ACAP Newsletter

January 29, 2007
 		 ACAP Newsletter

 
HIGHLIGHTS

ACAP Template Language for Employee Education on False Claims Recovery Now Available
As mentioned in the last newsletter, ACAP contracted with Adam Falk, Esq. of Feldesman, Tucker, Leifer, and Fidell, LLP to develop template language for the employee education provisions of the False Claims Act. Additionally, ACAP did a short summary of the January 11 CMS question and answer conference call on these provisions. These materials are available in the Members Only section of our website. (Members Only/False Claims Act.) These materials were reviewed with the Compliance Officers on their January 24 roundtable. (See below for a recap of the Compliance Officers call.)
Click to read this article.
 
PUBLIC POLICY AND ADVOCACY

State of the Union Addresses Health Care Issues
Click to read this article.
NHPRI Publishes Managed Pharmacy Issue Brief as States Talk of Medicaid Drug Carve-Outs
Click to read this article.
ACAP Signs Partnership for Medicaid Letter Urging Health Priorities in Congress
Click to read this article.
CHCS Will Highlight “Medicaid Best Buys” – Including Monroe Plan Strategy – During February 5 Conference Call
Click to read this article.
 
EXCELLENCE AND ACCOUNTABILITY

Recap: Medicare SNP Roundtable Call
Click to read this article.
Recap: Compliance Officers Roundtable
Click to read this article.
Recap: Chief Operating Officers Roundtable
Click to read this article.
Reminder: Chief Financial Officers Roundtable
Click to read this article.
Reminder: Chief Medical Officers Roundtable
Click to read this article.
 
NEWSFLASH

CalRHIO Announces Grant Opportunity for Safety Net Health Organizations
Click to read this article.
CEO Slyvia Kelly Testifies for Human Services Committee on Primary Care Case Management System
Click to read this article.
 
   
Upcoming ACAP Calls
 2/1 at 3 PM EST: Chief Financial Officers Roundtable
2/8 at 3 PM EST: Chief Medical Officers Roundtable
2/15 at 3 PM EST: Chief Information Officers Roundtable
2/22 at 3 PM EST: Pharmacy Directors Roundtable


 
Upcoming Events Calendar
Click to view calendar.


 

 
HIGHLIGHTS

ACAP Template Language for Employee Education on False Claims Recovery Now Available

 As mentioned in the last newsletter, ACAP contracted with Adam Falk, Esq. of Feldesman, Tucker, Leifer, and Fidell, LLP to develop template language for the employee education provisions of the False Claims Act. Additionally, ACAP did a short summary of the January 11 CMS question and answer conference call on these provisions. These materials are available in the Members Only section of our website. (Members Only/False Claims Act.) These materials were reviewed with the Compliance Officers on their January 24 roundtable. (See below for a recap of the Compliance Officers call.)

 
PUBLIC POLICY AND ADVOCACY

State of the Union Addresses Health Care Issues

 George W. Bush delivered the seventh State of the Union Address of his presidency on January 23rd – and his first before a Congress controlled entirely by the Democratic Party.  Recognizing the new political landscape on Capitol Hill, President Bush dedicated the bulk of his address to domestic policies that the White House believes may provide opportunities for the President and Democrats to work together.  These issues ranged from health care to immigration to renewable energy.  While many Democrats applauded politely during the President’s speech, it is very clear that many were holding their applause until they got more details about the proposals.  In fact, the luster seemed to be coming off many of these proposals the day after the speech as many of the details emerged.

Although many Democrats were particularly hopeful that the President would move in their direction on expanding health insurance coverage for the 47 million uninsured Americans, many of the emerging details of the Administration proposal have already been shunned by the Democratic Chairmen and Leadership.  President Bush’s health care proposal contained two elements.  First, he proposed making all health benefits taxable, with a standard tax deduction of $7,500 for individuals and $15,000 for households.  The value of any health benefits above those amounts would be taxed as income.  This Administration believes that this would give individuals a tax incentive to purchase health insurance through the individual insurance market.  According to the administration, 80% of the workforce would receive a tax cut as a result of this proposal, while 20%, those whom the administration described as having “gold-plated health plans,” would have a tax increase.  The second element of the proposal is called the “Affordable Choices Initiative.”  The Affordable Choices Initiative “will direct Federal funding to assist States in helping their poor and hard-to-insure citizens afford private insurance.”  The Administration would divert funds from disproportionate share hospitals (DSH) to fund this second element.  The Administration notes that all proposals are budget neutral.  Democrats and others immediately criticized the tax proposal as ill-conceived and dangerous.  The basic critiques of the policy fell along two lines:  (1) it threatened the employer-sponsored benefits provided to some workers while promoting movement to the individual insurance market and (2) it provided little real relief to the uninsured.  While many Democrats applauded President Bush for talking about the proposal, most decreed that it was dead on arrival.

On Medicare, more information has been coming out the Democrats approach to the Medicare Advantage program.  At an Urban Institute seminar on Private Plans in Medicare, Ways and Means Health Subcommittee Chairman Pete Stark suggested that overpayments to Medicare health plans offered an attractive pot of money for which to offset new expenditures, notably Medicare payments to physicians.  The overpayments, which were criticized by Democrats during the debate over the Medicare Modernization Act in 2003, have always been a place where it was thought Democrats would look for offsets or ways to save money in Medicare.  Of course, we will have to see how the debate emerges, but there is little doubt that Medicare Advantage will be one source of funding offsets in the months to come.

NHPRI Publishes Managed Pharmacy Issue Brief as States Talk of Medicaid Drug Carve-Outs

 Amid reports that numerous states are considering carving the pharmacy benefit out of managed care contracts, Neighborhood Health Plan of Rhode Island (NHPRI) has published an issue brief describing the success of its own managed approach to the drug benefit, the “managed pharmacy benefit.”

NHPRI defines the managed pharmacy benefit as an “evidence-based approach to the selection of prescription drugs that promotes more efficient and effective drug use among covered individuals.” The benefit is founded on three key elements:
 
  1. Use of a formulary to direct prescribing toward more efficacious drugs and to limit costs;
  2. Advice of a Pharmacy and Therapeutics Committee, made up of local providers and NHPRI practice managers, which provides input on the selection of drugs to be included in the formulary; and
  3. Availability of a fair and user-friendly exceptions process to outline the circumstances under which a provider can prescribe non-formulary drugs.
 In addition, an emphasis on use of generic drugs over brand-name has helped NHPRI save substantial funds. More than three-quarters of prescriptions dispensed to NHPRI patients are for generic drugs, topping fee-for service programs and commercial health plans, which typically dispense 50 percent generic and 50 percent brand-name.

Despite the carve out threat in Rhode Island, NHPRI has been able to control costs far more effectively than programs nationally. In fact, while drug costs for NHPRI have increased only 3.5 percent over three years, drug costs nationally have skyrocketed at the rate of almost 13 percent during the same period.

ACAP is planning a conference call within the next weeks for plans in states that are considering a drug carve out, and will develop a plan of action accordingly.

Please contact Meg Murray at 202.331.4601 for further information.
http://www.nhpri.org/matriarch/documents/ManagedPharmacyBenefit.pdf

 
ACAP Sharing Services
In the members only section of our website, there are several areas that we want to remind you to look at periodically, including a large section of shared documents, which includes disaster recovery plans, compliance documents, job descriptions. We also have several surveys we have done of our plans.
 
ACAP Signs Partnership for Medicaid Letter Urging Health Priorities in Congress

 ACAP signed a January letter drafted by the Partnership for Medicaid entreating Congress to place a high priority on several safety net health items. These items include:
 
  1. Preserve Medicaid’s integrity in any reform efforts,
  2. Reauthorize and fully fund the State Children Health Insurance Program (SCHIP),
  3. Prevent cuts to Medicaid reimbursement for safety net providers,
  4. Improve health care quality through care coordination, including managed care,
  5. Strengthen oversight of section 1115 Medicaid waivers and state plan amendments,
  6. Eliminate negative impact of Medicaid citizenship documentation requirements, and
  7. Ensure access to Medicaid services for newborns.
 The letter was distributed to members of Congress on January 25. The letter is available on ACAP’s website.

CHCS Will Highlight “Medicaid Best Buys” – Including Monroe Plan Strategy – During February 5 Conference Call

 On Monday, February 5, from 2 to 3:30 p.m. E.S.T., the Center for Health Care Strategies (CHCS) will hold a policy briefing call to highlight the recently-published Medicaid “Best Buys” for 2007. This call will outline five promising opportunities to improve the health of high-risk Medicaid beneficiaries and curb spending growth. States adopting these strategies can lead the health care system in providing cost-effective and high-quality care within Medicaid and beyond.

The CHCS publication praised the Monroe Plan for their initiative in the area of Care Management Program for High Risk Pregnancy “by improving its prenatal outreach program for Medicaid members, the Monroe Plan, a non-profit managed care organization in Rochester, New York, dramatically reduced NICU admissions, saving $2 for each dollar invested in the program.”

In this online event, the authors and panel of national experts will discuss the five strategies outlined in the brief for both improving the quality of services and curbing the growth in Medicaid spending.  States adopting these strategies could lead the health care system in providing cost-effective and high-quality care within Medicaid and beyond. The discussion will be moderated by Melanie Bella, Senior Vice President of the Center for Health Care Strategies. The panel includes:
 
  • Stephen Goldsmith, Innovations in American Government, Harvard's Kennedy School of Government
  • Diane Rowland, Kaiser Family Foundation
  • Dan Crippen, Former Director, Congressional Budget Office
  • MaryAnne Lindeblad, Washington State
  • Ray Scheppach, National Governor's Association (invited)
 To register for the conference call, click link and answer the short questionnaire.
http://www.innovations.harvard.edu/spotlight.html?id=182&preview=1

For the complete article, click link and download PDF file.
http://www.chcs.org/publications3960/publications_show.htm?doc_id=434341

 
EXCELLENCE AND ACCOUNTABILITY

Recap: Medicare SNP Roundtable Call

 The Medicare SNP Directors had their first roundtable of the year on January 18th. Beth Marootian from NHPRI led off a discussion about staff training for Medicare.  Beth and the other participants discussed staff training at different phases of plan development, including training for start up, on-going training, and future approaches plans were considering.

 
ACAP Job Bank
 ACAP plans can post job announcements in our job bank. Please see our website for more details. You can email job announcements to Christina Boye at cboye@communityplans.net.
 
Recap: Compliance Officers Roundtable

 ACAP Compliance Officers had their first roundtable of the year on January 24. On this call, Adam Falk, Esq. of Feldsman, Tucker, Leifer and Fidell, LLP reviewed the template employee education language for ACAP plans to use to satisfy the requirements of the False Claims Act. The template employee education language, as well as a summary of the January 11 CMS call on this topic, and the CMS State Medicaid Directors letter on the False claims act, are available on ACAP’s website. Go to Members Only/False Claims Act for a list of materials. Compliance Officers also heard from Cory Ludington, Compliance Officer at Community Health Network of Connecticut, about the recent challenges the plan has seen under the state’s Freedom of Information Act. The plan is in the process of appealing requests considered proprietary to the Connecticut Supreme Court.

Recap: Chief Operating Officers Roundtable

 ACAP COOs had their first roundtable of the year on January 25. On this call, Jenny Babcock, ACAP’s Assistant Director for Policy, presented highlights from a draft paper ACAP has produced on the Citizen Documentation Requirements of the Deficit Reduction Act. ACAP Policy Directors were also invited to participate in the call. After reviewing key components of Citizen Documentation Requirements, ACAP COOs and Policy Directors discussed the impact these requirements have had on enrollment, re-enrollment and overall membership.

Reminder: Chief Financial Officers Roundtable

 The next Chief Financial Officers Roundtable is Thursday, February 1 at 3 pm eastern time. An agenda and materials will be distributed prior to the call.

Reminder: Chief Medical Officers Roundtable

The next Chief Medical Officers Roundtable is Thursday, February 8 at 3 pm eastern time. An agenda and materials will be distributed prior to the call.

 
NEWSFLASH

CalRHIO Announces Grant Opportunity for Safety Net Health Organizations

 The California Regional Health Information Organization (CalRHIO) announced that it will make $670,000 from the Blue Shield of California Foundation available for grants to health care organizations that work with low-income, underserved populations. The grants – up to four $50,000 awards – will allow the health care organizations to participate in a statewide, health information technology initiative.

A foundation representative stated that the grant will help safety net “health care communities” – including public and rural hospitals, community clinics and public health departments - plan and implement health care data exchange programs. These communities may include health plans as well.

CEO Slyvia Kelly Testifies for Human Services Committee on Primary Care Case Management System

In Connecticut, switching to a primary-care case management system would affect more than 300,000 low-income individuals that are currently enrolled in the state's HUSKY or other Medicaid health plans such as the ACAP member Community Health Network of Connecticut.

Sylvia Kelly, CEO and President of Community Health Network, testified on January 18, 2007 for Legislators of the Human Services Committee regarding the success and importance of the HUSKY program. Ms. Kelly outlined some of the unique and distinctive qualities of the program:
 
  • HUSKY plans’ goal is to ensure that our members receive services.
  • When a member is enrolled in a HUSKY plan, they each receive a welcome call from our Outreach staff.
  • During the call, the member is assigned a primary care provider, offered assistance with scheduling an appointment and are informed that transportation is provided if needed.
  • The member is also asked questions to determine their health status, such as whether they are pregnant or have other medical needs.
    • For example, if a member is pregnant, our Nurse case managers will monitor the member’s pregnancy, identify risk factors and work with the member on obtaining prenatal care.
  • Outreach staff makes phone calls and sends post card reminders to members who are due or overdue for preventive services such as well-care and dental visits. During 2006, HUSKY plans collectively completed 225,000 outbound calls.
  • Every member receives a handbook and other educational materials describing eligible services and how to access care.
  • HUSKY plans also provide ties through relationships with other organizations who can help members with other needs, such as housing.
  • The results of HUSKY plans’ efforts have shown an improvement in the EPSDT (Early and Periodic Screening, Diagnosis and Treatment) scores for the State.
 Critics of the HUSKY program might have offered PCCM as an alternative option due to the recent debate over Freedom of Information litigation in Connecticut. Sylvia Kelly state that “the Freedom of Information Commission ruled that the MCOs are performing a “governmental function” and ordered DSS to amend its contracts with the MCOs to provide that the MCOs are subject to FOIA. Three of the MCOs, including CHNCT, appealed the ruling, and the Commission’s order has been stayed pending appeal. DSS did not appeal, and it has presented a proposed contract amendment to us.”

Ms. Kelly further testified to the Committee regarding this issue. She made the following comments on behalf of CHNCT:
 
  • CHNCT is committed to providing DSS and the legislature with all the information they need to monitor and evaluate Medicaid managed care.
  • As mentioned earlier, we provide encounter data and more than 100 reports a year to DSS. We are also audited by DSS annually.
  • We have two major problems with the contract amendment proposed by DSS. One issue with DSS’s proposed contract amendment is that it does not adequately deal with confidential information. We have contracts with service providers and vendors that require us to protect the confidentiality of their proprietary business information.
  • The FOIA statute and the DSS amendment do not give us any way to assert a trade secret claim directly to the Freedom of Information Commission if DSS decides to disclose our vendors’ proprietary information. This poses two problems for us: it is likely to involve us in litigation by vendors who have to try to protect their trade secrets, and it will make it harder for us to get national service providers (like our pharmacy benefits manager) to continue to contract with us for services we need. They don’t want to risk losing their rights to their confidential business information.
  • Our second issue is that we believe that being subject to FOIA will substantially increase our costs – both the costs of providing services and our administrative costs.
  • We believe that making all information about our negotiations with providers and vendors public will make it harder for us to obtain the best rates we could get otherwise. That will increase the costs to taxpayers.
  • We also believe that responding to FOIA requests will be costly. We have responded to some requests voluntarily. We’ve seen how broad and burdensome they can be. It has taken several days of staff time to identify and compile responsive documents. We’ve incurred legal costs to make sure that the documents can be disclosed without violating federal privacy laws or agreements with providers. It has required special computer programming to extract data from records that we have. There is no limit to the number of FOIA requests we can receive. These administrative costs will add up. As a non-profit organization, we do not have any resources to absorb these costs.
  • We believe tax dollars should be used for medical care rather than litigation and additional administrative expenses.
Upcoming Events

January Events

 
Mon Tues Wed Thurs Fri Sat/Sun
1 
 2 
 3 
 4 
 5 
 6/7 
8 
 9 
 10 
 11 
 12 
 13/14 
15 
 16 
Program Committee Meeting		 17 
 18 
Medicare SNP Call on Staff Training for Medicare		 19 
 20/21 
22 
 23 
 24 
3 PM EST
Compliance Officers Roundtable		 25 
3 PM EST
Chief Operating Officers Roundtable		 26 
 27/28 
29 
 30 
 31 
Behavioral Health Survey DUE		  
  
  

February Events

 
Mon Tues Wed Thurs Fri Sat/Sun
 
  
  
 1 
11 AM EST
Board Quality Management Committee Call

3 PM EST
Chief Financial Officers Roundtable

Salary and Benefits Survey DUE

ACAP Plan Survey DUE		 2 
 3/4 
5 
 6 
ACAP Fly-in		 7 
ACAP Fly-in		 8 
3 PM EST
Chief Medical Officers Roundtable		 9 
 10/11 
12 
 13 
ACAP Finance Committee Call		 14 
 15 
3 PM EST
Chief Information Officers Roundtable		 16 
 17/18 
19 
 20 
Executive Committee Call		 21 
 22 
3 PM EST
Pharmacy Directors Roundtable		 23 
 24/25 
26 
 27 
 28 
  
  
  

ACAP Mission: To improve the health of vulnerable populations through the support of Medicaid-focused community affiliated health plans committed to these populations and the providers who serve them.

 
Darnell Dent, Chairman Margaret A. Murray, Executive Director,
mmurray@communityplans.net, 202.331.4601

Association for Community Affiliated Plans
1400 Eye Street, NW, Suite 330
  Washington, DC 20005
http://www.communityplans.net
 Contact Us