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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.

How Ohio’s Behavioral Health Redesign impacts providers

Posted in Behavioral Health

Over the next year, Ohio community behavioral health providers (mental health and substance use addition providers) will be participating in a truly transformational time as a result of a statewide initiative called Ohio’s Behavioral Health Redesign.

Redesign will fundamentally alter the clinical and business processes of community behavioral health providers through the adoption of coding changes, enactment of a completely new service array and the implementation of Medicaid managed care.

In order to be prepared for these changes, many providers are engaged in a process of clinical and business transformation, as well as conducting a legal review of their managed care contracts and other internal and external legal structures in order to assess how the redesign changes will impact their agencies.

Today, over 400,000 adults and children receive services, at a total cost of approximately $900 million dollars. The implications of these changes are far reaching, with clinical, operational, quality and cost considerations.

Throughout health care, the importance of identifying and treating both mental health and substance use disorders is increasingly understood as a key driver of total health care costs and the excessive use of services, such as emergency rooms. The severe and pervasive opioid crisis is daily news. Ohio’s decision to expand Medicaid in 2014 helped to meet the huge demand for behavioral health services, and provided the behavioral health system with needed funding to address the demand.

In addition, in order to battle Ohio’s severe opioid addiction issues, state and federal lawmakers have passed laws increasing service flexibility and funding.

At the same time, the state has been working on the redesign of behavioral health services to improve quality, accountability and transparency of these important Medicaid services.

What is redesign and how does it impact behavioral health providers?

The redesign initiative is the result of the Kasich administration’s commitment to improve access to services and to “modernize” the regulations and business practices of providers. “Modernizing” includes using a more up-to-date menu of service codes and transitioning to national correct health care coding and accountability requirements.

The use of a more ‘up-to-date’ menu of codes sounds deceptively simple. The current menu of service codes provides the building blocks for today’s services and programs. Providers have been engaged in a process of clinical and business transformation; working with behavioral health experts to analyze current services, practitioners and payment rates and assessing the impact of the new requirements.

Individual clinicians and provider agencies are finding that this is a monumental shift in the way that they will operate in the future, causing them to rethink the way that they will provide individual services, and reconfiguring clinical and business processes in order to meet the demands of the new system.

The coding and accountability changes will also fundamentally alter the way that providers will bill for services. For instance, today, in the other parts of the Medicare, Medicaid and commercial insurance, the practitioner providing the service must be identified in order to bill.

In the current behavioral health system, agencies must meet standards and requirements for practitioners, but can bill without including the practitioner’s unique code on the bill.

In the new system, practitioner requirements are being increased and they will be expected to provide services at the “top of their scope of practice.” The new credentialing requirements will provide the system with a higher level of clinical expertise when compared to the current requirements.

While most providers agree that raising the bar and having more highly credentialed staff is an admirable goal for many reasons, some providers have voiced concern about the implementation of the new requirements due to the clinical staff workforce shortage that currently exists even under the broader standard in place today. Other associated coding changes are designed to increase provider accountability and accuracy in billing.

When will the redesign changes take place and how will it work?

As a result of the recently passed biennial state budget, the coding and service redesign changes described above will be effective starting Jan. 1, 2018. The budget bill also provided for the implementation of these same services from the current fee for service payment method into Medicaid managed care.

Providers have been paid under a fee schedule for many years. The General Assembly wanted to delay the managed care implementation until July 1, 2018 to allow the coding and service changes to go into effect before the shift to Medicaid managed care.

Governor John Kasich vetoed the delay provision. However, in an historic action, the General Assembly recently overrode the governor’s veto of the managed care delay. As a result of the veto overrides, Medicaid managed care firms will take responsibility for the new services on July 1, 2018.

Currently, Medicaid managed care firms are holding regional meetings around the state to educate providers about the requirements of each managed care plan to be a part of their network.

Accordingly, providers are engaging experienced advisors to assist with an analysis of the new regulatory landscape, provide advice regarding business considerations, conduct a review of managed care contracts, and analyze potential alliances to better promote efficiencies and advance their sophistication in contract negotiations while being mindful of any antitrust issues that these types of alliances may present.

Providers should be preparing now and consulting with those familiar with the changes in order to be prepared to meet the upcoming challenges associated with this significant transformation of Ohio’s system of mental health and substance use disorder services. Communities, families and individuals lives depend on a smooth transition.

Report Regarding Drug Purchasing in Ohio

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

Today Ohioans Against the Deceptive Rx Ballot Issue announced opposition to the ballot issue on drug pricing in Ohio. More than 30,000 doctors, nurses and pharmacists, business and labor and the state’s largest organization serving individuals with AIDS/HIV announced their opposition to the proposal.

A policy report was released in September 2016, providing an analysis of the impact of the ballot issue on state programs, other local government entities and businesses. Vorys Health Care Advisors (VHCA) and Health Management Associates (HMA), analyzed the proposed initiated statute. 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 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.

Click here to download the full report.

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
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.

PLANS FOR WEEK OF MARCH 20 AND BEYOND
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.