This week, our In Focus section reviews the four new payment models addressing radiation oncology, kidney care, and end-stage renal disease released by the Centers for Medicare & Medicaid Services (CMS), through the Center for Medicare and Medicaid Innovation (CMMI) on July 10, 2019. Two of the models would be mandatory in randomly selected geographies and were published as proposed rules: the End-Stage Renal Disease Treatment Choices (ETC) and Radiation Oncology (RO) models. For these two proposed models, stakeholders have until what will likely be mid-September 2019 (60 days following publication of the forthcoming publication of the proposed rules in the federal register) to submit comments to CMS. The other two models are voluntary demonstrations: the Kidney Care First (KCF) and Comprehensive Kidney Care Contracting (CKCC) models. This is the first time this administration has proposed a mandatory model since the hip fracture and cardiac bundled payment models, which were cancelled in 2017. For these two models stakeholders will not have the opportunity to submit comments.
This week, our In Focus section reviews the California fiscal 2019-20 budget. California Governor Gavin Newsom signed his first budget, and much of its related legislation on June 27, 2019. The budget appropriates $214.8 billion ($147.8 billion General Fund) in total spending with $19.2 billion in reserves. The total reserves includes $16.5 billion in the Rainy Day Fund, $1.4 billion in the Special Fund for Economic Uncertainties, $900 million in the Safety Net Reserve, and nearly $400 million in the Public School System Stabilization Account.
This week, our In Focus section reviews publicly available data on enrollment in capitated financial and administrative alignment demonstrations (“Duals Demonstrations”) for beneficiaries dually eligible for Medicare and Medicaid (duals) in nine states: California, Illinois, Massachusetts, Michigan, New York, Ohio, Rhode Island, South Carolina, and Texas. Each of these states has begun either voluntary or passive enrollment of duals into fully integrated plans providing both Medicaid and Medicare benefits (“Medicare-Medicaid Plans,” or “MMPs”) under three-way contracts between the state, the Centers for Medicare & Medicaid Services (CMS), and the MMP. As of May 2019, approximately 372,600 duals were enrolled in an MMP. Enrollment was flat from May of the previous year.
A team of HMA consultants, led by Izanne Leonard-Haak and Matt Roan, have collaborated with organizations under a Centers for Medicaid and CHIP Services (CMCS) contract to provide support to CMCS on the Medicaid Innovation Accelerator Program.
HMA subject matter experts, Gina Eckart, Marlana Thieler, and Rich VandenHeuvel, provided guidance and education for the Reducing Substance Use Disorder and Improving Care for Medicaid Beneficiaries with Complex Care Needs and High Costs program areas through webinars, technical support assistance to participating states, resource papers, and bi-weekly program updates.
The team completed a webinar that launched a new technical resource describing approaches to combine Medicaid data with additional data sources to help state Medicaid agencies develop data analytics to better understand populations with serious mental illness. The webinar replay and transcripts are available on the CMS website.
This week, our In Focus section section highlights some of the key findings of the Spring 2019 Fiscal Survey of States, released this month by the National Association of State Budget Officers (NASBO). The association conducted surveys of state budget officers in all 50 states from March through May 2019. The findings in the report focus on the key determinants of state fiscal health, highlighting data and state-by-state budget actions by area of spending. Below we summarize the major takeaway points from the report, as well as highlight key findings on Medicaid-specific and other health care budget items.
This week, our In Focus section provides a high-level overview and an analysis for how health plans should consider two related and significant policy statements from the Centers for Medicare & Medicaid Services (CMS) about opportunities to further integrate care for dually eligible individuals. Specifically, the CMS April 24, 2019, State Medicaid Director letter (SMDL) outlines new opportunities for states, largely working with health plans, to test models of integrated care, including opportunities to continue current financial alignment initiatives (FAIs).[i] CMS also issued final rules related to Medicare Advantage Dual Eligible Special Needs Plan (D-SNP) definitions and requirements for Medicare-Medicaid integration activities and unified grievances and appeals for calendar year 2021.[ii] Together, these guidance documents should present greater opportunities for health plans to partner with CMS and states to integrate care for dual eligible beneficiaries.[iii]
The Connecticut Office of Health Strategy and Department of Public Health recently announced that the State Innovation Model (SIM) Healthcare Innovation Steering Committee has approved the Health Enhancement Community (HEC) initiative proposed framework. This blueprint is designed to build or expand collaborations across the state to improve healthy weight and physical fitness, advance child well-being, and strengthen health equity. The HEC initiative will further residents’ health and well-being by addressing both clinical need and the social determinants that impact overall health.
This week, our In Focus section reviews the Texas 2020-21 biennium budget. The Texas Legislature adjourned its biennial legislative session on May 27, 2019, after adopting a $250.6 billion budget (all funds). The total budget is 6.3 percent higher than the 2018-19 budget with an increase of $14.8 billion.
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.
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.