Author: ITUP


CA to Receive $1M for Medi-Medi Coordination

Earlier today, the Department of Health and Human Services (HHS) announced that California will be one of 15 states to receive federal funding to develop better ways to coordinate care for people with both Medicare and Medicaid coverage, also known as “dual eligibles” or “Medi-Medi’s.”

Dual eligibles are often people with the most complex and costly health care needs, and this program will hopefully:
(1) eliminate duplicative services for these patients,
(2) expand access to care and improve the lives of dual eligibles, and
(3) lower costs spent on the Medi-Medi population.

The other 14 recipient-states are: Colorado, Connecticut, Massachusetts, Michigan, Minnesota, New York, North Carolina, Oklahoma, Oregon, South Carolina, Tennessee, Vermont, Washington and Wisconsin.

According to CMS administrator Donald Berwick, “beneficiaries who are in both Medicare and Medicaid can face different benefit plans, different rules for how to get those benefits and potential conflicts in care plans among providers who do not coordinate with each other. This can be disastrous for those beneficiaries who are most vulnerable and in need of help.”

Congratulations, California!

UCLA Health Policy Center’s New Blog

Today, UCLA’s Center for Health Policy Research, the office that gives us analysis of the California Health Interview Survey and supplies California with the most accurate estimates of the insured and uninsured alike, launches its new blog, Health DATAbytes.

We at ITUP drafted a guest blog for Health DATAbytes that speaks to the way accurate data enable us to do our job and do it better. Here’s a quick snapshot of that post…

It has been quite an exciting time for health policy in America! With passage of landmark health reform legislation last March, we sit on the precipice of our country’s single largest expansion of coverage, the greatest simplification of our health care and delivery systems, and the potential to radically improve public health.

However, to reach those potentials and ensure robust implementation of reform, it will be imperative that members of the public – especially those who will gain coverage through these policies – are knowledgeable about the law and how it will affect them.

Typical media coverage of health reform is not proportionate to the public’s knowledge of the details, which is admittedly difficult considering the length and density of the bill. Beginning last year, many federal regulations were instituted, hundreds of state-level bills were passed, and large funds were allocated, all with the goal of implementing these measures. This web of action only makes it more difficult for everyone – the uninsured, under-insured, and already insured – to comprehend how this legislation will affect them personally.

In our experience at ITUP arguably the best way to increase this knowledge is through the use and dissemination of public health data. Since our founding in 1996, we have relied on research by the UCLA Center for Health Policy Research in our public awareness and education efforts. In particular, since its launch in 2001, we have continually looked to the Center’s California Health Interview Survey (CHIS) for the most accurate and reliable information on the state of Californian’s health, insurance coverage and access to care…

For more, check out the rest of our post at the new Health DATAbytes.

California Exchange Board to Meet Next Week

JUST IN! The first meeting of Board the California Health Benefit Exchange is scheduled for next Wednesday, April 20th at 10:00 am in Sacramento.

Here is the meeting agenda.

And for more, check out the new CA Exchange website.

Federal Budget Deal Includes Health Cuts

Late last Friday night, on the verge of the first federal government shutdown in 15+ years, President Obama, Sen. Harry Reid, and Congressman John Boehner agreed to a budget for the rest of 2011.

The agreement contains $38 billion less spending compared to last year’s budget. Thirty-four percent (34%) of the cuts come from HHS, the Dept. of Education, and the Dept. of Labor. It is, as the President notes in his address, “the biggest annual spending cut in history.” For more on the agreement and a general list the reductions it contains, see this SF Chronicle article.

There are a number of cuts specific to health care that have a direct bearing on ACA implementation. These include:

  • Removal of $3.5 billion in unused funds in the Children’s Health Insurance Program (CHIP);
  • Reduction of $2.2 billion in subsidies for the ACA’s Health Care Cooperatives, not-for-profit entities that would compete with private, for-profit health insurance companies. The cut represents half of the budget for the cooperatives in the current fiscal year, but funding levels would revert back to $4.4 billion in fiscal year 2012 unless there is further action to limit it.
  • Elimination of the ACA’s Free Choice Voucher program which would have allowed some employees to opt out of employer coverage and instead use employer money to buy insurance through the Exchange. Ending the program will save the government $4 billion over 10 years, but it wouldn’t result in any immediate spending cuts because it isn’t set to begin for three years.

Since the current occupant of the White House is the same President that signed the ACA, it is improbable that he would ever sign a law that completely undoes health reform. It is worth noting, however, that this budget compromise — a negotiated resolution that he brokered — contains significant cuts in funding to two provisions of the ACA.

While some are fearful that this marks the beginning of the end for the ACA, there probably isn’t yet cause for alarm since these two programs are not at the heart of the law. But these cuts, and last month’s removal of the 1099 reporting provision is the first time we’re seeing the ACA being chipped away and underfunded. We’ll have to wait as see whether this is a one-time cost savings step or the start to a trend in which the ACA is underfunded piece-by-piece.

Health Care Crisis Hits Home

I’ve recently befriended an amazing woman, Mona Motwani, a former civil rights attorney who is currently in the midst of a great struggle for her health and life.

In late 2005, Mona started feeling sick with ambiguous symptoms and became so ill by the fall of 2007 that she could barely function. She visited more than a dozen doctors over 10 months who couldn’t figure out what was wrong, and it wasn’t until July 2008 that Mona was correctly diagnosed with late-stage Lyme Disease and its related co-infections: Babesiosis, Bartonella, and Ehrliciosis.

Lyme, a disease caused by a tick bite, can be incredibly painful and sometimes deadly. For Mona, it has been debilitating. You can find a partial list of symptoms here.

What’s worse, this episode has cost Mona and her family well over $100,000 in medical bills. Because she is undergoing “experimental” treatment that includes a semi-permanent picc line, her insurer refuses to cover most of the costs. In fact, after paying for one month of treatment, her insurer informed her on December 24, 2010 that none of her IV meds (at $3,000 – $4,000 per month) would be covered.

CBS 5 in San Francisco recently ran this compelling news segment about Mona and her fight against Lyme Disease. Be sure to check it out.

Also, make sure to track Mona’s progress on her blog, and if you’re in and around San Francisco, consider supporting Mona at a fundraiser in her honor on May 12th.

Focus is Squarely on Budget Crisis… in DC

For the past three months, attention in Sacramento has been affixed on the state’s $26.6 billion budget shortfall, the recently passed cuts that will shrink the deficit in half, Republican’s unwillingness to allow voters to decide on tax extensions, and the Governor’s deliberations on what to do next.

Recently, however, eyes have turned to Washington D.C. as the 2011-12 federal budget has taken center stage.

Over the past several months, instead of passing a yearlong budget bill, Congress has settled for several short-term, stop-gap budget bills — most of them including billions in cuts to health and human service programs. Today, President Obama rejected another short-term plan, a House Republican offer to cut $12 billion in exchange for keeping the government open for 7 more days. He has declared, in essence, it is time for Congress to decide upon a long-term budget.

Simultaneously, Congressman Paul Ryan, chair the House Budget Committee, earlier today reveled a Republican Budget Resolution which reads less like a fiscal road map and more like a political manifesto that envisions an alternative structure to the federal government. Among others, the House Republican plan calls for:

  • rescinding the ACA’s Medicaid expansion,
  • eliminating the entitlement in Medicaid, replacing it with a block grant,
  • radically transforming Medicare from a health insurer for seniors to a system through which members would be subsidized to pick from a list of private insurance plans,
  • cutting the top tax rate for both individuals and corporations from 35% to 25%, and
  • reducing the number of federal income tax brackets.

Yesterday, Democratic governors of 16 states and the Virgin Islands sent this letter opposing the Medicaid block grant proposal, arguing that House Republican plan would “severely undercut our ability to provide health care to our residents and adequately pay providers.”

No Clear Resolution in Sight

Much like the budget situation in Sacramento, it is unclear how D.C.’s budget quagmire will be resolved. Senate Democrats have passed a budget plan that includes $33 billion in cuts, but House Republicans have ignored that option, instead supporting Representative Ryan’s more radical proposal.

With the existing stop-gap budget expiring on Friday, April 8th, many in D.C. are gearing up for the first federal government shutdown since 1995-96.
Will it happen? With the two sides still far apart and the deadline just three days away, it’s looking more and more likely with every passing hour.

Promoting Reform Through Payment Restructuring

As part of our Delivery System Reform Issue Workgroup, ITUP recently produced this white paper that discusses, among others, opportunities 
under 
health 
reform
 for 
California to 
achieve cost
 savings and improvement in care by imposing various, novel reforms and payment techniques in Medi-Cal, Medicare, Health Families and private insurance.

Alternative payment schemes could include:

  • Capitation Variations,
  • Bundled Payments,
  • Pay-for-Performance,
  • Mixed Payment Mechanisms,
  • Value-Based Insurance Design,
  • Reference Pricing, and
  • the PROMETHEUS System

In an interview with Suzanne Delbanco of Catalyst for Payment Reform, she recommends we change payment structures by:
(1) linking payments to health care provider performance,
(2) removing incentives for delivering excess medical services, and
(3) setting reference prices for particular types of services.

Delbanco hopes we can “jump start a movement toward changing the way we pay for health care in the United States, so that a greater proportion of payment is either tied to performance somehow or is actually designed to cut waste out of the system.”

With so much change occurring so quickly, this could be the moment that payers experiment with novel reimbursement mechanisms and become true catalysts for change and cost savings in our health care delivery system.

HHS Releases Long-Awaited ACO Rule

Yesterday, the Department of Health & Human Services issued this proposed regulation for Accountable Care Organizations (ACOs), part of the ACA’s Medicare Shared Savings Program.

An ACO generally is a group of health care professionals (ideally, in concert with a health plan) that receive and distribute payments, provide care coordination, invest in infrastructure, redesign care processes, and reward high quality and efficient services. For more on ACOs, read this recent ITUP report.

According to the rules announced yesterday, groups of care providers can qualify as ACOs when they provide primary care for at least 5,000 patients, and in order to achieve savings, they must meet 65 quality standards that focus on patients’ care, coordination, patient safety, preventive health emphasis, and success in treating the most sick patients.

Several providers and plans in California have already merged or formed joint ventures and alliances in anticipation of the ACO rule, including a group out of San Diego.

While this rule — and this first generation of ACOs — will focus on seniors, there is a growing sentiment that the ACO structure, with emphasis on coordination and shared savings, will have a place in the health care system beyond Medicare.

Will that be the case? Will groups in California be identified as ACOs for the purposes of the ACA’s Shared Savings Program? Time will tell…

ITUP Summary of Counties’ LIHP Applications

On March 18th, we noted that DHCS had recently published copies of 26 counties’ applications for the Waiver’s Low Income Health Program (LIHP).

Based on the projections in their applications, counties predict the total number of people covered under the LIHP to be approximately 455,000, — with the vast majority (upwards of 345,000) covered under MCE.

To help you understand and compare each of the 20+ page applications, we just put together a LIHP summary and analysis.

In one document, you will find:

  • a simple outline of the LIHP;
  • a list of conditions on and requirements for counties’ involvement;
  • a comparison of each of the 26 counties’ approach to their LIHP;
  • an analysis of proposed delivery systems and mental health networks;
  • a comparison of anticipated enrollment; and
  • a comparison of anticipated costs and federal match.

We hope you find this helpful.

County LIHP Applications County LIHP Applications.pdf