Tag: State News

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REFORM- Why Medicaid is ‘ripe for innovation’

 
 

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Some decent arguments on why the tech money guys should place more bets in Caid.

 
 

 
 

Clipped from: https://www.beckerspayer.com/leadership/why-medicaid-is-ripe-for-innovation.html

Medicaid startups receive significantly less outside investment compared to Medicare Advantage organizations, but there’s still key opportunities to innovate under the program and serve enrollees in new ways.

According to a Feb. 27 article in Health Affairs, the top 10 MA-focused startups have raised more than $20 billion combined in venture funding, compared to $1.5 billion for the top 10 Medicaid-focused startups. But in 2021, CMS spent $734 billion on Medicaid, compared to $427 billion on MA in 2022.

“Medicaid is ripe for innovation, as startups serving Medicaid enrollees have received an order of magnitude less funding than their MA peers, despite almost double the market size,” the authors wrote. “COVID-19 has removed cultural and regulatory barriers to technological adoption, and increased interest by private investors.”

According to the authors, Medicaid has noticeably less outside investment compared to MA because the program is different in each state and caring for beneficiaries can be more challenging. 

Still, they wrote that four key opportunities exist for Medicaid startups to better serve members in the future: improve thin margins by utilizing new software and technology solutions, address social determinants of health to improve care quality, focus on health equity as an opportunity for cost savings, and move to align payments with improved care outcomes.

“So much of Medicare innovation has been about revenue optimization,” Rajaie Batniji, MD, PhD, co-founder and CEO at Waymark, told Becker’s. “In Medicaid, there’s no revenue optimization game to be played. What you need to do is actually improve care delivery.”

San Francisco-based Waymark is eighth on the list of Medicaid startups that have raised the most outside capital — the company closed on a $45 million financing round in January 2022.

Launched in 2021, Waymark manages a network of community health workers, pharmacists, behavioral health therapists and coordinators in clinics to manage care between Medicaid patients and primary care providers. Starting this year, the company has partnered with Aetna’s managed care plan in Virginia to provide community-based care services in the Richmond and Tidewater areas. 

“There’s a lot more stability and a lot more opportunity in Medicaid because of the fact that you’re actually forced to focus on truly improving outcomes rather than improving risk scores,” Dr. Batniji said, referring to recent MA risk adjustment changes from CMS.

Dr. Batniji shared that while there are many different Medicaid programs across the country, there are also many commonalities that allow beneficiaries to receive community-based care. 

He believes investors have stepped away from Medicaid largely for two reasons: lower margins compared to MA, and because Medicaid enrollees spend less time enrolled in the program compared to MA members on average, meaning desired outcomes need to be achieved more quickly. But Dr. Batniji also points out that there’s significantly more Medicaid members out there, suggesting that a lot more opportunity exists — if the right care model does.

CMS reported 81 million Medicaid members in 2022, compared to about 31 million MA members as of February 2023. 

“There’s a huge opportunity to bring proven interventions around community-based care in partnership with local providers that health plans are already working with to improve outcomes and to meet the goals and objectives of patients, providers and state regulators in one maneuver,” Dr. Batniji said.

 

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How Louisiana plans to spend $196M during Medicaid redeterminations

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: About 30% of it will go to Big Hospital and pharmacies to make sure they can keep Medicaid revenues going (er, I mean “enrollee outreach.”) Some will go to a public awareness campaign (about 6%), about 6% ($11M) will go to hire more state staff to process eligibility and existing state staff will get a modest raise ($1.3M). So all told about 88% of the money budgeted to make sure Medicaid redeterminations go well is going to the private sector. Seems legit.

 
 

 
 

Clipped from: https://www.beckerspayer.com/payer/how-louisiana-plans-to-spend-196m-during-medicaid-redeterminations.html

Louisiana is planning to spend $195.8 million as it redetermines Medicaid eligibility for the roughly 2 million residents receiving benefits from the program, according to the Louisiana Illuminator. 

The funding will be split over the next two fiscal years, according to the report. In the current budget cycle — which runs through June — Gov. John Bel Edwards’ proposal calls for $106.6 million in federal funding, according to the report. In the next fiscal year, $89.2 million will be budgeted, composed of an equal amount of state and federal funds. 

Of the $106.6 million allocated during the current budget cycle, $66.4 million will go to hospitals, pharmacies and nonprofits to help connect Medicaid enrollees with the state health department, according to the report. Another $11 million will be allocated to hire more staffing for the health department’s call center, Medicaid mail center and Medicaid eligibility unit. Current Medicaid eligibility staff members will receive $1.3 million in extra pay. 

Additionally, $12.8 million will be spent in the current fiscal year on a statewide promotional campaign that includes billboard, newspaper and radio advertisements about the Medicaid enrollment process, according to the report. Another $4.2 million will be used on fliers, letters and stamps targeting enrollees. 

The $89.2 million allocated in the next budget cycle will continue some of those initiatives, according to the report. Funding will also be used for a social media campaign, community canvassing, and technology upgrades to improve Medicaid tracking. 

The Louisiana Legislature’s staff anticipates that 355,000 people will be removed from the state’s Medicaid rolls over the next year, while the state health department estimates the figure will be between 280,000 and 350,000, according to the report.

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TECH- House moves toward using Medicaid data to enroll families in free and reduced-price lunch program

 
 

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Automatically enrolling Medicaid kids in free lunch programs moving forward in NH. Right now the argument is whether to have an opt-in model or just do it.

 
 

 
 

Clipped from: https://newhampshirebulletin.com/2023/03/29/house-moves-toward-using-medicaid-data-to-enroll-families-in-free-and-reduced-price-lunch-program/

 
 

Allowing Medicaid direct certification could help the state sign up an additional 7,000 students for free and reduced-price lunches who qualify now. (Amanda Mills | Centers for Disease Control and Prevention)

For families making up to 185 percent of the federal poverty level, New Hampshire public schools offer free or reduced-price lunches, a federal program intended to reduce childhood hunger among low-income residents. But first comes an application. 

In order to get the discounted prices for lunches, a parent or guardian must write down the income of everyone in the family – including kids, if they are working – note how often the income arrives, and record any additional payments like alimony or regular support from relatives. Then, the parent must send the application back to the school, whether through their child, in person, or online.

This year, New Hampshire is considering a different approach: Medicaid. A federal program created in 2010 would automatically enroll students in free and reduced-price lunch plans using Medicaid enrollment data. That data includes families’ incomes already, eliminating the need for an application in most cases. 

Last year, Gov. Chris Sununu opted against signing up the state for the program. At the time, he said he wanted the Legislature to direct him to do it in statute. That decision meant that the state cannot participate in the program in the upcoming 2023-2024 school year; the earliest it can participate if it applies to join this year is the 2024-2025 school year. 

This year, lawmakers appear prepared to give Sununu that direction. The House Finance Committee voted to recommend House Bill 601 on Tuesday, requiring the state to enter the program, known as Medicaid direct certification.

Hunger prevention advocates are optimistic. Allowing Medicaid direct certification could help the state sign up an additional 7,000 students for free and reduced-price lunches who qualify now, said Laura Milliken, executive director at New Hampshire Hunger Solutions. That change could make a meaningful difference to many lower-income students’ nutrition, she said. 

“It’s disappointing to us that we couldn’t get it done sooner, but we’re hopeful that it does get done because people are having a hard time right now,” Milliken said in an interview. 

But House Republicans have also added an amendment to the bill that would require participants to opt in to the direct certification program, an addition that would make New Hampshire’s program unique among the 39 states that currently participate. 

“We are opposed to opt-in language and worry that it would not be consistent with the goals of the Medicaid direct certification pilot program,” Milliken said. “Thirty-nine other states are participating in the pilot program and none of them uses an opt-in.” 

Still, Milliken said the organization is supporting the broader bill. 

For many families that meet the income requirement for free and reduced-price meals – up to $55,000 per year for a family of four – entering the program can be a major boost; children receiving reduced-price meals pay 40 cents for each lunch, compared to up to $4 per lunch for those not qualifying. But not every family applies, and schools must adopt strategies to persuade them to participate. 

Proponents say joining the Medicaid direct certification program would help school districts recoup more money from the federal government for their meal programs. It would also lead to a more accurate count of the number of students receiving free or reduced-price meals, a key number that determines how much each district receives in state adequacy funding.

States are barred by federal law from accessing their residents’ Medicaid data without express permission. The Medicaid direct certification program grants that permission to the states that have enrolled. 

But some Republican lawmakers have voiced skepticism over entering the state into the program, a move they said could subject the state to more federal rules. Instead, those opponents have suggested finding ways to utilize the state’s Medicaid data without federal involvement. 

“Though the necessity of providing funding for an adequate education is clearly a matter of interest to this committee, so too is our duty to jealously guard our state sovereignty,” wrote Rep. Arlene Quaratiello, an Atkinson Republican.

Supporters say the program would provide schools a new tool to help students whose families may not be signing up for free and reduced-price lunch due to lack of awareness, forgetfulness, or stigma. Some kids and families are reluctant to sign up, fearing embarrassment at school, advocates say.

The issue gained new urgency last year, when a COVID-era temporary federal initiative came to an end that allowed all students to receive meals at school, regardless of income. That change forced schools to kick off awareness campaigns to remind parents that they now needed to apply for free and reduced-price lunches if eligible.

“In most school districts, free and reduced meal participation is still down,” Milliken said, comparing current numbers to pre-COVID-19 numbers. “You have to think about the fact that there are families whose kids started school during the pandemic who didn’t know that there was (an application) because they didn’t need to apply for free and reduced-price lunch.”

She added: “I think schools are doing their darndest to get people to know if they can sign up, but I think it underscores why something like Medicaid direct certification is so important, because people at this moment in time have so much on their plates.” 

The amended bill must survive a vote on the House floor next week, as well as the Senate process. A bipartisan group of senators endorsed the idea last year, indicating that there could be support this year. But a number of new senators have entered the chamber since the last election. 

Speaking to the House Finance Committee in March, Sununu said he had set aside $30 million in his proposed budget to fund the administration of the Medicaid direct certification program in New Hampshire. But he again left it to lawmakers to approve the creation of the program in state law.

“You can debate whether you should or shouldn’t do that,” Sununu said. “My budget builds in the opportunity that if you do that, it’s all good.”

Addressing Sununu, Rep. Mary Heath, a Manchester Democrat, showed appreciation for the new stance. “I think that’s a win-win for our state, and I’m certainly hoping that this body will go along with that.” 

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PROVIDERS (NH)- ‘We’re teetering on the edge.’ Are Medicaid rates making it harder to age at home?

Clipped from: https://newhampshirebulletin.com/2023/03/22/were-teetering-on-the-edge-are-medicaid-rates-making-it-harder-to-age-at-home/

 
 

 
 

 
 

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Two main HCBS providers are saying they are out if they don’t get millions more in this year’s budget theater.

 
 

 
 

Edrie Fortin, with nurse Ellen DeStefano, was able to age at home in Manchester thanks to in-home care she received from Waypoint of New Hampshire through the Medicaid-funded Choices for Independence program. Fortin died in 2022 at age 95. (Courtesy | Waypoint of New Hampshire)

Instead of living in nursing facilities, nearly 3,800 Granite Staters are in their own homes and communities thanks to the help they receive with basic needs like bathing, transferring from a wheelchair to bed, managing medications, making meals, and getting to medical appointments.

Approximately 600 of them risk losing that care in July if the state doesn’t increase what it’s paying providers through the Medicaid-funded Choices for Independence (CFI) program, which covers the cost of housekeeping and personal care services for people who want to age at home and qualify for Medicaid.

The heads of Ascentria Care Alliance and Waypoint of New Hampshire, who have 600 CFI clients between them, said they will leave the program in July if lawmakers do not increase their Medicaid payments. They said they’ve stayed in the program this long only by fundraising to cover their losses.

It’s still early in state budget negotiations, but their rate requests far exceed the 3.1 percent increase Gov. Chris Sununu has proposed in his two-year budget. Their departure would leave their clients few options; the state has a massive shortage of direct care workers, and long-term care nursing facilities are full.

“It’s turned into, we used to subsidize (the care) somewhat, to now, it’s going to break the organization if it continues at this rate,” said Angela Bovill, president and CEO of Ascentria. “It’s not that we don’t care. We haven’t stopped caring or we wouldn’t have been subsidizing it the last bunch of years. But the subsidy numbers are getting so high, that it’s no longer even a viable question.” 

It’s been a moral and practical decision, Bovill and Borja Alvarez de Toledo, president and CEO of Waypoint, said.

Even with fundraising and temporary American Rescue Plan money, Ascentria and Waypoint  said they can’t pay their direct care workers more than $13.50 an hour, so little that in 2020, 32 percent of those in New Hampshire relied on some kind of public assistance, according to PHI, a national policy organization focused on elder care and disability services. 

“I can’t go to sleep at night and continue to treat the staff that we hire this way because it’s not right,” said Alvarez de Toledo. “And we’ve been doing it because we care about the seniors. And who’s going to take care of them? At some point, I’m like, ‘Wait a minute, is this our responsibility? Do I have to, year after year, raise half a million dollars to just break even in this contract?'”

 
 

Doris Morton, an in-home-care provider at Ascentria Care Alliance, cares for Irene Rousseau of Concord. (Courtesy | Ascentria Care Alliance)

Amy Moore, director of in-home care at Ascentria, said it has become so hard to recruit staff at that salary that her agency is turning down 100 client referrals a month and increasingly relying on families or close friends to provide CFI services. 

About four years ago, about 40 percent of the agency’s care givers were family members and friends caring for a loved one. Now it’s 90 percent, Moore said.

“Those people have all had to leave careers, move, and uproot their lives,” she said. “Those family members are the only reason, frankly, we still have a program going, and we’re teetering on the edge. That’s a very broken system.”

The fragile finances are hurting clients, too, Alvarez de Toledo said.

Unable to recruit or retain workers, Waypoint is providing clients fewer services than what they’ve qualified for. “They’re authorized for 25 hours, and you say, ‘Well, I can only give 12. That’s what they’re getting from us,” Alvarez de Toledo said. “And that’s not OK either.”

Services approved versus services provided

A 2021 federal lawsuit against the state Department of Health and Human Services alleges it paid for only 55 percent of the services it approved for CFI clients in 2018 and 2019. New Hampshire Legal Assistance, Disability Rights Center – New Hampshire, AARP Foundation, and the Nixon Peabody law office, who brought the case on behalf of four plaintiffs, have asked a judge to certify it as a class action lawsuit.

Jake Leon, spokesman for the Department of Health and Human Services, said there are a number of reasons why CFI participants do not receive all their authorized services. They often don’t request the transportation services they could, or they don’t receive them because they are in the hospital or a short-term rehabilitation center for a surgery, illness, or some other reason, he said in an email. Concerns about COVID-19 have led some to forgo services, he said. Others have very specific preferences about which worker delivers services in their home.

The New Hampshire Fiscal Policy Institute identified additional reasons in a 2022 analysis.

The workforce shortage was a big one but not the only one. Determining financial eligibility for Medicaid can be very complex, it said. There can be long waits for documentation and approval, and finding the right information or methods for applying for Medicaid can be difficult. And getting approval for services for in-home care can take longer than those for provided in nursing homes.

In Oct. 2021, the median processing time for Medicaid application approval was 36 days for nursing facilities and 45 days for CFI services, the analysis found. In some cases,  the wait was 90 days, it said. “These long delays mean people may not receive critically needed services,” the report said.

$153.2 million in lost funding

CFI services are available to people who are over 18, have a chronic illness or disability, qualify for nursing-home level care, and are eligible for Medicaid. The state sets the reimbursement rate and splits the cost with the federal government. 

It’s a much less expensive way to care for people who would otherwise go to a nursing home.

A year of CFI services costs less than $20,000 compared to $80,000 to $100,000 for a nursing home, Alvarez de Toledo said. And nursing homes can’t accommodate hundreds of new patients. As it is, the state’s hospitals say they are unable to discharge patients to long-term care, sometimes for weeks, because nursing homes have so few available beds. 

But the state has not funded the CFI program as generously as it has nursing home care, according to the New Hampshire Fiscal Policy Institute analysis.

 
 

In a 2022 analysis, the New Hampshire Fiscal Policy Institute found that organizations providing in-home care through the Choices for Independence program would have received an additional $153.2 million between 2011 to 2021 if the state has more closely kept up with inflation. (Screenshot | New Hampshire Fiscal Policy Institute)

 It found that the state’s Medicaid payments to nursing facilities kept better pace with inflation than its CFI payments for in-home care did. Between 2011 and 2021, the CFI providers would have received an additional $153.2 million had the state adjusted their Medicaid rates for inflation the same way it did for nursing home services, the institute found.

‘If I said to you, ‘We’re going to develop a program that makes the client happy, keeps the client in their home, saves the state money, benefits the hospitals, and benefits the nursing homes,’ you would say, ‘Where can we implement this program?'” said Keith Kuenning, director of advocacy at Waypoint. “We have that program. Right now. It’s ongoing in New Hampshire, except the program is on the verge of collapse because they won’t fully fund it the way that they need to.” 

‘I’m not sacrificing the people who work for us’

Leon said his agency supports the kind of comprehensive review of CFI rates that’s called for in Senate Bill 86. The bill would also put $40 million each of the next two years into Medicaid rate increases, but it is not yet determined how that will be divided up.

There’s lots of competition for that money. The state’s 10 community mental health centers, which rely on Medicaid for 70 percent of their budgets, requested a 21.5 percent to 23 percent increase in their rates.

Leon noted that the department requested and received funding from the Legislature to increase what it pays for CFI services over the last five years. He said in fiscal year 2022, payments for personal care services increased 15 percent, while payments for homemakers services rose by 6 percent. Leon said rates have increased since 2018 by 3 percent or 4 percent each year. 

Kuenning characterized those numbers as accurate – but misleading. 

For at least a decade, the state has paid CFI providers less than the cost of delivering CFI services, he said. A 6 percent increase on an underfunded system is not sufficient, he said.

“If those were adequate, why is Ascentria losing $1.5 million a year? Why are we losing $500,000 a year?” said Kuenning of Waypoint’s work with its 200 clients. “It’s true that they’ve given us the raises, but honestly, it doesn’t do enough to make a difference to keep our program running.”

Leon said the department has invested $30 million in federal money into increasing the workforce with retention and hiring bonuses and stipends. The agency also worked with the state Department of Employment Security to recruit and train additional service workers, he said.

Providers like Ascentria and Waypoint argue that solving the workforce shortage must begin with an increase in their $13.50 hourly wage, which would require rate increases,  not only temporary stipends and bonuses.

When asked about potentially losing Waypoint and Ascentria in the CFI program, Leon said, “A loss of provider may impact the provision of service to New Hampshire’s most vulnerable citizens, but a thorough analysis would be necessary to determine the extent of that impact.”

It looks certain that Medicaid rates will increase in the next budget. Sununu’s proposed 3.1 percent annual increase won’t be enough, according to Medicaid-funded organizations. 

Ascentria and Waypoint said their requested 11 percent increase for homemaker services would bump that hourly payment from $21.60 to $24. The 33 percent increase they are seeking for personal care services would bring that hourly payment from $22.48 to $30. 

It would be enough just to break even, Bovill and Alvarez de Toledo said. It wouldn’t be enough to pay a competitive wage or give clients all the services the state has said they qualify for, they said. 

“As mission driven organizations, we can’t say, ‘Well, we’re delivering our mission to seniors because we’re really not’,” said Bovill. “I’m not sacrificing the people who work for us on behalf of an attempt to care for some other people, because then everybody fails. And I can’t see how that’s an acceptable answer to anything.”

This article was written with the support of a journalism fellowship from The Gerontological Society of America, The Journalists Network on Generations, and the John A. Hartford Foundation.

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Safety-net providers sue to stop Medicaid carveout

 
 

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Facilities that make lots of money off the 340B scam are now resorting to “equity” as their last defense against the long-planned reform in NY.

 
 

 
 

Clipped from: https://www.politico.com/newsletters/weekly-new-york-health-care/2023/03/27/safety-net-providers-sue-to-stop-medicaid-carve-out-00088890

By ZACHARY SCHERMELE 

03/27/2023 10:00 AM EDT

Presented by HANYS and GNYHA

Beat Memo

Two safety-net providers are taking the state Health Department to court in a last-ditch effort to prevent a disputed Medicaid carveout from taking effect.

Evergreen Health, along with Heritage Health and Housing, a not-for-profit that operates a federally qualified health center in Harlem, filed a lawsuit in New York Supreme Court on Friday seeking an injunction of the carveout before it takes effect April 1.

They allege the long-planned effort to merge Medicaid pharmacy benefits under a single state program violates federal law and is discriminatory.

The litigation escalates an ongoing battle at the eleventh hour over the proposed change to how millions of New Yorkers will soon access their medication. The plan, a remnant of Gov. Andrew Cuomo’s last fiscal budget proposal, in 2021, could potentially save the state hundreds of millions of dollars, according to Gov. Kathy Hochul’s proposed budget.

But fierce opposition, mainly from safety-net providers who financially depend on a decades-old federal program known as 340B, which would be sidelined under the new rules, stalled the reform for years.

At a budget hearing in late February to discuss the carveout, Housing Works CEO Charles King was one of several protesters arrested on trespassing charges after disrupting the proceedings to oppose the measure.

New York City Mayor
Eric Adams and Ashwin Vasan, the city’s health commissioner, have also come out against the carveout, saying it would disproportionately harm LGBTQ patients and patients living with HIV.

“DOH will wreak immeasurable harm upon New York’s safety-net health care providers and the largely low-income persons dependent upon those providers for their health care and medications,” the complaint says.

Supporters of the program, including the Pharmacists Society of the State of New York, say that community pharmacies need it to survive, and that the change would allow patients greater access to choose where they get their medications.

The New York State Health Department did not immediately respond to a request for comment on Sunday.

IN OTHER NEWS:

— No one spoke up for or against proposed rate changes to ambulance fees in New York City at a public hearing Friday, leading FDNY officials to close the hearing early. The changes, which were first reported by POLITICO, would raise the cost of basic life-support ambulance services to $1,385 from $900. They would also charge patients $20 per mile traveled rather than $15, among a few other hikes.

The new fee schedule would ultimately bring in more than $16 millions in revenue for the city in fiscal year 2024, an FDNY spokesperson told POLITICO in February. It is expected to go into effect in the spring.

In a written statement to the FDNY, David Jones and Stephen Krause, the president and executive vice president of the nonprofit Community Service Society, opposed the new fee schedule, saying it would have the “unintended consequence of compelling New Yorkers to forgo medically necessary ambulance services to avoid the prospect of a large bill.”

ON THE AGENDA THIS WEEK:

Tuesday at 10:30 a.m. — The Cannabis Association of New York will hold a press conference as it lobbies lawmakers in Albany.

Thursday at 10 a.m. — The New York City Council’s Health Committee will hold an oversight hearing on improving access to in-community and at-home health care.

GOT TIPS? Send story ideas and feedback to Maya Kaufman at mkaufman@politico.com.

Want to receive this newsletter every weekday? Subscribe to POLITICO Pro. You’ll also receive daily policy news and other intelligence you need to act on the day’s biggest stories.
 

Odds and ends

NOW WE KNOW — Having trouble sleeping? You might live in the wrong city.

TODAY’S TIP — Could the causes of eczema be in the air we breathe?

STUDY THIS — The use of certain hormonal birth control methods may be associated with a 20-30 percent increased risk of breast cancer, according to researchers at Oxford.
 

What We’re Reading

— Patients on the drug aripiprazole should be better informed about the risks of gambling addiction, The Guardian reports.

— Via the Huffington Post: The Ozempic craze has pushed people in eating disorder recovery a step closer to relapsing.

— U.S. life expectancy remains on the decline relative to other countries.

— Cannabis use at older ages can carry special risks. Read what they are.

— The first signs of Alzheimer’s might be in your eyes, new research suggests.

— Via The New York Times: “Philadelphia tells residents to consider bottled water after chemical spill”
 

AROUND POLITICO

— Florida is using a little-known law to punish abortion clinics, reports Arek Sarkissian.

MISSED A ROUNDUP? Get caught up on the New York Health Care Newsletter.
 

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RX- Another Voice: Medicaid pharmacy program reform is greatly needed

 
 

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: An op-ed in favor of reforming how NY Medicaid pays for Medicaid drugs.

 
 

 
 

 
 

Clipped from: https://buffalonews.com/opinion/another-voice-medicaid-pharmacy-program-reform-is-greatly-needed/article_8831c81e-c4c9-11ed-8f1d-c7a7f811ea6c.html

SUBSCRIBE: $1 for 3 months

New York is reforming its Medicaid pharmacy program to remove managed care and pharmacy benefit managers (PBMs) and directly administer these benefits for enrollees. This change cannot come soon enough.

Health insurance plans and PBMs are paid to administer the pharmacy program and patients are required to participate in one of 16 managed plans. They can only use pharmacies in the PBM network. Patients are precluded from using a pharmacy that may be in their neighborhood or close to their place of work.

When a managed care plan in Ticonderoga recently dropped one of the only two pharmacies in the area from its network, patients were unable to obtain needed medications. We must do better than having the state pay financially motivated corporations to make business decisions that disrupt and restrict patient access to needed care.

Plans have their own drug formulary. Medicaid enrollees can only use drugs on the plan formulary, which means that what may be covered for one patient may not be covered for another. The current system also imposes significant administrative burdens on prescribers to comply with the complex maze of plan requirements, protocols, processes and paperwork in order to help our patients get the drug coverage they need and deserve. Every day, physicians deal with plan and PBM denials, delays and rejections that waste their time and delay patient access to treatment.

Come April 1, News York State will launch the New York State Medicaid pharmacy program known as NYRx. It will provide one formulary covering all FDA-approved medications. NYRx has one set of rules for prescribers and will provide better access to lifesaving therapies for Medicaid patients.

The New York State Academy of Family Physicians was the first medical society in New York to advocate for a single payer system of universal health. We see the state’s decision to launch NYRx as a first and transformative step toward reform of health care in New York.

Absent enactment of single payer legislation, the academy has advocated for streamlining and standardizing health coverage to reduce administrative burdens and make health care easier to access for patients and for those who care for them. NYRx will simplify the pharmacy benefit for all with Medicaid. Patients will not be limited by pharmacy network requirements and varying plan requirements and processes. Also, removal of for-profit health plans and PBMs from this benefit will save money that can be applied to Medicaid coverage and patient services.

Health plans, PBMs and others oppose NYRx. The governor and Legislature must resist these efforts. New Yorkers with Medicaid need a simplified and standardized pharmacy benefit directly administered by New York State, as was the case a decade ago. NYRx is a model for the much broader system reforms we continue to advocate for to benefit all New Yorkers.

Dr. Andrew Symons, of Tonawanda, is president of the New York State Academy of Family Physicians.

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FWA- If the government cut Medicare fraud, it wouldn’t have to cut Medicare

 
 

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Ruh-roh. Yet another person saying the quiet part out loud.

 
 

 
 

Clipped from: https://thehill.com/opinion/finance/3910370-if-the-government-cut-medicare-fraud-it-wouldnt-have-to-cut-medicare/

 
 

iStock.

President Biden says he’s not gonna let Republicans cut the financially challenged Medicare program. “A lot of Republicans, their dream is to cut Social Security and Medicare,” Biden said in February. “Well, let me say this: If that’s your dream, I’m your nightmare.” Well, how about at least cutting Medicare fraud?

Medicare and Medicaid fraud is rampant. The National Health Care Anti-Fraud Association recently estimated Medicare and Medicaid fraud totaling about $100 billion a year. Others believe that’s a conservative estimate.

New video from CNBC’s Contessa Brewer highlights some of the problems in South Florida, which is ground zero for Medicare fraud. Brewer says the “business of stealing Medicare and Medicaid cash has never been as brazen.”

Maybe, but it’s been very brazen for decades. A young Chris Wallace, then with ABC, reported on Medicare fraud in 1994. And here’s a “60 Minutes” report from 13 years ago in which reporter Steve Kroft warns viewers that the story may raise their blood pressure. And it should.

And while those stories are about Florida, here’s a decade-old National Public Radio story about a Texas doctor indicted for $375 million in fraudulent Medicare and Medicaid billing.

One reason criminals can steal so much is Medicare and Medicaid spend so much.

Total Medicare spending in 2022 was $982 billion, with $755 billion of that total coming from the federal government and $227 billion in premiums paid by Medicare beneficiaries to the government. Medicaid, which is a federal/state health insurance program for low-income families, spent $864 billion in 2022.

The federal government estimates that 7.5 percent of spending on traditional Medicare in 2022 was for “improper payments,” which includes both fraud and errors in billing.

For Medicaid, it was 15.6 percent.

What all the imprisoned criminals interviewed in these stories agree on is that defrauding Medicare and Medicaid is easy. Criminals open a small office because Medicare requires that vendors have an address. They put in a desk and chair, though there is seldom anyone actually in the office. Then they buy a list of stolen Medicare beneficiaries’ information and start billing the government.

The biggest scams often involve what’s known as durable medical equipment (DME), which includes a range of items such as wheelchairs, prosthetic limbs and oxygen-related equipment.

Note that this isn’t a rap on federal law enforcement trying to catch the fraudsters. They are doing their best, though they are understaffed and underfunded. And they do catch some of the criminals, as the news stories demonstrate.

Centers for Medicare and Medicaid officials boast that they have been reducing improper payments and fraud, and kudos to them for that. But no one really knows how much Medicare and Medicaid fraud there is, because many fraudsters may never be caught.

The best way to identify the criminals may be when they start getting really greedy. Here’s a good example from a series on Medicaid fraud that appeared in the New York Times in 2005. “It has drawn dentists like Dr. Dolly Rosen, who within 12 months somehow built the state’s biggest Medicaid dental practice out of a Brooklyn storefront, where she claimed to have performed as many as 991 procedures a day in 2003.”

Had Dr. Rosen kept her billings to, oh, say, 500 procedures a day, she might have stayed under the government’s radar. That’s a joke, but you get the point.

One Medicaid official in the Times story estimated that perhaps 40 percent of New York City’s Medicaid spending was fraudulent. 

Texas had its own Medicaid dental fraud. Several Texas dentists were charged and convicted of scamming the system of millions of dollars by putting braces on children who didn’t need them. As the Dallas ABC affiliate, WFAA, reported, “Medicaid records showed Texas spent $184 million on Medicaid orthodontics in 2010 — nine times more than California, which spent $19.5 million.”

It was WFAA that discovered and exposed the fraud, not federal or state officials.

The point is that if the federal government were better at preventing Medicare and Medicaid fraud, the programs could save perhaps $100 billion a year or more. While that wouldn’t solve Medicare’s long-term financial challenges, it would certainly help delay the day of reckoning.

No private sector company could survive with that much fraud. Credit card companies, and even private health insurers, have much lower fraud rates.

While no one defends the fraud, many politicians and bureaucrats don’t seem that interested in trying to fix it. Indeed, when Republican state legislators propose verifying state Medicaid rolls to ensure recipients are qualified, Democrats usually push back.

What’s clear is that there is a way to cut Medicare without hurting Medicare patients, and that’s to cut the fraud. But it’s much less work, and perhaps more politically rewarding, to just attack political opponents.

Merrill Matthews is a resident scholar with the Institute for Policy Innovation in Dallas, Texas. Follow him on Twitter @MerrillMatthews.

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MCOs- UPMC Review Confirms PA Medicaid as National Model for Behavioral-Physical Health

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Some highlights of what UPMC is doing in its whole-person model. TL/DR: increased SA treatment, increase primary care and increase screenings for SDH needs.

 
 

 
 

 
 

Clipped from: https://www.miragenews.com/upmc-review-confirms-pa-medicaid-as-national-971974/

PITTSBURGH, PA (March 22, 2023)—Experts from UPMC Health Plan and Community Care Behavioral Health Organization recently published a state mental health policy description that shows how Pennsylvania’s county-based model of Medicaid behavioral health managed care exemplifies the integration of services to support “whole-person” care. The piece appears in the journal Psychiatric Services.

In Pennsylvania, Medicaid behavioral health is funded through and managed by counties that contract with behavioral health managed care organizations. The counties also manage human services, such as those related to aging, children and youth, and housing. Having all these services coordinated under one umbrella allows for the use of a “human services integration” model for delivering Medicaid-funded behavioral health and other supportive services. This model supports engagement with physical health managed care organizations and multidisciplinary care teams for individuals with co-occurring medical health conditions.

“The strategies, lessons learned, and metrics we have outlined demonstrate that a whole-person approach to behavioral health care facilitates positive outcomes, coordinates community and physical health supports and resources, and aligns providers to focus on the best interest of the individuals we serve,” said Matthew Hurford, MD, President of Community Care Behavioral Health Organization and Vice President of Behavioral Health for UPMC Insurance Services. “Coordinating and managing care with county partners ensures a personalized approach to care that more smoothly and comprehensively integrates behavioral, physical and other needs.”

This whole-person care model has resulted in the following noteworthy outcomes:

  • The number of Community Care members receiving medication-assisted treatment—a highly effective form of substance use treatment that involves prescription medication and therapeutic support—increased 43 percent from January 2018 to June 2022.
  • Primary and specialty care use in a widespread health integration model increased over a two-year period by more than 30 percent, while overall medical costs decreased by 15 percent due to a reduction in hospital-based services.

 
 

  • Increased routine screening of social needs built into several managed care and provider-based care strategies resulted in connecting individuals with resources to address health disparity-related needs, including housing, food security, employment, and job training to better support long-term recovery.

“We believe this integrated approach leaves no stone unturned in addressing the clinical and other needs of individuals seeking behavioral health services,” said James Schuster, MD, Chief Medical Officer for the UPMC Insurance Services Division. “This kind of coordination and cooperation may, in part, be why Mental Health America once again rated Pennsylvania among the top three states in the country for addressing mental health challenges.”

/Public Release. This material from the originating organization/author(s) might be of the point-in-time nature, and edited for clarity, style and length. Mirage.News does not take institutional positions or sides, and all views, positions, and conclusions expressed herein are solely those of the author(s).View in full here.

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MH/BH- SAMHSA Gives $1M to 15 States Competing for Spot in CCBHC-Medicaid Demonstration

 
 

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: SAMHSA is restarting the CCBHC grants after a 7 year break.

 
 

 
 

Clipped from: https://bhbusiness.com/2023/03/21/samhsa-gives-1m-to-15-states-competing-for-spot-in-ccbhc-medicaid-demonstration/

States vying for spots in the Medicaid demonstration program for certified community behavioral health clinics (CCBHCs) are getting a financial boost from the federal government.

The Substance Abuse and Mental Health Services Administration (SAMHSA) awarded 15 states $1 million planning grants to help pay for the application and development process required to join a Medicaid demonstration program. The program increases funding for CCBHCs, and creates prospective payment models, giving CCBHCs the needed stability and flexibility to provide comprehensive behavioral health services.

However, only 10 states that get planning grants can join the demonstration program in 2024. This is an application year in the competitive process to join the Medicaid demonstration.

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“I think states that see the value in that model of care are really not inclined to wait around four to six years from now,” Rebecca Farley David, a senior advisor for the National Council for Mental Wellbeing, told Behavioral Health Business. “They want to go after it right now. They want to make those transformations. They want to start to see the results.”

Eventually, all states will have the chance to join the demonstration program. However, states that are actively reforming their mental health systems would rather not be left in the cold until the next round of admissions to the program in 2026.

This is the first time the federal government has released these planning grants since 2016.

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The states that got the planning grants are Alabama, Delaware, Georgia, Iowa, Kansas, Maine, Mississippi, Montana, North Carolina, New Hampshire, New Mexico, Ohio, Rhode Island, Vermont and West Virginia.

CCBHCs must provide nine core services, which give patients timely access to encompassing and coordinated mental health, addiction treatment and psychiatric services. 

The National Council for Mental Wellbeing, a nonprofit advocacy group, tracks more than 500 CCBHCs operating in 46 states plus Puerto Rico, Washington D.C. and Guam.

Only 10 states presently participate in the Medicaid prospective payment demonstration. The Bipartisan Safer Communities Act expanded the demonstration to include 10 new states every two years starting in 2024.

Safety net clinics that become CCBHCs in the first place can serve 900 more people than before receiving the designation, a 23% increase in access to behavioral health services, according to a National Council for Mental Wellbeing.

I think states that see the value in that model of care are really not inclined to wait around four to six years from now.

Rebecca Farley David, senior advisor for the National Council for Mental Wellbeing

The Medicaid demonstration program is meant to give CCBHCs the stability and financial security to provide expansive and coordinated services. After detailed negotiations between states and clinics that are influenced by federal guidance, states establish prospective per-day or per-month payments. In contrast, present Medicaid fee-for-service funding often fails to provide the margins needed to sustain community-focused clinics, David said.

The demonstration program is fundamentally different from the various waiver programs. Waivers are accessible to any state at any time. Demonstration programs are restricted in multiple ways — in this case, by the number of participants or other requirements.

The intensive nature of the demonstration program requires significant resources from states to apply and be ready for it, hence the planning grants from SAMHSA.

“When you look at the CCBHC model and what it requires of clinics and what it requires a state, it really is a very intense and transformative effort,” David said. “It’s not as simple as the states applying for the opportunity to be in the demonstration. They have to do all kinds of work during the planning year in order to become ready to participate in the demonstration should they be chosen.” 

The states certify their clinics and then develop new payment rates and models, billing and payment processes and make community needs assessments to measure how and which clinics will face demands for services, David said.  

The CCBHC model was created in 2014 via the Excellence in Mental Health Care Act. Since its implementation, CCBHCs have been able to increase staffing levels. In 2022, 450 active CCBHCs hired 11,240 new staffers as of August 2022.

Interest in the model has ballooned in recent years as the coronavirus pandemic revealed and worsened the nation’s behavioral health struggles. CCBHCs have received major backing and expansion from Congress via the most recent omnibus funding bill and the Bipartisan Safer Communities Act, which passed on the heels of the Uvalde, Texas massacre.

The interest in growing the model continues within the Biden administration. The administration’s proposed budget for the federal fiscal year 2024 includes extended funding for CCHBCs and several transformative efforts that total about $656 million.

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FWA (NY)- Schenectady ambulette service pays $800K over Medicaid fraud

 
 

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Ismat Farhan stole $862,000 from you via your W-2 using a services not provided scam for his ambulance company. He did not say thank you.

 
 

Clipped from: https://www.timesunion.com/news/article/schenectady-ambulette-service-pays-800k-medicaid-17849729.php

Ismat Farhan, owner of USA Medical Transport, will pay $862,500 to the New York State Medicaid Program, according to the settlement.

 
 

SCHENECTADY — New York Attorney General Letitia James on Monday announced a settlement with the owner of a Schenectady-based medical transport company that was found to have billed Medicaid at least $400,000 for transportation services that were not provided.

Investigators determined that Ismat Farhan, through his company USA Medical Transport, submitted more than 2,500 false claims where either the transportation services never happened, did not occur as described or lacked the required documentation, according to the settlement agreement.

“Medicaid is meant to help support the medical needs of vulnerable New Yorkers, not to pad a company’s profits,” James said in a statement. “Farhan and USA Medical Transport took advantage of their patients and taxpayers by billing Medicaid for thousands of services that were never provided.”

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Farhan will pay $862,500 to the state’s Medicaid program, according to the settlement.  

Under state and federal false claims law, state authorities can fine Medicaid providers up to three times the amount they can prove was fraudulently billed. It’s common for the state to settle with the provider for double the amount, according to the attorney general’s office.

USA Medical Transport is still providing services. An attorney for Farhan declined to comment on the settlement. The agreement requires 25 percent of the company’s Medicaid reimbursements to be held back to satisfy the settlement.

Medicaid recipients are eligible to receive transportation to and from appointments with health care providers. Medicaid reimburses enrolled transportation companies for these services. To operate as a Medicaid transportation provider, a transportation company must certify that it will follow the Medicaid program’s rules and regulations, including submitting claims only for services that took place and maintaining thorough records documenting those claims.

State investigators found that between June 2015 and February 2020, Farhan submitted fraudulent claims to Medicaid, including for rides that were not provided, mileage amounts significantly greater than the ride, single rides that should have been bundled as a group ride, and tolls that did not occur.

The company also reported rides by drivers with suspended licenses, including Farhan.

The investigation was conducted by the Albany Regional Office of the Attorney General’s Medicaid Fraud Control Unit. The unit seeks to identify Medicaid fraud and protect nursing home residents from abuse and neglect. Anyone with information about Medicaid fraud or about an incident of abuse or neglect of a nursing home resident can file a confidential complaint online or call the MFCU hotline at 800-771-7755.