President Trump Issues Executive Order on Affordable Care Act

In the first few days of his Administration, President Trump issued several Executive Orders.  Of particular note for the health care system and health centers was his first Executive Order, Minimizing the Economic Burden of the Patient Protection and Affordable Care Act Pending Repeal.  We have heard from many health center advocates who want to know how this action will affect their centers and their patients.

Let’s look at what Executive Orders are and how this will impact the health care environment.

What is an Executive Order?

By definition, an Executive Order is “a rule or order issued by the president to an executive branch of the government and having the force of law.”   These have been used by almost every President and are often a way for the President to use his or her authority to outline and implement policies, without Congressional approval.  They are also used symbolically to send a message about a President’s policy agenda or proclamations such as “National Health Center Week.”

What did this Executive Order do?         

First and foremost, while the Executive Order does technically carry the weight of the law, it cannot and did not repeal the Affordable Care Act.  That cannot be done without Congressional action.

The Executive Order stated that President Trump would like to see the “prompt repeal of the Affordable Care Act” and instructed Federal agencies, such as the Department of Health and Human Services, to reduce the “economic burden” of the ACA while it waits for Congressional action.   Specifically, the Executive Order instructed agencies to:

  • “take all actions consistent with law to minimize the unwarranted economic and economic burdens of the Act”
  • “waive defer, or grant exemptions from ACA requirements” and
  • grant states “greater flexibility in implementing health care programs”

The Order also states that agencies must follow proper rule-making procedure to change any regulations that are already in effect.

What remains to be seen by all in Washington and across the country, is how the Administration follows through on these steps and what impact it will have on the health care environment

One complication is timing – Representative Tom Price, the Administration’s nominee for Secretary of Health and Human Services, and Seema Verma, the nominee for Administrator of the Centers for Medicare and Medicaid Services, are both awaiting confirmation before they can assume their new roles.  Further, it is still unclear how the Executive Order will impact Congress’ work on repealing and replacing the Affordable Care Act, including whether it might make them feel that they can take more time to decide upon next steps.  One concern mentioned is that the new Administration might immediately stop enforcing the tax penalty behind the individual mandate, but during his confirmation hearing yesterday, Representative Price stated that he would not take administrative action to undermine the mandate in advance of Congress repealing and replacing the law.

Feel free to stay in touch with NACHC about any questions or concerns you might have about Executive Orders as we all watch closely to see what impact this will have at the national, state and local level.

2016: A Regulatory Year in Review

NACHC’s Regulatory Affairs Department has seen a lot of action over the last year, as the current Administration is wrapping up its remaining days in Washington, DC and has been working to propose and finalize a wide range of policy and administrative activities.

Highlights have included:

CMS:

  • The final rule governing Medicaid Managed Care Plans: This is the first regulations on Medicaid Managed Care that CMS has finalized in years and covers policies guiding all areas of Medicaid Managed Care, including contract reviews and setting rates.  There were several items of importance for FQHCs including:
    • Clarifying rules about health center’s participation in value based payment arrangements in Medicaid Managed Care
    • Clarifying that incentive payments must be in addition to PPS, not in place of.
  • CMS State Health Officials Letter issued on PPS wrap around payments in Medicaid Managed Care
    • States may choose to “delegate” wrap around payments, only if the arrangement meets all of the requirements of an Alternative Payment Methodology (APM).
  • Medicare Physician Fee Schedule Final Rule: While this rule largely does not impact FQHC Medicare payments, it included several important provisions for FQHCs:
    • Implementation of an FQHC- specific market basket to be used as an annual inflation update for the Medicare PPS, in place of the Medicare Economic Index (MEI). This goes into effect January 2017
    • Easing the requirements for FQHCs to bill for chronic care management
  • The final rule on MACRA implementation: This is a major revision of the Medicare Part B payment system, which includes implementation of MIPS and Advanced Alternative Payment Methodologies (APM).  FQHC Medicare payment is not impacted by this new rule, but health centers are encouraged to voluntarily report these measures to demonstrate the quality of care they are providing to Medicare beneficiaries.
  • Process for enrolling new sites in Medicare: We continue to ask CMS to streamline the process for new FQHC sites to enroll in Medicare, and recently learned that they have taken steps to do so, by establishing a standardized – and much simpler – protocol for Regional Office reviews.  More information on this coming soon.

HRSA

  • Draft Health Center Compliance Manual In August, BPHC published its long-awaited draft of the Compliance Manual, which consolidates many existing PINs and PALs into a single resource with information about requirements and how to demonstrate compliance.  NACHC was supportive of BPHC’s efforts, and submitted extensive comments about how the document could be further strengthened and clarified.
  • Further changes proposed for auto-HPSA scoring: In July, HRSA’s Bureau of Health Workforce proposed changes intended to standardize and automate the process for determining auto-HPSA scores.  Among other changes, they propose to :
    • measure poverty among a health center’s patient population by using Census data for those areas located 30-minutes or less from each site
    • assign scores at the site level rather than the organizational level.

NACHC has significant concerns about both of these proposals, as discussed in our comments.  We have met with BHW staff on several occasions to discuss our concerns and are currently participating in a Workgroup to address them.  We also continue to monitor other developments impacting shortage designations, including issues around provider data.

  • No new 340B policies – but lots of questions: HRSA’s Office of Pharmacy Affairs published two proposed regulations around 340B (both on relatively minor issues), but to date neither has been finalized.  Most notably, the draft mega-guidance – published in August 2015 – has not been finalized.  In addition, CMS’s final rule on Medicaid managed care provided no clarity around the relationship between Medicaid managed care and 340B.  Nonetheless, the scrutiny on 340B continues to intensify, and health centers are finding it increasingly difficult to retain savings associated with 340B.  Also, NACHC continues to work with the 340B office to streamline the process for new health center sites and pharmacies to become eligible for 340B.
  • FTCA: NACHC staff have met with and written to HRSA leadership requesting clarity and/or a streamlined process to confirm that FTCA covers specific types of services provided to non-patients (e.g., writing prescriptions for Naloxone for patients to give to family members) and telemedicine “touches.”  We are waiting for an official response from HRSA.

 

SAMHSA

  • Increasing how many patients a provider can treat with Medication Assisted Treatment (MAT): As many of you are dealing with the opioid epidemic in your communities, the Substance Abuse and Mental Health Services Administration (SAMHSA) increased the cap on the number of patients that a physician can treat using MAT, up from 100 to 275.   In addition, it is working on additional information on the implementation of the Comprehensive Recovery and Addiction Act, which would allow physicians assistants and nurse practitioners to use MAT.
  • SAMSHA is seeking to make improvements in privacy policies for patients seeking treatment for substance use disorder (42 CFR Part 2). To date, it has only released a proposed rule (see NACHC comments) that would update these regulations to consider improvements in health care to more appropriately integrate patient information, while maintaining appropriate privacy regulations.

It has been a busy, but important year in Regulatory Affairs and with a new Administration coming into office, we expect 2017 to be just the same.  We want to thank you all for your time and attention in helping to formulate NACHC’s position on these rules and regulations and look forward to working with you in the New Year.   And don’t forget – you can always find up to date information and resources on our Regulatory Affairs site.

 

Happy Holidays!

Colleen and Susan

 

CurrentCare: Rhode Island’s Health Information Exchange

A special thanks to Laura Adams, President & CEO of the Rhode Island Quality Institute; Chuck Jones, President & CEO of Thundermist Health Center; Matthew Roman, Chief Operating Officer of Thundermist Health Center; and Jane Hayward, CEO of the Rhode Island Health Center Association for their contributions to this post. 

 

By Thao-Chi Tran

Health information exchanges (HIEs) are entities that facilitate the access and sharing of patient information electronically, and are emerging as key tools in the drive to achieve the Triple Aim (improving patient experience and population health while reducing system costs). States have been active in developing and facilitating HIEs through various federal grants and state legislation. Since the passage of Rhode Island Health Information Exchange Act of 2008, the state has been working to improve health care coordination through its statewide HIE known as CurrentCare.

CurrentCare in Rhode Island

CurrentCare is owned and operated by the Rhode Island Quality Institute (RIQI), a 501(c)3, and the state-designated Regional Health Information Organization. RIQI’s board consists of CEO-level leaders representing health plans, hospitals, physician groups, health centers, consumers, employers and state government.  In 2015, over 490,000 patients were enrolled in CurrentCare, and now even more patients are being served through HIPAA-compliant agreements to share data among providers.  Patients are enrolled through their physician offices, at hospitals, free-standing labs, long-term care facilities, etc.  Enrollment is voluntary and allows health information including medication histories, laboratory results, diagnostic reports and clinical summaries to be shared and accessed electronically among providers.   Rhode Island was the first statewide HIE in the nation to upload alcohol and substance abuse treatment information from 42 CFR Part 2 mental health providers.  A provider must have a treating relationship with the patient to access the patient’s health information. Health centers in particular have played a major role in educating patients about CurrentCare and enrolling them into the HIE.

CurrentCare was implemented with federal grant funds from the HITECH Act. To ensure the sustainability of CurrentCare, RIQI and its partners in state government and the private sector implemented a voluntary contribution where multiple entities agreed to contribute to a $1 per member per month (PMPM) operate and scale the system.   The $1 PMPM is based on the number of “covered lives” for whom each of the entities provides health insurance. These payers include Medicaid, the State as an employer, all major commercial insurers in the state, and self-funded employers, such as CVS, Brown University, AAA and Amica.  RIQI also has other funding streams from fee-based products and services and grants.

Today, RIQI is piloting a dashboard that alerts primary care providers, in real time, of patients’ emergency department and hospital admissions and discharges. The dashboard enables them to immediately see the reason for the admission and the pattern of admissions, and to view clinical summary reports as well as identify the hospital system in which their patients were admitted. The pilot group has observed lower hospital readmission and emergency department return rates compared to providers in CurrentCare that lack the dashboard. This function exhibits the potential to improve care coordination between hospitals and primary care practices and to reduce health care costs.   Analysis of the data for the basic alerting function shows an approximate 12% relative reduction in hospital readmissions and a 22% relative reduction in ED visits for patients whose providers receive alerts versus patients whose providers do not, a trend that is consistent over more than 18 months.

The Health Center Experience

Thundermist, a health center serving nearly 43,000 patients in Rhode Island, is piloting the dashboard and is also using CurrentCare as a resource to gather information on patients that do not meet quality of care measures. Through the state HIE, staff have been able to find patients’ prior health screenings and tests that are not recorded in the health center’s electronic health record (EHR). This allows Thundermist to prevent duplication of health care services and improve patient care and outcomes without having to invest significant amounts of time in tracking down this information.[1] This has also has implications for the health center’s performance measures.  The next phase for CurrentCare includes levering its analytics capabilities for prediction and early intervention, and developing more real-time care summaries served up inside of the clinician workflow based on clinician-derived preferences.

Until a basic level of interoperability is reached, the use of HIEs will still need to be complemented by separate access to various existing electronic health records. The formatting of clinical reports retrieved from a HIE may not include specific details that certain providers need to treat patients. The inconsistency of EHR types utilized by different health care settings and the lack of technology that would allow different EHRs to communicate are other major barriers to exchanging health information electronically.  While this is exactly the challenge that CurrentCare solves by collecting, normalizing, organizing, and storing the data regardless of the EHR platform from which it originated, not all states have a CurrentCare-like infrastructure in place.

Despite the challenges, there are opportunities for health centers to improve patient outcomes as well as performance. By participating in a HIE a health center is able build stronger relationships with other providers and better understand and respond to their patients’ experiences beyond the health center’s walls. Although states and providers may assume additional financial costs to operate and engage in HIEs, patients’ health care quality is increasing as a result. In addition, better care management via HIEs can potentially reduce health care costs. HIEs, such as CurrentCare, have made noteworthy strides in the field of health information technology.  As HIEs develop and interoperability increases, there will be more opportunities to improve care coordination and effectively address the needs of patients.

Learn More About HIEs

To learn more about the different types of HIE’s and the challenges and barriers associated with each, checkout NACHC’s new publication Health Information Exchange: Opportunities and Challenges for Health Centers on MyNACHC.

 

[1] Providers in CurrentCare can send data to the HIE, but do not receive data other than alerts, and have to access various health systems to retrieve certain health information.

Are you an Essential Community Provider?

Are you on the list?

CMS has released its draft 2018 Essential Community Provider list, the list used by Qualified Health Plans in the Marketplace to meet the ECP contracting requirement.    Take a look at the announcement below to find out how to determine if you are on the list and if not, how to complete the petition process to get your name on the list.  Please note, if you want to submit a petition, you must do so before the October 15, 2016 deadline.  Any questions should be directed to essentialcommunityproviders@cms.hhs.gov.

 

Announcement of Public Release of the Draft HHS Essential Community Provider (ECP) List and Petition for the 2018 Benefit Year:

 

For the Marketplace’s 2018 benefit year, the Centers for Medicare & Medicaid Services (CMS) has released the updated Essential Community Provider (ECP) Petition to collect more complete data from providers who qualify as an ECP and wish to appear on CMS’s ECP list for the 2018 benefit year.  The ECP petition is a web-based questionnaire that is available at the following link: https://data.healthcare.gov/cciio/ecp_petition

 

CMS releases an updated list of ECPs on an annual basis to assist issuers in complying with the requirements under 45 CFR 156.235.  Under that regulation, ECPs are defined as health care providers who serve predominantly low-income, medically underserved individuals.  They include health care providers defined in section 340B(a)(4) of the Public Health Service (PHS) Act; entities described in section 1927(c)(1)(D)(i)(IV) of the Social Security Act (SSA); State-owned family planning service sites, governmental family planning service sites, not-for-profit family planning service sites that do not receive Federal funding under special programs, including under Title X of the PHS Act; or Indian health care providers. 

 

The Draft HHS ECP list for the 2018 benefit year is embedded within ECP petition and can be viewed by clicking the button “Check to see if you are on the list” under question 6 of the petition located at https://data.healthcare.gov/cciio/ecp_petition.  Providers included on the draft HHS ECP list for the benefit year 2018 reflect those providers who submitted an ECP petition between December 9, 2015 and July 11, 2016 and were approved by CMS for inclusion on the ECP list through the ECP petition review process.  CMS has published this draft HHS list of ECPs to provide entities on the list an opportunity through the petition process to notify CMS of any necessary corrections and missing provider data.  In addition, CMS solicits providers who do not yet appear on the HHS ECP list but believe they satisfy the ECP inclusion criteria, as outlined in the ECP petition, to petition to be added to the list. 

 

CMS is accepting petitions from qualified providers until 11:59 p.m. ET on October 15, 2016, for data corrections and additions to be considered for the 2018 ECP List.

 

Providers who need technical assistance with the ECP petition or may have general questions may receive assistance by emailing their question(s) to the following mailbox: EssentialCommunityProviders@cms.hhs.gov.  Providers should write in the subject line of the email the following: “Comments on ECP Petition.”  

 

 

MEET NACHC’S FEDERAL AND REGULATORY AFFAIRS SUMMER INTERNS

Joshua Fleming, MPP Candidate, University of Michigan – Ann Arbor, Contact Info: jfleming@nachc.org

Joshua joins NACHC as a graduate student from the Gerald R. Ford School of Public Policy at the University of Michigan. His primary interests include health care finance, Medicaid managed care and political advocacy. Born and raised in Bay City, Michigan, Joshua has blended his two primary passions: political engagement and health policy into one while working as a Field Organizer for the Michigan Democratic Partjoshy, a Constituent Services Intern for the Michigan House of Representatives and a Public Health Services Intern at a county health department. Upon obtaining his BA in Public Administration, Joshua enlisted as a HIV/AIDS Educator in the Peace Corps, serving in Swaziland where he engaged in efforts to prevent and mitigate the spread of HIV in sub-Saharan Africa and enhance financial literacy and micro-loan opportunities for those in his community. At the University of Michigan, Joshua serves as Managing Editor of the Michigan Journal of Public Affairs and as a Rackham Merit Fellow, a prestigious fellowship for graduate students who have records of superior academic achievement and come from traditionally underrepresented backgrounds in their respective academic disciplines. After graduating next May, Joshua plans to pursue work in the federal government or a think-tank, helping to formulate and analyze proposals to expand health care access while controlling costs.

Doron Shore, BS Canididate, American University, Contact Info: dshore@nachc.org

Doron Shore is an intern in the Regulatory and Federal Affairs departments from Ardmore, Pennsylvania, a doronPhiladelphia suburb. Currently, Doron is a rising senior at American University pursuing a B. S. in Public Health. In the fall semester of 2015, Doron attended the American University Public Health Abroad Program in Nairobi, Kenya. There, he took public health classes and interned at a school in Kibera, which is regularly considered the largest urban slum in Africa. While in Kenya, he also conducted a public health survey focusing on malaria with his classmates. Returning from his amazing experience abroad, Doron recognized that we do not need to travel half way around the world to a developing country to witness communities struggling with public health issues. As an intern with regulatory and federal affairs departments, he is committed to learning more about careers in the public health field and how community health centers are making people across America healthier.