TOP STORY
- ACAP, GW Issue "VIP" Proposal to
Integrate Care for Dual Eligibles
PUBLIC POLICY &
ADVOCACY - Up Next in the Ongoing Series of Congressional
Existential Crises: The Doc Fix
- ACAP Comments on Medical Loss Ratio Requirements
- ACAP Call Discusses MLR, Essential Health Benefits
Guidance
- CMS Inspector General Eyes Medicaid Managed Care
EXCELLENCE & ACCOUNTABILITY -
ACAP Names Marcelline Coots of Passport Health Plan Third Annual Making a
Difference Winner
- Two Staff at ACAP Plans Among Those Named to
CMS’s Innovation Advisors Program
-
Deadline for Nominations for National Environmental Leadership Award in
Asthma Management Coming in February
SAFETY NET PLAN NEWS - CalOptima’s Margaret Tatar Named Chief of CA DHCS Managed Care Division; Greg
Buchert Moves to HMA
- Bay Area COHS Plans Featured in NPR Report
- IEHP
Expands its Health Navigator Program
ACAP MEETINGS - Registration Open for ACAP’s February Legislative Fly-In
- Mark Your Calendars for ACAP’s Spring Meetings in Seattle
UPCOMING ACAP
CONFERENCE CALLS
January 18, 3 p.m. ET ACAP CMO/Pharmacy Director Roundtable
January 24, 3 p.m. ET
HEDIS Call Series: Weight Assessment in Children
January 27, 3 p.m. ET
Care Transitions Networking Call
January 31, 3 p.m. ET
ACAP Fall Fly-in Pre-Briefing (1 of 2)
February 2, 3 p.m. ET
ACAP Fall Fly-in Pre-Briefing (2 of 2)
ACAP, GW Issue "VIP" Proposal to Integrate Care
for Dual Eligibles
Yesterday, ACAP
issued a paper written by researchers from the George Washington University
School of Public Health & Health Services which outlines a new proposal for
providing care to individuals eligible for both Medicare and Medicaid, or “dual
eligibles.”
The paper by Jane Hyatt Thorpe, J.D. and Katherine Jett Hayes, J.D. of George
Washington University outlines a new state plan option where states would choose
qualified health plans to provide highly integrated care services for dual
eligibles under a framework of beneficiary protections and standards for
financial integrity set by the Federal government.
While dual eligibles number only about 9 million nationwide, they account for an
outsized proportion of state and Federal health care spending: roughly $230
billion between Medicaid programs and the Federal government in 2006, or 36
percent of all Medicare spending and 39 percent of Medicaid spending. But it is
difficult to say what this spending brings. Concerns about quality
abound—largely because care for dual eligibles is financed separately by the
Medicare and Medicaid programs. Coordination between the two is inconsistent,
resulting in incentives to shift costs between Medicare and Medicaid. As a
result, neither program optimizes the use of limited resources.
The new state plan
option, which ACAP has dubbed the Very Integrated Program (VIP), would be a
distinct, permanent program featuring a fully-integrated, capitated model of
care that can be chosen by states through a permanent choice within the Medicaid
State Plan. States would contract with managed care organizations (MCOs) to
provide care for dual eligibles, while CMS would set standards for strong
patient protections covering areas including participant rights, eligibility,
application procedures, administrative requirements, services, payment, quality
assurance, and marketing guidelines.
"As it stands, our
framework for care for dual-eligible beneficiaries is a set of work-arounds that
hold up an inherently flawed system. It’s making fragmentation of the system
worse, and unintentionally increasing wasteful care,” said ACAP Chief Executive
Officer Margaret A. Murray. “The ‘Very Integrated Program’ outlined in this
paper clears up many of the misaligned incentives and barriers inherent in a
program that involves two levels of government. It’s a state option that has a
real opportunity to improve care. Congress should look closely at this proposal;
it has appeal to members on both sides of the aisle.”
The paper’s authors
pointed to statements from MedPAC showing that characteristics and health needs
of dual eligibles vary from state to state. “States are in very different places
when it comes to their populations of dual eligibles. Current opportunities to
integrate care and financing for dual eligibles are time-limited,” said
co-author Jane Hyatt Thorpe, J.D., Associate Research Professor at the George
Washington University School of Public Health and Health Sciences. “The new
state plan option allows states to design a permanent program in partnership
with federal officials that integrates financing and care across the Medicare
and Medicaid programs to better meet the needs of dual eligibles.”
ACAP recently hosted
a call that described the proposal in more detail.
You can listen to an archived
recording of the call and Q&A by dialing 1-888-203-1112, replay passcode
76253237.
Up Next in the Ongoing Series of Congressional
Existential Crises: The Doc Fix
Although the eyes of the political world are on Iowa, New Hampshire and South
Carolina, policy eyes remain focused on Washington, where behind-the-scenes
negotiations persist over how to address the myriad upcoming tax, Medicare, and
program extensions coming due in the next month.
As you know, Congress passed a two-month extension of a package that included
the payroll tax, unemployment insurance, and Medicare physician payments to
allow them to go home for Christmas with a (somewhat) clear conscience. By the
end of February, Congress will have to decide what to do and it is unclear how
things will be resolved. What is becoming clear is that the Republicans’
strategy of bringing nearly every major must-do bill to a crisis point is
starting to wear thin on the American people and increasingly Republican leaders
are seeking to reverse some of the PR damage that has caused. But they still
must confront a significant number of their rank-and-file members who hate
compromising with Democrats and President Obama. This dynamic muddies the
picture of how this debate will play out in the end.
What we do know is that Democrats and Republicans are discussing how to prevent
cuts in Medicare physician payments, although the duration of that delay—a
1-year, 2-year, or a permanent extension—is yet to be determined. Interestingly,
Nancy Pelosi appointed Allyson Schwartz, the leading advocate to provide a
permanent doc fix, as a House Democratic negotiator to the conference committee.
This signifies the Democrats’ view of a permanent fix as a top priority. But the
problem with a permanent doc fix has always been less about “will” and much more
about “way” – specifically, the “way” to come up with the $300 billion needed to
address the problem. But it’s an interesting sign about the priority House
Democrats are placing on the issue.
To be certain, Congress will not allow Medicare physician payments to be cut by
27%. The question surrounds the duration of the fix. ACAP will keep an eye on
these developments.
On Friday, President Obama’s Department of Justice published their brief in the
Supreme Court case that will determine the constitutionality of the law. Not
surprisingly, the brief states that the law (and the individual mandate in
particular) is well within the bounds of the Constitution’s Commerce Clause and
therefore should be allowed to be implemented. Needless to say, there are some
who disagree. The Supreme Court is scheduled to take up the case in March, with
a decision being rendered in June. Every possible legal resource you could ever
want, including a copy of this brief, can be found at
www.justice.gov/healthcare.
ACAP Comments on Medical Loss Ratio Requirements
On January 6, ACAP submitted comments to CMS on Section 2718 of the Public
Health Service Act (PHSA) as it relates to medical loss ratio requirements in
the Affordable Care Act. Two provisions of the PHSA in particular have
implications for MLR requirements going forward.
Section 2718 (b) expands the definition of “quality improvement activities” to
include the costs of conversion to the ICD-10 set; ACAP commended this
definition as quality improvement activities are included in the numerator of
the medical loss ratio.
Section 2718 (f) deals with rebates to enrollees in group markets and reporting
of historical MLR data. ACAP supported a requirement that issuers provide
rebates to policyholders as opposed to enrollees, in order to reduce
administrative burden on plans, and asked that historical MLR data only be shown
for years in which there was a federal MLR requirement and definition such that
plans would not be required to back-calculate MLR in years prior to 2011, when
no federal requirement existed.
ACAP Call Discusses MLR, Essential Health Benefits
Guidance
On January 4, ACAP staff discussed the guidance
issued by HHS on MLR referenced above and guidance explaining HHS’ proposed
approach to defining Essential Health Benefits (EHB) as required by section 1302
of the Affordable Care Act. The EHB package will be used as a coverage “floor”
for health plans serving the Medicaid expansion to 138 percent of the federal
poverty line and for qualified plans serving Exchanges. The policy would require
states to select an existing health plan to set a “benchmark” from one of the
following insurance plans:
• One of the three largest small group plans in the state;
• One of the three largest state employee health plans;
• One of the three largest federal employee health plan options;
• The largest HMO plan offered in the state’s commercial market.
A
recent report
by the CMS Office of the Inspector General, issued in late December, examined
the steps Medicaid MCOs are taking to meet federal program requirements. The
report reflected well on Medicaid managed care plans: a survey of 46
organizations in 13 states found that all surveyed health plans reported meeting
federal requirements, having a compliance plan in place, and performing
continuous monitoring, auditing and employee training.
The report, however, identified areas of concern
with respect to potential fraud in Medicaid managed care; the primary concern,
shared by states and MCOs, related to services billed but not received.
Accordingly, the OIG made several recommendations to states, including requiring
contracted plans to find a way verify with beneficiaries whether services
providers billed for were actually received, such as sending explanations of
benefits (EOBs) to beneficiaries. OIG also recommended that CMS update its
guidelines around Medicaid managed care fraud and abuse, which have not been
revisited since 2000.
In a recent letter to CMS, ACAP responded to this
recommendation by noting that many states do not require plans to send EOBs to
members when a claim is denied in order to avoid unnecessary confusion. ACAP
does not support the mandated use of EOBs, but would be willing to consider
their use if limited to a narrow set of services known to be subject to
fraudulent activities.
Excellence and Accountability
ACAP Names Marcelline Coots of Passport Health Plan Third Annual Making a
Difference Winner
In February, ACAP will present its third annual Making a Difference Award to
Marcelline Coots, Public Affairs Manager at Passport Health Plan. She was
selected for this award in recognition of nearly 15 years of community service
that routinely went well beyond her duties at the Louisville, Ky.-based plan.
Ms. Coots, one of the first hires at Passport Health Plan, started her career in
1997 as a community affairs representative. Over time, she took it upon herself
to become the health plan’s primary event planner. She was responsible for
planning Healthy Hoops-KY, an event focused on children with asthma, which has
screened more than 1,000 youngsters in the past four years, resulting in fewer
emergency room visits and the need for rescue medications.
Ms. Coots also developed a cultural and linguistics conference which over eight
years educated more than 1,600 physicians, dentists, pharmacists, and nurses on
compliance with Title VI of the Civil Rights Act and delivery of culturally
competent care to diverse populations.
Passport Health Plan CEO Mark Carter, in nominating Ms. Coots for the award,
noted that she would routinely go the extra mile to get the job done. And in at
least one case, this was literal: to ensure that Passport would always have a
driver available for taking an oversize vehicle to community outreach events,
Ms. Coots took time to obtain a CDL license.
“Marcelline embodies the mission of Passport Health Plan—to improve the health
and quality of life of our members,” he wrote. “She exemplifies this statement
in words and actions every day.”
“ACAP’s member plans include thousands of employees who wake up every morning
and work to make a meaningful difference in the lives of their health plan
members,” said Meg Murray, ACAP CEO. “Ms. Coots is a model of the best that ACAP
plans have to offer.”
Ms. Coots was selected by a committee of human resources directors from ACAP
health plans. Nominees were judged by how well they support ACAP’s principles of
advocacy for beneficiaries, care, access to quality health care, and a
commitment to the public good.
The award will be formally presented by ACAP Vice President for Quality
Management and Operational Support Deborah Kilstein at Passport’s headquarters
in February. A donation will be made in Ms. Coots’ name to the
Ohio Valley Educational Cooperative
Head Start program, where Ms. Coots has actively participated in their
advisory council and community board.
Two Staff at ACAP Plans Among Those Named to
CMS’s Innovation Advisors Program
Tonya Moody of AmeriHealth Mercy Health Plan and Deborah Peartree of Monroe Plan
for Medical Care are among the 73 individuals named by CMS on January 3 to the
first class of its Innovation Advisors program. The group of Innovation Advisors
will work with the CMS Innovation Center to test new models of care delivery in
their organizations and communities, find what works, and share successful
models regionally and nationally.
“We’re looking to these Innovation Advisors to be our partners—we want them to
discover and generate new ideas that will work and help us bring them to every
corner of the United States,” said CMS Innovation Center Director Rick
Gilfillan, M.D.
The 73 individuals were selected from 920 applications through a competitive
process, and include clinicians, allied health professionals, health
administrators and others.
Deadline for Nominations for National Environmental Leadership Award in
Asthma Management Coming in February In December, the Environmental Protection
Agency opened nominations for the 2012 National Environmental Leadership Award
in Asthma Management. The award recognizes health plans, health care providers
and communities for their efforts in delivering excellent environmental asthma
management as part of their comprehensive asthma care services. Several ACAP
member plans and their parent organizations are past winners of this award,
including the Monroe Plan for Medical Care, Neighborhood Health Plan, Boston
Medical Center and Children’s Mercy Hospital.
A set of health-plan-specific criteria is available
here. In
addition to national recognition during Asthma Awareness Month (May), winners
receive a place in the EPA’s
Hall of Fame, press
materials for promotion in winners’ communities, and the opportunity to share
your experiences with other programs, funders and decision-makers. For more
information, visit the
EPA’s Web site.
The deadline for applications is February 21, 2012.
CalOptima’s Margaret Tatar Named Chief of CA DHCS Managed Care Division; Greg
Buchert Moves to HMA
In late December, California Governor Jerry Brown named
Margaret Tatar, Executive Director for Public Affairs at CalOptima, head of the
Medi-Cal Managed Care Division of California’s state Department of Health Care
Services.
“[It] speaks volumes about the great respect we have for Margaret and
her dedication to the Medi-Cal program,” said CalOptima CEO Richard Chambers.
“Her contributions to CalOptima and Orange County residents have been
significant, and we understand the great value she will bring to all of
California in her new role.”
Ms. Tatar will leave CalOptima in January to begin
her duties in Sacramento. All of us at ACAP wish her the best in her new
endeavor.
Separately, CalOptima announced that its COO, Greg Buchert, M.D.,
M.P.H., would in January become a Principal Consultant at Health Management
Associates. Dr. Buchert had been CalOptima’s COO since 2005.
“Greg helped CalOptima develop and attain our current position as a model community health
plan serving Medicaid members,” added Chambers. “We thank him for his leadership
and applaud his commitment to pursue excellence in managed care on a wider
scale.”
Bay Area COHS Plans Featured in NPR Report
A recent NPR piece revisits
the idea of the “public option” in the context of health reform and imagines
what a public option might have looked like – and arrives at the idea of the
County-Operated Health Systems (COHS) in California.
The NPR piece features
interviews of Alameda Alliance for Health CEO Ingrid Lamirault and Sumi Souza of
San Francisco Health Plan. Click
here to read (or listen to) the piece.
IEHP
Expands its Health Navigator Program
Inland Empire Health Plan recently
announced that it would expand its Health Navigator program to the Inland Empire
High Desert in January. The program helps IEHP members get the preventive care
they need while reducing avoidable emergency room visits and hospitalizations.
The "Health Navigator" makes a home visit and helps the member and family
understand how, when and where to get the medical care they need.
The High
Desert expansion follows a first-year launch where IEHP connected its Health
Navigators to more than 1,700 of its members in and around San Bernardino and
Riverside, Calif. To date, the program has decreased avoidable emergency
department visits by approximately 40 percent.
"The program serves as a link
between members, providers and the health plan, which ultimately leads to better
coordination and care," said IEHP CEO Dr. Bradley Gilbert. For more information,
refer to IEHP’s
press release.
ACAP Meetings Registration Open for ACAP’s February Legislative Fly-In
ACAP’s Exchange Meeting, Policy Face-to-Face and Legislative Fly-In, scheduled
for February 7 and 8, is now open for
registration. A meeting agenda and other details are available on the
registration page.
ACAP February Fly-In
February 7-8 |
register
The Renaissance Hotel
999 Ninth Street NW
Washington, DC 20001
Hotel and Lodging: ACAP’s room block at the Renaissance Hotel is currently
full. Contact Joseph Person
at (202) 204-7516 for information about hotel alternatives – or to cancel a
reservation at the Renaissance.
Mark Your Calendars for ACAP’s Spring Meetings in
Seattle
ACAP will hold three meetings in Seattle during the week of March 12:
ACAP Chief Information Officers Meeting
March 12-13
ACAP Spring Board of Directors Meeting
March 13-14
ACAP Spring Medicare Meeting
March 15-16
All three events will be held at: The Hotel Monaco Seattle 1104 4th Avenue
Seattle, WA 98101
(206) 621-1770
ACAP has reserved a block of rooms for the discounted rate of $159; to reserve
under the block, call the hotel at (206) 621-1770 and ask for the ACAP group
rate. The discount will be available until February 13, 2012 – again, ACAP
cannot guarantee hotel and group rate availability.
More details about the spring meetings will come in a future edition of ACAP
Community News.
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Association for Community Affiliated Plans 1015 15th
Street, N.W., Suite 950 | Washington, DC 20005 Tel.
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Ms. Coots, one of the first hires at Passport Health Plan, started her career in
1997 as a community affairs representative. Over time, she took it upon herself
to become the health plan’s primary event planner. She was responsible for
planning Healthy Hoops-KY, an event focused on children with asthma, which has
screened more than 1,000 youngsters in the past four years, resulting in fewer
emergency room visits and the need for rescue medications.