- Primary care physicians accept Affordable Care Act exchange plans more often than Medicaid, but not as much as employer-sponsored health insurance, according to a Health Affairs study.
- The analysis found that PCP in-network participation was 91% in the ACA marketplace. That’s compared to 75% in Medicaid and 100% for employer-sponsored plans.
- The researchers also discovered that one-third of in-network physicians don’t have appointments available for new Medicaid patients.
Narrow networks have become commonplace in both ACA plans and Medicaid, used by payers to control costs and ensure physicians provide quality care by meeting specific measures. Those networks remain rare in the employer-sponsored market, though.
Members usually prefer broader networks, and narrower networks can increase frustrations and disrupt continuity of care.
The study authors suggested that the results provide insight into the challenges that patients face. The findings can also “assist policymakers in recognizing the trade-offs involved in allocating scarce resources while improving access to high-quality healthcare.”
The report looked at the in-network rate for PCPs for 10 states: Arkansas, Georgia, Illinois, Iowa, Massachusetts, Montana, New Jersey, Oregon, Pennsylvania and Texas.
The 10-state appointment availability average was 73% for ACA plans, 83% for employer-based coverage and only 63% for Medicaid. Those rates were consistent across all states studied. The only state where ACA plans had worse numbers to Medicaid was in Massachusetts (51.9% for ACA plans; 55.3% for Medicaid).
Study authors said the differences in choice of providers for each insurance type shows “inherent trade-offs in increasing coverage.”
“Policies to expand physicians’ participation in the marketplaces will depend on policy priorities, beneficiaries’ preferences and whether the benefits outweigh the costs of expanding physician participation in various insurance market segments,” they added.
An Avalere report last year found that more restrictive networks make up 73% of ACA plans. That’s an increase from 68% in 2017 and 54% in 2015.
In comparison, Kaiser Family Foundation said only 8% of companies offering health benefits had narrow networks in 2017. That was the same percentage as the previous year. A mere 6% of companies said they eliminated hospitals or health systems from a network over the past year to reduce cost.
Medicaid managed care plans also offer narrow network plans. However, a Health Affairs report warned about physician turnover in those plans. That report found that Medicaid narrow networks had a three percentage point higher turnover rate in one year and 20 percentage point higher rate through five years compared to non-narrow network plans.
The Trump administration is halting billions of dollars of payments to insurers under the Affordable Care Act’s risk-adjustment program, a move that further disrupts the insurance market and could lead to more premium increases next year.
Citing conflicting federal court decisions on the program, the CMS said it cannot collect or disburse funds under the risk-adjustment program. All in all, the program was slated to shift $10.4 billion among insurers in 2017, according to the agency.
The permanent program was meant to reduce the incentive for health insurers to cherry-pick healthy members. It shuffles money from plans with healthier-than-average members to those with larger numbers of sicker, higher-cost members. The program is based on a patient’s risk score, which is determined by a person’s demographic information and health condition.
But U.S. District Judge James Browning of New Mexico ruled in February that HHS couldn’t use statewide average premiums to come up with its risk-adjustment formula because the agency wrongly assumed the ACA required the program to be budget-neutral.
“CMS has asked the court to reconsider its ruling, and hopes for a prompt resolution that allows CMS to prevent more adverse impacts on Americans who receive their insurance in the individual and small group markets,” CMS Administrator Seema Verma said in a July 7 statement.
America’s Health Insurance Plans said it was “very discouraged” by the CMS’ decision, which comes as insurers determine their premiums for 2019 and states review those proposals.
“The decision will have serious consequences for millions of consumers who get their coverage through small businesses or buy coverage on their own,” the group said. “It will create more market uncertainty and increase premiums for many health plans—putting a heavier burden on small businesses and consumers, and reducing coverage options. And costs for taxpayers will rise as the federal government spends more on premium subsidies.”
The risk-adjustment program has been a source of frustration for small insurers and ACA co-ops that claim the formula makes their membership bases look healthier than they are. One reason could be that newer insurers have limited information on their members’ health status and claims history. Legacy insurers that have a wealth of patient data may have a leg up on coding. Small health plans also have far less capital than more established insurers to comfortably make large risk-adjustment payments.
The CMS has asked Judge Browning to reconsider his ruling and is awaiting a decision. The agency said it will release additional guidance for insurers on issues related to the risk-adjustment program, including appeals and how this will affect medical loss ratios.
The Department of Justice announced its largest healthcare fraud takedown ever, charging 601 people for falsely billing Medicare, Medicaid and the U.S. military’s TRICARE program to the tune of more than $2 billion.
The massive enforcement initiative — which spanned 58 federal districts — swept up 165 doctors, nurses and other licensed health professionals, including 76 doctors accused of prescribing and distributing opioids and other prescription painkillers.
Since last July, HHS has barred 2,700 people from participating in federal healthcare programs, including 587 providers charged with opioid diversion and abuse.
Ashlee McFarlane, former federal prosecutor and partner at Gerger Khalil Hennessy, told Healthcare Dive via email that the takedown shows DOJ “is committing significant resources to criminally prosecuting anyone who prescribes drugs or distributes opioid prescriptions outside the normal course of medical practice. … Federal authorities are sending a message about opioid drug abuse in our nation and using the hammer of criminal prosecution to combat it.”
Indeed, 162 of the 165 medical professionals nabbed in the sting were charged with opioid-related crimes. The takedown serves as a cautionary tale for providers that avoiding any suggestion of over-prescribing and diversion isn’t just good for patients’ health — it can save them costly fines, loss of government reimbursement and even jail time.
The investigations included 84 opioid cases involving more than 13 million illegal doses of opioids, according to DOJ.
Among those caught in the crackdown were 124 defendants in DOJ’s South Florida district for false claims totaling more than $337 million. One sober living facility illegally recruited patients, paid kickbacks and conducted fraudulent urine testing, billing the government more than $106 million for alleged substance abuse treatments.
In a Michigan case, a doctor paid kickbacks to two home health agency owners, resulting in more than $12 million in false insurance claims. The widespread operations were led by DOJ’s Health Care Fraud Unit in conjunction with the Medicare Fraud Strike Force, a collaboration of DOJ’s criminal division, U.S. attorney’s offices, the Federal Bureau of Investigation and HHS’ Office of Inspector General.
“These are despicable crimes,” Attorney General Jeff Sessions said in a statement. “That’s why this Department of Justice has taken historic new steps to go after fraudsters, including hiring more prosecutors and leveraging the power of data analytics.”
In fiscal year 2017, the federal government won or negotiated more than $2.4 billion in healthcare fraud judgments and settlements.
In all, the government reclaimed $2.6 billion last year, including $1.4 billion for the Medicare Trust Funds and $406.7 million in federal Medicaid money. DOJ opened 967 criminal healthcare fraud investigations and filed 439 cases involving 720 defendants. Of those, 639 were convicted.
The U.S. House of Representatives overwhelmingly passed legislation Friday that would make it easier for providers to treat patients suffering from opioid addiction.
In a 396-14 vote, the House approved the Support for Patients and Communities Act, a package of smaller bills that attack the opioid crisis on multiple fronts.
American Hospital Association Executive Vice President Tom Nickels said the trade group was especially pleased to see overwhelming support for provisions that would expand the use of telehealth services for substance use disorder; guide improved care for infants with neonatal abstinence syndrome; and increase the types and capacity of providers offering medication-assisted treatment.
Lawmakers similarly said it is critical to be innovative and flexible in developing care plans for people dependent on opioids.
“This is an important step in our work to leverage technology to meet the healthcare needs of our communities,” said Rep. Doris Matsui (D-Calif.). “The integration of telemedicine into our healthcare ecosystem is one way we can expand access to treatment and services for patients with addiction.”
Two other key parts of the package include partially repealing what is known as the Institutes for Mental Disease exclusion, a 1960s-era law that blocks Medicaid funding from inpatient stays in mental health and behavioral health facilities. The other rolls back enhanced privacy protections for addicts that forbid any physician or other medical provider from sharing a patient’s medical history with another practitioner who is treating that patient.
The bill also aims to encourage conversations about opioid dependence by covering screening for addiction as part of Medicare beneficiaries’ first physical examination.
The Centers for Medicare & Medicaid Services asked stakeholders Wednesday for input on how to change the Stark Law to allow for better care coordination and new alternative payment models or other novel financial arrangements.
The American Hospital Association has been vocal in pushing for changes to the physician self-referral law, calling it outdated. AHA argues the law presents “nearly impenetrable roadblocks in the move toward value-based care.”
The agency specifically is requesting input on what new exemptions to the Stark Law are needed to protect accountable care organization models, bundled payment models and other payment models, including how to allow coordination care outside of an alternative payment model. It also asks for help examining definitions for terminology such as risk-sharing, enrollee, gain-sharing and other terms.
The Stark Law, enacted in 1989, aims to cut down on financial incentives impacting physician care decisions. It prohibits certain Medicare-payable referrals to entities they have a financial or familial relationship with, and stops such entities from filing Medicare claims for referred services, unless exempted under certain instances.
CMS says that it is issuing the RFI in response to comments it has received that raised concern that the Stark Law is impeding participation in healthcare delivery and payment reform efforts.
“We are particularly interested in your thoughts on issues that include, but are not limited to, the structure of arrangements between parties that participate in alternative payment models or other novel financial arrangements, the need for revisions or additions to exceptions to the physician self-referral law, and terminology related to alternative payment models and the physician self-referral law,” the CMS notice states.
In a statement submitted by AHA to the House Subcommittee on Health of the Committee on Ways and Means, the group urged Congress to step in to change Stark Law to allow hospitals and physicians to more closely work together.
“Congress should create a clear and comprehensive safe harbor under the anti-kickback law for arrangements designed to foster collaboration in the delivery of health care and incentivize and reward efficiencies and improvement in care,” AHA said. “In addition, the Stark Law should be reformed to focus exclusively on ownership arrangements. Compensation arrangements should be subject to oversight solely under the anti-kickback law.”
CMS Administrator Seema Verma appears to be sympathetic. In a Wednesday blog post, she said the Stark Law may be prohibiting value-based arrangements that HHS has made a priority to shift towards. Previously, Verma said that CMS was going to put together an inter-agency group to examine potential changes to the law.
“I think that Stark was developed a long time ago, and this gets to where we are going modernizing the program,” Verma told AHA President and CEO Rick Pollack during a webcast in January. “The payment systems and how we are operating is different, and we need to bring along some of those regulations and figure out what we can do. And I’m not sure that this is not going to require some congressional intervention as well.”
CMS is asking for comments to be submitted on the RFI by August 24.
The Trump administration released the inaugural Medicaid and CHIP “scorecard” on June 4, which is intended to reveal how states are performing under the programs.
The Centers for Medicare & Medicaid Services said the scorecard, which publicly posts state and federal Medicaid outcomes including hospital readmissions, is in an effort to increase transparency within the programs and offers “taxpayers insights into how their dollars are being spent and the impact those dollars have on health outcomes.”
More than 75 million people are covered under the programs, which cost taxpayers about $558 billion per year.
The initial version of the scorecard only includes measures which are voluntarily reported by states, including health system performance and state administrative accountability, as well as federally reported measures. The Centers for Medicare & Medicaid Services announced it was developing the scorecards late last year as part of a “turn the page” initiative.
“This first release is a huge step forward but it is only the first step,” CMS Administrator Seema Verma said in a press meeting. The agency plans to add additional reporting information in the future, including opioid-related and home-based, service-related quality measures.
She added that the agency might consider mandatory reporting, as well as new measures, in the future.
Verma, however, dodged questions when pressed about what the agency plans to do with the performance data and declined to rule out, for example, considering state performance in Medicaid waiver request evaluations.
The National Association of Medicaid Directors criticized (PDF) the scorecard, and said it was concerned about the accuracy of the data and what conclusions may drawn when making comparisons across states with significant structural differences.