This week, our In Focus section reviews the Pathways HUB model, an approach designed to help coordinate outreach by specialized community health workers who are incentivized to engage high-need populations. An HMA webinar, held May 9, 2019, with Mark Redding, co-developer of the Pathways HUB model, and Heidi Arthur, HMA can be viewed here.
Clinical Services
HMA Analysis of Modernizing Part D and Medicare Advantage to Lower Drug Prices and Reduce Out-of-Pocket Expenses Final Rule
On May 16, 2019, the Centers for Medicare & Medicaid Services (CMS) issued its final rule, Modernizing Part D and Medicare Advantage to Lower Drug Prices and Reduce Out-of-Pocket Expenses (Final Rule). The proposed rule, which was issued in November 2018, included a number of provisions intended to improve drug price transparency and expand use of utilization management tools to further Medicare Advantage and Part D cost-cutting efforts. However, in response to significant pushback from beneficiary advocates, physician groups, insurers, and pharmaceutical stakeholders, CMS elected not to implement key provisions. These include proposals to allow Part D plans to exclude protected class drugs from formularies as a result of price increases or if the drug is a new formulation of an existing single-source drug as well as proposed reforms to pharmacy price concessions that would require discounts be passed on to beneficiaries at the point of sale. Commenters in opposition to the pharmacy price concession proposal contend that these reforms would result in higher Part D premiums. While CMS has postponed addressing this provision in this Final Rule, the recently issued Department of Health and Human Services (HHS) Office of Inspector General (OIG) proposed rule, if finalized, may include fundamental changes to these pricing arrangements and other federal safe harbors to the anti-kickback statute.
Kentucky Releases Medicaid MCO RFP
This week, our In Focus section reviews the Kentucky Medicaid managed care organizations (MCOs) request for proposals (RFP), issued by the Kentucky Finance and Administration Cabinet on May 16, 2019. The Kentucky Cabinet for Health and Family Services (CHFS), Department for Medicaid Services (DMS) will select up to five Medicaid MCOs to manage health care services for more than 1.2 million people, starting July 2020. Contracts are estimated at more than $7 billion.
HMA Conference to Feature Insights from 40+ Speakers, Including Health Plan CEOs, State Medicaid Directors, Providers
Pre-Conference Workshop: September 8, 2019
Conference: September 9-10, 2019
Location: Chicago Marriott Downtown Magnificent Mile
Health Management Associates is proud to announce its fourth annual conference on trends in publicly sponsored health care: The Next Wave of Medicaid Growth and Opportunity: How Payers, Providers, and States Are Positioning Themselves for Success.
The HMA conference has emerged as a premier informational and networking event, attracting more than 450 executives and policy experts. Speakers this year include state Medicaid directors and leaders from Medicaid managed care, hospitals, clinics, community-based organizations, and other providers.
CMS Announces Primary Cares Initiative
On April 22, 2019, the Centers for Medicare & Medicaid Services (CMS) Innovation Center announced the Primary Cares Initiative (PCI), which will present eligible providers and other entities with the opportunity to engage in value-based payment and direct contracting payment models for primary care beginning in January 2020. CMS designed PCI to reduce expenditures and preserve or enhance quality of care for beneficiaries in Medicare fee-for-service (FFS). PCI is comprised of two tracks, Primary Care First (PCF) and Direct Contracting (DC). The PCF track, which builds on the Comprehensive Primary Care Plus (CPC+) initiative, is intended for individual primary care practices and seeks to reward providers for reductions in hospital utilization and total cost of care through performance-based payment adjustments. Also, under the PCF track, practices that specialize in serving high-need and/or seriously ill populations will receive adjusted payments to account for the populations served. Providers that participate in these models will qualify as participating in an Advanced Alternative Payment Model and be eligible to receive full bonus payments under CMS’s Medicare Incentive Payment System (MIPS).
HMA Opioid Experts Are in Demand
As the national opioid epidemic continues, HMA experts are sharing their vast knowledge and experience related to substance use disorders (SUD) and addiction treatment systems with providers, policymakers and other stakeholders addressing this crisis.
HMA MACPAC Report Published
A team of HMA colleagues including Sarah Barth, Sharon Silow-Carroll, Esther Reagan, Mary Russell and Taylor Simmons completed a study for the Medicaid and Children’s Health Insurance Program (CHIP) Payment and Access Commission (MACPAC) to examine care coordination requirements for several Medicare-Medicaid integrated care models.
The study’s final report, Care Coordination in Integrated Care Programs Serving Dually Eligible Beneficiaries – Health Plan Standards, Challenges and Evolving Approaches, is posted to the MACPAC website.
The final report details state and federal managed care contract requirements for care coordination, summarizes stakeholders’ perspectives on care coordination based on structured interviews, and highlights promising care coordination practices and challenges for ensuring effective care coordination for dually eligible beneficiaries.
CMS Increases Monitoring and Evaluation Requirements for Section 1115(a) Medicaid Demonstrations
This week, our In Focus reviews the implications of the new federal guidance for state waivers with community engagement, premiums, non-eligibility periods, and other personal responsibility provisions.
Background
On March 14, 2019, the Centers for Medicare & Medicaid Services (CMS) issued several new guidance documents that significantly increase the level of monitoring and evaluation required for Section 1115(a) Medicaid Demonstrations. These new requirements apply to community engagement, premiums, and other waiver provisions that impact eligibility and enrollment, and affect states currently with such waivers as well as any states proposing these ideas. Changes in reporting, data collection, and waiver monitoring processes will be necessary, and soon—as the materials details compliance dates for these significant new requirements.
Patient Protection and Affordable Care Act; 2020 Proposed Notice of Benefit and Payment Parameters
This week, our In Focus reviews the Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2020. The new proposed rule does not contain as many major changes as the 2019 rule, but there are requests for comment on potentially important rulemaking starting in 2021 and guidance on important policy, such as:
Analysis of Key Medicare Proposals in the President’s FY 2020 Budget
This week, our In Focus comes to us from HMA Senior Consultant Narda Ipakchi. On March 11, 2019, the White House released President Trump’s budget for fiscal year (FY) 2020, which includes a number of legislative and administrative proposals related to Medicare that would reduce net Medicare spending by $811 billion over the next ten years. It is important to note that the legislative proposals included in the President’s budget are non-binding and serve as recommendations to Congress where they may or may not be advanced. Under a Democratic-majority House of Representatives, many of the legislative proposals outlined in the FY 2020 budget are unlikely to advance. Several of the policies, however, such as reductions to Medicare bad debt and implementing site neutral payment systems were also proposed by the previous administration. Administrative proposals are more likely to move forward, as the administration can implement these policies through its regulatory channels.