 August 2, 2007 |
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Upcoming ACAP Calls
There will be no Staff Roundtables during August 2007. Sept. 20: Pharmacy Directors Roundtable
Upcoming Events Calendar
 
ACAP Links
 
ACAP Members
Affinity Health Plan Alameda Alliance for Health AlohaCare AmeriHealth Mercy Boston Medical Center HealthNet Plan CareOregon CareSource Children's Mercy Family Health Partners 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 Keystone Mercy 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 Prestige Health Choices Santa Clara Family Health Plan Total Care Virginia Premier |
| PUBLIC POLICY AND ADVOCACY |
Legislative Update After seven months of discussion, debate, and delay, the United States House of Representatives and Senate are poised to pass their versions of legislation reauthorizing the State Children’s Health Insurance Program. Although radically different in scope and cost, these bills represent a clear victory for Congressional Democrats who placed SCHIP reauthorization as a top legislative priority for the 110th Congress and are fighting low public approval ratings and media characterizations of a “do-nothing Congress.” This pressure on Democrats to pass the legislation before the August recess has been met with strong opposition from many Republicans in the House and Senate who are complaining that the legislation is too broad, expands coverage to too many new people, and amounts to, in their own words, “Hillary-care.” Although the bills hadn’t passed either body as of press time, it seems as if both bills would pass, with the next step moving to the House/Senate conference negotiations. The House and Senate take widely varying approaches to their bills. The Senate’s is a relatively minimalist bill, reauthorizing the program for an additional $35 billion over five years, limiting coverage for adults and for those with higher incomes, and including some other good, but not particularly controversial issues. The Senate pays for this package with a $.61 increase in the tobacco tax. By contrast, the House of Representatives package is a $90B over 5 year package which includes a $50B over 5 years expansion in SCHIP, a fix in physician payments under the Medicare fee-schedule, and makes significant changes in Medicare and Medicaid policy. The House legislation also reauthorizes the Medicare Advantage Special Needs Plan (SNP) program for dual eligibles and institutionalized beneficiaries and establishes new standards required of SNPs. This package is paid for by, among other things, a $.45 tobacco tax, the equalization of payment rates between Medicare Fee-for-Service and Medicare Advantage, and other provisions such as an additional 7% in the Medicaid drug rebate on brand name drugs. ACAP has written letters to both the House and the Senate urging support for their versions of the legislation, but also expressing concerns about provisions in both bills and asking these health leaders to work with ACAP in conference to address these concerns – specifically cuts in Medicare Advantage payments, standards for SNP plans, and the failure to couple an increase in the drug rebate with an extension of the rebate to health plans. Both bills have attracted a Presidential veto, although it is unclear at this time how many Republicans will join the President to vote against expanding health care for low-income children. Unfortunately, although the Stupak/Bingaman Drug Rebate Equalization Act legislation has been in the play throughout the SCHIP debate, at the time of this writing, it does not appear that this ACAP-supported legislation will be included in either package – thanks in large part to strong sympathies among some Democratic members that the drug manufacturers will be injured by our legislation. A last minute effort by ACAP to include the legislation in the House seemed to have paid off earlier this week – only to find that the provision was stripped out at the last minute! The House SCHIP legislation also seems to have been amended to increase the Medicaid drug rebate from 20% to 22% from the Committee mark, thus seriously threatening health plans by making it more financially attractive to carve Rx from the health plans’ capitation payments (see story on the pending Lewin Report). In the Senate, Senator Bingaman is intending to offer his amendment to include the provision in the bill. However, it appears that a solid majority of Senators are opposing most amendments, and that effort is likely to fail. The next step for ACAP to enact the Drug Rebate Equalization Act is in the conference committee. The House/Senate Conference Committee is the place where negotiators from the House and Senate work out differences in the bills and come to a single bill that can be presented to the President for his signature. ACAP is currently working on a strategy for our Washington staff, our allies in other Associations and plans, and ACAP’s own member health plans to raise awareness of the urgent importance of including the DRE in the House/Senate conference agreement. Because the DRE provision is unlikely to be included in either the House or Senate packages, Safety Net Health Plans can only be successful in including the DRE in the SCHIP package by using the August recess to meet with their Representatives and Senators, contact their staff and tell them the impact that a prescription drug carve out would have on your ability to manage care for your Medicaid beneficiaries. ACAP will be seeking input from health plans about the financial impact they will suffer, along with the impact on your ability to coordinate care for your neediest of beneficiaries. Health plans should be prepared for ACAP to be very active in August and September to try to lift this provision into the conference. Once the action plan has been distributed, ACAP members can direct any questions they have to Jenny Babcock or Chris Koppen.
ACAP Sharing Services
ACAP Releases Factsheet
on Medicaid and Health Plan Contracting for Behavioral Health
Services: The Role of Carve OutsIn 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. The most common conditions seen in Medicaid populations include Behavioral Health diagnoses. These conditions, as either primary or secondary diagnoses, are significant causes of morbidity, while treatment, especially pharmacological management, is a leading cost driver. The purpose of this factsheet was to review various carve-out and vendor relationships used by states and Medicaid managed care plans to deliver behavioral health services to Medicaid enrollees and to begin to assess the impact of these contracting strategies on clinical programs and services. A survey was developed to ask health plans about Medicaid and health plan contracting for behavioral health services for the five major state Medicaid Programs: TANF, SCHIP, Children with Special Health Care Needs (CSHCN), Supplemental Security Income (SSI), and Medicaid for adults with disabilities. The survey questions were organized by categories of care, including: (1) core services; (2) residential care; (3) intermediate levels of care; (4) provider network functions; (5) pharmacy; (6) emergency care; (7) home care; and (8) clinical behavioral health programs. The survey was sent to 25 health plans, of which 18 responded. To see the survey results, click here. Note that a variety of carve-out and vendor strategies are used in states and health plans to implement the Medicaid behavioral health benefit. These relationships are listed in detail for each ACAP health plan to facilitate sharing of best practices in behavioral health management. Carve-out and vendor relationships can best be evaluated by considering the extent to which the contract relationships help a behavioral health program meet it goals of access, convenience and coordination, clinical quality improvement, and cost. |
| EXCELLENCE AND ACCOUNTABILITY |
ACAP to Host Medicare SNP Meeting Focused on Care Management for ACAP CMOs and Medicare Directors ACAP will host its next Medicare SNP meeting on September 17th, 2007 in Washington DC for ACAP CMOs and Medicare Directors. The focus of the meeting is care management and models of care, and a draft agenda can be found by clicking here. This meeting is scheduled in tandem with ACAP’s next legislative fly-in, which will be in Washington, DC on September 18th and will focus, in part, on educating Congressional Members and staff about ACAP’s Medicare SNPs. Additional emphasis during the legislative fly-in will be placed on advocating for SCHIP reauthorization, passage of the Drug Rebate Expansion Act of 2007, and inclusion of safety net health plans in health information and health disparities legislation. Also please click here to register online and to view hotel information. |
| NEWSFLASH |
ACAP on Vacation August 6-10, 2007 ACAP Staff will be out on vacation next week. Meg Murray (mmurray@communityplans.net) will be periodically checking her email for anything major that arises. The staff will respond to all requests as soon as possible when staff returns. Community Partners, Inc. Wins the Second “Supporting the Safety Net” Award ACAP announces Community Partners, Inc. of Amherst, Massachusetts as the recipient of ACAP’s second “Supporting the Safety Net” award. “We are thrilled to see Community Partners recognized for their significant contributions to making Massachusetts’ health reform a reality,” said Christina Severin, Executive Director of Network Health, the Massachusetts-based health plan that nominated Community Partners for the ACAP award. “Network Health and Community Partners share a commitment to making affordable, high-quality health care accessible to low- and moderate-income residents, and we have been honored to work with Community Partners to achieve our shared mission.” Community Partners has created “one-stop shopping” for outreach workers by developing and maintaining a comprehensive Web site and online catalogue of documents, tools, meetings, and information on publicly funded health programs. In addition, Community Partners has developed in-person and online forums and other unique services to promote sharing of information about Massachusetts’ recent landmark health reform among outreach workers, advocacy groups, government agencies, and other pertinent parties. Community Partners’ work thus directly contributes to the goal of health reform — to ensure that all Massachusetts residents have access to affordable, high-quality health care. The replicable and sustained work of Community Partners, Inc. will be highlighted in a future ACAP staff roundtable for quality managers and disease management directors of ACAP’s member plans. "This is an excellent community-based program that reduces the number of uninsured. ACAP is pleased to recognize the outstanding work of Community Partners," said Sylvia Kelly, President and CEO of Community Health Network of Connecticut and the co-chair of ACAP’s Quality Management committee.
ACAP Job Bank
ACAP Hosted Its 5th
Annual CEO Summit on July 24-25 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. Meg Murray opened the meeting by reflecting that while 40% of all Medicaid beneficiaries are in managed care, only 16% of the dollars are in capitated payments. For children, the percentage is higher with almost 50% of all Medicaid children in managed care and 70% of all SCHIP children in managed care. The major themes that emerged from the sessions included:
On July 25 ACAP released a new report which underscores the important role of Medicaid health plans in states where landmark health care reform efforts are underway. The report, Medicaid Health Plans: A Turnkey Solution for Expanding Health Insurance Coverage for the Uninsured, was written by The Lewin Group and sponsored by the Association for Community Affiliated Plans (ACAP). It focuses on health plans in California and Massachusetts – two states that are breaking new ground in expanding coverage to uninsured residents and setting an important trend for the rest of the nation to follow. Underscoring the White House threat to veto the State Children’s Health Insurance Program reauthorization bill, Secretary Leavitt wrote that states should “ensure that their citizens have access to basic private insurance coverage.” This timely paper demonstrates that, on the contrary, expansion of Medicaid and SCHIP through Medicaid health plans is indeed an effective way to cover the uninsured. Rather than subsidizing the purchase of commercial health insurance through tax credits or other incentives for low-income people, states are better served to cover low-income uninsured individuals by building on a platform of Medicaid managed care plans already operating in those states. “States looking to cover low-income uninsured people don’t have to look too far,” said Margaret Murray, Executive Director of ACAP. “The Medicaid plans are right in their backyard and ready to work with the states on the expansion programs.” The report provides case studies that demonstrate how Massachusetts and several California counties capitalized on existing Medicaid health plans as “turnkey” solutions to quickly, efficiently and economically provide coverage to low- and moderate-income persons. Specifically, these plans were able to
The Turnkey report highlights five programs that Medicaid health plans offer: four “Healthy Kids” programs in diverse California counties, served by Health Plan of San Mateo, LA Care, San Francisco Health Plan and Santa Clara Family Health Plan, and one high profile statewide program – Commonwealth Care, served by BMC HealthNet Plan, Neighborhood Health Plan and Network Health – in Massachusetts. The full report is available at www.communityplans.net. A recording of an Audio Conference Call introducing the report and featuring presentations by Darnell Dent, CEO of Community Health Plan of Washington, and Margaret Murray, CEO, Association for Community Affiliated Plans is also available. Affinity Health Plan Helps Member Receive Heart Transplant According to an article in the PRWeb on July 27, 2007, Long Island resident Sylvester Killings, 45, was in dire straights prior to joining Affinity Health Plan in 2006. Born with rheumatic fever, Sylvester had long suffered from various ailments which were made worse by drug and alcohol use. After an accident placed him in the hospital, he learned his heart condition had worsened and he needed a heart transplant to live. With no where to turn, Sylvester relied on Affinity to help him stay sober while keeping him on track to obtain, and maintain, a new heart. Sylvester’s story is a testament to Affinity’s Cardiac service offerings. Unlike most Prepaid Health Services Plans (PHSPs) or Health Maintenance Organizations (HMOs), Affinity provides a range of cardiac services including transplant placement and rehabilitation, largely for underserved populations reliant on Medicaid. “I was confused and didn’t know what to do,” said Sylvester, who joined Affinity Health Plan just a year ago. “Affinity did a great job. They sent me to a top hospital and got this heart for me.” “Sylvester truly represents the heart of our membership,” said Maura Bluestone, President and CEO of Affinity. “We are filled with people who care about people, and the service Sylvester received is how we strive to handle all of our Members. We’re proud of the fact we not only cover major cardiac services, but also work hard to keep members healthy long after surgery.” Affinity’s network of providers offer a range of cardiac services not usually covered by managed care plans. Further, Affinity gives its Members, traditionally underserved Medicaid recipients, access to the top hospitals in the New York metro area, including Columbia Presbyterian Hospital. Santa Clara County Children’s Health Initiative Improves Children’s Health A recent brief by Mathematica presents findings from a survey of families with children who are enrolled in the Healthy Kids program in Santa Clara County, California showing improvements in their health. Launched in January 2001 by the Santa Clara County Children’s Health Initiative (CHI), Healthy Kids provides health insurance coverage to children in the county with household incomes up to 300 percent of the federal poverty level ($62,000 for a family of four) who are ineligible for the two major state insurance programs, Medi-Cal and Healthy Families. The vast majority of Healthy Kids children have household incomes below 250 percent of the federal poverty level, low enough to qualify them for one of the state programs, but they are ineligible for these programs because of their immigration status. This brief describes the positive impact of Healthy Kids on children’s health status, including perceived health, functional limitations, and school days missed because of health problems. Click here to access the brief. California Budget Delay and Depletion of Safety Net Fund Result in MCO Payment Cuts A $2 billion safety net fund including dollars from the State of California and the federal government has been exhausted, impacting Medicaid providers. Depletion of the fund, called the Medical Providers Interim Fund and intended to help pay Medicaid providers during difficult budget times, was created in 1998 and allows the State to continue paying Medicaid providers when there is no state budget. California has been without a budget since July 1. Although the Assembly has approved a spending plan, an impasse has been reached because Senate Republicans demand additional spending cuts. As a result, the State has cut a payment to Medicaid managed care plans from $223 million to $143 million, and Medicaid will not be able to make an estimated $227 million payment to hospitals and nursing homes if the Legislature does not pass a budget by Thursday. New CHCS Brief Outlines Enrollment Options for Medicaid Managed Care for People with Disabilities CHCS published a paper in July 2007 by author John Barth that describes managed care enrollment options for people with disabilities, including a new hybrid model – opt-in, opt-out enrollment – that shows promise in Wisconsin for satisfying consumers as well as state and MCO partners. The paper is a technical assistance brief in response to a growing number of states that are planning, implementing, or expanding Medicaid managed care programs for people with disabilities. It demonstrates how states are faced with a wide array of potential options when choosing program features. One design element that has critical implications for program success is the enrollment model. Both the voluntary and mandatory enrollment models offer benefits and drawbacks from the consumer, state, and MCO perspectives, but states are encouraged to look beyond these more traditional options. The paper can be accessed here: http://www.chcs.org/publications3960/publications_show.htm?doc_id=512076 CHCS has recently produced additional resources addressing providing Medicaid managed care for complex populations, including defining best managed care practices for these beneficiaries, such as developing care management strategies, creating measures to effectively evaluate programs, and reviewing best practices in consumer and advocate outreach and engagement. These can be accessed at http://www.chcs.org/.  |
| Upcoming Events |
August Events |
| Mon | Tues | Wed | Thurs | Fri | Sat/Sun |
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3 |
4/5 |
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6 ACAP on Vacation |
7 ACAP on Vacation |
8 ACAP on Vacation |
9 ACAP on Vacation |
10 Deadline for Data Submission for Sherlock Financial Metrics ACAP on Vacation |
11/12 |
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13 |
14 |
15 Asthma Data Due to CHCS |
16 |
17 Deadline for Data Submission for Sherlock Operational Metrics |
18/19 |
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20 |
21 |
22 |
23 |
24 |
25/26 |
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27 |
28 |
29 |
30 |
31 |
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September Events |
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1/2 |
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4 |
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8/9 |
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10 Deadline for Asthma Benchmark Data Submission by Participating Plans to the Center for Health Care Strategies |
11 |
12 |
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14 |
15/16 |
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17 Medicare SNP Meeting for CMOs and Medicare Directors on Care Management and Models of Care ACAP Legislative Fly-In |
18 ACAP Legislative Fly-In |
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20 |
21 |
22/23 |
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24 |
25 |
26 |
27 |
28 |
29/30 |
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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 |