 April 17, 2007 |
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Upcoming ACAP Calls
April 29: COO Roundtable May 3: Compliance Roundtable May 10: CIO Roundtable May 16: Quality Management Directors/Medicare Directors Roundtable (changed from original date of April 19) May 17: CFO Roundtable May 24: CMO Roundtable June 7: Pharmacy Directors Roundable (changed from original date of May 31)
Upcoming Events Calendar
 
ACAP Links
 
ACAP Members
Affinity Health Plan Alameda Alliance for Health AlohaCare Boston Medical Center HealthNet Plan CareOregon CareSource Colorado Access Commonwealth Care Alliance Community Choice Health Plan Community Health Network of Connecticut Community Health Plan of Washington Contra Costa Health Plan Denver Health Health Plan of San Mateo Health Plus Health Right, Inc. Hudson Health Plan L.A. Care Health Plan MDWise Mercy Care Plan Monroe Plan for Medical Care, Inc. Neighborhood Health Plan Neighborhood Health Plan of Rhode Island Network Health NJ Horizon Healthcare Santa Clara Family Health Plan Total Care Virginia Premier |
| PUBLIC POLICY AND ADVOCACY |
Legislative Update With the House still in recess and the Senate back in session, Washington is gearing up for the beginning of a long legislative push up to the July 4th recess. Among the items on the agenda – the FY08 budget resolution, the FY08 appropriations bills, Senate consideration of stem cell research and Medicare prescription drug price negotiations, and SCHIP reauthorization. ACAP’s top legislative priority, extending the Medicaid drug rebate to Medicaid health plans, is ready to go “prime time” as the legislative language is being finalized and vetted among ACAP members and ACAP staff have been meeting with Hill staff to reintroduce the bill in the Senate and seek a lead sponsor in the House of Representatives. Now that the legislative language has been changed to address concerns from last year (i.e., protecting health plans’ pharmaceutical utilization management mechanisms, preserving the prohibition against double dipping in the 340b discount drug pricing program, and allowing positive formularies), ACAP is going to talk with Senator Bingaman, last year’s Senate sponsor, and have targeted several Representatives as potential sponsors in the House. ACAP plans should be prepared to activate themselves within the next few weeks to get cosponsors for this legislation – particularly ACAP plans from states that are contemplating carving RX out of the plans' payments to get access to the drug rebate. Check your email over the next few weeks for an Action Alert about getting cosponsors for the drug rebate bill. ACAP is also turning its sights on ensuring that safety net health plans (SNHPs) are a part of Congressional efforts to improve America’s health information technology infrastructure. Chris Koppen, ACAP’s Washington Representative, continues to meet with Committee staff to ensure that SNHPs are part of the reintroduced Health IT legislation this year. However, in a recent discussion with Committee staff, Chris became concerned that SNHPs could again be left behind (more due to the larger scope of issues than a lack of support for their inclusion) when the bill is reintroduced this year. Therefore, ACAP has activated its members in HELP Committee member states to contact their Senators and ask them to communicate with Chairman Kennedy to include safety net health plans in his Health IT legislation. ACAP will continue to monitor progress on this issue, but asks all health plans to ensure that their Senators and Representatives are familiar with your plans and the good work you do – this will help to ensure that they are ready to take up our causes when the time comes! In addition to the drug rebate and Health IT, ACAP is also working to convince the Chairman of the Senate Health Education Labor and Pensions Committee, Senator Ted Kennedy, that he should include safety net health plans in legislation he is working on to address racial and ethnic health disparities. Last years legislation gave “health plans” an opportunity to participate in some of the research and grant opportunities under the bill, but did not provide special consideration for safety net health plans. To address this, ACAP has been working with Senator Kennedy’s staff to include the definition of safety net health plans in the bill and to provide priority funding for SNHPs along with other safety net providers like public hospitals and community health centers. In addition to the efforts of ACAP’s Washington Representative, ACAP also enlisted the help of ACAP-member Network Health’s Chief Medical Officer Dr. Pano Yeracaris to participate in a conference call with Senator Kennedy’s staff to explain Network Health’s efforts to address health disparities among its members. In addition, Dr. Yeracaris explained the unique role that a health plan can have in addressing health disparities from a more global perspective, rather than simply an individual provider perspective. Kennedy’s staff is vetting the revised version of the bill with other Senate staff and says that they will be introducing the legislation “soon.” Any health plans that have been working to address health disparities among their membership should begin preparing to communicate with their Senators about your efforts – laying the groundwork for future work on this issue. The Senate Finance Committee held a hearing on Wednesday to examine payments to health plans under the Medicare Advantage program. Witnesses included representatives from MedPAC, the Congressional Budget Office, Independence Blue Cross/Blue Shield, and the Center for Studying Health System Change. In particular, the committee members were rejecting wholesale cuts in payments to health plans but expressed concerns that the higher payments to health plans over traditional Medicare payments were not being accompanied by any way of measuring whether any additional value is being provided for those higher payments. Members were concerned that cuts in payments would reduce access to MA plans in many parts of the country, particularly rural areas and urban areas with relatively low health care costs. In addition, the sole plan representative on the panel argued that the care coordination given by HMOs and PPOs are not available in either the traditional Medicare program or the MA Private Fee for Service Program. The witnesses also doubted that care coordination could be replicated in the traditional Medicare program through the expansion of electronic health records or the creation of a FFS care coordination benefit. This hearing likely predates an effort to cut payments to health plans through the Congressional budget process. Dingell Introduces Bill to Require Dental Coverage in SCHIP, Raise Dental Payments John Dingell (D-MI) introduced a bill (HR 1781) to help improve the delivery of dental services to low-income children enrolled in Medicaid and SCHIP, CQ HealthBeat reports. As reported in the news, the legislation would require dental coverage under SCHIP, expand dental coverage to additional children, provide access to qualified dentists, and improve efforts to track dental health among children. The bill would also authorize $50 million in fiscal year 2008 and each subsequent year for grants to states to improve the delivery of dental services in Medicaid and SCHIP, authorize $40 million annually from FY 2008 through FY 2012 for grants to help underserved areas recruit and retain dental providers, require HHS to develop a dental health program to increase awareness and prevention, and allow states to use SCHIP to supplement dental coverage for children with private health insurance. The bill language currently does not appear to allow Medicaid MCOs or safety net health plans to participate in grant programs, but ACAP staff is prepared to lobby for inclusion. A companion bill was introduced in the Senate by Senator Bingaman (D-NM).
ACAP Sharing Services
Senate War Supplement
Bill Halts CMS GME RuleIn 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. A provision in the Senate version of the war supplement bill would bar CMS from promulgating regulations to prevent federal Medicaid funds from being used for indirect medical education (IME) or graduate medical education (GME). The President’s 2008 Budget included a proposal to discontinue IME and GME payments by administrative rule, without the benefit of Congressional action. If signed by the President, this provision will prevent CMS from halting GME funding. Some states make GME payments directly to providers, while others do not, thereby including the GME payment in MCO capitation rates. CBPP Includes ACAP’s Drug Rebate in List of Legislative “Savers” to Fund SCHIP The Center on Budget and Policy Priorities (CBPP) last month published a report and accompanying fact sheet highlighting numerous proposals that would produce spending offsets that, together or individually, would be sufficient to pay for SCHIP for the next five years. The 110th Congress has instituted Pay-As-You-Go (or PAYGO) rules, requiring that all legislative spending proposals be accompanied by offsetting proposals that produce at least as much in savings. As reported in a previous ACAP newsletter, the Senate agreed that $50 billion would be reserved for SCHIP reauthorization at the end of March; the following week the House of Representatives also included $50 billion for SCHIP in its budget. Funding in this amount would allow for continued coverage of all currently-enrolled individuals in the program, as well as expansions to all eligible children who are not currently covered. CBPP included in its list of possible revenue sources the ACAP Proposal to extend the federal drug rebate to Medicaid Managed Care plans. CBPP wrote that Medicaid MCOs are exempted from manufacturers’ rebates on drugs because “when the rebate law was enacted in 1990, it was assumed that managed care plans could negotiate discounted drug prices as favorable as those available under the rebate system.” Now, however, it has been demonstrated that MCOs do not receive discounts equal to those provided under the fee-for-service rebate system. Expanding the drug rebate program to Medicaid managed care plans would ensure that Medicaid actually gets the lowest drug prices available and would lower state managed care reimbursement rates. CBPP included that the CBO score estimates savings at approximately $1.8 billion over five years. Other offsetting proposals included in the paper are:
Health Affairs Article by Fairbrother Illuminates Churning Problem A new article in Health Affairs by Gerry Fairbrother of the Cincinnati Children's Hospital Medical Center and coauthors appearing in the March/April Health Affairs illustrates that a “sizable” number of children – between 43 percent (in Oregon) and 66 percent (in Pennsylvania) – received continuous coverage for at least two years from Medicaid. However, the report also explains that between 16 percent (in Pennsylvania) and 41 percent (in Oregon) of children had at least one gap in coverage during the three year period preceding the survey. Gaps tended to be short-term and are likely to have resulted from paperwork delays. Longer term coverage of children supports strategies such as disease management for chronic conditions and increased immunization that can improve health outcomes. The paper is based on a survey of children covered by Medicaid as of December 2003 in California, Michigan, Ohio, Oregon, and Pennsylvania. The article is available online at www.healthaffairs.org/1330_issue.php.  |
| EXCELLENCE AND ACCOUNTABILITY |
Recap: Marketing Roundtable On the March 22, 2007 Marketing Roundtable, Peggy Oehlmann reviewed the timelines for the Marketing Benchmarking Survey. The deadline for survey completion has been extended to April 27, 2007. Please contact Peggy with any questions about the survey. Jenny Babcock presented both an overview of state efforts to provide universal health care coverage and an introduction to citizen documentation requirements. Several plans reported decreases in new Medicaid enrollments since the citizen documentation requirement went into effect in July 2006, despite concurrent growth in other product lines. However, there has not been an upsurge in enrollee complaints about the requirements. Some plans have proactively produced education materials to facilitate the process and have agreed to send them to ACAP for posting on the website.
ACAP Job Bank
Recap: Provider
Relations RoundtableACAP 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. On the March 29, 2007 Provider Relations Roundtable, Pat Barta, ACAP quality consultant, presented an overview of recent trends in provider network instability and the impact it has on consumer desire for uninterrupted access to preferred providers. Health plans reported that instability can arise from providers leaving high-cost-of-living geographic areas, from provider perception of being inundated with work, and from provider discomfort with health plan administrative policies. Providers appear to remain connected to plans which demonstrate a sense of mission by adding services (e.g., transportation) and benefits (e.g., dental).and by revamping administrative procedures (e.g., claims). Reminder: QM Directors Roundtable Date Has Been Changed The QM Directors Roundtable has been changed from April 19th to May 16th at 3 pm eastern time. Medicare Directors (and anyone else interested) are also invited to attend this roundtable. The topic of this call will be the health risk assessment form, VES-13, developed by the RAND Corporation and used to assess quality of care for vulnerable older members. Debra Saliba, MD, from RAND will present an overview of the tool, and Craig Newton of MercyCare will describe how his health plan uses the VES-13 on its Medicare members. A reminder will be sent and materials posted to our website prior to the call. Reminder: Medicare SNP Roundtable Reminder: Medicare SNP Roundtable on Tuesday April 16 at 1:00 pm eastern daylight time. Please note the time for this call. This roundtable discussion will feature Virginia Premier Health Plan’s CMS site visit on the new SNP Medicare product. Jill Cousins will present components of the visit and address plan questions about the experience. Reminder: COO Roundtable Reminder: COO Roundtable on Thursday April 26 at 3 pm eastern daylight time. The topic for discussion will be how health plans use their Web sites for member communication about health issues. Reference will also be made to the 2007 NCQA Accreditation requirements for Web-based health tools. Pharmacy Directors Roundtable Changed Pharmacy Directors Roundtable changed from May 31 to June 7. Due to a scheduling conflict, the next Pharmacy Directors Roundtable will be changed from Thursday May 31 at 3 pm eastern time to Thursday June 7 at 3 pm eastern time. Please contact Pat Barta (patbarta@communityplans.net) with any topics to add to the agenda. |
| NEWSFLASH |
New York Legislature Freezes Medicaid MCO Premiums, Approves SCHIP Expansion to 400 Percent of FPL Earlier this month the New York Legislature approved Gov. Eliot Spitzer's 2008 state budget proposal to raise the eligibility level for New York’s SCHIP program – called Child Health Plus – to 400 percent of the federal poverty level (FPL). In addition, the budget includes several spending cuts, such as freezes in premiums paid to Medicaid health plans. Child Health Plus currently covers children to 250 percent of the FPL. If the eligibility expansion is implemented, New York will have the highest eligibility level in the nation, allowing children in a family of four with an income of $82,000 to enroll, for example. Kaiser reports that the income eligibility increase would make most of New York's 400,000 uninsured children eligible for the program. The New Jersey SCHIP program currently covers children to 350 percent of the FPL. In addition to the SCHIP eligibility increase, the Legislature’s budget also proposes to simplify the Medicaid enrollment process, and proposes more than $900 million of the $1.3 billion in health care spending cuts requested by Spitzer, including the MCO premium freeze and cuts to nursing homes and hospitals. This story is available at http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=44029. Medicaid Developments in Virginia “Virginia is considering lowering payments to Medicaid HMOs,” Patrick Finnerty, director of the state Department of Medical Assistance Services recently conveyed to the Richmond Times. “HMOs' profits from Medicaid have been increasing, and payments should reflect HMOs' success at cutting costs. Payments might be reduced or modestly increased this year, compared with the 4% to 7% annual increases in the past,” Finnerty stated. The Richmond Times further reported that “an independent consultant is calculating payment rates that will take effect in July. In 2006, the department decided to cap HMO earnings on Medicaid business at 8% -- any earnings above that rate must be returned to the state. The move was intended to ensure that HMOs do not overcharge for their services. HMOs made a combined profit of more than $98 million in 2006, or about 8% of revenue. Two HMOs, Amerigroup and CareNet, last year reported earnings of 16.9% and 12.2%, respectively. Patricia Tanquary Named New Chief of Contra Costa Health Plan Patricia Tanquary, a veteran health plan administrator, has been named the new Executive Director of the Contra Costa Health Plan (CCHP). Ms. Tanquary has been Deputy Executive Director of CCHP the past two years. Prior to being recruited to Contra Costa, she spent 18 years with Kaiser Permanente in a variety of capacities. She replaces Rich Harrison, who retired this month. "We are happy to have such an experienced and well-qualified person on staff to succeed Rich Harrison," said Dr. William Walker, Director of Contra Costa Health Services. "The 65,000 people served by the Health Plan will continue to receive excellent service under Patricia’s leadership." Ms. Tanquary has a Masters in Social Work from San Diego State University and both a Masters in Public Health Administration and a Doctorate in Social Welfare from U.C. Berkeley. She spent four years teaching social work and health courses and managed the undergraduate social work internship program at San Diego State. She was Associate Administrator for French Hospital and Health Plan in San Francisco for five years, assisting them in implementing one of the four first Medicare Risk Demonstration Projects by Centers for Medicare and Medicaid Services (CMS). With Kaiser, she served as Director of Member Services for Northern California and then as Hospital and Health Plan Administrator for Kaiser Hospital at San Rafael. She then became the Continuing Care Leader for Kaiser at three Kaiser hospitals: Redwood City, Santa Clara and San Jose. There, she initiated a case management program for high-risk populations. She was subsequently promoted to Director of National Provider Contracting for all Kaiser Regions. Her team provided and managed national contracts that accounted for regional size and model variations throughout Kaiser. "I feel like my entire career has been preparing me for this challenge," Ms. Tanquary said of her new position. "I am lucky to have worked with such talented staff the past two years and will do my best to equal their great work." Hudson Health Plan CEO Georganne Chapin Writes Perspective Article for Journal News: Health Care, Not 'Insurance,' for Everybody The text of Ms. Chapin's Article appears below. The way to fix our health-care system is to stop trying to make insurance the solution, and focus instead on getting people the health care they need. The number of people in the United States who have no way to pay for health care continues to grow, even as costs continue to rise. Absent a national approach, states have begun experimenting with initiatives that encourage more employer coverage, require individuals to purchase private policies, and expand public programs. These initiatives cannot succeed because they are based on a failed model: the same insurance system that got us into trouble in the first place. What's wrong with insurance? Let me answer that. First, insurance is temporary. Whether for a home, a car, fine art, or "health," insurance contracts are written for a brief, defined period - a year or less. If you have a private policy, and you cost your company too much or otherwise look undesirable at the end of that period, you'll either pay a lot more or you'll lose coverage altogether. Government insurance for the poor is also temporary. If at the end of your approved period your income has risen only a few dollars, or if you moved and didn't receive your renewal papers, you'll find yourself with no coverage. Finally, if you're one of the shrinking number of Americans lucky enough to be offered insurance through work (and you can afford to pay the co-premiums), you know that your benefits and even the doctors you can use might change from every year. Oh, and don't quit your job, or move out of state, because then you may never get coverage. Second, insurance is based on minimizing risk and maximizing profit - concepts incompatible with protecting the health of individuals and the public at large. The insurance business depends on building reserves, limiting services, minimizing pay-outs, and refusing to cover people or situations that threaten to cost too much. This model doesn't work for live human beings, who need preventive care, who have babies, who change jobs and move from place to place, who get sick, who age. This is why the plans under way in Massachusetts, California, and (it appears) soon New York, will not work: they propose to include ever more people in a system that provides temporary coverage, is bureaucratically unwieldy, and does nothing to control costs. Each member of a family could end up with a separate policy - with its own distinct benefits and expiration date. Doctors and hospitals will be even more confused than they are today, trying to figure out how and whom to bill, which services are covered and - worst of all - whether the patient's policy will be in effect long enough to complete her chemotherapy for cancer. I recently met a Canadian fellow in his forties who told me about his work, caring for an older man disabled from a neurological disease. "Dave" said that he was employed by the government - that the job didn't pay much but he enjoyed the work, and it gave him time to read, do other volunteer work, and tend a garden. I chimed in, "Yes, and you don't have to worry about your insurance." Dave gave me a bewildered look. "Medical insurance," I clarified. He still looked confused. "Your health insurance," I said. "Because Canada has universal coverage." "Oh!" he exclaimed, finally understanding my point. "Yes, we all get health care." Health care, not "insurance." Health care, not "coverage." We have a model for this in the United States, and though it might be imperfect, it's a great start. It's called Medicare. Medicare is permanent (once you qualify, you can't lose it). It's universal (everybody over 65 can get it). And it's portable, uniform and consistent (you can move anywhere in the country, doctors and hospitals know what it covers, and they know how and whom to bill). Using Medicare as a model, we can put everybody into one big pool. We can use insurance companies for their networks, their claims-payment systems, and (in some cases) their expertise in disease management. We can cut out the profiteering on people's bodies and lives. And we can start talking about which health-care services are basic and necessary for all people, and set about making sure that everybody can get them. Texas Settlement May Increase Medicaid Reimbursements for Physicians and Dentists Who Treat Children, May Require Corrective Action from Managed Care Organizations Kaiser Daily Reports on April 11 cited an Austin American-Statesman article reporting that under a lawsuit settlement presented to U.S. District Court Judge William Wayne Justice the preceding Monday, Texas would be required to increase Medicaid reimbursements by 25 percent for physicians and 50 percent for dentists who treat children. In addition, the settlement, if approved, would require Texas to investigate whether children are receiving incomplete checkups and, if not, to determine whether corrective action should be taken when MCOs do not provide complete checkups. According to Kaiser, the settlement is in relation to a class-action lawsuit filed in 1993 on behalf of Texas families who alleged that the State had violated Medicaid rules. The lawsuit is intended to encourage more providers to accept new Medicaid beneficiaries by providing higher payments, and is an effort to ensure children are receiving regular medical and dental checkups. If approved, the settlement will affect 1.8 million children covered by Texas Medicaid and may cost the State $700 million over two years. The settlement would also require the State to hire more providers in underserved areas and improve a toll-free hot line that answers parents' questions about obtaining coverage for their children, and make the State hire new case workers to help parents navigate the State health care system. CMS Initiates DOQ-IT University to Help Providers Access HIT Last week CMS introduced the new Doctor’s Office Quality Information Technology University, or DOQ-IT U, developed to support the use of health information technology (HIT) in doctors’ offices. According to CMS’ press release, “DOQ-IT U is an interactive, Web-based tool designed to provide solo and small-to-medium sized physician practices with the education for successful HIT adoption, including lessons on culture change, vendor selection and operational redesign, along with clinical processes.” This service is available at no charge. The website will provide learning modules in various areas, including assessment, planning and implementation methodologies that are disease and population specific, incorporation of clinical decision support, and evidence-based medicine guidelines. Surveys, utilization tracking, and Continuing Medical Education/Continuing Education Unit (CME/CEU) offering/issuing capabilities will also eventually be included. Several lessons are available now and focus on physician office workflow redesign, culture change, and communication necessary for successful EHR adoption, implementation of care management, and the incorporation of a strong patient self-management component to clinical care. Disease-specific modules, starting with diabetes, will include a patient self-management component. DOQ-IT U is being developed and managed by the Quality Improvement Organization (QIO) program, under contract to CMS. A QIO is present in each U.S. state, territory, and the District of Columbia. More information is available on CMS’ DOQ-IT U website at http://elearning.qualitynet.org. |
| ACAP VENDOR ALLIANCES |
2007 Sherlock Benchmarking Project As discussed at the last ACAP Board meeting in March, ACAP has endorsed working with the Sherlock Company for a second year to collect comprehensive administrative Medicaid benchmarks. Participation costs $6200 per plan and is not mandatory. An invitation from the Sherlock Company to participate was distributed by ACAP on April 11, 2007. Please contact Peggy Oehlmann (poehlmann@communityplans.net) if you need a copy of the invitation. Please contact Doug Sherlock if you are interested in participating or finding out more information on the technical aspects of data collection and dissemination of results. If you have questions about the purpose and/or history of ACAP’s involvement in this project, please contact Peggy Oehlmann. |
| Upcoming Events |
April Events |
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7/8 |
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19 3 PM EDT Quality Management Directors Roundtable |
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21/22 |
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26 3 PM EDT Chief Operating Officers Roundtable |
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28/29 |
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May Events |
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3 Compliance Roundtable |
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5/6 |
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10 CIO Roundtable |
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12/13 |
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16 Quality Management Directors/Medicare Directors Roundtable |
17 CFO Roundtable |
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19/20 |
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24 CMO Roundtable |
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26/27 |
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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 |
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Association for Community Affiliated Plans 1400 Eye Street, NW, Suite 330 Washington, DC 20005 http://www.communityplans.net Contact Us |