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February 22, 2016

Washington Health Policy Week in Review Archive 685193b9-a1b1-4fc6-a627-2110eaad9e49

Newsletter Article


Medicare and Insurance Industry Officials Agree on Quality Metrics

By Andrew Siddons, CQ Roll Call

February 16, 2016 -- Public and private health insurance providers on Tuesday announced a new set of quality measurements meant to make reporting requirements for doctors and care providers more consistent and efficient. By easing the reporting complexity for clinicians, insurers are also hoping to bring down costs for themselves and consumers.

While individual payers currently utilize their own measurements, insurers have come together to agree on core measures in seven areas. The effort was led by the Centers for Medicare and Medicaid Services (CMS) and America's Health Insurance Plans, an industry trade group.

"Everywhere you go in healthcare, people ask for universally one thing–simplify, simplify, simplify," Andy Slavitt, the acting administrator for the CMS, said in a telephone briefing Tuesday.

Doctors currently deal with an average of seven or more insurers, each with their own system for measuring performance, according to Douglas E. Henley, the chief executive of the American Academy of Family Physicians. That means health care providers must pay attention to 50 to 100 measures, which "creates a lot of chaos and confusion," he said.

The new core set of 21 measures, "if harmonized across payers, would certainly simplify the life of every family physician," Henley added.

The new measurements will be adopted by CMS as well as many private insurers, ultimately covering around 70 percent of all health care payers. CMS, which already uses some of the new measurements, will begin implementing the rest of the changes, including eliminating redundant measures, through its rulemaking process later this year. Private insurers are expected to phase in the changes starting in 2017.

The core measures announced on Tuesday will be in seven areas, including: primary care; cardiology; gastroenterology; HIV and Hepatitis C; medical oncology; obstetrics and gynecology; and orthopedics.

The measurements are a result of an effort by many organizations, known as the Core Quality Measure Collaborative, and Tuesday's announcement won praise from numerous outside groups.

Carol Sakala, the director of childbirth connection programs at the National Partnership for Women and Families, said that by eliminating time wasted grappling with poorly-aligned measurements, the new measures would help doctors focus on providing high-value care to patients.

"When we ask them to devote precious resources to measurements, it will be for measures that matter," she said.

Groups representing cardiologists, however, pointed out that two measures aimed at patients with hypertension offer different blood pressure control targets. One of the measures is a less strict blood pressure control level tailored specifically to older patients with diabetes or kidney disease. The American College of Cardiology and the American Heart Association groups worry that the two levels might be misinterpreted. "These measures could confuse patients and providers," the groups said in a joint statement.

But the quality measures announced Tuesday can be adjusted as needed, said Slavitt, who encouraged patients and physicians to provide feedback. The collaborative that wrote the measures, he said, "will stay intact to monitor adoption of the measure sets and identify and release new measures that can be added over time."

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Arkansas Governor: Time Running Out for Medicaid Expansion

By Marissa Evans, CQ Roll Call

February 19, 2016 -- Arkansas Gov. Asa Hutchinson accused the Obama administration of inflexibility in its negotiations with the state over his proposal for an alternative approach to Medicaid expansion under the 2010 health care law, and he warned that the existing program may be allowed to expire at the end of the year if an agreement is not reached by April.

The Republican governor, in Washington for a gathering of the National Governors Association, said at a news conference that his administration's negotiations with the Department of Health and Human Services (HHS) for waivers to permit federal funding for his planned "Arkansas Works" alternative have not been going well. The program needs the waivers to allow provisions that require unemployed beneficiaries to be referred to job training programs and working beneficiaries to enroll in employer-sponsored plans. It would replace the expiring Medicaid expansion effort the state launched in 2014.

"This administration is not interested in a change in behavior [for beneficiaries], they simply want to provide the Medicaid benefits," Hutchinson said. "I'm interested in helping to encourage different behaviors."

Under the Affordable Care Act, state Medicaid programs could be expanded to include low-income enrollees who make up to 138 percent of the federal poverty line. The cost is 100 percent covered by the federal government until 2017, when states must take on a portion of the cost that will grow to 10 percent by 2020. Thirty-one states and the District of Columbia are participating in the expansion.

HHS Secretary Sylvia Burwell wrote in a Feb. 16 letter to Hutchinson that while his goals for the program are "quite innovative," some of them "push the bounds of what is allowed under Medicaid law" and could negatively affect beneficiaries. The Obama administration has thwarted states' efforts in the past to set work requirements as a condition of being in the program.

"With respect to your interest in incentivizing work, we agree with you that increasing employment in the state is an important state and federal objective," Burwell wrote. "We would like to work with you to identify potential solutions to support this goal, consistent with Medicaid's role as a health coverage program."

Burwell also wrote in her letter that she is committed to continuing a discussion about how to make job training and employment opportunities more attractive to beneficiaries.

Since inheriting the Medicaid expansion effort from his predecessor, Hutchinson has been pushing for an overhaul that he says would help move beneficiaries out of the program so they could afford to pay for health insurance themselves, and subsequently save the state millions of dollars. But, he said, ending the expansion program altogether would put a $100 million hole in the state budget. Hutchinson said he wants to secure the waivers before he presents his new plan to the legislature in April during a special session.

"To continue our Medicaid expansion, we need not only these reforms but we need a financial path to make sure we're not draining money from general revenues in terms of education and other essential needs of the state," Hutchinson said.

Arkansas' existing expansion program buys private health insurance for residents who qualify for Medicaid.

Hutchinson said that the proposed program's provision to require working people who qualify for Medicaid to sign up for employer-sponsored plans would save the state $29 million per year.

But timing is also an issue for Arkansas. The waivers the state is pursuing allow exceptions from the normal Medicaid expansion requirements set by HHS. Another type of waiver that gives states even greater flexibility have not been sought by Arkansas because, Hutchinson said, they don't "seem to be a priority" for the outgoing Obama administration.

"I see Medicaid expansion as a tool to move people up the economic ladder, and there's a lot of things you can do to encourage that worker training, to instill work as opportunities as the fabric of the program," Hutchinson said. "This administration can't do that because it's an entitlement. Once you qualify, you got it and you cannot put constraints on that."

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Michigan Seeks Medicaid Waiver for Flint Crisis

By Marissa Evans, CQ Roll Call

February 19, 2016 -- Michigan Gov. Rick Snyder, caught up in a national uproar over lead-tainted water in Flint, is exploring all possible sources of federal aid—including Medicaid and the Children's Health Insurance Program.

While the state expanded Medicaid coverage for 605,000 low-income residents in April 2014, Snyder this month filed for a new federal waiver that would allow 15,000 additional Flint residents to be covered. The Republican governor says more coverage for young patients and pregnant women "will mitigate the risks of lead exposure and result in better identifying any long-term health challenges, including behavioral issues."

Under the waiver, beneficiaries would have access to doctors, behavioral health specialists, nutrition support and other education and social services. The Centers for Medicare and Medicaid Services is reviewing the request.

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HHS Pushes Congress to Rescue Puerto Rico's Medicaid Program

By Melanie Zanona, CQ Roll Call

February 18, 2016 -- The administration is pressing Congress to strengthen Puerto Rico's ailing health care system as lawmakers weigh a slate of proposals to help the financially troubled territory.

The Health and Human Services Department (HHS) is seeking to gradually expand eligibility for Medicaid, the federal health insurance program for the poor, to 100 percent of the federal poverty line in Puerto Rico, as well as lift an annual cap on federal Medicaid contributions. The cap was $329 million in 2015.

HHS officials said on a press call Thursday that the current limit leaves the territory unable to effectively respond to public health emergencies, such as the Zika virus that is being spread by mosquitoes in Latin America and poses a threat to pregnant women and babies.

The White House is pressuring lawmakers to raise the federal matching rate in Medicaid from 55 percent to 60 percent, and eventually raise the federal share of Medicaid funds to 83 percent. The rates for U.S. territories are statutorily set at 55 percent, while the rates for states in the U.S. range from 50 to 75 percent.

HHS Secretary Sylvia Mathews Burwell and Treasury Secretary Jack Lew met with Puerto Rican labor leaders, religious officials, and business executives this week. HHS officials emphasized that a permanent solution to make the territory financially stable must include health care changes. There are 1.6 million Medicaid enrollees in Puerto Rico, but 600,000 people are at risk of losing their health care coverage because of expiring Medicaid funding and 3.5 million people on the island don't have access to routine treatments, according to officials.

The administration already moved to lower prescription drug costs earlier this year by providing Puerto Rico access to the Medicaid drug rebate program, but it is seeking additional legislative action from Congress, which did not provide financial aid to Puerto Rico in the fiscal 2016 omnibus spending law (PL 114-113). Lawmakers are still weighing how to address the commonwealth's debt crisis, including a plan (HR 4199) that would allow Puerto Rico to use the bankruptcy process in exchange for the creation of an oversight council.

Separately, President Barack Obama is requesting $250 million in an emergency supplemental funding package to help pregnant women in Puerto Rico combat Zika, which has been linked to birth defects. HHS officials say the women and children on the island are being primarily served by Medicaid.

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Officials Propose Increased Medicare Advantage Rates

By Kerry Young, CQ Roll Call

February 11, 2016 -- Senate Finance Chairman Orrin G. Hatch warned President Barack Obama's health secretary Thursday not to try to move toward direct federal negotiations on drug prices, though there is no indication that the administration is poised to do so.

The Utah Republican reminded Health and Human Services (HHS) Secretary Sylvia Mathews Burwell that the 2003 measure (PL 108-173) that created the Medicare Part D drug program deliberately assigned the task of negotiating pharmaceutical prices to the insurance companies that manage this benefit. Hatch told Burwell that he has heard "rumblings" that the White House is considering whether it could use an executive order to allow direct negotiations by federal officials to lower the costs of drugs in the Medicare Part D plans, which is projected to cover roughly $90 billion in purchases this year.

"Such an executive order would be in violation of the law, as the statute explicitly prohibits such interference in private negotiations," Hatch told Burwell on Thursday during a Senate Finance hearing on her department's fiscal 2017 budget request. 

Growing drug costs have become an increasingly hot topic in American politics. GOP presidential contender Donald Trump and the contestants for the Democratic slot, Hillary Clinton and Sen. Bernard Sanders, I-Vt., have spoken in favor of direct Medicare drug negotiations. In its fiscal 2017 budget request, the White House reiterated its support for allowing HHS to negotiate directly on certain expensive medicines, without fleshing out in great detail how this approach would work.

Burwell didn't directly answer Hatch's question about whether the White House has considered any executive action, instead emphasizing that her department is focused on both the needs of the developers of new medicines and of Americans facing high pharmacy bills. Burwell cited a forum on pharmaceuticals that HHS held in November as an example of her approach. 

"It's not just drug prices," Burwell said. "It's about innovation, which is why we actually brought everyone in for a conversation about both of those issues at the end of last year so that we could hear from industry as well as consumers in terms of the issue. As we think about it and the steps that we have taken, we are focused on both innovation as well as that affordability."

Burwell noted that Rob Portman, R-Ohio, had raised concerns about the impact of drug spending on deficits.

"We take that very seriously and are looking for the opportunities that we can do in terms of drug prices," said Burwell. She pointed out a series of steps that the administration has already taken to address concerns about prescription costs, including narrowing a Medicare coverage gap that forced seniors to shoulder some of their drug costs.

Before raising his concerns about Medicare Part D drug negotiations, Hatch complimented Burwell on her performance as HHS secretary. Senators agreed that Burwell has reached out actively to lawmakers in both parties, even amid continuing deep partisan splits over the implementation of the 2010 health care law.

"I want to keep working with you," Hatch said. "Listen to our side, too, and maybe you'll get a lot done."

At the hearing, Burwell addressed a wide range of issues. She promised to follow up on concerns that Sen. Johnny Isakson, R-Ga., raised about seemingly slow progress at the Food and Drug Administration on the review of new sunscreen ingredients. She and Sen. Rob Portman, R-Ohio, discussed their mutual interest in taking steps to curb the widespread use of opioid painkillers that has often served as a pathway to narcotic addiction and heroin use. And Sen. John Thune, R-S.D., asked Burwell to address long-standing concerns about Indian Health Service operations in his state, as Rep. Kristi Noem, R-S.D., had done at a House Ways and Means Committee hearing on Wednesday. 

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Ambitious CMS Hip-Knee Pilot Program on Track for April Start

By Kerry Young, CQ Roll Call

February 16, 2016 -- Medicare appears on track to start in April a test program that will make about 800 hospitals financially responsible for how well people fare after knee and hip replacements, despite pleas from industry groups for more time to prepare for the major reimbursement change.

The Centers for Medicare and Medicaid Services (CMS) seems unlikely to offer further concessions on its Comprehensive Care for Joint Replacement (CJR) program after having last year shifted away from the original January 2016 start date. The draft proposal for the CJR program was first unveiled in July 2015. 

The debut would contrast somewhat with how some other federal rules on medical payments have been handled, said Todd Johnson, chief executive officer of HealthLoop, a Mountain View, California-based company that has developed tools for automating ways for doctors to check in easily with their patients. The implementation of the ICD-10 medical billing codes, for example, was repeatedly delayed due to objections from doctors before taking effect last year.

"In terms of new regulations, that's pretty darned quick coming through CMS. Hospitals have gotten used to constant delay" on agency proposals, said Johnson, whose firm developed a kit to help hospitals prepare for the CJR program.

Officials at CMS "say they are going to do something but then they push it back, they push it back, they push it back," Johnson said. "Not in this case."

The agency has stuck with a requirement that hospitals within 67 selected regions participate in the hip-and-knee program, despite complaints from providers. The 67 areas of the country sweep in hospitals in places such as New York, San Francisco and Los Angeles and greater Orlando, Florida, with limited exceptions. Under the program, the hospitals could get higher pay if their patients do well in the 90 days following hip and knee replacements, or have to repay Medicare if their patients are judged to have fared poorly.

With the program, CMS is taking on a fairly common medical procedure for people on Medicare, with more than 400,000 procedures performed on those enrolled in the program in 2014 at a cost of $7 billion. Medicare officials long have been concerned about poor results in some regions, with rates of complications and infections three times higher at some hospitals than others. Expenses for surgery and recovery vary as well, ranging from $16,500 to $33,000, according to CMS.

The speed with which the CJR was handled reflects a drive by the Obama administration to try to leave a stamp on Medicare in its final months, according to Health and Human Services Secretary Sylvia Mathews Burwell. She has said there was a "very aggressive timeline" to get the draft CJR program out for review last year, as the department wanted it up and running in 2016.

"It's important for us to get the bundle done and start implementing before we go," Burwell said at a Feb. 5 pen and pad session with reporters.

The hip-and-knee replacement project is one of the major initiatives led by the Center for Medicare and Medical Innovation (CMMI), which was created by the 2010 health law. The goal of CMMI is to improve the medical care provided to senior citizens and the disabled by moving away from Medicare's longstanding fee-for-service approach. Under the fee-for-service model, Medicare has given the same reimbursement regardless of whether the care was poor or exemplary. In the future, hospitals, doctors and other providers of health care will need to pay the same kind of attention to the results delivered to patients that participants in the hip-and-knee model must, Burwell said.

"It tells people where we, as a large payer, are going," Burwell said. "It's something that is helpful for them."

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