HRMS) suggest that providers could be having more conversations with their patients about issues surrounding their health care. Patients who have low incomes and have forgone needed care because they couldn’t afford it are often at risk of having their concerns go unaddressed by providers. In this blog post, we present findings from the HRMS that demonstrate the need for progress in patient-provider communication and suggest strategies for improvement. Patients Rate Their Health Care And Providers Highly But Gaps In Communication Exist In the September 2016 round of the HRMS, most nonelderly adults gave high ratings for the health care they received, and most had high levels of trust in their usual providers. On a scale of 0 to 10, in which 10 indicates complete trust, the median rating for health care and for trust in one’s provider was 7–8. The most common response for provider trust was 9–10 (Exhibit 1), but almost one-third of adults from minority racial/ethnic backgrounds rated their trust in their provider below the median of 7–8, compared with about one-fifth of white, non-Hispanic adults (data not shown). Exhibit 1: Nonelderly Adults’ Ratings Of Their Health Care And Their Trust In Their Usual Providers Source: Health Reform Monitoring Survey, quarter three, 2016. Notes: Sample for rating of health care is limited to adults who received care in the past 12 months. Sample for rating of trust in provider is all nonelderly adults. We combined two versions of a question on trust (trust your provider and trust your provider with your health care) and three versions of a question on rating health care (rate your health care, rate the quality of your health care, and rate how well your health care met your health needs). Usual provider is defined as the provider seen most often for care. Most adults felt comfortable talking with their usual providers about potentially sensitive issues, including health and health care challenges, concerns about the cost of health care, and events in their lives that caused worry or stress (Exhibit 2). Nearly all adults (90.2 percent) were comfortable talking with their provider about at least one sensitive issue, with the highest levels of comfort reported for health and health care challenges (88.1 percent) and lower levels of comfort reported for life challenges and stresses (81.1 percent) and concerns about the costs of health care (71.1 percent). However, patient-reported comfort also varied across demographic groups. White, non-Hispanic adults were more likely to say they were comfortable talking about each of these issues than adults of other racial/ethnic backgrounds (data not shown). Exhibit 2: Share Of Nonelderly Adults Who Were Asked About Potentially Sensitive Issues By Their Usual Provider And Own Comfort With Conversations About Potentially Sensitive Issues Source: Health Reform Monitoring Survey, quarter three, 2016. Note: Sample is limited to adults who saw their usual provider at any time in the past 12 months. Gaps also appear in the frequency of provider-initiated conversations about sensitive issues. Overall, providers asked about these issues fairly often; about 61.2 percent of patients reported that their usual provider had asked about at least one potentially sensitive issue over the past 12 months. Providers asked most often about life challenges and stresses (53.2 percent) and health and health care challenges (41.6 percent). They were much less likely to ask about concer[...]

Addressing The Gap In Noncommunicable Disease Data With Technology And Innovation

Thu, 21 Sep 2017 17:04:26 +0000

On September 22, 2017, a correction was made in the second paragraph of this blog post. High-quality health data is the backbone of strong public health policies. When government officials and public health professionals understand the factors that influence health, they can make informed decisions about how and where to target public health interventions and resources.  In low- and middle-income countries, noncommunicable diseases (NCDs) account for 67 percent of deaths but only 1 percent of global health funding (see page 5). As the NCD epidemic reaches all countries—regardless of income level, high-quality, quickly accessible data that provide information about NCD risk factors are the lever for action. Bloomberg Philanthropies has an ambitious plan to address critical health data needs—with twenty low- and middle-income countries participating in our Data for Health initiative. Data for Health focuses on three broad needs at the country level: improving birth and death registration data; strengthening the link between health data and policy decisions; and exploring innovative approaches to NCD surveillance by using mobile phone surveys. The four-year initiative, a partnership with the Australian Government’s Department of Foreign Affairs and Trade, provides $100 million to partner with countries on these issues. Mobile Phone Surveys Because of marked increases in mobile phone ownership, tapping into this technology for survey purposes has the potential to be a resource-saving complement to the gold-standard household survey—and mobile phone surveys have the advantage of being feasible to conduct at more frequent intervals. The continuous flow of data to the public health sector allows for more rapid interventions and the early detection of new trends. Previously, when survey data were collected by interviewers using smartphones and tablets, field workers, traveling from residence to residence, were always collecting the data. The Data for Health mobile phone survey is the first nationally representative survey in which questions are asked through cell phone networks and respondents answer by using their own mobile devices. Conducting surveys using mobile phones without visiting households allows surveys to be done more frequently and more cheaply, thus complementing detailed, in-person household surveys. Within the Data for Health initiative, mobile phone surveys are being piloted in two countries (Zambia and Morocco) alongside the World Health Organization’s (WHO’s) NCD risk factor household survey—STEPwise—using the same standardized questions and protocols. Our program partners (the US Centers for Disease Control and Prevention, CDC Foundation, WHO, and Johns Hopkins University) will directly compare findings to quantify the bias introduced by this new mobile phone method before applying this method to additional countries. For example, Zambia is the first country where the mobile phone survey has been rolled out nationally, beginning in July 2017, and to date, 89 percent of the needed sample size has been completed. An additional advantage of this method is that data analysis can follow quickly after the survey is completed as all data are electronically submitted. Through several microtrials in three countries, the initiative is supporting additional research, and practical knowledge is being gained. Data for Health partners are filling research gaps on the effectiveness of incentives to increase survey completion; different modalities (such as voice versus text); and ethical, legal, and societal issues raised by the mobile phone method. These learnings will be used to improve future mobile phone surveys. Other Data For Health Activities In addition to our mobile-phone survey work, Data for Health partnered with Rwanda’s Ministry of Health to support its systematic collection of information on deaths outside of a hospital. This was a critical step toward[...]

The Future Of CHIP: The KIDS Act Of 2017

Thu, 21 Sep 2017 13:30:37 +0000

At this particular moment, when the future of Medicaid—the nation’s largest public insurer of low-income children—is once again under threat, it might strike some as paradoxical to be reviewing a bill whose title is “Keep Kids’ Insurance Dependable and Secure Act of 2017.” Introduced on September 18 by Senators Orrin Hatch and Ron Wyden, the Chair and Ranking Member of the Senate Finance Committee, respectively, the KIDS Act (S. 1827) would extend funding for the Children’s Health Insurance Program through Fiscal Year 2022. Exactly when, and in what fashion, a CHIP funding extension might advance is unclear, although without question the emergence of a bipartisan proposal from the leading members of the Senate committee of jurisdiction comes as a welcome sign. The Need For Extended CHIP Funding Funding for CHIP officially runs out on September 30, in less than two weeks. The Medicaid and CHIP Payment and Access Commission (MACPAC), which advises Congress on federal Medicaid and CHIP policy, previously has estimated that by summer 2018, all states will have exhausted their federal allotments. But programs providing essential public benefits to people cannot simply close down overnight; either as a practical or operational matter; in states that run CHIP separately rather than as an extension of Medicaid, the funds technically might still be there, but the steps needed to start closing the program would need to begin much sooner unless the state is willing to entirely replace lost federal funding with its own money. CHIP’s Structure, Size, Program Design, And Impact Enacted in 1997, CHIP was intended to function as a companion to Medicaid. Participating states have the option of using their federal CHIP allotments either to establish programs that operate entirely separately from Medicaid or to expand their Medicaid coverage beyond the federal minimum for children up to 18 (138 percent of the federal poverty level). Most states use a combined approach, expanding Medicaid to some extent while offering a separate companion program for families with modest incomes that nonetheless exceed their state’s upper Medicaid eligibility threshold. Compared to Medicaid, federal CHIP allotment accounts for a relatively modest number of the children who depend on public insurance. In FY 2016, out of the nearly 46 million children enrolled in either Medicaid or CHIP, 8.9 million relied on CHIP to meet the cost of coverage, while Medicaid insured 37 million that year. In other words, for every child whose coverage is financed through the federal CHIP allotment, 4 children depend for their coverage on federal Medicaid funding. And even within CHIP, most of the actual coverage is derived from a Medicaid expansion. Of the 8.9 million children insured through CHIP, the majority (about 5.2 million compared to nearly 3.7 million) receive their coverage as part of Medicaid rather than through a separate program. Despite its modest size and scope, CHIP has been widely credited with helping reduce the percentage of U.S. children without health insurance, from nearly 14 percent in 1997 to fewer than 5 percent by 2015. Overwhelmingly, the children assisted by CHIP are the lowest-income children in the US; nearly all states target CHIP to children with family incomes twice poverty or lower. What Happens If CHIP Funding Is Not Extended? Should Congress fail to extend federal CHIP funding, CHIP children covered through a Medicaid expansion would be protected, at least through the end of Fiscal Year 2019, by the Affordable Care Act’s Medicaid maintenance of effort requirement for children. At the same time, the loss of CHIP funds would mean that CHIP’s enhanced allotment formula would be replaced by a state’s normal Medicaid federal funding formula (between 50 percent and 75 percent of total state expenditures). Put another way, CHIP Medicaid expansion children [...]

Pharmacy Benefit Management Of Opioid Prescribing: The Role Of Employers And Insurers

Thu, 21 Sep 2017 04:05:08 +0000

In the last two decades, prescribing rates for opioids have increased nearly three-fold, from 76 million prescriptions in 1991 to approximately 207 million prescriptions in 2013.  This remarkable volume of opioid prescribing is unique to the United States, where 2015 prescribing amounts were nearly four times those in Europe.   Sadly, this much more frequent prescribing of addictive medications is connected to an epidemic of deaths related to abuse of opiates and other drugs of abuse.  Drug overdose deaths are now considered a national emergency, topping 59,000 in 2016.  The abuse of opioids can be seen as the leading public health emergency in the United States faces today. The startling increase in the use of opioids has many causes.  Two decades ago, health providers perceived that pain was under-treated, and in 1998 the Joint Commission formally recognized pain as the fifth vital sign.  At the same time, drug companies developed and promoted a new generation of synthetic opioids, and added extended release as well as abuse deterrence formulations.   Doctors prescribed, and patients consumed, these drugs in ever increasing quantities. At the same time, illicit forms of opioids became more widely available and abused.  Now, with the harrowing increase in mortality attributed to opioid abuse, it is time to look for new solutions. As the adverse consequences resulting from opioid misuse became apparent, employers sought the help of pharmacy benefit managers which responded by developing prospective (i.e., pre-dispensing) and retrospective utilization review programs to detect and intervene in unsafe prescribing of these addictive medications. Patients and prescribers who were engaged in unsafe behavior were identified and educated. Other interventions, in the form of member-specific drug limits, dispensing restricted to a single pharmacy, and prior authorization to ensure use for an appropriate diagnosis, were implemented – all programs shown to reduce opioid abuse. These programs had positive effects, but the magnitude of the opioid epidemic continued to increase. Additional Tools Pharmacy benefit management companies have still more aggressive utilization management techniques to guide physician prescribing, including such tools as quantity limits, step therapy to emphasize generics and restricted formularies.  We believe these can be used to bring about more appropriate use of opiates for pain management.  However, some prescribers may resist embracing recommended guidelines to address this epidemic at the broad population-level.  The American Medical Association (AMA) for example has criticized such programs as heavy-handed, cookie-cutter approaches, and has counseled that providers should be making these decisions on behalf of patients, taking into account individual patient needs.  To be sure, prescriber autonomy and respect for the physician-patient relationship are of paramount importance. However, there is little evidence to show that past opioid prescribing habits are necessary or appropriate, and there is a great deal of evidence that they have produced significant harm. With widespread recognition that more aggressive control was called for, the Centers for Disease Control and Prevention (CDC) assumed the lead, announcing a Guideline for Prescribing Opioids for Chronic Pain in 2016.  The CDC Guideline was based on three principles: opioids should be used only when necessary; only at the lowest dose and for the briefest duration needed; and when used, caution should be exercised and patients monitored closely.  The Guideline made specific recommendations such as implementing step therapy requiring the use of immediate release formulations before extended release drugs when initiating treatment for chronic pain, avoiding doses greater than 90 Morphine Milligram Equivalents  per day, and limiting prescrip[...]

ACA Round-Up: Bipartisan Market Stabilization Efforts Stall; Iowa 1332 Waiver Application Advances; And More

Wed, 20 Sep 2017 17:40:10 +0000

On September 19, 2017, Senator Lamar Alexander (R-TN), Chair of the Senate Health, Education, Labor, and Pension (HELP) Committee, announced that after two weeks of bipartisan hearings on individual market stabilization, Republicans and Democrats “have not found the necessary consensus . . . to put a bill in the Senate leaders’ hands that could be enacted.” Senator Patty Murray (D-WA), the ranking member of the HELP committee, released a statement thanking Senator Alexander for undertaking the bipartisan process. She noted that however that: We identified significant common ground and I made some tough concessions to move in Chairman Alexander’s direction when it comes to giving states more flexibility. I am disappointed that Republican leaders have decided to freeze this bipartisan approach and are trying to jam through a partisan Trumpcare bill, but I am confident that we can reach a deal if we keep working together—and I am committed to getting that done Apparently, Republican leaders have decided to concentrate their efforts for the time being on passing the Graham-Cassidy legislation. Perhaps bipartisanship will return to the fore if those efforts fail, but in the meantime the individual market continues to face continuing uncertainty and instability in some parts of the country. A bipartisan group of ten governors, some of whom had testified in the hearings, urged a bipartisan approach rather than pursuit of Graham-Cassidy in a letter to Senate Majority Leader Mitch McConnell (R-KT) and Minority Leader Chuck Schumer (D-NY). CMS Moves Iowa 1332 Waiver Application Along Also on September 19, 2017, the Centers for Medicare and Medicaid Services preliminarily declared Iowa’s application for a 1332 state innovation waiver complete, opening a thirty-day comment period. The Iowa waiver is the most radical state innovation waiver proposed to date. It would abandon the ACA’s cost-sharing reductions for low-income residents in Iowa, using the federal funds that would have gone for the reducing cost sharing to fund increased premium credits. These credits would be available to individuals who would qualify for ACA premium tax credits, but they would also be available also to individuals with incomes above 400 percent of the federal poverty level, the maximum income level for ACA tax credits. The waiver would pull Iowa out of the federal exchange, allowing it to determine premium credit eligibility itself. Iowan individual market consumers would be restricted to a single standardized silver plan, which would be offered under a contract between insurers and the state. Individuals who failed to maintain continuous coverage for twelve months without a sixty-day gap in coverage would be denied access to certain special enrollment periods. Finally, Iowa is requesting pass-through funding for a reinsurance program, but unlike other states that have requested or obtained a 1332 reinsurance waiver, Iowa is not putting up any of its own money for the program. There are serious questions as to whether the Iowa waiver request complies with certain procedural and substantive requirements of the 1332 innovation waiver program. There is also the matter of how Iowa can possibly implement its program by November 1, 2017, unless it has been putting its program in place without waiver authority. The federal comment period ends on October 19, 2017, and it is very hard to see how CMS could meaningfully consider comments and approve the program for implementation on November 1. Limits And Disclaimer Regarding Use Of Health Plan Quality Star Ratings Finally, on September 19, 2017, CMS released a frequently asked question at its website stating that agents, brokers, and insurers directly enrolling individuals through will only be allowed to display health plan quality star ratings in Virginia a[...]

Non-Emergency Medical Transportation: Will Reshaping Medicaid Sacrifice An Important Benefit?

Wed, 20 Sep 2017 15:09:14 +0000

Medicaid delivers care to 74.5 million individuals for less money than any other large-scale health financing mechanism. A 2016 Henry J. Kaiser Family Foundation study noted that “spending per enrollee is lower for Medicaid compared to private insurance after controlling for differences in sociodemographic and health characteristics between the two groups.” One reason might be that Medicaid covers certain inexpensive, non-medical services that, when delivered early in the progression of chronic diseases, can check or slow the diseases, thereby improving beneficiaries’ health and saving money. One non-medical service—transportation to medical appointments—has been part of Medicaid since its inception in 1966 and addresses one of the socioeconomic disadvantages that prevent Medicaid beneficiaries from accessing health services. It is suggested that 3.6 million Medicaid beneficiaries “miss or delay care” annually due to transportation problems. Although non-emergency medical transportation (NEMT) is a mandatory Medicaid benefit, states can limit its availability through federal waivers. As Medicaid enters a period of unprecedented experimentation and, potentially, reduced federal resources, NEMT remains a critical feature of the program. NEMT In Context Since its inception, Medicaid has provided beneficiaries with transportation to medically necessary health care services. NEMT is found as early as 1966 in the “Handbook of Public Assistance” (Supplement D), the program’s earliest comprehensive federal interpretive guidance. Additionally, as part of the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit, states are required to offer children (from birth to age 21) and their families “necessary assistance with transportation” to and from providers. In practice, NEMT provides Medicaid beneficiaries who lack the means to travel to and from medical appointments with the most appropriate and least costly form of transportation, which may involve the use of livery vehicles, vans, or public transit. Despite federal funding and regulations, Medicaid is best understood as a set of diverse state-directed programs. This diversity carries into NEMT, as states deploy several models to manage and finance the benefit: Dominant model: brokers and managed care organizations (MCOs). The majority of states have evolved to deliver NEMT through NEMT-focused brokers or MCOs (which typically subcontract with NEMT brokers). In most of these states, the broker or MCO receives a capitated payment to manage the NEMT benefit. Other models: State entities: A few states rely on government entities such as Departments of Transportation to provide the service and directly fund those entities through an annual contract to reimburse ride providers on a per-ride (fee-for-service) basis. Local service providers: Other states deliver NEMT through county or municipal ride services that may, in turn, fund independent taxi companies—and pay these transportation providers on a fee-for-service basis. For several reasons, states have increasingly chosen NEMT brokers and MCOs over the other models. As in fee-for-service in medical care, there is worry that fee-for-service transportation incentivizes overuse, and it has been linked to program integrity problems in a few states. In contrast, most NEMT brokers receive a capped amount of money and therefore need to manage limited funds by, for example, assuring the assignment of the least expensive appropriate form of transportation necessary and monitoring trip information to identify the most efficient, highest-quality ride providers. Due to lags and gaps in national Medicaid data, it is challenging to compile a contemporary snapshot of NEMT usage, although transportation researchers at Texas A&M estimated $2[...]