Saturday, March 31, 2018

Infectious disease deaths decline, but U.S. sees wide disparity in outcomes

By Steven Ross Johnson | March 27, 2018

Fewer Americans are dying from infectious diseases compared to three decades ago, but the outcome gap between rural and urban areas of the country has widened, according to a new study.

Deaths from infectious diseases decreased by 18% in the U.S. between 1980 and 2014, according to a study published Tuesday in JAMA, dropping from 42 deaths per 100,000 people to 34 deaths per 100,000.

But rural counties aren't seeing the same improvements in infectious disease mortality as their urban counterparts, researchers found. One of the biggest drivers of that inequality is the steady decline in access to healthcare services in many rural areas.

"As a country we are doing much better, but certain counties are still lagging behind and are in fact getting worse," said study co-author Ali Mokdad, professor of global health and epidemiology at the University of Washington School of Public Health.

Lower respiratory infection was the leading cause of mortality in 2014, accounting for more than 78% of all infectious disease deaths that year. Such infections can include conditions commonly caused by environmental pollutants such as pneumonia, bronchitis and asthma.

Lower respiratory infection also had the largest mortality disparities. Counties ranked in the lower 10th percentile had an average of only 18 deaths for every 100,000 people while counties that ranked in the 90th percentile had 43 deaths per 100,000.

A 2017 Centers for Diseases Control and Prevention report found death rates for heart disease, cancer, unintentional injury, chronic lower respiratory disease and stroke were all higher in rural areas compared to urban environments. Like Tuesday's study, the CDC report suggested a combination of limited healthcare access and a higher frequency of health-risk behaviors were major contributors to those outcomes.

Mokdad said factors such as lower income level and education, limited access to quality care and higher frequency of health-risk behaviors like smoking, substance use and obesity can usually predict the health outcomes of a community, regardless of the disease.

He said people living in medically underserved areas often go through a vicious cycle of engaging in unhealthy behaviors when they can't access healthcare services consistently or take advantage of preventive services. Such individuals often delay seeking treatment until their condition has become more advanced, reducing their chances of recovery.

"People under stress are more likely to behave badly," Mokdad said.

Mokdad said such societal factors help to explain why so many rural communities have been hit hard by the opioid epidemic in both the high proportion of drug overdose deaths and the number of those who have died from infectious diseases like HIV/AIDS and tuberculosis; both of the latter are heavily concentrated in the Southeast.

Health departments and healthcare providers in rural areas must first identify the specific issues on a neighborhood level in order see significant progress toward improving their health outcomes, said Dr. Jeffery Duchin, public health officer for Seattle and King County in Washington.

"We find that we have basically a 20-year spread in life expectancy between people living in different parts of our county," Duchin said. "So, knowing who's at risk within your county is the most important thing."

Improving healthcare access and quality alone is not enough to address the underlying issues that created such disparities, according to Duchin. He said providers need to look at how they can address non-medical, societal factors such as poverty, crime, lack of stable housing, and food insecurity in order to affect long-term change.

"In order to decrease health disparities across any geographic area, be it a county or our country, we really need to address the upstream drivers of poor health in addition to providing good access to quality medical care to everyone," Duchin said.

Steven Ross Johnson has been a staff reporter for Modern Healthcare magazine since 2013 and covers issues involving public health and other healthcare news. Johnson has been a freelance reporter for the Chicago Tribune, Progress Illinois, the Chicago Reporter and the Times of Northwest Indiana and a government affairs reporter for the Courier-News in Elgin, Ill. He received a bachelor's degree in communications from Columbia College in Chicago and a master’s degree in journalism from the Medill School of Journalism at Northwestern University.

http://www.modernhealthcare.com/article/20180327/NEWS/180329918?utm_source=modernhealthcare&utm_medium=email&utm_content=20180327-NEWS-180329918&utm_campaign=hits

Friday, March 30, 2018

Who in healthcare wins/loses in omnibus bill?

By Susannah Luthi | March 21, 2018

Congressional leaders released the long-awaited $1.3 trillion, two-year omnibus spending bill after days of wrangling behind closed doors over contentious policies that included an embattled stabilization package for the individual market that would fund cost-sharing reduction payments and a $30 billion reinsurance pool. Here's what did and did not make it into the bill.

Total HHS appropriation: $88 billion

Winners:

Insurers that fought to keep a new policy that phases down their share of the cost of prescription drugs not covered by Medicare while raising it for drugmakers.

The National Institutes of Health, which received a $3 billion boost in funding, bringing its total budget to more than $37 billion.

Opioid addiction abatement efforts, which received $500 million to develop alternative pain medications. HHS also received $3.6 billion to fight drug abuse.

Rural communities, which will see a hefty $135 million increase in healthcare program funding, including $100 million for drug addiction treatment and prevention.

Telehealth in rural areas will get a boost in grants and HHS' total spending on rural communities will be $290.8 million.

Community health centers will receive a $135 million increase over last year to expand addiction prevention and treatment services as well as access to overdose reversal drugs.

Providers would see a quicker resolution to their Medicare appeals as Congress funnels $182 million toward reducing a backlog of more than 500,000 appeals.

Children's providers will get a boost in their reimbursement rates under the Child Care and Development Block Grant, which got a major $2.4 billion increase over last year. The Children's Hospitals Graduate Medical Education Payment Program will get a $15 million boost to support pediatric medical training.

Abstinence-only sex education gets $25 million in state grants.

Flu prevention. Congress is increasing funds to combat the flu by $218 million, a 68% boost, to improve the response to pandemic flu and ramp up research to develop a universal flu vaccine.

Losers:

Insurers that had been optimistic following the weekend's negotiations for CSRs and reinsurance.

The Affordable Care Act, which now faces several attempts to limit data or grant opportunities related to the legislation.

Drugmakers, who wanted to offload some of their newfound financial liability for the Medicare Part D donut hole back to insurers.

Susannah Luthi covers health policy and politics in Congress for Modern Healthcare. Most recently, Luthi covered health reform and the Affordable Care Act exchanges for Inside Health Policy. She returned to journalism from a stint abroad exporting vanilla in Polynesia. She has a bachelor’s degree in Classics and journalism from Hillsdale College in Michigan and a master’s in professional writing from the University of Southern California.

http://www.modernhealthcare.com/article/20180321/NEWS/180329972?utm_source=modernhealthcare&utm_medium=email&utm_content=20180321-NEWS-180329972&utm_campaign=financedaily

With no fix in omnibus budget bill, insurers set to hike premiums, rethink selling individual plans

By Shelby Livingston | March 22, 2018

In a blow to health insurers, the House on Thursday passed a $1.3 trillion, two-year omnibus spending bill that didn't include funding for cost-sharing reduction payments or a federal reinsurance program. Insurers had been lobbying hard to get something included in the massive spending bill. Absent that lifeline, insurers will likely be raising premiums and rethinking their participation in the individual market in 2019.

The omnibus bill, which the Senate must pass by midnight on Friday to avoid a government shutdown, marks what most feel was a final shot at passing measures to bring down premiums in the individual market before plans must decide where to sell and how to price coverage next year.

The industry's dominant lobbying group, America's Health Insurance Plans, and the Alliance for Community Health Plans, which represents not-for-profit insurers, are regrouping after the loss.

"We're discouraged at the moment, but we're not giving up quite yet," ACHP CEO Ceci Connolly said, adding there's still a chance that stabilization measures could be added as an amendment to the spending bill. "We are disheartened to see efforts to make this suddenly about stock prices or profits … This is a conversation about premiums for 2019, and it's for working families."

A $30 billion reinsurance program—health insurers' top priority—was dropped from the spending bill along with funding for cost-sharing reduction payments on Monday. That came despite bipartisan support for the package after lawmakers on both sides disagreed over policy demands from the Trump administration, including the auto-renewal of short-term plans and applying anti-abortion language to the cost-sharing payments.

Without a federal reinsurance program that would have helped subsidize care for high-cost plan members, some health insurers could hike premiums further or exit the individual market altogether.

"Failure to stabilize the individual market further raises health insurance costs for Americans who purchase their own coverage," said Daniel Hilferty, president and CEO of Independence Blue Cross. "Premiums should be more affordable, which is why reinsurance as well as cost-sharing reduction payments for middle-class families are absolutely critical."

John Baackes, CEO of LA Care Health Plan, which tripled its individual market enrollment in 2018 to 76,000 paid customers, said reinsurance is especially important for counties or states with only one insurer.

"The reinsurance fund was a safety valve. Without that, they are going to have more plans dropping out," Baackes said.

Zeroing out the individual mandate penalty will cause insurers to raise rates, and funding for cost-sharing payments could have helped blunt those premium increases for some consumers, Baackes said.

Joel Ario, managing director of Manatt Health and former director of HHS' Office of Health Insurance Exchanges, agreed that funding for a reinsurance program would have sent a positive signal to insurers participating in the individual market. But he said many plans that raised premiums for 2018 to account for the loss of the cost-sharing payments are now profitable, which means they're more likely to keep selling plans.

"They are starting from a better position on the balance sheet, so I'm still hopeful we'll have good participation in ACA-compliant market," Ario said.

On the other hand, some experts insist that the individual health insurance market is better off without funding for cost-sharing reduction payments and reinsurance. They say consumers, particularly ones that receive subsidies, would have ended up paying more if the federal government resumed paying cost-sharing subsidies.

When the Trump administration halted cost-sharing reduction payments in October, insurers and state regulators in many states responded by raising premiums for silver-level exchange plans only, which in turn boosted the size of the premium tax credits that the majority of exchange enrollees received, insulating them from the premium hikes. Other consumers were about to get 2018 gold-level plans at a cost similar or lower than the silver plan, or a bronze-level plan with no premium.

Funding the cost-sharing reduction payments would reverse that trend, sending the price of gold and bronze-level plans higher and causing confusion for customers who had switched to those plans in 2018. Reinsurance funding, on the other hand, could have reduced premiums by an average of 10%, according to the Congressional Budget Office. While that would have benefited enrollees ineligible for federal financial assistance, it wouldn't have much effect on subsidized customers.

Matthew Fiedler, a fellow at the Brookings Institution, said the stabilization package would have had little effect on whether or not health insurers chose to play ball in the individual market in 2019.

"Insurers participate when they think they can make money doing so, and this package wouldn't have affected their ability to be profitable in this market," Fiedler said. "Adjusting prices appropriately to reflect whether there's a reinsurance program of CSR payments is relatively straightforward."

Insurers already found a way to adjust their premiums to account for the absence of cost-sharing reduction payments. They hiked 2018 rates by an average of 20% strictly to account for those missing payments. Several analyses, including one published this week by the White House Council of Economic Advisers, found that though insurers struggled financially in the first few years of the ACA exchanges, most are now breaking even or making a profit in the individual market.

What may be of more concern at this point is the potential proliferation of plans that skirt ACA rules in 2019. Proposed rules would expand access to short-term health plans and association plans that don't offer many of the consumer protections required by the ACA. Enrollment in noncompliant plans, along with the zeroing out of the individual mandate penalty at the end of last year, create uncertainty in what the risk pool will look like in 2019. It's likely healthy people will be siphoned out of the individual market, leaving behind the sickest, costliest and most heavily subsidized consumers.

"You could see some insurers saying: I don't know how to price for this market. I'll come back when the dust settles," Fiedler said.

Shelby Livingston is an insurance reporter. Before joining Modern Healthcare in 2016, she covered employee benefits at Business Insurance magazine. She has a master’s degree in journalism from Northwestern University’s Medill School of Journalism and a bachelor’s in English from Clemson University.

http://www.modernhealthcare.com/article/20180322/NEWS/180329961?utm_source=modernhealthcare&utm_medium=email&utm_content=20180322-NEWS-180329961&utm_campaign=financedaily

What every woman should know about Social Security

By Mary Beth Franklin

Women tend to live longer than men, meaning they spend more time in retirement and often do so with less savings, given their lower average lifetime earnings. They are also more likely to live alone in old age due to widowhood or divorce. Consequently, women represent more than half of all Social Security beneficiaries age 62 and older and two-thirds of all beneficiaries over the age of 85.

Here are the top 10 things women need to know about Social Security benefits.
(Updated March 2018 with 2018 earnings test limits.)

You Earned It

If you work for at least 10 years and earn a minimum of 40 work credits, you are entitled to a Social Security retirement benefit as early as age 62 or disability benefits even sooner if you can’t work because of severe illness or injury. Retirement benefits are based on your highest 35 years of earnings. If you work less than that, the zero earnings years in the 35-year-calculation will reduce your retirement benefit.

Marriage benefit

If you are married, you may be entitled to Social Security retirement benefits, both on your own work record and as a spouse. A spousal benefit is worth between one-third and one-half of the husband’s benefit, depending on your age at time of claim. In most cases, you would be paid the higher of the two benefits, not both.

Disappearing opportunity

If you were born on or before Jan. 1, 1954, you are eligible to claim only spousal benefits on your husband’s earnings record when you turn 66, allowing your own retirement benefits to continue to grow by 8% per year up to age 70. Younger workers will never have this choice. Whenever they file for Social Security, they will be “deemed” to file for all available benefits and would be paid the higher of the two amounts.

Same-sex marriage

Lesbian couples are entitled to the same Social Security benefits as heterosexual couples. Couples must be married at least one year to claim benefits as a spouse. If entitled to benefits on your own earnings record and as a spouse, you would be paid the higher of the two amounts. But if you were born on or before Jan. 1, 1954, you have the option to claim only spousal benefits at 66 and switch to your own larger retirement benefits at 70.

Collect on your ex

If you were married at least 10 years, are divorced and currently single, you may be able to collect Social Security benefits on your ex’s earnings record. And if you have been divorced at least two years and both former spouses are at least 62 years old, you can collect benefits as an “independently entitled spouse” even if your ex has not yet claimed benefits. But to collect only spousal benefits while your own benefits keep growing up until age 70, you must have been born on or before Jan. 1, 1954.

Caregiving spouse

If your husband is collecting either Social Security retirement or disability benefits and you are caring for his minor child under age 16 or a permanently disabled adult child, you may be eligible for a spousal benefit regardless of your age. Once the youngest child turns 16, you will lose your benefits until you qualify for retirement benefits as early as age 62.

Survivors have choices

If you are entitled to a Social Security retirement benefit on your own earnings record and you are a surviving spouse, you can choose whether to collect your retirement or survivor benefit first and switch to the other benefit later if it would result in a larger amount. Reduced survivor benefits are available as early as age 60. Full benefits — worth 100% of what your late husband was collecting or entitled to collect at time of death — are available at your full retirement age (FRA) but they do not grow larger if you wait beyond FRA to collect them. However, retirement benefits increase by 8% per year for every year you postpone collecting them beyond FRA.

Public employees offset

Public employees, including teachers, in about a dozen states are not covered by Social Security. If you have a public pension based on work where you did not pay FICA taxes and your try to collect Social Security benefits as a spouse or survivor, those benefits could be reduced or wiped out by the Government Pension Offset provision. The rule reduces any potential Social Security benefits by two-thirds of the amount of the public pension.

Earnings test

Anyone who collects any type of Social Security benefits — as a worker, spouse or widow — before full retirement age while continuing to work could lose some or all of their benefits to the earnings test. They would forfeit $1 in benefits for every $2 earned over $17,040 in 2018. Any benefits lost to the earnings cap would be reinstated at full retirement age in the form of higher monthly benefits.

New suspension rules

If you are collecting benefits on your husband’s earnings record and he decides to suspend his benefits at full retirement age to earn delayed retirement credits, beware that your spousal benefits would stop, too. Under new rules that took effect last year, anyone can still suspend benefits at full retirement age, but no one can collect benefits on that worker’s record during the suspension. There is an exception for divorced spouses. If an ex-spouse suspends benefits, it will not affect the benefits of a former spouse.

http://www.investmentnews.com/gallery/20170609/FREE/609009999/PH/what-every-woman-should-know-about-social-security

UPMC, Highmark continue their Medicare Advantage feud

By Paul Barr | March 27, 2018

UPMC is still quietly fighting to end its relationship with Highmark Health's Medicare Advantage program in Pennsylvania.

Although the UPMC health system and Highmark previously had settled another dispute, UPMC's just-released financial statements for Dec. 31 noted that it appealed a state ruling requiring it to accept Highmark Medicare Advantage patients beyond the expiration of a consent decree in June 2019.

Pennsylvania's Supreme Court will hear arguments for the case in May, according to the case docket.

"We are confident that the Pennsylvania Supreme Court will be persuaded by Judge Pellegrini's decision supporting in-network access to UPMC hospitals in Pittsburgh and Erie through 2019 for Highmark Medicare Advantage Security Blue and Freedom Blue members and will affirm," a Highmark spokesperson said in an email.

Representatives of UPMC couldn't be reached for comment.

The two organizations are moving more into each other's traditional lines of business, with UPMC's net patient revenue not that much greater than its health insurance revenue, and Blues affiliate Highmark owning its own health system, eight-hospital Allegheny Health Network.

For the six months ended Dec. 31, UPMC reported net patient service revenue less bad debt of $3.9 billion, and insurance enrollment revenue of $3.6 billion.

Meanwhile, in the same six-month period in 2017, UPMC's profit on its unrestricted net assets was $892 million (excluding $44 million in other changes to unrestricted net assets). The profit was bolstered by investment and financing gains of $146 million.

Operating income totaled $111 million on operating revenue of $8.12 billion, producing an operating margin of 1.4%.

UPMC is converting to a Dec. 31 year-end from June 30 beginning in 2018.

Correction: UPMC and Highmark had not earlier indicated the dispute was resolved. Also UMPC does compare its financial results results to previous years in the latest report, as it converts to a new fiscal year.

Paul Barr, a healthcare journalist since 2004, is responsible for Modern Healthcare’s feature stories. Barr most recently was a senior editor for Hospitals & Health Networks, but before that worked six years at Modern Healthcare as news editor and two years as a reporter. In 2016 he won a Jesse H. Neal award for best single story, and in 2015 was a finalist for best series. Prior to 2004, he covered financial matters for various publications. Barr has a bachelor’s degree in economics and master’s degrees in journalism and business from the University of Illinois.

http://www.modernhealthcare.com/article/20180327/NEWS/180329916?utm_source=modernhealthcare&utm_medium=email&utm_content=20180327-NEWS-180329916&utm_campaign=dose

Agents and Brokers Influence Medicare Member’s Decisions

28-Mar-2018

Deft Research has just published its 2018 Medicare Shopping and Switch Study which reports on the Fall annual enrollment period (AEP) activities of both senior consumers and health insurance agents. The study covers both the reasons seniors have for shopping and switching and the various information channels they use when making decisions.

The study re-affirms the idea that people need the help of an insurance professional when making health plan decisions. Consumers have reported that the tools found on Medicare.gov and other websites often provide them with lots of information but no help making a decision – in fact many wind up more doubtful than they began.

Part of the problem is that a set of health plans placed together for consideration usually produces more questions. A clear decision does not emerge.

When faced with such a choice, consumers seek a way to make a selection based on trust. Trust is the most fundamental element of the consumer-health plan relationship and consumers seek it in various forms. One form is the trustworthiness to be found in brand reputation, "Does the brand take care of people if they get sick?" Another form comes through the affirmation of a knowledgeable person such as an insurer's own representative or an agent.

The Need for Agents

Over time, despite the emergence and refinement of on-line shopping resources, we have seen the percentage of seniors using health insurance agents has remained relatively stable. We have also seen that agents create an environment which makes seniors more comfortable with switching.

According to the study, agents facilitate almost 50% of the occasions when a senior switches from one plan to another.

When an agent talks with a senior, the respondents to our survey most often report that a Premium-to-Benefit analysis occurs. This analysis includes a review and assessment of drug coverage, as well as a check on whether the consumer’s doctors are in the network.

The conclusion one could reach is that senior health plan consumers who are serious about finding a plan that is better for themselves, often need personal assistance.

Medicare switchers were 3.8 times more likely than non-switchers to receive help from an agent during the 2018 AEP.

We find that agents gravitate toward products that are lucrative for them to sell. For example,

77% of agents in the health insurance business sell Supplemental Medicare coverage (Medsupp). While only 43% sell Prescription Drug Plans (PDP’s). A significant proportion of agents forgo the PDP opportunity, and only 3% sell PDP’s only.

We also find that Deft's 2018 Medicare Shopping and Switch Study results support the idea that agents must consider the ease and speed of sales. With a large bulk of business to be closed in the short AEP timeframe, if the agent is to meet sales goals, products that take more time to explain and inject more uncertainty cannot be favored over simpler products.

Consistent with this statement, the study found that:

Although only 25% of Medicare Advantage enrollment is in a PPO, agents report that over half of their sales are PPO’s.
Forty percent of agents said their PPO sales had grown this year and a similar percent (43%) said they expect PPO sales to grow again next year.

PPO’s have larger networks and fewer restrictions on access to doctors and hospitals. This fits our idea of simpler, easier, and faster to sell. This means that without changes to the system, we cannot expect agents to be leaders in promoting new products with more complicated networks, formularies, and tiers.

Health plans are under pressure to control costs and engage consumers. Agents are important players in this market. If health plans are to succeed in their charge, agents will likely play a role in that success. In order get the best out of agents we have several actions insurers can take:

We have found in several studies that insurers could develop agent tools that go beyond the plan selection tools currently available. These would certainly include easy interfaces for checking on doctor and hospital availability. They also need to go further in helping consumers understand what would happen in various dire circumstances – if you needed to go to the emergency room, where would you be taken? What would it cost? Under situations of distress, who would help you and assure your coverage would work? What services are likely to be needed in an entire episode of care? Agents can’t be expected to provide these answers, but they would communicate them to their clients, and with this we see a tool for understanding whether a narrow network plan would work for them.
The study suggests that insurers should know that agents are critical of the agent service they receive from health plans. 95% of agents said they were more likely to sell the health plans who provided good service to them over others who do not.
The study also found that providing extra incentives, vacations, trips to conferences, additional bonuses and gifts to agents, is motivating to the majority. Two-in-five agents are not given the opportunity to earn extra incentives. Here is perhaps a gap in the market for insurers to help fill.

Learn more about Deft’s Senior Market Insights Service.

https://blog.deftresearch.com/resources/agents-and-brokers-influence-medicare-members-decisions?utm_campaign=2018%20MSS_Study%20&utm_source=hs_email&utm_medium=email&utm_content=61728821&_hsenc=p2ANqtz-9b--vHY0LwdYyCSP_gwb4HUFqNwURnDdMiqUjCcD9Qa9NIdVkI37lzMre0_ZUb4nOWIRFn861yS9WYYoHaF_nKzqlAdsFAiSE_ToKQFo5uiVBCqAo&_hsmi=61728821

Maine governor balks at submitting Medicaid expansion plan to CMS

By Harris Meyer | March 30, 2018

Like other state Republican officials across the country, Maine Gov. Paul LePage has argued his state can't afford to expand coverage to low-income adults even though the federal government would pick up the bulk of the cost.

But a new national report from the Brookings Institution shows 31 expansion states have incurred negligible costs so far, at least partly because federal expansion dollars cover costs the states were bearing prior to expansion. That finding runs counter to conservative claims that Medicaid expansion spending is an "out-of-control wildfire" for states.

Another new report, from Manatt Health, found that the net cost of Maine's expansion would be half of what LePage claims.

Maine voters overwhelmingly passed a binding ballot initiative in November mandating Medicaid expansion under the Affordable Care Act by July 2018. It was strongly backed by the Maine Hospital Association and the Maine Medical Association.

LePage, who previously vetoed five expansion bills, is balking at sending the CMS a plan to implement the voter-passed expansion by the April 3 deadline set in the initiative. He is demanding that the Legislature first come up with $60 million in budget savings to fund the expansion's first year. Expansion supporters are reluctantly preparing to file a lawsuit to require implementation of the ballot initiative.

"Show me the money," LePage told lawmakers in his State of the State speech last month. "It would be fiscally irresponsible for the Legislature to demand we implement Medicaid expansion without adequate funding."

Manatt Health found, however, that Maine would only need $30.5 million, not $60 million, in additional net funding to cover an estimated 50,000 people who would enroll in the first year. That would rise to $48.5 million to cover 68,000 people in 2020, and $61.9 million to cover 71,000 people in 2021.

The federal government would contribute $316.6 million in the first year, $445.3 million in the second year, and $489.5 million in the third year. The federal share of total expansion costs would be 94% in the first year, dropping to 90% in 2020 and thereafter.

Julie Rabinowitz, LePage's press secretary, rejected Manatt's state cost estimate, which is similar to the estimate issued last year by the state Office of Fiscal Policy and Review. She said the assumption that expansion would save the state money is "reckless," given what she described as other states' "spending overruns" on Medicaid expansion and their underestimates of enrollment.

She also cited Maine's bad experience with its previous Medicaid expansion, which was enacted prior to LePage's tenure and before the federal government began paying for expansion under the ACA.

Expansion supporters say Maine could cover the first-year expansion cost without additional budget appropriations at least through May 2019 by tapping remaining budgeted dollars in its Medicaid account. In addition, the state's recent revenue forecast projected a budget surplus of $128 million, which also could be applied to the expansion cost.

"They should set aside some of that surplus for Medicaid expansion costs," said Jeffrey Austin, the Maine Hospital Association's vice president for governmental affairs. "It's the law and they know it's going to cost money."

But LePage has proposed to use those surplus funds to bring the state income tax system into conformity with the tax cut law passed by Congress in December by cushioning higher-income people from the law's rollback of deductions for local and state taxes.

"He sweeps most of that money into additional tax breaks to corporations and wealthy people, then he turns around and says we don't have money for Medicaid expansion," said Robyn Merrill, executive director of Maine Equal Justice Partners and a leader of the campaign to expand Medicaid. "That's really disingenuous."

LePage and GOP leaders in the other 17 states that haven't expanded Medicaid base much of their opposition to expansion on its affordability, arguing that it's been a fiscal disaster in expansion states.

Opponents, such as the conservative Foundation for Government Accountability, say states have enrolled far more people than expected, with much higher costs than originally projected. They also contend states can't count on the federal government to continue picking up 90% of the cost, as required by the ACA.

But Brookings' report found that expansion enrollment has either fallen short of or not substantially exceeded expectations, and that there were no significant increases in state spending as a result of expansion.

The report noted that various categories of previously covered Medicaid beneficiaries can now enroll under the ACA expansion program, which sharply reduces the state's share of its Medicaid costs under the enhanced federal matching rate. In addition, expanded Medicaid pays for various costs the states previously were paying outside of Medicaid.

In Maine, the Manatt report projects the state will generate savings from the shift of various groups from the traditional state Medicaid program, called MaineCare, to expanded Medicaid. Those groups include pregnant women, breast and cervical cancer patients, disabled people, HIV patients, correctional inmates needing hospital care, and people needing mental health and substance abuse services.

But LePage has refused to consider any of those offsetting savings. "Those programs aren't necessarily winding down at the same time," Rabinowitz said.

Expansion supporters hope the Democratic-controlled state house and the Republican-controlled state senate will reach a budget deal in April that includes Medicaid expansion funding in exchange for tax cuts that offset tax increases in the new federal tax law. As part of the deal, Republicans might agree to override LePage's likely veto of expansion funding.

"We'd rather work this out rather than fight it out in court," Merrill said. "Our focus is getting healthcare to people as soon as possible. They've been waiting too long as it is."

Meanwhile, LePage is awaiting the CMS' response to his Medicaid waiver requestto establish work requirements, premiums, a $5,000 asset test, and an end to retroactive eligibility for Maine's 267,000 current beneficiaries. His administration projects the waiver would lead to several thousand fewer people on Medicaid.

Merrill said her group would file a lawsuit challenging the work requirement if it's approved by the CMS. The hospital association opposes the end to retroactive coverage for people who receive healthcare services and are found to be Medicaid-eligible, which would increase uncompensated care for providers.

There is also concern about Maine's proposed $5,000 asset test to determine Medicaid eligibility for people applying based on low income. The CMS previously has not approved any state waivers for asset tests, said MaryBeth Musumeci, a Medicaid policy analyst at the Kaiser Family Foundation.

Depending on the details, an asset test could potentially disqualify many people if they own a home or vehicle or have savings. The ACA has no asset test for Medicaid expansion enrollees, which has made coverage more widely available to the working poor.

"That would be a first, and a reversal of a rule the ACA changed," Musumeci said.

Harris Meyer is a senior reporter providing news and analysis on a broad range of healthcare topics. He served as managing editor of Modern Healthcare from 2013 to 2015. His more than three decades of journalism experience includes freelance reporting for Health Affairs, Kaiser Health News and other publications; law editor at the Daily Business Review in Miami; staff writer at the New Times alternative weekly in Fort Lauderdale, Fla.; senior writer at Hospitals & Health Networks; national correspondent at American Medical News; and health unit researcher at WMAQ-TV News in Chicago. A graduate of Northwestern University, Meyer won the 2000 Gerald Loeb Award for Distinguished Business and Financial Journalism.

http://www.modernhealthcare.com/article/20180330/NEWS/180339984?utm_source=modernhealthcare&utm_medium=email&utm_content=20180330-NEWS-180339984&utm_campaign=financedaily

California hospitals try to block proposal to ban Medicaid providers from 340B

By Susannah Luthi | March 30, 2018

A 340B battle is brewing in California, where Medicaid providers may get banned from using the federal drug discount program if the governor's budget proposal moves forward.

The scale of Democratic Governor Jerry Brown's proposal to carve Medicaid out from 340B took hospitals by surprise, said Amber Ott of the California Hospital Association. Providers of all stripes are banding together to block the initiative that would hit almost half of hospitals in a state where roughly one-third of the population, or more than 14 million people, is covered by Medicaid

Ott said hospitals project the change would cost them hundreds of millions of dollars.

California's legislative effort to curb the 340B program is the most drastic under serious consideration on a state or federal level, although it isn't new. Delaware attempted a similar ban through regulation, but ultimately the CMS barred the state from implementing it. California providers are riled, saying that it would essentially take money out of California's system and funnel it into the federal government.

Saving money is a key reason for the proposal, as it would help replenish the state's General Fund. Federal law prohibits any double-dipping in both the Medicaid drug rebate program and the 340B drug discounts. If a provider collects the 340B discount for the drugs it dispenses to Medicaid patients, the state won't get the federal rebate.

While the governor's office has not determined how much it estimates the measure would save, the Department of Health Services projects that the Medicaid prescription drug program would garner $4.1 billion in savings, which would grow if Brown's proposal carries forward.

Yet hospitals point out that California retained just over $1.3 billion of that estimated $4.1 billion because the federal government pays most of the Medicaid expansion costs as well as its share of traditional Medicaid.

"From policy perspective that's concerning — that you're taking hundreds of millions of dollars out of California system and giving two-thirds of it to the federal government," Ott said.

The California Hospital Association officials said that there isn't enough publicly available data for them to quantify the exact financial impact on providers, but preliminary surveys project the change would cost hospitals hundreds of millions of dollars.

Sarah Hesketh of the California Association of Public Hospitals — which represents 21 hospitals that are all both disproportionately reliant on Medicaid and enrolled in 340B — said that should providers decide to stay enrolled in 340B to get discounts for their Medicare patients they would continue to be subject to the 340B provider rules banning them from group negotiations for lower drug prices. This would have the unintended consequence of hurting the providers who care for the most Medicaid patients.

"While our competitors could enter into group-purchasing arrangements likely at a cheaper price, we would be paying full price for a significant number of our patients," Hesketh said.

More than 170 of California's 400 hospitals get 340B drug discounts from manufacturers as required under current federal law, and the prospect of this change is uniting a vast swath of the state's provider community as they try to keep the proposal out of Brown's revised budget that is due in mid-May.

Should they fail there, hospitals will turn to the Legislature. State lawmakers will take up the revised budget and have until June 15 to pass it.

The measure has already had its hearing in the state Senate's budget health subcommittee and later this month the Assembly's budget health subcommittee will examine it as well. Their recommendations on the provision, should it make it into the governor's final budget, will decide whether it becomes state law or not.

The Washington debate around curbing 340B growth has pitted Big Pharma against hospitals. But that isn't the case in Sacramento, according to Barbara Glaser who lobbies for the California Hospital Association. The proposal came from the Department of Health Services and so far it has united clinics and hospitals to fight against it as a battle of state versus federal interests.

"At a time when our healthcare programs are facing incredible threats at the federal level, stability in state policies and regulations that support California's safety-net institutions and programs are needed now more than ever. Although the repeal of the Affordable Care Act and Medicaid entitlement reform did not move forward last year, we expect continued pressure to reduce Medicaid costs and disrupt the ACA," the letter from the coalition that includes health systems, hospital associations, HIV and AIDS groups, the California Rural Indian Health Board, and psychiatric and mental health groups, said.

The reasoning behind Brown's proposal isn't only about cost-savings for the state. He and analysts have pointed to the administrative complexity of preventing any double-dipping into both the Medicaid drug rebate program and 340B. Officials note that the complexity has grown since ACA expanded both the 340B program and Medicaid.

Ott conceded that administration did become more complicated with the ACA, which expanded the Medicaid rebate program to managed care plans. One-third of Californians are on Medicaid, and 80% of the state's Medicaid population is in managed care.

An in-depth report on the proposal by the California Legislative Analyst's Office recommends that the Legislature seriously consider Brown's plan, citing the post-Affordable Care Act expansion of both Medicaid and 340B as tangling the state efforts to capture all the savings.

The analysis estimates that about 1,500 provider sites care for Medicaid patients and dispense 340B-discounted medications, and notes that the proliferation of extra middlemen like contract pharmacies add to the complexities.

Last year, California lawmakers ultimately rejected a proposal that would have banned contract pharmacies from dispensing 340B drugs to Medicaid patients.

The latest proposal also aims to prevent any double-dipping and protect the state Medicaid's program integrity.

While the California Legislative Analyst's Office said this along with the cost-savings should push the legislature to consider the proposal seriously, it could encourage many Medicaid patients to drop out of the 340B program entirely due to administrative burden. In that case, the study notes, the state might need to consider raising the Medicaid reimbursement rate.

The legislative analyst also looks at potential alternatives to the full carve-out of Medicaid from 340B: a prohibition or limit on contract pharmacies from dispensing 340B drugs to Medicaid patients, as was proposed last year; a prohibition or limit on certain covered entities from dispensing some or all 340B drugs to Medicaid patients; a decision to pay for 340B drugs at cost within managed care; or to maintain the status quo.

It is unclear how many states may follow suit with similar 340B measures, even as Washington lawmakers debate how they want to address the program.

Ohio and Oregon have both banned contract pharmacies from dispensing 340B drugs.

http://www.modernhealthcare.com/article/20180330/NEWS/180339974?utm_source=modernhealthcare&utm_medium=email&utm_content=20180330-NEWS-180339974&utm_campaign=financedaily

Supporting nutrition, supporting health and independence

March 29, 2018

Supporting nutrition, supporting health and independence

By Lance Robertson, ACL Administrator and Assistant Secretary for Aging

We all know that good nutrition is the foundation of good health. Healthy eating can help people achieve and maintain a healthy weight, prevent the onset of chronic diseases, reduce inflammation, and speed recovery from injuries. On the other hand, poor nutrition is connected to a variety of health problems.

Earlier this month, I had lunch with Vice Admiral Jerome Adams, the U.S. Surgeon General. I shared some of the things ACL was working on during National Nutrition Month, and we talked about how important nutrition is for the people ACL serves.

VADM Adams gets it. “People who don’t have enough healthy food are more likely to be hospitalized, tend to experience longer hospital stays, and are more likely to be readmitted after discharge. Good nutrition is important to everyone, but it is even more critical for those at risk for being food insecure, such as older adults and people with disabilities, many of whom already are already at increased risk of hospitalization.”

Unfortunately, a variety of factors can make it harder for older adults and people with disabilities to get the nutrition they need.

As we age, our bodies generally become less able metabolize food, and many people with disabilities have unique nutrition needs. If people do not fully understand those needs, it can be very difficult to make informed choices that lead to better health. In addition, both older adults and people with disabilities can face barriers to eating well. For example, a lack of public transportation could limit access to fresh groceries, and some people need the support of a caregiver to prepare or eat meals.

ACL is working with the aging and disability networks to help address these issues.

The Older Americans Act (OAA), passed in 1965 and reauthorized in 2016, acknowledged the importance of good nutrition for older adults by creating two important meal programs.

The Congregate Meal Program brings people together for meals in group settings such as senior centers, while the Home-Delivered Meal Program provides meals for frail, homebound, or isolated individuals. Both programs serve people age 60 and over, and, in some cases, their caregivers, spouses, and people with disabilities.

Both programs offer nutrition-related services and other important benefits, in addition to the meal. Congregate meals provide companionship, access to other health activities, and wellness programs — nearly two-thirds of providers of congregate meals also offer health promotion programming. Home-delivered meals provide an opportunity for social interaction and informal safety checks. In fact, sometimes the person delivering the meal is the only person the older adult sees regularly; without the meal delivery, the older adult could be completely isolated.

The impact of these programs cannot be overstated. First, they play a key role in preventing senior hunger and food insecurity. They also help seniors remain independent. In a recent survey, 63 percent of congregate meal recipients and 93 percent of home-delivered meal recipients reported that the meals allowed them to continue living in their own homes.

Similarly, many of the ACL services and supports that help people with disabilities avoid isolation and remain active in their communities help increase access to nutrition. ACL also supports programs to help people with disabilities understand and manage their individual nutrition needs, while other ACL initiatives aim to increase the nutrition knowledge of the professionals who provide services and medical care for people with disabilities.

For example, ACL’s National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) has funded projects studying nutrition interventions for a variety of populations, including people with psychiatric disabilities and spinal cord injuries. In addition, many ACL-funded University Centers for Excellence in Developmental Disabilities (UCEDDs) have professionals on staff with expertise in disability and nutrition.

UCEDDs in five states are partnering with the Association of University Centers on Disabilities (AUCD) and the Walmart Foundation on the “Nutrition is for Everyone” program. The program provides nutrition education, including direct training, for people with disability and community members. In my home state of Oklahoma, the program is supporting nutrition education training, in English and Spanish, for families with children with disabilities. The training is taught by two parents of children with disabilities. The program is also working with the Oklahoma Self-Advocacy Network to offer training to people with disabilities on fitness, healthy eating, and interacting with their health care team.

Many State Councils on Developmental Disabilities are also taking an active role in promoting nutrition. For example, South Carolina is funding a “Fit for Life” program that promotes health and wellness for young adults and adults with disabilities. They do this by pairing fitness classes with nutritional support and trips to the grocery store.

Food is an important part of everyone’s day. And for older adults and people with disabilities, it is vital to be well nourished — not just fed — to live the healthiest possible life. At ACL, we are committed to our continued work the aging and disability networks and other partners to support good nutrition as key part of helping people live independently. And while National Nutrition Month is coming to an end, we will keep spreading the word about eating well and living well – I hope you will join us!

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Today the Centers for Medicare & Medicaid Services (CMS) released the January 2018 monthly report

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Today the Centers for Medicare & Medicaid Services (CMS) released the January 2018 monthly report on state Medicaid and Children's Health Insurance Program (CHIP) eligibility and enrollment data.
The full report is available on Medicaid.gov at https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/index.html

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