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March 8, 2016

Washington Health Policy Week in Review Archive cfce1649-314b-4c5e-aa56-5d7c220a4004

Newsletter Article


Medicaid Expands for Children, Pregnant Women Poisoned by Flint Water

By Stephanie Akin

March 4, 2016 -- Thousands of children and pregnant women exposed to lead in the drinking water in Flint, Mich., will have access to health care, under an emergency Medicaid expansion announced Thursday.

The Department of Health and Human Services (HHS) said the measure would extent Medicaid eligibility to approximately 15,000 children and pregnant women exposed to contaminated water last year, when state and federal officials for months failed to inform the city’s residents of elevated levels of lead and bacteria. The agreement would also provide extended coverage for approximately 30,000 Flint residents already eligible for Medicaid. HHS did not say how much the expanded services would cost.

"This Medicaid expansion is critical to ensuring that Flint families exposed to high lead levels get the care and support they need, including blood lead level monitoring and comprehensive health services," Congressman Dan Kildee, D-Mich., said.

The announcement came as 25 house Democrats, including Minority Leader Nancy Pelosi and members of the Congressional Black and Progressive Caucuses, prepared to visit the city Friday. The trip would be the third congressional delegation in Flint since President Barack Obama declared a state of emergency there in January. A Democratic presidential debate between Hillary Clinton and Sen. Bernard Sanders, D-Vt, is scheduled there Sunday.

House Democratic Whip Steny H. Hoyer, who visited the city last week, said the Medicaid expansion would be "a major step toward meeting our nation’s obligation" to helping the people of Flint.

"These citizens deserve every tool at the federal, state and local level to identify and correct the extent of the lead exposure and treat its immediate and long-term effects," he said. "I will continue to join with my colleagues, including Rep. Kildee and the rest of the Michigan delegation who have been working hard on behalf of Flint, to ensure that they receive the support from Congress they need in the months and years ahead."

In addition to the Medicaid expansion, the federal Office of Head Start recently announced an added $3.6 million in emergency money to bring more children into the early education program and expand health services for children and families affected by the lead-tainted water. Elevated blood-lead levels can contribute to learning disabilities and other long-term health problems in children.

A bill that would provide federal money and loans to improve drinking water and water infrastructure was expected to reach the Senate floor as early as next week, Sen. Debbie Stabenow, D-Mich, told Roll Call.

"I think that there’s a tremendous amount of good will and desire to support what’s happening, to fix the infrastructure, to support the health and nutrition needs of people in Flint," Stabenow said Wednesday.

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Medicare Hits Goal on Linking Payments to Quality Metrics Early

By Kerry Young, CQ Roll Call

March 3, 2016 -- Medicare officials estimate that almost $1 of every $3 spent in the traditional fee-for-service program now runs through one of the special projects that are designed to judge the quality of care provided to the nation’s elderly and disabled people.

The Centers for Medicare and Medicaid Services (CMS) on Thursday announced that it had reached a goal early of tying 30 percent of fee-for-service reimbursements to alternative payment models, such as so-called accountable care organizations that require providers to coordinate on patients' care. As of January, about $117 billion of a projected $380 billion in annual fee-for-service payments were estimated to fund these projects. Last year, Health and Human Services Secretary Sylvia Mathews Burwell announced a goal of tying 30 percent of fee-for-service payments to alternative payment models by the end of 2016.

The shift is among the lower-profile changes in the American medical system due in part to the 2010 health overhaul. The law gave CMS a $10 billion fund and new authority to test ways to try to shift Medicare away from a longstanding tradition of paying for services without holding providers accountable for how well they helped people preserve or regain their health.

CMS Chief Medical Officer Patrick Conway on Thursday cited the January announcement of 121 new accountable care organizations as a sign of the success of these efforts and a reason for reaching the 30 percent goal ahead of time.

CMS is seeking through these alternative payment models to change the incentives in medical care. The traditional approach rewards doctors for care that can result in needless duplication of medical tests, for example, which frustrate patients while doing nothing to improve their care. The alternative models stress a more coordinated approach to care, in which these kinds of missteps are supposed to occur less often and doctors may be more likely to detect early signs of worsening disease.

"At the end of the day, people know this is the right thing to do" Conway said on a press call about more coordinated care.

The estimates unveiled Thursday were evaluated by CMS’ Office of the Actuary and found to be sound and reasonable. Before the implementation of the 2010 health law, Medicare paid essentially nothing through alternative payment models, CMS said. By 2014, about 20 percent of payments were made through alternative payment models.

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MedPAC Members Push for Expansion of Telehealth Services

By Kerry Young, CQ Roll Call

March 4, 2016 -- Advisers to Medicare urged greater acceptance of telehealth services in the federal program for the elderly and disabled, although they are not yet at the point of issuing formal recommendations to spur greater use of computers and phones in delivering medical services.

Medicare Payment Advisory Commission (MedPAC) commissioners said they are concerned that current reimbursement policies are limiting access to more convenient access to their doctors.

"I worry that we are being far too conservative" about the use of telehealth in Medicare, said Scott Armstrong, a MedPAC member who is chief executive officer of Seattle-based Group Health Cooperative, which serves about 650,000 people.

Medicare now largely limits telehealth payments through its traditional fee-for-service program to cases where people live some distance from providers, thus largely restricting this service to rural areas. Medicare Advantage programs and demonstration programs such as accountable care organizations also can provide medical consultations via computer or phone.

The Medicare policies lag the expectations that many people have for their medical care, Armstrong said. Many of the new enrollees conduct much of their shopping and business online, and also have grown accustomed to the convenience of contacting their doctors electronically as well, Armstrong said. In some cases where telehealth is widely used, 60 to 70 percent of people’s contact with their doctors is handled remotely, he said.

"If we are going to be relevant to the customers who will age into Medicare one day, we need to be offering these kinds of alternatives," Armstrong said.

MedPAC member Craig Samitt argued that telehealth services would be a superior alternative for handling many tasks that now require people to visit doctors' offices.

"There are a lot of different scenarios where telehealth should replace existing services," particularly in primary care, said Samitt, who is chief clinical officer at insurance giant Anthem.

MedPAC Chairman Francis J. Crosson said he agreed with Samitt's view, and signaled that the commission will continue looking at the issue of telehealth. The remote contact with doctors offers significant convenience to patients, Crosson said, adding that he receives his medical care through an organization that offer telehealth services.

"It's very popular with me as well as other patients," he said.

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Postacute Care Overhaul Timeline Questioned by MedPAC Members

By Kerry Young, CQ Roll Call

March 3, 2016 -- Medicare officials should look for opportunities through administrative action to speed changes in the program’s highly fragmented approach to paying for care of the elderly and disabled after hospital stays, advisers to Congress said.

A 2014 law envisions leaving the current system largely in place through 2026 or 2027, said MedPAC commissioner Kathy Buto, a veteran federal health adviser. Despite congressional interest in overhauling the system, shepherding legislation through Congress to change that timeline significantly will be a challenge.

"We are talking 10 years before we will see anything new," said Buto at the panel’s Thursday meeting.

Buto asked if there is any way to encourage the use of existing Centers for Medicare and Medicaid Services tools to more quickly establish a "glide path" toward an overhaul of the payment system, such as the use of demonstration projects.

MedPAC is preparing to vote next month on material for a highly anticipated report in which it will advise Congress on how to move toward a unified payment system for post-hospital care. Medicare paid $59 billion in 2013 for such care, more than double the amount in 2001, according to MedPAC.

Medicare has different reimbursements for patients with often similar conditions treated in four settings. Those are skilled nursing homes, specialty inpatient rehabilitation centers, long-term care hospitals and at-home care with the help of aides. There's often little evidence to guide frail people recovering after strokes and surgeries as to which approach to care might help them most. The fragmentation adds to the stress that many families face as relatives are discharged from hospitals.

A 2014 law (PL 113-185) championed by now Ways and Means Chairman Kevin Brady, R-Texas, is intended to both simplify the payment system and gather evidence on how different approaches to post-hospital care work. The law set a June 2016 deadline for MedPAC’s first report on the post-hospital care payment overhaul. This measure sets in place a series of subsequent deadlines, which currently would push out the timing of a payment overhaul as Buto outlined.

Lawmakers in both parties remain interested in overhauling the post-acute care system, eyeing potential savings that could be used as offsets in future budget agreements. That political pressure could speed the pace of the overhaul ahead of the IMPACT Act's timeframe.

Warner Thomas, a MedPAC member and the chief executive officer of the Ochsner Health System in New Orleans, also called for encouraging CMS to use demonstration projects to jumpstart changes within the field of post-hospital care. "There is real opportunity for folks that want to innovate," he said Thursday.

CMS already has several major demonstration projects underway in other fields of care to try to reward hospitals and medical practices for better coordinating the care of patients. Among these are a test that will put hospitals in 67 regions of the country at financial risk if patients don't fare well after undergoing hip and knee replacements. Another program is seeking to better coordinate the care of cancer patients.

MedPAC members also discussed Thursday how judgments would be made about the quality of care provided under a more unified Medicare approach to payments for post-hospital services.

"Maybe we should have higher expectations" such as monitoring how well patients fare 90 days after an admission instead of 60 days, said Mary Naylor, a MedPAC member and professor at University of Pennsylvania School of Nursing.

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Hospitals Argue Against Anthem Purchase of Cigna

By Jad Chamseddine, CQ Roll Call

March 2, 2016 -- The American Hospital Association (AHA) is renewing its opposition to Anthem Inc.’s acquisition of Cigna Corp., arguing the transaction would further hurt competition by increasing the Blue Cross and Blue Shield Association’s market power in the health insurance industry.

The hospital association said in a letter to Assistant Attorney General Bill Baer the merger would "further entrench" Blue Cross health insurance plans in an already uncompetitive system.

Anthem is part of Blue Cross Blue Shield, an association composed of 36 independent and locally operated Blue Cross and Blue Shield companies that provide health insurance coverage to about 105 million members across the country.

"The addition of Cigna adds 14.7 million more lives," the hospital association said. "That is more than one third of the entire U.S. population."

The hospital association—the largest trade organization representing hospitals, health systems and other health care organizations—has been urging lawmakers and regulators to block the deal since the transaction was first announced in July.

AHA members were invited to voice their opposition to the merger during hearings held by the House and Senate Judiciary committees last year. The association, over the past six months, sent several letters to the Justice Department pointing to extreme consolidation and lack of choice for consumers in choosing insurance as reasons to block the combination.

This is the first time, however, the hospital group focused on Anthem's membership in the Blue Cross association as a reason for regulators to reject the deal.

AHA argues throughout the letter the increased market power Blue Cross would gain from the Cigna transaction would lead to a rise in premiums and further help the health insurance group keep out smaller competitors. Blue Cross is able to negotiate better discounts because of its scale, a crucial factor which new entrants lack. The hospital association pointed to a Justice Department study regarding new health care insurance entrants that shows the difficulty facing new entrants.

"New insurers cannot compete with incumbents for enrollees without provider discounts, but they cannot negotiate for discounts without a large number of enrollees," Justice’s study said.

Besides being able to band together in offering better deals to enrollees, AHA said Blue Cross members are aided by the name, which brings "brand familiarity." According to a study by consulting firm McKinsey, the brand "is likely to play a key role in consumer choice on the exchanges."

The hospital association said even Anthem’s plans to expand have been thwarted in Blue Cross-dominated jurisdictions where Anthem lacks a Blue Cross license. Anthem operates under several names including Amerigroup and Simply Healthcare in more than a dozen states where it doesn't qualify to be a Blue Cross licensee based on local net revenue requirements.

"Despite its size and business acumen, Anthem’s effort appear to have failed because it could not compete effectively outside its assigned territories against another" Blue Cross provider, AHA said, accusing the Blue Cross rules of hurting competition.

AHA argues Anthem's ultimate goal is to incorporate Cigna members into the "Blue system" by rebranding the Cigna name and taking advantage of the "Blue network" in other states where it lacks a license.

But Anthem disputes the letter’s accuracy, saying not all 14.7 million members would join the Blue Cross association. Anthem is a Blue Cross licensee in "only 14 states," it said, and "outside those 14 states, the Blues will continue to compete just as they did prior to the acquisition."

"Cigna products will not become Anthem BCBS products in states where we do not have a Blue license," an Anthem spokeswoman said in an email.

AHA disputes that Cigna would be a strong competitor, though, saying "even if Cigna did jockey against other Blue plans for some opportunities when the deal was closed" it would not introduce "significant" competition to alleviate damages done by the deal.

The incorporation of Cigna into Anthem will prove tricky and was a source of contention between the two companies during takeover discussions. When Cigna initially rejected an offer by Anthem in June, Cigna CEO David Cordani questioned how the combined company would "comply with the intricate rules and constraints administered by the BCSBA."

Cordani also highlighted some of the points made by AHA regarding the lack of real competition in areas where the Blue Cross association is the major provider of health care.

Cordani pointed to several antitrust lawsuits that "could redefine the market for all of its member companies." The Blue Cross members were hit last month with another antitrust lawsuit, accusing the association of conspiring among its members to hurt several medical centers in the state of Oklahoma.

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House Eyes Ways to Stem Long-Term Care Costs

By Kerry Young, CQ Roll Call

March 1, 2016 -- Congress is mulling options for addressing the growing cost of providing long-term care for the elderly, including financial aid for caregivers and using insurer-run Medicare Advantage plans to coordinate care and prevent some patients from having to be transferred to nursing homes.

About $340 billion was spent on long-term care services in 2014, according to most recent estimates, with family members absorbing untold additional costs.

"Long-term care right now is often funded in a backdoor way by women and families who take time off their jobs and who cut into their salaries and overtime," Kathy Castor, D-Fla., said a House Energy and Committee Health Subcommittee hearing on Tuesday. "There must be a solution for that."

The Senate in December approved by unanimous consent a bill (S 1719) from Susan Collins, R-Maine, that would create a "national family caregiving strategy." A companion measure (HR 3099) from Rep. Gregg Harper, R-Miss., has 14 Republicans cosponsors and 32 Democratic cosponsors and would examine ways ease the financial toll on caregivers.

At the hearing, Reps. Leonard Lance, R-N.J., and Kurt Schrader, D-Oreg., pressed for action on a bill (HR 4212) that looks to the Medicare Advantage program as a path for allowing more of the nation’s elderly to delay or avoid moves into costly nursing home care.

It would create demonstration projects to see if providing in-home care and other community support such as home delivery of meals and transportation services. Sen. Charles E. Grassley, R-Iowa, has a Senate version (S 704).

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