Say Ahhh! A Children's Health Policy Blog

States must file a Medicaid State Plan Amendment (SPA)

2012-05-17T15:12:46Z

Ever had an employer promise you a raise and not deliver? Sure, occasionally the payroll department delays getting the money in your paycheck, but generally speaking, you expect your employer to follow-through. Will this be the case with the mandatory bump-up in Medicaid payment rates to Medicare-equivalent levels for primary care services? Wonk-warning ahead - this discussion gets thickly into the weeds of Medicaid policy. (For a basic primer on the proposed rule that will increase primary care reimbursement in Medicaid, enacted as part of the Affordable Care Act, check out my earlier blog.)

Although the federal government is picking up 100 percent of the tab for the increase, the law establishes a point in time - July 1, 2009 - as a base for the increased federal reimbursement. In other words, states that have decreased primary care service rates since July 1, 2009, will need to restore payment rates for affected primary care physicians, subspecialists and practitioners. Given continuing fiscal challenges, we may well expect those states to be less than enthusiastic about implementing this critical increase intended to help assure adequate access to essential primary care services in Medicaid.

So who are those states? Well that's not so easy to determine. According the most recent annual Kaiser 50-State Medicaid Budget Survey, 11 states decreased payments to primary care physicians in 2011 and nine (9) did so in 2012. The survey doesn't list the states, but it does give some examples. However, because the survey did not collect these data in 2009, the simple fact that states decreased rates in the most recent two years doesn't tell us if those rates are below those in place on July 1, 2009. Regardless of whether states will need to restore cuts, the law requires all states to reimburse primary care services at levels equivalent to Medicare in calendar years 2013 and 2014.

So what are states required to do and what will the federal government do to make sure primary care physicians receive this much-needed boost, particularly given that some states may be reluctant to follow through?

First, states must file a SPA to reflect the increase in applicable fee schedule payments in 2013 and 2014 unless, for each of the billing codes eligible for payment, the State currently reimburses higher than the respective Medicare rates in those years. Under existing Medicaid regulations which address federal authority to enforce state compliance (42 CFR 430.35), CMS has the authority to fully or partially withhold Medicaid payments to a state that has not met a state plan requirement or if, in practice, it is out of compliance with a federal requirement.

States must develop a methodology for increasing managed care rates and submit it for approval to CMS prior to 2013.

While it is relatively straightforward to implement the increased rates in a fee-for-service environment, it gets more complicated when states pay managed care entities on a full or partially capitated basis. In order to receive the enhanced federal matching rate, states must obtain information from managed care entities to make a reasonable estimate of the increased amounts to be paid for each of the specified services to eligible physicians. The state then must develop a methodology for calculating the differential to be paid to the managed care entity. This methodology must be submitted by the state to CMS for approval before January 2013.

States must amend their managed care contracts to ensure that primary care physicians benefit directly from the rate increase.

In amending these contracts, states also must require managed care entities to provide sufficient evidence, as determined by the state, that they have met the increased payment requirement. CMS plans to conduct a state-by-state review of managed care contracts to further assure compliance with federal regulations.

Primary care physicians and practitioners provide essential preventive and routine care services that keeps kids and families healthy and save health care expenses down the road. We commend CMS for proposing a process to assure providers get the increased reimbursement rates they are entitled to by law. The proposed rule, which was published in the federal register on May 11, 2012, can be found here. The deadline for comments is June 11, 2012. As always with proposed regulations, it's just as important to let CMS know what you like as it is in suggesting areas that can be improved. We'll be drafting comments on the proposed rule and will be happy to share with partners soon.

Medicaid Controls Health Care Costs Better than Other Insurers

2012-05-16T13:38:43Z

Since 2008, we've heard reports about growing Medicaid enrollment and consequently, a rise in its cost (which was mainly incurred by the federal government). Of course we now know that the increases in Medicaid enrollment, and subsequently Medicaid spending, coincided with the worst economic downturn since the Great Depression.

And by now, Say Ahhh! readers are familiar with our frequent efforts to get out the facts and to debunk the myths of out-of-control spending that are promulgated by some. That said, given the current threat to Medicaid and CHIP by the House-passed Sequester Replacement Reconciliation Act, it bears repeating that: 1) the enrollment increases in Medicaid have been recession driven 2) Medicaid is cost-effective and does a much better job of controlling health care costs than do other insurers in the health care sector.

Three recent reports, and their accompanying info graphics, help illustrate these points.

The Kaiser Commission on Medicaid and the Uninsured's Enrollment-Driven Expenditure Growth: Medicaid Spending During the Economic Downturn FFY2007-2010 reveals that the 2.5 percent average annual spending growth in Medicaid is slower than per capita costs in national health expenditures, Medicare, and the private health sector. With 5.5 percent average annual growth spending, the private sector outpaces all benchmarks with which it is compared and even doubles Medicaid spending.

Urban Institute's analysis in Medicare, Medicaid and the Deficit Reduction, illustrates that Medicaid per capita expenditures on average were lower than the private sector throughout the last decade. Compare the private sector's 9.1% growth in the first half of last decade and 4.5% growth in the latter half of the decade to Medicaid's per capita growth rates of 2.9% and 2.7%, respectively. Authors Holahan and McMorrow note that Medicaid's lower costs are due to the fact that more enrollment was seen among adults and children than the aged and disabled, as the latter group costs more money. However, continued growth of the disabled population in the program, is one reason for overall expenditure growth. That is of course, in addition to the two economic recessions experienced in the last decade, during which times, enrollment increased.

Finally,an analysis from Bloomberg Government finds that Medicaid spending has been mostly flat for the last decade, after adjusting for inflation and population growth. At both the beginning and the end of last decade, per capital costs average out at about $350, having hit its highest per capita cost of $400 in 2005. Below, a graph summarizes spending for the five states with the highest Medicaid expenditures in comparison to the national average.

In sum, these recent analyses of Medicaid spending exhibit that Medicaid is better at controlling health care costs than other insurers, and increased spending in the program is driven by enrollment.

Medical Homes: Local Focus, Better Health

2012-05-14T15:17:54Z

As policymakers across the country look to balance their budgets, some are turning to Medicaid, recycling the same harmful policies they've used year-after-year: eliminating coverage for vulnerable Americans, restricting critical benefits like prescription drug coverage, imposing premiums on those who can't afford them, and slashing already-low provider reimbursement rates.

Community Catalyst and Georgetown University Health Policy Institute Center for Children and Families created the States of Innovation blog series to shine a spotlight on states that are trying to find a better way. We will highlight states that are pioneering new approaches to making Medicaid more sustainable without harming - and often by improving - care for the millions of vulnerable seniors, people with disabilities, children and low-income parents that rely on Medicaid.By Siobhan Brown, Community Catalyst

By Siobhan Brown, Community Catalyst

For the most vulnerable populations, the health care system can be a maze leading not to better health, but to fragmented, costly, and inefficient care. By providing care management and creating a strong health care delivery infrastructure at the community level through a medical home program, North Carolina has made remarkable strides in improving quality and continuity of care and improved health for Medicaid beneficiaries while significantly reducing costs. For example, Community Care of North Carolina (CCNC), North Carolina's medical home program created a statewide diabetes initiative that has improved the health of diabetes patients through improved glucose, blood pressure, and cholesterol control. Between 2000 - 2002, CCNC's diabetes management program is estimated to have saved $2.1million.

Jasmine's story helps illustrate what is happening behind those numbers. Jasmine is a North Carolina teen with type 1 diabetes[4]. Her mom knew that as her daughter was entering middle school it was very important that she develop the skills to manage her illness. The American Diabetes Association hosts summer camps to provide kids with the skills and confidence they need to manage their own care. Jasmine's mom didn't have the money to send her to camp, but through CCNC, Jasmine's nurse care manager identified scholarships that allowed Jasmine to attend the camp. By providing healthcare, facilitating access to community resources and empowering people to be active partners in their health care, North Carolina is improving health and quality of life while reducing costs for Jasmine's family as well as thousands of other families like them.

To find out more about how CCNC works, including Jasmine's story, you can view this video produced by the Ash Institute at Harvard's Kennedy School of Government.

What is North Carolina Doing?

CCNC is a statewide public-private partnership that serves more than 1.2 million Medicaid beneficiaries as well as 70,000 low-income, uninsured residents. The state's 100 counties are organized into 14 health networks, and within these health networks there are approximately 1,500 medical homes, 4,300 providers, and 600 care managers statewide.

Through CCNC's extensive care management services, CCNC strives to improve health by ensuring access to care and community services. The CCNC care managers identify which enrolled members will benefit most from care management services, develop individualized care plans, provide health education and guidance on self-management of illness, facilitate positive relationships with and link patients to community services, plan and coordinate transitional care, and, when appropriate, make home and hospital visits. As Jasmine's story illustrates, the work that the medical homes are doing extends well beyond the exam room.

CCNC has invested providers with ownership of the program, thereby engaging them in the process of health improvement and through partnerships with community resources and other community physicians. CCNC has created a strong network of support for the patients.

While support and a basic framework are provided at the state level, CCNC has found that health can be improved more concretely through the empowerment of patients and engagement of providers at the local level. CCNC has developed statewide health improvement initiatives, but they are flexible enough to meet the specific needs at the network or community level. Further, because the networks are better positioned than the state to understand the specific needs of their communities, networks are able to develop their own health initiatives to address regional health issues.

What Results Has North Carolina Achieved?

Despite the increasing enrollment of people with severe chronic physical and mental health concerns, CCNC has accomplished a variety of health improvements, including:

* a dramatic decline in emergency room use and preventable hospital admissions

* improvements in testing for and control of cholesterol, blood pressure, and diabetes that exceed national benchmarks

* a significant decrease in asthma-related hospitalizations

CCNC has not only improved the quality of care and the health of patients, but has also provided significant savings to North Carolina and its taxpayers. Within its first years, CCNC was already achieving a savings of more than $100 million per year. An independent audit estimates that between 2007 and 2009 CCNC saved nearly $1.5 billion.

Continued expansion of CCNC programs may help the state to reap even more savings and provide higher quality care to more people. North Carolina is one of 15 states that received a planning grant from the Centers for Medicare & Medicaid Innovation to improve care for those who are enrolled in both Medicare and Medicaid (dual eligibles). As part of these integration efforts, the state is proposing to expand the CCNC medical home program to all eligible duals, which would provide medical home services for duals in all types of living situations, including nursing homes. Strong emphasis is placed on improving the engagement and input of beneficiaries and their caregivers.

What Can Other States Do?

With the passage of the Affordable Care Act (ACA), many states are looking to create or expand patient-centered medical homes or implement the ACA Health Homes Option. The Health Home Option in the ACA offers states an excellent opportunity to take advantage of increased federal matching funds to build a system, like North Carolina's, that provides tangible improvements in health and wellbeing for Medicaid patients.

CCNC has been working for many years to develop the program into what it is today and other states cannot be expected to implement a program of this size or scope immediately. But states can start with smaller programs, and then invest those savings into expanding the program over time. CCNC's efforts provide a sense of what can be achieved through a commitment to continuous program improvement.

Quality Mothers Deserve Quality Care!

2012-05-11T16:09:09Z

By Cynthia Pellegrini, March of Dimes

It sounds like a rejected Hallmark card: "Sending you wishes for high quality maternal and child health care, today and every day." But on Mother's Day, it's especially appropriate to talk about healthy women, healthy pregnancies, and healthy babies and children.

For many of us in the health policy field, it would have been easy to miss the slow but steady increase in attention paid to the quality of obstetrical and maternity care. Thanks to the efforts of the March of Dimes and other maternal and child health advocates, provisions related to the development of perinatal and pediatric quality measures were included in the Child Health Insurance Program Reauthorization Act of 2009 (CHIPRA), requiring the Agency for Healthcare Quality and Research to produce new measures on a specific timeframe. Those provisions served, in turn, as a model for many of the broader quality initiatives included in the Affordable Care Act in 2010. The National Quality Forum (NQF) has endorsed a growing list of perinatal measures over the past 3 years (currently over 30 for pregnancy and neonatal care), while the Joint Commission announced its Perinatal Care measures core set in late 2009 and began collecting that data in spring 2010.

Meanwhile, certain aspects of perinatal care were under additional scrutiny. In particular, concern arose about the practice of scheduling elective deliveries before 39 weeks of complete gestation as a growing body of research indicated the importance of the final weeks in utero and the increased risk of the need for Neonatal Intensive Care Unit (NICU) care for newborns delivered before 39 weeks. The March of Dimes identified this as a key actionable priority, developed and tested an extensive toolkit for hospitals to use in ending this practice, and urged its adoption through its network of chapters in every state. Other organizations took up the cause as well; a 39 week quality measure was endorsed by NQF and is one of the five measures in the Joint Commission's Perinatal Care core set.

In many communities, the results have been dramatic. Some hospitals and systems that have implemented a "hard stop" on elective deliveries prior to 39 weeks have reported decreases of more than 20 percent in NICU days. The March of Dimes recently completed development of a service package for hospitals seeking to implement a hard stop policy but interested in more support. The service package includes access to a data portal that will provide real-time feedback, grand rounds, access to experts, and more. This package is being made available at no cost to 100 hospitals in 2012; the request for applications recently closed with far more than that number having been received.

In mid-2011, the March of Dimes opened conversations with the Association of State and Territorial Health Officials (ASTHO) about setting goals for President David Lakey's presidential challenge around healthy infants. It was calculated that, by implementing a set of targeted interventions, states could expect to reduce their preterm birth rates by 8 percent. The target interventions are: a hard stop on elective deliveries before 39 weeks; access to the drug 17p to prevent preterm labor for women who have had a previous preterm birth; tobacco cessation for pregnant women; and changes in assisted reproductive technology to better manage the creation of high-order multiple births. In 2011, Dr. Lakey challenged his fellow health officers to adopt the goal of reducing preterm birth by 8 percent by 2014. And the response has been tremendous -- as of this writing, thirty states' health officers have publicly accepted the challenge and are moving forward to address it, with more still expected to join.

They say that nothing breeds success like success, and in this case the enthusiasm certainly continued to build. In February 2012, the U.S. Department of Health and Human Services (HHS) took a major step toward helping to ensure healthy pregnancies and healthy babies for all women with the launch of the Strong Start program. Strong Start has two distinct but interrelated components: first, an effort to reduce the scheduling of elective deliveries before 39 weeks of gestation for all women, and second, a $43 million grant program to test three promising approaches toward prenatal care for at-risk women on Medicaid. HHS and the American College of Obstetricians and Gynecologists added their support to March of Dimes consumer education materials to produce a set of co-branded products that would reinforce the messages of the 39 weeks component of Strong Start. States and other applicants have responded energetically to the Strong Start grants opportunity, forming coalitions of partners all dedicated to testing the models of group prenatal care, birthing centers, and maternity health homes. Applications for the grant program are due soon, with funding announcements expected in September.

All of these and many other important initiatives are combining to create to a critical mass in the movement to improve perinatal health care. It won't happen overnight, and there's obviously still much more to do. But we are making meaningful progress - for the past three consecutive years, the rate of premature birth has registered small but significant declines after rising for more than three decades. We can make a difference for healthier women, babies and families.

We're on our way to providing quality perinatal care to all women. Happy Mother's Day to all the moms out there - past, present, and future!

House Passes Sequester Replacement Bill - Could Impact Kids Health Care

2012-05-10T19:02:30Z

Today the House of Representatives passed the "Sequester Replacement Reconciliation Act". As we've mentioned before, the Senate is not planning to take up the measure and the Administration has issued a veto threat should the lopsided measure reach the President's desk. Despite those assurances, it is worth looking into the measure as it telegraphs the House position on future discussions about circumventing the sequestration triggered by last year's bipartisan budget agreement.

CCF's Martha Heberlein has put together a fact sheet on the measure and the impact it would have on health care coverage for children and families. Her brief identifies two provisions as posing the greatest threat to children's health care coverage:

The repeal of the Affordable Care Act's stability protections, also known as "maintenance-of-effort" provisions, that have helped children and families maintain access to affordable coverage and helped drive down the number of uninsured children to the lowest level on record. If the stability provisions are rescinded, states could eliminate Medicaid for anyone who is covered at state option, as well as cut eligibility, shut down enrollment, or even abolish their CHIP programs, putting coverage at risk for more than a third of Medicaid and CHIP beneficiaries

The cancelation of an innovative, pay-for-performance program that has encouraged states to connect eligible children to coverage. In the states that received rewards in 2011, an additional 1.1 million kids were enrolled above expected levels. While the incentive payments do not necessarily fully explain this increase in enrollment, they certainly help to support the states in reaching these children.

In other words, the measure would weaken the cost-effective Medicaid and Children's Health Insurance Program that have worked so successfully to help uninsured children. With one in five children living in poverty and many parents unable to find affordable health coverage for their families, it does not seem to be an ideal time to undermine cost-effective programs that have helped protect the health of our nation's children.

Those supporting the cuts have justified their position by pointing to egregious examples of Medicaid "waste, fraud and abuse". Program integrity is vitally important to all publicly funded programs whether it is health care providers, transportation firms or defense contractors that are receiving the funding. We don't walk away from defending our country or building roads because of a few bad actors. Don't you think the same should hold true for programs that help protect the health of our nation's children and families?

Medicaid Primary Care Services Get An Overdue Raise

2012-05-09T19:06:12Z

Primary care is one of our best buys in health care because of its proven effectiveness in improving health outcomes and avoiding more costly health services. This is particularly true for children as they move through different phases of development, and people with chronic health conditions. But it's also a well-known fact that primary care providers are paid on the lower end of the health care payment spectrum. So we were pleased that, among the many provisions of the Affordable Care Act, was a plan to boost payments for primary care services for Medicaid beneficiaries, with the federal government picking up the tab for increasing state Medicaid rates to the equivalent of Medicare in calendar years 2013 and 2014.

Today, the Centers for Medicaid and Medicare Services released its proposed rule to implement this provision. The rule gives physicians with a specialty designation of family medicine, general internal medicine, or pediatric medicine, as well as related subspecialties, a long overdue raise. The rule clarifies that primary care services rendered by practitioners under supervision of a physician - such as physician assistants and nurse practitioners - will receive the enhanced payment as well. It also applies to subspecialists, such as a pediatric cardiologist, who provide primary care services. The rules unfortunately fall short in one key area - they do not include OB-GYN services, which CMS states is beyond the definition of primary care services in the law.

The federal government will pick up 100% of the difference in cost between what states were paying as of July 1, 2009 and the applicable Medicare rate. Translation - if your state reduced provider rates after July 1, 2009, it will have to restore those decreases at its regular Medicaid matching rate.

The new rates apply to services delivered through Medicaid managed care plans, and the rule proposes that states incorporate the increased payment in their contracts with these entities. CMS intends to work with states to develop a methodology for identifying the differential in capitated rates that should be made to managed care entities. In turn, the managed care entities will be required to provide sufficient documentation to the states to demonstrate that their payments to these providers, whether capitated or fee-for-service, meet the new requirements.

The proposed rule also gives a raise to providers who give qualified pediatric immunizations to kids enrolled in Medicaid in states that participate in the Vaccines for Children program. This is the first increase in payment (which appears to be in the 50% range above current rates based on the state-by-state payment chart) for administering vaccines since 1994. This part of the rule has a new benefit for children who participate in the VFC program because they are uninsured or have insurance that does not cover vaccines. Currently, providers can charge whatever their regular rates are for administration of vaccines to uninsured or underinsured children, although many do so for free. Under the proposed rule, the providers that do charge uninsured or underinsured families cannot charge more than the posted state Medicaid reimbursement rate.

We've only scanned the 78-page proposed rule in an effort to get this long awaited information posted as soon as possible. We'll continue to review the proposed rule and provide more details soon. Keep in mind that the comment period on this proposed rule is 30 days from when the rule is published in the federal register (TBD). In the meantime, you can find the rule here or at www.ofr.gov/inspection.aspx.

For additional information see the CMS Fact Sheet.

House Budget Committee Reports Out Bill to Eliminate MOE & CHIPRA Bonus

2012-05-09T13:32:16Z

In an effort to circumvent the bipartisan debt ceiling agreement reached last year, the House Budget Committee passed a measure Monday that, if enacted, would undermine the success our nation has achieved in driving the uninsured rate for children down to a record low. (It has numerous other issues as well, and for a thorough review, we encourage you to see the Center on Budget and Policy Priorities latest paper on the topic.)

The legislation approved by the committee would eliminate automatic spending cuts (i.e., the "sequestration") to discretionary programs slated to go into effect in 2013 under the bipartisan debt ceiling agreement reached last summer. As Say Ahhh readers know, the debt ceiling agreement called for the sequestration to occur if a "super committee" failed to develop an alternative way to address the budget deficit. And, fail it did.

The House is expected to pass the measure on Thursday, but the Senate has indicated that it is not interested in taking it up. Without action by Congress, the automatic cuts take effect in January 2013, as planned.

House Budget Chairman Paul Ryan has made an all-out effort to frame his package as cracking down on fraud, abuse and wasteful spending. But, those claims have been refuted and the proposal is being widely viewed as an effort to shield the Defense Department from cuts by extracting even more money out of programs that are important to low and moderate-income families. We would like to highlight two of the cuts that would turn the clock back on the success the U.S. has made in reducing the uninsured rate for children.

The plan would repeal the Medicaid and CHIP stability protection (aka maintenance of effort) provisions that have helped so many children maintain health care coverage during these tough economic times. As my colleague Martha Heberlein blogged about last week, If these protections were rescinded, coverage for more than a third of Medicaid and CHIP beneficiaries would be placed at risk. Without the stability protections, states could reduce coverage to mandatory federal minimum levels in Medicaid and scale back or even entirely eliminate their CHIP programs. (The last time this ugly provision reared its head, CBO estimated that over half of states would take this route.)

The measure would also eliminate a performance-based incentive plan that rewards states for doing an exemplary job of connecting uninsured kids to coverage. The incentive plan is one of several successful strategies that have helped to connect the lowest income uninsured children to coverage. Data on the bonuses show that in the 23 states that received bonuses in FY 2011, an additional 1.1 million kids were enrolled above expected level.

Medicaid and CHIP are cost effective programs that have helped meet a critical need for children and families across the country. It is troubling that there are attempts to cloak these cuts under the oft-repeated waste, fraud and abuse mantra. Research has shown that the likelihood of fraud and abuse on the part of Medicaid beneficiaries is extremely low and the experience of at least one state that has streamlined enrollment practices is that doing so actually helped it to reach a remarkably low error rate.

At CCF, we have found that streamlining enrollment does not translate to fraud and abuse. To the contrary, it takes a complex and confusing enrollment process, adds the latest technology to minimize duplication of effort, and creates a path to coverage that is both accurate and efficient at connecting children to coverage they are eligible to receive. In other words, it improves government efficiency, something that all policymakers should be able to support.

Wisconsin's 1115 Waiver Approved - Bad News/Good News

2012-05-08T17:52:21Z

Medicaid waivers have been a very hot topic lately! Just take a look at my colleague Joan Alker's blog on recent action around waivers. You may have heard that CMS recently approved Wisconsin's 1115 waiver for the state's BadgerCare program. Most of the changes will affect adults with incomes over 133% of the FPL. Premiums will be increased for adults, retroactive eligibility will end, and adults will be dropped from BadgerCare for a year if they miss a premium payment, just to name a few of the changes in the waiver. The waiver is set to begin on July 1, 2012 and end on June 30, 2013. All of the changes in the waiver are summarized in this brief written by Jon Peacock from the Wisconsin Council on Children and Families. Governor Walker's administration claimed that the waiver would also give Wisconsin the opportunity to align with the Affordable Care Act (ACA) and test what's going to come in 2014 and Jon Peacock also wrote a great brief on why this waiver is actually totally inconsistent with the ACA.

In situations like these, I often try to not just look at the bad news but also attempt to find the good news. It helps me to start with the bad news, that way I can leave my thinking on a positive note. The bad news, or maybe I should say the worst news, from this waiver is that 17,000 adults are expected to lose coverage. Additionally, Wisconsin is still seeking federal approval for an Alternative Benchmark plan that would limit benefits and increase co-pays for 300,000 people in BadgerCare.

However, the good news is that the maintenance of effort (MOE) provision in the Affordable Care Act will protect many children and their parents from losing coverage and Secretary Sebelius refused to waive it. In its first proposal, Wisconsin wanted to raise premiums, end retroactive eligibility, etc. for not only adults, but also for children. Had the state's original proposal been approved, it was estimated that 65,000 people would have lost coverage, including 29,000 children.

Other states might want to take note of CMS' decision to not waive the MOE in Wisconsin. Secretary Sebelius has made it clear that HHS will not be approving any MOE waivers in other states either. When asked about waiving MOE requirements in Wisconsin last month, she replied.

"That isn't something that will happen in Wisconsin or any place else. We are eager to work with states for ways to save money but also to keep the most vulnerable people with the health care that they need. Short-term money saving often ends up with a less productive workforce with folks coming in through the doors of the emergency room with no payment system at all. That leads to more uncompensated care and higher cost for disease. It's a lose-lose situation." (Source: Tim Stumm, Wisconsin Health News, April 12).

I hope you agree with me that it's better to leave on a positive note...

Have You Thanked a Nurse Lately?

2012-05-07T13:07:34Z

I'm really bad at keeping up with all these national days, weeks and months of recognition. I somehow missed the opportunity to indulge on National Potato Chip Day (March 14). I didn't even notice that Ohio Governor Kasich signed a proclamation earlier this year designating February 6 as National Pork Rind Day. But today I found a national celebration I can really rally behind - National Nurses Week (May 6 - 12).

What a great idea -- celebrating the people who immunize our kids, listen to our concerns and advise us on important preventive health care for our families. Frankly, I can't imagine how anything would get done in a health care setting without nurses.

My last interaction with a nurse was during my annual exam with my nurse practitioner. Even though I see her only once a year, she has a major impact on my health. She doesn't let me justify away those extra pounds (hope she doesn't read about my plans to celebrate national potato chip day next year) but she also doesn't make harsh judgments. I always wonder how she has the ability to take so much time with her patients and really listen. A nursing student accompanied her during my last visit. When she was out of the room tracking down more information to share with me on vitamins, the student nurse told me she is amazed by how she is able to handle a full caseload while taking the time to be fully engaged with every patient that walks in the door.

When my super-human nurse practitioner came back to the room, I figured it was time to whisk me out of the office but she insisted on catching up on other things. She asked me about my family and my job. When she learned that I worked on health care issues, she was curious about the Affordable Care Act. She really had not heard very much about it. (I guess she's been too busy spending quality time with patients to spend much time trying to decipher all the misinformation that's been circulating on the new health law.) She was thrilled with the fact that insurance companies have to spend more on actual health care, that people would no longer be denied coverage based on pre-existing conditions and that women would no longer be charged higher premiums than men.

Nurses are critically important to our nation's efforts to improve the quality of care and reach more uninsured people through the Affordable Care Act. The new health law recognizes that fact and includes provisions to make sure that nurses get the support and training they need. For more on the importance of nurses and what the Administration is doing to support their hard work, please read the statement on National Nurses Week issued by HHS Secretary Kathleen Sebelius and report on how the new health law has benefitted nurses.

Remember, thanking a nurse is good for your health while eating pork rinds and potato chips will only cause you to need a nurse. Happy Nurses Week!

Waiver Frenzy

2012-05-04T19:28:37Z

Interesting events have kept Medicaid waiver watchers very busy in the last week. On Friday April 27th final regulations creating new requirements for state and federal public process to allow for public input when Medicaid waivers are developed and considered went into effect. A summary I did with Samantha Artiga at Kaiser Commission on Medicaid of the new rules is available.

Last week, Say Ahhh! reported that three states rushed to submit their waivers right before the rule went into effect, in order to avoid these new requirements on public input. This week we learned that it was actually five states: Kansas, New Mexico, Nevada, Ohio and Florida (amendment).

Also on Friday, CMS released a "State Medicaid Director" letter to provide further guidance on the implementation of the revised review and approval process. And CMS debuted a new user guide and website with a comprehensive list of all waivers by state and their statuses. All pending waivers are currently open for a 30-day informal federal comment period. Spread the word to all waiver watchers and we will share more information on this next week...

Packard Releases New Report on Impact of Children's Health Care Advocacy

2012-05-04T18:17:40Z

By Gene Lewit and Liane Wong, The David and Lucile Packard Foundation

Those of you who are regular Say Ahhh! readers know that more children have health insurance coverage today than at any point in the nation's history. The steady growth in children's health coverage did not happen in a vacuum. State and federal leaders and program directors, policy and grassroots advocates, and concerned citizens - not to mention key pieces of federal legislation - all contributed to this success. In particular, state efforts, to grow and improve their children's coverage programs, supported and urged onward by policy and grassroots advocates, played a crucial role in the growth in children's coverage.

Today, the David and Lucile Packard Foundation and Mathematica Policy Research released new findings on the impact of children's health care coverage advocacy in the states. This brief, Applying Advocacy Skills in Tumultuous Times: Adaptive Capacity of Insuring America's Children Grantees, is the latest from the evaluation of the Packard Foundation's multi-year, multi-state, Insuring America's Children (IAC): States Leading the Way grantmaking strategy launched in 2007. One of IAC's goals was to broaden and strengthen the state-based children's health advocacy ecosystem to support the expansion of children's coverage at the state and federal levels en route to our goal of covering all of America's children. As the nation engages in the implementation of health care reform and attempts to address a number of other pressing problems, we believe the findings in the just released brief hold lessons not only for children's coverage advocates and funders but for broader advocacy efforts as well.

What ultimately transpired between 2007 and 2010 was a tumultuous period characterized by a severe economic downturn, an intense political battle around the reauthorization of the Children's Health Insurance Program, and widespread erosion of employer sponsored health insurance, capped by an intense debate on national health reform.

So, how did state-based advocacy groups navigate these rapidly shifting state and federal environments? By analyzing four years of comprehensive data, the evaluation team at Mathematica found that support of capacity and network building among state-based advocacy groups of different sizes strengthened their communications and policy capacity to make children's coverage a priority both within their own states, in other states, and at the national level. The groups' work strengthened popular support for the broad goal of insuring all children and supported many targeted policy goals, such as expansion of CHIP eligibility, program improvements, and simplified, more efficient enrollment and retention practices.

Findings from the study highlight the key strategies that advocacy groups pursued aggressively to prepare for and respond effectively in a dynamic environment, including:

* Building and adapting strategic partnerships as the economic and political contexts in their states were shifting. Advocacy groups assumed new and expanded leadership roles within state-based coalitions;

* Serving as critical sources of information and analysis to state policymakers and other key stakeholders. Advocacy groups strengthened their reach and influence;

* Employing consistent and positive messaging. Advocacy groups successfully broke through the mire of a gloomy economic forecast and sometimes combative political atmosphere;

* Leveraging technical assistance and external support by the Packard Foundation, such as peer-to-peer learning.

Advocacy groups were able to maximize their individual and collective efforts. As the goal of ensuring that all children have health care coverage becomes increasingly attainable, understanding how advocates have carried out this work in different and dynamic environments can provide lessons for future advocacy efforts on a variety of issues. The full details of these findings can be found on the Packard and Mathematica websites. To learn more about Insuring America's Children: States Leading the Way, visit our website.

Where Would 1.1 Million Kids Be Without the CHIPRA Performance Bonus?

2012-05-03T13:10:21Z

When CHIP was reauthorized in 2009, the Performance Bonus was designed to reward states for enrolling more Medicaid-eligible children. As my colleague, Jocelyn Guyer, pointed out on Tuesday, the House Energy and Commerce Committee voted last week to eliminate these bonuses.

While this raises questions of whether the Committee supports the intention of connecting the poorest of children to affordable health coverage (as the bonuses were designed to do) perhaps the larger question is where would those newly-covered kids be if states didn't have the incentive to streamline and simplify their programs to enroll more eligible, uninsured kids?

Data on the bonuses show that in the 23 states that received bonuses in FY 2011, an additional 1.1 million kids were enrolled above expected levels. The most (123,000) can be found in the state of Ohio. While we can't say that the bonuses fully explain this jump in enrollment, it would certainly be fair to say that they get some of the credit for supporting states in reaching these kids.

As we've seen over the years, Medicaid and CHIP have been responsible for driving the uninsured rate of children down to record lows. These bonuses have been an important incentive in making this progress and dismantling them threatens to undercut the great success we've seen in Medicaid and CHIP.

89,000 Pennsylvania Children Lose Medicaid Due to Shortsighted Policies & Bureaucratic Backlogs

2012-05-03T11:46:55Z

By George Hoover, Pennsylvania Partnerships for Children

Having dedicated my career to making health care coverage accessible to all Pennsylvanians, I am dismayed over recent actions by the state that are jeopardizing health care access for children.

The number of Pennsylvania children covered through Medicaid has plummeted by about 89,000 in recent months, including many kids with life-threatening medical needs who were hastily -- and wrongly -- cut from Medicaid despite meeting the eligibility requirements.

Those wrongly dropped from Medicaid included a 5-year-old undergoing treatments for leukemia and an infant with congenital heart deformities. They also include a severely disabled 12-year-old who requires home health care and a pair of 9-year-old twins -- one diagnosed with autism, the other with a hearing impairment -- who rely on Medicaid to provide supports and services critical to their development and learning.

Many of these children rely on Medicaid not only for physical health services, but also critical behavioral health services that help them get by day to day. To understand how this happened and how we can fix it requires a quick history of the health care coverage crisis that has been quietly unfolding in Pennsylvania since last summer.

Last August, the Department of Public Welfare began sending out hundreds of thousands of renewal notices to Pennsylvania families receiving Medicaid, allowing these families 10 to 15 days to provide documentation to keep their children enrolled in Medicaid. If DPW did not receive and process all requested paperwork within this 10 to 15-day deadline, the child was dropped from Medicaid, even if the deadline was missed due to DPW's own bureaucratic backlogs.

Locally, this poorly planned process cut off Medicaid to more than 2,000 children in Dauphin County, nearly 1,600 in York County and more than 2,500 in Lancaster County. There's another troubling aspect to this story: Families whose children are no longer income eligible for Medicaid are referred to the Children's Health Insurance Program, or CHIP, yet we have not seen an increase in CHIP enrollment that corresponds to the drastic Medicaid enrollment decline.

In a state with near universal coverage for children, where have these children gone? ?And what can be done to ensure these children, and others, are not put at risk due to lack of access to health care?

Part of the solution lies in the Affordable Care Act. Look beyond the heated political rhetoric and it's easy to see how the ACA is helping to keep young Pennsylvanians healthy at a time when our state policies are putting children's health care at risk.

More than 1.1 million Pennsylvania children are benefiting from the ACA's prohibition on lifetime limits on health care. Insurance companies can no longer deny coverage for children in Pennsylvania with pre-existing conditions, and nearly 65,000 young adults can now remain on a parent's health insurance coverage up to age 26.

Why should any of this matter to Pennsylvanians who don't have kids? Because we all benefit, financially and otherwise, when children are healthy. Healthy kids grow up to be healthy adults. Families are less likely to put off medical care for their children and run the risk of needing more costly and complicated medical treatments later.

Fortunately, Governor Tom Corbett has embraced a critical aspect of the ACA that state lawmakers should support, too. The state is moving ahead with plans to create a health insurance exchange, a user-friendly, online insurance marketplace that will enable all families with children to obtain and maintain high-quality health insurance in a streamlined way.

If we do it right, Pennsylvania's exchange will allow children to have access to the behavioral and physical health benefits they need to be healthy. The governor and General Assembly should enact necessary legislation this spring to get the exchange up and running. The commonwealth has been a national leader in providing affordable, accessible, quality health care coverage for children through Medicaid, CHIP and Cover All Kids -- efforts that have been supported by governors and lawmakers of both parties for over two decades.

The ACA helps us build on those efforts, and it does so at a critical time when we have seen children's access to health care jeopardized through shortsighted policies at the state level.

Low Income Kids will be Hit Hardest if Effort to Raid CHIPRA Performance Bonuses Succeeds

2012-05-01T18:07:21Z

In my house, I have a general policy for my three boys that they can't use the words "stupid" and "dumb" unless they are truly warranted (e.g., you can't call your brother stupid for forgetting the napkins when setting the table, but, I let it go when they decided that Anthony Weiner had acted stupidly). Still, when the Energy and Commerce Committee voted last week to cancel performance bonus payments to states that enroll more low-income children in health care coverage, I had a hard time restraining myself from using this type of harsh language.

Created by the Children's Health Insurance Program Reauthorization Act (CHIPRA) of 2009, the bonuses reward states for demonstrating concrete success in enrolling low-income uninsured children in Medicaid. To qualify, states must adopt one of a series of measures that simplify enrollment in coverage and reach enrollment targets. To date, the bonuses have worked exactly as intended - rewarding states for tackling the challenge of making sure that the lowest-income children in this country are connected to coverage. While the bonuses only modestly offset the cost of successfully enrolling more eligible children in Medicaid, they have had an "outsized" impact by inspiring states to make it easier for eligible children to be enrolled in affordable health plans. States across the country seem to appreciate the additional fiscal help, modest thought it is, as well as the all-too-rare public recognition of their hard work and innovation. Indeed, states from Washington and New Mexico to Louisiana and New Jersey have enjoyed the benefits of the bonuses (See map below). Last year, 23 states across the country received a little over $296 million in bonuses.

The cancelation of the performance bonuses is certainly not the only (or even the most problematic) provision included in the Energy and Commerce Committee's recent mark. To the contrary, as my colleague, Martha Heberlein has described elsewhere, the repeal of the stability protections (aka "maintenance-of-effort requirement") would be potentially devastating to America's children. And, if the committee's decision to eliminate federal Exchange grants were adopted and signed into law, it would wreak havoc with health reform implementation.

But, the Energy and Commerce committee decision to go after the performance bonuses is very troubling. It could imperil the nation's recent success in driving the uninsured rate of children to record lows by removing an important incentive to continue to make progress. Plus, ironically, during debate over reauthorizing CHIP, President Bush and a number of members of congress argued against the broader bill on the grounds that it didn't do enough to enroll the poorest children in coverage. Connecting the poorest children with affordable health care coverage is the primary goal of the CHIPRA performance bonuses. So, without stooping to call the idea stupid or dumb, it is safe to say that eliminating the performance bonuses is short-sighted and contradicts the objective of making coverage of the poorest children a top priority for this country.

Medicaid and CHIP Waiver Transparency Rules Take Effect Today: CMS Unveils New Waiver Website

2012-04-27T14:39:31Z

As regular readers of Say Ahhh! know, CMS has issued final regulations on public input and transparency with respect to Section 1115 Medicaid and CHIP waivers. These rules have been a loooong time coming and much needed since 1115 waivers can be very consequential. And today, April 27th, 2012, the rules become effective.

My last blog on this topic mentioned some of the highlights - a 30-day public comment period at the state level for which states must provide the full application they are planning to submit to the federal government. This may not sound like much, but as many state advocates have experienced, the waiver development process often leaves many frustrated people in its wake. Waiver "concept papers" often use general terms like "promoting personal responsibility" and promote apple pie reforms like "promoting efficiency and higher quality" without any meat on the bones to explain how this will be achieved. The rules also call for a federal comment period once the application is finalized and submitted. For a full description of what the new process will look like, please look at the brief I co-authored for the Kaiser Commission on Medicaid on the new requirements.

Another long time frustration of waiver watchers has been the inability to obtain reliable information from the federal government on what states had actually submitted waivers and what those waivers requested. Here too the situation looks to improve as well - CMS is unveiling a new website today which will include a comprehensive list of all waivers by state and their status (i.e. active, expired or pending). And CMS has created a new "Idea Factory" which allows for the public to comment on pending waivers in exciting new ways - Check it out!

I am writing this on Thursday, April 26th and apparently three states, Kansas and New Mexico and Nevada are rushing to submit their waivers TODAY so that they can avoid the new requirements to seek careful input from their citizens. My daughter says they need to "suck it up" and play by the rules like everyone else. Then she asked, "What are they afraid of???"