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Vorys Health Care Advisors

For health care reformers, the challenge is to improve care quality and expand access to providers and services while controlling costs. It is not a job for the timid. Instead, it requires creativity, experience and leadership. Vorys Health Care Advisors’ strategic solutions and guidance exemplify each of these imperatives. Our health care and Medicaid consultants help providers, business decision makers, state and federal government agencies and professional associations respond to the complex needs of health care consumers by discovering, developing and implementing innovative policies and programs.

Lesser-known CBO findings about the American Health Care Act

Posted in Affordable Care Act, Health Care Reform, Medicaid

As reported by Harris Meyer at Modern Healthcare, a deeper dive into the Congressional Budget Office (CBO) scoring of the American Health Care Act (AHCA) reveals rich data.

Top-line numbers from CBO analysis of the House proposal predicted the bill would:

  • Increase in the number of uninsured Americans by 24 million over the 10 years
  • Reduce the federal deficit by $337 billion

Here are 13 other key CBO findings cited by Modern Healthcare:

  1. By 2026, individual-market premiums would be 20% to 25% lower for a 21-year-old, 8% to 10% lower for a 40-year-old and 20% to 25% higher for a 64-year-old.
  2. Medicare disproportionate share hospital payments (DSH) would increase by $43 billion from 2018 to 2026 due to a significant rise in the uninsured population.
  3. Medicaid DSH would increase by $31 billion over 10 years.
  4. Total federal Medicaid payments to states would decline by $880 billion, or 25%, by 2026.
  5. Under the per-enrollee cap on federal Medicaid payments, states’ actual per-capita costs would grow annually 0.7 percentage points faster than federal payments from 2017 to 2026.
  6. Five million fewer low-income adults would be enrolled in the Medicaid expansion programs by 2026.
  7. By 2026, Medicaid expansion states would have only 5% of expansion enrollees left for whom they would receive enhanced federal matching payments.
  8. Consumers would have a harder time comparison-shopping for health plans because the minimum actuarial-value requirement would be repealed and insurers could sell subsidized plans outside the exchanges.
  9. The repeal of the actuarial-value requirement would prompt many insurers to offer plans with higher deductibles and higher cost-sharing. That, and the loss of ACA cost-sharing subsidies in 2020, would significantly increase out-of-pocket costs for lower-income enrollees.
  10. About 7 million fewer people would have employer-based coverage by 2026 due to: elimination of the employer and individual mandates and penalties, reduction in employer sponsored insurance, and potential for employers to send higher income workers to purchase coverage in the individual market with new premium tax credits.
  11. The 30% premium penalty for buying insurance after a coverage gap would lead to about 2 million fewer people buying coverage after 2018. Those who pay the penalty would likely be sicker people.
  12. By 2026, the average premium tax credit to help people buy coverage would be about 50% less than under the ACA.
  13. About 52 million Americans, or 19% of the non-elderly population, would be uninsured in 2026, up from 10% under the ACA. People aged 50-64 with incomes under 200% of the federal poverty level would make up a larger share of the uninsured.

Vorys Health Care Alert: A deeper look into the ACA replacement bill

Posted in Affordable Care Act, Health Care Reform, Medicaid

Please see the newest Vorys Health Care Alert for a deeper look into the House Republican’s proposed legislation to repeal and replace the Patient Protection and Affordable Care Act (ACA). If enacted as proposed, the plan would implement changes in the areas of:

  • Insurance, mandates, penalties, and tax credits
  • Medicaid, expansion, and per capita caps
  • Risk pools, health savings accounts
  • Other areas

The bill would not change several other popular aspects of the ACA.

Vorys attorneys Matthew E. Albers, Jolie N. Havens, Suzanne J. Scrutton, and Nita Garg, and Vorys Health Care Advisors Maureen M. Corcoran and Marisa P. Weisel provide an analysis of each of these topics on the Vorys Website.

The Vorys Health Care Team will continue to provide updates on federal health reform efforts and other health care proposals as they evolve.

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What’s next for the American Health Care Act?

Posted in Affordable Care Act, Health Care Reform

On March 13th, the Congressional Budget Office released an assessment of the impact of the American Health Care Act.

This week, the House Republican health reform proposal moves to the House Budget Committee, where it will be heard and marked up on Thursday. Here, the two individual bills passed by the House Ways and Means and Energy and Commerce Committees last week will be combined into one piece of legislation.  The Budget Committee is chaired by Rep. Diane Black (R-TN.),

If the bill passes the Budget Committee, it will move to the Rules Committee, where Budget Chair Black will offer amendments to facilitate the bill’s passage through the full House.

House Speaker Paul D. Ryan (R-Wis.) has previously said he hopes to schedule the full floor vote for the week of March 20. If the bill passes the House, it will head to the Senate.  If the bill meets the rules to use the budget reconciliation process, it could be fast-tracked through the Senate and will need only 50 votes to pass.

Prior to the release of the CBO analysis, there was speculation that the bill might not garner sufficient votes to pass since the legislation drew complaints from conservative and moderate republicans, democrats, advocacy organizations, and think tanks who either expressed concern that the bill did not go far enough to repeal the Affordable Care Act, and/or noted concern about how many Americans could lose insurance coverage. We’ll have to see whether the timelines change as people digest the CBO analysis.


House Republican per-capita cap proposal for Medicaid would decrease funding, increase number of uninsured

Posted in Affordable Care Act, Health Care Reform, Medicaid

A new report from Loren Anthes at The Center for Community Solutions outlines the potential for Ohio’s Medicaid program to lose between $19 to $26 billion between 2019 and 2025 because of the House Republican’s proposed health reform legislation (the American Health Care Act); these predictions closely align with the new Congressional Budget Office (CBO) analysis of the same bill.

As mentioned in a recent Vorys Health Care Advisors blog post, the House Republican Plan would fundamentally change Medicaid’s financing structure from a federally-matched entitlement to a per-capita cap program that would include some funding for states to continue Medicaid expansion (Group VIII enrollment) for a few years.  According The Center for Community Solutions report, this change would leave Ohio policymakers with tough decisions regarding funding for all individuals receiving Medicaid in the state:

  • “Ohio would need to contribute or cut $7.2 – $9.5 billion in state funding through 2025 to maintain projected funding levels for the entire program, with specific population funding changes as follows:
    • Children: Shortfall of $2 – 2.3 billion
    • Adults: Shortfall of $3 – 4.3 billion
    • Disabled: Shortfall of $2.2 – 2.7 billion
    • Aged: Surplus of $1.9 billion
    • Group VIII: Shortfall of $1.7 – 2.1 billion
  • It is unclear if a per capita model would conflict with standards of actuarial soundness, potentially compromising the ability for Ohio to have a privatized delivery system through managed care.”

As widely reported today, the CBO report predicts that the American Health Care Act would cause 14 million fewer individuals to have health insurance in 2018 across the United States, in large part because of the proposal’s repeal of the penalties associated with the Affordable Care Act’s individual mandate.  Moreover, the CBO predicts insurance losses would dramatically increase after 2018 because of changes in Medicaid financing:

“Later, following additional changes to subsidies for insurance purchased in the nongroup market and to the Medicaid program, the increase in the number of uninsured people relative to the number under current law would rise to 21 million in 2020 and then to 24 million in 2026. The reductions in insurance coverage between 2018 and 2026 would stem in large part from changes in Medicaid enrollment—because some states would discontinue their expansion of eligibility, some states that would have expanded eligibility in the future would choose not to do so, and per-enrollee spending in the program would be capped. In 2026, an estimated 52 million people would be uninsured, compared with 28 million who would lack insurance that year under current law.”

The CBO report goes on to state that the proposal would produce “a reduction of $880 billion in federal outlays for Medicaid.”  According to the Center on Budget and Policy Priorities, this considerable cut in federal funding would directly shift Medicaid costs to states, undoubtedly forcing states to to end or limit Medicaid expansion while simultaneously decreasing access and benefits for other (non-expansion) enrolled individuals.

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Vorys Client Alert: A summary of the Republican House plan to replace the Affordable Care Act

Posted in Affordable Care Act, Health Care Reform

On March 6, 2017, House Republicans released proposed legislation  to repeal and replace the Patient Protection and Affordable Care Act (ACA). Vorys attorneys Matthew E. Albers, Jennifer Bibart Dunsizer, Linda R. Mendel, Christine M. Poth and Nita Garg summarize the proposal on the Vorys Website.


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House Republican health plan would shift estimated $560B in Medicaid costs to states, impact all Medicaid enrollees

Posted in Access, Affordable Care Act, Behavioral Health, Health Care Reform, Medicaid

The House Republican plan to reform Medicaid projects federal savings of more than $500 billion dollars over 10 years, and the Center on Budget and Policy Priorities, a nonpartisan research and policy institute, estimates this plan would significantly shift Medicaid costs directly to states, “effectively ending the Affordable Care Act’s (ACA) Medicaid expansion for 11 million people while also harming tens of millions of additional seniors, people with disabilities, and children and parents who rely on Medicaid today.”

It is reasonable to argue that a 90% federal match for the expansion population is too much of a federal contribution to be sustained for the long run and states need to have ‘more skin in the game’. However, the effect of the House proposal would be a massive cost shift to states for the entire Medicaid program, guaranteeing that consumers’ access to care will suffer.

There are two Ohioans worth mentioning who will be effected by this cost shift. First, there is Dave. He’s about 48 years old and has a serious addiction. He is one of the 700,000 Ohioans who received coverage through Ohio’s Medicaid expansion; finally able to get treatment for his addiction.  His physical health has improved and he’s been able to work more steadily, but recovering from his addiction will take some time. He’s on the path to recovery. Ohio’s assessment of the expansion shows there are many Ohioans like Dave – people who were uninsured and gained access to health care that not only improved their physical and mental well being, but also made it easier for them to work and seek work and to improve their personal financial situations. Dave may not continue to have Medicaid coverage if funding for the Medicaid expansion populations is decreased and eventually eliminated.

Second, there is Molly. She is 33, has Down’s Syndrome, and receives a Medicaid home and community based waiver that allows her to share a house, work her job at the coffee shop, and enjoy her life in the community. She is one of the roughly 90,000 Ohioans who are elderly and/or disabled who receive home and community services, representing a small number of people enrolled in the Medicaid program, but accounting for a high proportion of overall Medicaid costs. Molly and other non-expansion individuals are not included in the House’s proposed cuts to Medicaid expansion, but will still be affected by the proposal’s shift in how the entire Medicaid program would be funded. The Center on Budget and Policy Priorities analysis estimates that overall, the house draft bill “would cut federal spending for the Medicaid program by an additional $280 billion over the next decade” on top of the proposed cuts to eliminate Medicaid expansion. These cuts would occur because of the plan’s intention to move Medicaid away from an entitlement program and into a per-capita cap system, which would account for neither the costs for community services (like those being used by Molly) rising at more than the rate of inflation, nor the cost of other significant health events Molly and Medicaid-enrolled individuals may encounter as they grow older.

Let’s not lose sight of the impact on Dave and Molly as the debate in Congress continues.

See the full analysis at the Center on Budget and Polity Priorities Blog.

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Multi-System Youth: Update, Ohio Budget Activity

Posted in Medicaid, multi-system youth, Presentations

Stakeholders and legislators continue to advocate to improve service capacity and delivery for youth served by multiple child-serving systems in Ohio. In strong partnership with the Public Children Services Association of Ohio (PCSAO), a number of legislators created the Joint Legislative Committee on Multi-System Youth through Ohio’s last biennial budget (H.B. 64 of the 131st General Assembly) to study  issues affecting multi-system youth, including custody relinquishment.  Please see our original post on the charges of this Committee, which was Co-Chaired by Senator Randy Gardner and Representative Sarah LaTourette.

Last summer, after holding seven hearings and receiving testimony from youth and their families, service providers, State Agency officials, and policy experts, the Committee released a list of recommendations to address the needs of multi-system youth and their families.  Briefly, the recommendations ask relevant State Agencies to:

  1. Establish a state-level crisis stabilization fund to address unmet and uninsured needs of Ohio’s multi-system youth and families who are in crisis and/or unable to access appropriate levels of care and services.
  2. Design a Medicaid-reimbursable service consistent with High-Fidelity Wraparound principles to coordinate the care, services, and supports that youth and their families need.
  3. Establish a unified strategy for data collection and sharing across child serving systems to identify resource utilization, service utilization patterns and gaps, and monitor outcomes.
  4. Develop youth and family focused peer support services.
  5. Modernize Ohio’s Family and Children First Councils.
  6. Fund an independent evaluation of timely access to children’s and youth’s residential and inpatient mental health treatment in the State of Ohio.

Now, almost a year after the Legislative Committee held its first hearing, Senator Gardner, Representative LaTourette, and a robust group of stakeholders are working to implement the recommendations above through Ohio’s next biennial budget.  The list of multi-system budget requests closely follows the recommendations of the Committee, and it includes both funding and policy items that could be included in Ohio’s budget for State Fiscal Years 2018-2019. Stakeholders will continue to work closely with Senator Gardner and Representative LaTourette, state agencies, and the public to make sure these issues and recommendations are priorities throughout the entire budget process.

On January 30, 2017, Maureen Corcoran and Marisa Weisel of Vorys Health Care Advisors and Gayle Channing Tenenbaum of The Center for Community Solutions presented about multi-system youth to the Attorney General’s Task Force on Criminal Justice and Mental Health. This Task Force, co-chaired by Attorney General Mike DeWine and Justice Evelyn Lundberg Stratton, Retired, and Of Counsel at Vorys, met to discuss criminal justice and mental health issues affecting Ohio’s children and youth. The audience was composed of individuals who work in the fields of criminal justice and/or mental health, both inside and outside of state government. This passionate group demonstrated a deep understanding of children who receive services form multiple systems, and many expressed appreciation for the work being done to bring attention and potential solutions to the challenges facing multi-system youth and their families.

New Report Regarding Drug Purchasing in Ohio

Posted in Access, Drug Pricing, Health Care, Medicaid, Pharmaceuticals

A proposed initiated statute to change state prescription drug purchasing in Ohio would be difficult if not impossible to implement, according to a new report issued by Ohio public health policy experts.

The report, released today from Vorys Health Care Advisors (VHCA) and Health Management Associates (HMA), analyzes the proposed initiated statute to change state prescription drug purchasing in Ohio. The research team was led by VHCA President Maureen Corcoran and Barbara Coulter Edwards, Managing Principal with HMA, both well-known in the health care field with extensive experience in Medicaid.  The report includes data and information gathered from state agencies likely to be impacted by the proposal.  The independent analysis was commissioned by the Pharmaceutical Research and Manufacturers of America.

“There would be little to nothing to be gained under the Act,” said Corcoran. “Instead the state could see increased costs in administrative functions in an effort to comply, while at the same time losing valuable supplemental rebate arrangements currently in place with drug manufacturers.”

The proposed initiated statute seeks to prohibit the state from entering into contracts where the “net cost” of a prescription drug purchased by the state is more than the “lowest price paid” by the U.S. Department of Veterans Affairs (VA).

If adopted, the proposed statute would affect roughly 4 million Ohioans. In addition to Ohio Medicaid, the state retirement systems and certain programs operated by state departments, the report also describes potential negative impacts on entities outside of state government, e.g. state universities and community colleges, the RxOC purchasing collaborative, BestRx, and concerns about access to VA-administered drugs now available to military veterans.

The Act would not apply to the approximately seven million Ohioans who use private insurance or other coverage.

The report concludes that:

  • It is highly unlikely the proposed statute could be implemented.
  • It is highly likely the proposed statute would fail to achieve its purpose.
  • It is highly likely that pharmacy programs of entities outside of state government would be negatively impacted.
  • State agencies would need to take other extreme measures in an attempt to comply with the mandate, which could result in higher copays, decreased access to community pharmacies, or even limits on available drugs for impacted individuals.

Click here to download the full report.

Date Nears for States to Implement CMS Access Rule

Posted in Access, CMS, Health Care, Medicaid, Regulations

On January 4, 2016, the Center for Medicare and Medicaid Services (CMS) implemented sweeping new requirements for ensuring access to specific categories of Medicaid services. The final rule, released on November 2, 2015, and titled Medicaid Program; Methods for Assuring Access to Covered Medicaid Services, creates a very important vehicle for beneficiaries, service providers, their associations and advocacy organizations to have meaningful input in the construct of states’ fee-for-service Medicaid payment methodologies.  Per the final rule, states must submit initial access review plans, including stakeholder feedback, to CMS by July 1, 2016.

The new regulation requires states to demonstrate compliance with the statutory requirement that Medicaid payments are sufficient to enlist enough providers to ensure access to covered services for beneficiaries is equivalent to that of the general population.  This access requirement applies to fee-for-service payments and does not apply to managed care, waiver, or demonstration program payments.

The new regulation mandates baseline and follow-up reviews of access to core services in the areas of:

  • Primary care (physician, federally qualified health center, clinic, dental);
  • Specialty physician;
  • Mental health and substance use;
  • Obstetrics (prenatal, labor and delivery, postpartum); and
  • Home health.

Additional mandatory reviews are triggered when:

  • Payments are reduced or restructured;
  • New services are implemented; and
  • High levels of access complaints are received.

Further, access reviews must:

  • Describe the population including considerations for its care, service utilization, and payments, for adults, children and individuals with disabilities;
  • Measure whether beneficiary needs are fully met;
  • Document the providers reviewed are enrolled with Medicaid; and
  • Demonstrate access to care within a specific geographic area.

States must issue the initial access monitoring review plan by July 1st of 2016 and submit an update of a subset of service categories by July 1st every three years thereafter.  The plan must be developed in consultation with the state’s medical care advisory committee and the data analysis and supporting documentation made available for public review and comment at least 30 days prior to its submittal to CMS.

When an access deficiency is identified, states are required to develop and submit a corrective plan to CMS within 90 days and must remediate the deficiency within 12 months.  States that fail to take remedial action risk the loss of federal financial participation.  To correct access issues, CMS suggests states can:

  • Increase payments;
  • Improve provider outreach, enrollment, and retention;
  • Enhance transportation;
  • Improve care coordination; and/or
  • Modify provider licensing and scope of practice policies.

In deference to unique state circumstances and in the interest of granting flexibility, CMS did not promulgate a specific format for the access review plans.  Some data elements will be mandatory, however, including a comparison of Medicaid payments to other public and private insurance payments, by provider type and site of service.  Suggested data elements include:

  • Time and distance standards;
  • Providers participating in the Medicaid program;
  • Providers with open panels;
  • Providers accepting new Medicaid patients;
  • Service utilization patterns;
  • Identified beneficiary needs; and
  • Logs of beneficiary and provider feedback.

CMS expects states to solicit stakeholder input during development of the access and remedial action plans as well as on an ongoing basis.  States are required to establish a mechanism – surveys, ombudsman, or equivalent – to receive input from stakeholders and to log the volume and nature of this input and their responses to it.  CMS will rely on this mechanism to understand access to care concerns and may, as a result, require states to monitor additional services.   States are required to investigate, analyze and respond promptly to public input.  Should stakeholder concerns not be adequately addressed by the state, they may be raised with CMS directly.

As previously noted, states must submit their initial access monitoring review plans to CMS by July 1, 2016.  As part of this process, draft plans must be available for review and public comment at least 30 days prior to being finalized and submitted to CMS, and draft plans are expected within the next two to three months.  Advocates, providers, and provider associations will want to become familiar with the access rule as they prepare to engage in the stakeholder input and public comment processes.  On March 16, 2016, CMS posted a Frequently Asked Questions (FAQs) document about implementing the access rule that addresses both stakeholder input and public comment.


New on the HealtHITech Law Blog: proposed updates to federal confidentiality of alcohol and drug abuse patient records Regulations

Posted in Behavioral Health, privacy, Regulations, SAMHSA

As reported by Vorys attorney J. Liam Gruz on the HealtHITech Law Blog, the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) recently published a proposed rule which would amend the Confidentiality of Alcohol and Drug Abuse Patient Records regulations, found in 42 C.F.R. Part 2.

SAMHSA’s long awaited proposed rule seeks to modernize the confidentiality provisions to better reflect the current treatment system, particularly with respect to ease of transferring records and patient information, while still maintaining privacy protections for those receiving substance use treatment.

Read the entire post at the HealtHITech Law Blog.