Positive Outcomes for Medicaid Expansion Demonstration in Cleveland

By Kersten Lausch

Research demonstrating the value of Medicaid expansion continues to grow. The following is an overview of a recent study that examined how the MetroHealth Care Plus program in Cuyahoga County, Ohio impacted patient care. [Note: Unfortunately, access to the full text of Cebul et al.’s article in Health Affairs requires paid subscription or purchase.]

What is Care Plus?
In February 2013, prior to Ohio’s decision to expand Medicaid, CMS approved a Medicaid waiver that enabled a county-owned hospital (MetroHealth System) and two local FQHCs (Care Alliance and Neighborhood Family Practice) in Cuyahoga County to offer Medicaid-like coverage to residents (ages 18-64) with incomes at or below 133 percent of the federal poverty line. To finance Care Plus, the hospital used the $36 million annual subsidy it receives from Cuyahoga County taxpayers and drew down enhanced federal Medicaid matching dollars.

Over the next 11 months, Care Plus provided coverage to 28,294 patients who were able to receive benefits without co-pays through the program’s defined network, which included the three partner organizations and other community providers (e.g., community mental health centers). Care Plus patients formally transitioned to Ohio’s expanded Medicaid program on January 1, 2014.

What did the study find?
Between 2012 and 2013, Cebul and colleagues found that patients enrolled in Care Plus had better care and health outcomes than those who remained uninsured. For example, the researchers found that, compared to those who were continuously uninsured, Care Plus patients with diabetes improved over 13 percentage points on the diabetes composite standard (a combined metric for assessing quality of diabetes care).

The researchers also found that the total cost of care for patients enrolled in Care Plus was 28.7 percent below the budget cap set by CMS for the program to remain budget neutral.

What supported these outcomes?
In addition to giving patients access to care, Cebul et al. concluded that the program’s defined provider network and delivery system innovations helped to support the quality and cost outcomes. Specifically, all three partner organizations:

  • Used the same electronic health records platform;
  • Had patient-centered medical home-recognized primary care practices; and
  • Publicly reported performance in a regional health improvement collaborative.

The article by Cebul and colleagues was published in July’s Health Affairs issue, which was dedicated to the 50th anniversary of Medicaid. Several articles within the issue feature the substantial role played by health centers. For more information, read our post “Health Affairs’ July Issue Commemorating 50 Years of Medicaid Highlights Significant Role Played by Health Centers.”

Health Affairs’ July Issue Commemorating 50 Years of Medicaid Highlights Significant Role Played by Health Centers

By Tracy Sexton

July’s Health Affairs issue is dedicated to the 50th anniversary of Medicaid. Unsurprisingly, several articles within this issue feature the substantial role played by health centers, another program celebrating 50 years of service, in providing care to a significant portion of the Medicaid population. In Shin and colleagues’ article discussing the interdependence of the health center and Medicaid programs, the authors review the rich history of the Medicaid-health center relationship while stressing the importance of a continued and evolving partnership. [Note: Unfortunately, access to the full text of Shi et al.’s article requires paid subscription or purchase.]

Authors explain that Medicaid and health centers work together to accomplish a key goal – that is, improving access to quality primary care for otherwise un-served populations – by providing needed sources of primary care and the financing to support and expand it. The article notes that both Medicaid and federal health center grants have helped make health center growth possible by sustaining provided services. Health centers can help Medicaid achieve its growing focus on population health by, for example, serving complex patients with complicated health needs, particularly when other providers are still limiting their participation in Medicaid or not accepting Medicaid patients at all. In addition, health centers provide continuous care even when patients experience interruptions in Medicaid coverage. This is especially important for those with chronic conditions who require consistent and reliable care. Finally, given the substantial reach into underserved communities nationally, leveraging Medicaid-health center partnerships can reach uninsured and other patient populations by ensuring interventions reach all patients. Looking forward, authors state that a more “deliberate” and “purposeful” collaboration between Medicaid and health centers can accelerate advancements in quality and efficiency by sustainably financing accessible health care for underserved patients.

Just as health centers serve a substantial number of patients with Medicaid, they also serve a high proportion—about twice the national rate—of patients with both Medicaid and Medicare. These so-called “dual eligible” patients tend to be highly complex, in poverty, members of racial/ethnic groups, suffer from multiple chronic conditions, and have high rates of preventable hospitalizations and emergency department (ED) visits. Wright and colleagues explore the link between use of health centers and both hospitalizations and ED visits for ambulatory care sensitive conditions among those patients enrolled as dual eligibles. Specifically, they examine rates of these kinds of visits and hospitalizations among dual eligible patients living in Primary Care Service Areas containing a health center, comparing those who sought care at a health center with those who did not. This was done by collecting and analyzing fee-for-service Medicare Part A and Medicare Part B claims data from 2008-2010. Individuals were considered health center users if they had visited a health center one time or more within a year. The authors find that Black and Hispanic dual-eligible health center patients are less likely to be hospitalized for ambulatory-care sensitive conditions when compared to those not seeking care at a health center. However, the same trend is not seen for emergency department visits. Therefore, the authors conclude that strong evidence exists to suggest that health centers help reduce racial and ethnic disparities in hospitalizations for ambulatory care-sensitive conditions among dual-eligible patients and that further efforts are needed to reduce potentially avoidable emergency department visits.

Reading these articles, it is evident that Medicaid and health centers have a rich history that has dramatically and positively altered the way low income individuals are able to receive care. By eliminating barriers to access and removing health disparities at a feasible cost of service, health centers and the Medicaid program have demonstrated a powerful collaboration which must not only continue, but strengthen and evolve over the next 50 years.

NACHC submits Medicaid Managed Care Comments

On July 27, NACHC submitted our final comments on the CMS Proposed Rule on Medicaid Managed Care. We encourage you to review our  final comments in full. We would like to thank everyone who provided feedback on our draft comments, with a special thanks to those who submitted comments to CMS on behalf of their organization.

NACHC is also currently reviewing several other Proposed Rules with upcoming comment deadlines listed below. Please be on the lookout for more information on our draft comments as the comment deadlines approach.

  • CMS Notice for Comment on the new Essential Community Provider Petition Process (comments due at www.regulations.gov by August 4, 2015) 
  • HRSA’s Notice of Proposed Rulemaking on 340B Ceiling Price & Civil Monetary Penalties (comments due at www.regulations.gov by August 17, 2015)
  • CMS Notice of Proposed Rulemaking on Medicare Physician Fee Schedule (comments due at www.regulations.gov by September 8, 2015)

As always, we encourage you to review these rules and our draft comments when they are made available. We also encourage you to submit your own comments reflecting your state or local experience. Please feel free to contact Colleen Meiman (cmeiman@nachc.org) should you have any questions about these rules or any other issues for the Regulatory Affairs Department.

Request for Comments on CMS Medicaid Managed Care NPRM

NACHC is pleased to share our draft comments on the recent CMS proposed rule on Medicaid managed care. This rule is the first time since 2002 that CMS has proposed to update the rules governing Medicaid Managed Care Organizations (MCOs.)  As such, it touches on a broad range of issues of direct relevance to health centers and their patients, including but not limited to:

  • The intersection of the 340 program and Medicaid managed care
  • Network adequacy standards for MCOs
  • Whether FQHCs can receive state funding for providing outreach & enrollment assistance to Medicaid MCO enrollees.
  • States’ responsibility to make wrap-around payments directly to FQHCs
  • Credentialing requirements under MCOs
  • Value-based purchasing initiatives
  • Beneficiary protections

Before submitting these comments to CMS, we welcome your comments on our draft. To ensure NACHC has adequate time to consider your input, please send any feedback to Colleen Meiman (cmeiman@nachc.org), Director of Regulatory Affairs, by Monday July 20.

**Note that the 3-4 highlighted items indicate areas where we are still seeking information ad/or finalizing our recommendations.

In addition, we strongly encourage your organization to submit your own comments on this proposed regulation. Please feel free to adapt or copy the language included in NACHC’s comments to suit your needs; we also encourage you to add examples based on your own experiences.  Note that your comments must be submitted no later than 5 p.m. ET on July 27.  You can submit them electronically by following the “Submit a comment” instructions at http://www.regulations.gov.

If you have any further questions, please contact Colleen Meiman, Director of Regulatory Affairs at cmeiman@nachc.org.

Victory for the ACA: Moving Forward after King v. Burwell

King v. Burwell — Image Credit Ted Eytan

The King v. Burwell Supreme Court decision on Thursday marked a huge victory for ACA proponents. In a 6 -3 ruling, SCOTUS upheld health insurance premiums for eligible individuals in all states—regardless of whether their marketplaces were state or federally-established. The decision was met with both relief and applause by President Obama’s administration. With Congress still without a contingency plan as of Thursday morning, the ruling in favor of Burwell likely saved policymakers from months of legislative chaos, while also preserving health insurance for over 6 million Americans.

With the wait finally over, we are now left to consider what the Court’s recent decision means for the ACA moving forward. This is the last in a series of posts that have examined the case’s details and possible implications leading up to last Thursday’s big decision.

Breaking down the majority opinion

Chief Justice Roberts, joined by Justices Kennedy, Breyer, Ginsburg, Kagan, and Sotomayor, read the opinion confirming the legality of health insurance subsidies across all 50 states. Prior to the decision, many believed the ruling would be decided on the Chevron rule—or namely whether the federal agency (IRS in this case) had made a reasonable interpretation of the statute at hand. Instead, the Court announced the IRS was no health insurance expert and the Court, rather than the IRS, should determine the “correct reading” of the law.

The Court concluded the phrase underlying the whole case, “established by a state,” was indeed ambiguous. However, when read in relation to the ACA as a whole, the Court determined the underlying purpose of the law relied too heavily on the availability of subsidies across all marketplaces for “marketplaces” to be interpreted as solely those “established by a state.” In the majority’s opinion, limiting subsidies to only state-established marketplaces would undermine the entire healthcare system—something Congress would never have intended to do. Chief Justice Roberts synthesized these ideas in his concluding statement:

Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them. If at all possible, we must interpret the Act in a way that is consistent with the former, and avoids the latter.

Understanding the dissent

In a heated dissent, Justice Scalia, on behalf of himself, Justice Thomas, and Justice Alito, declared the Court’s majority decision as “interpretive jiggery-pokery” that omits the plain meaning interpretation of “established by a state.” Justice Scalia accuses the majority of once again rewriting the ACA to save it from its demise. As stated by Justice Scalia, the “opinion changes the usual rules of statutory interpretation for the sake of the Affordable Care Act. That, alas, is not a novelty.”

The dissent goes on to dismiss each of the points presented in the majority opinion; however, the opinions of Justice Scalia are perhaps best be summed up by his new nickname for the ACA: “SCOTUScare.”

What’s next for the ACA?

While the King v. Burwell ruling does not safeguard the ACA from additional legal attacks, it sets the precedent that the ACA is here to stay—at least through the end of President Obama’s second term. The ruling supports Congress’s intent to improve, not hurt, insurance marketplaces with the ACA—making similar court litigation unlikely in the future.

Although some fear the decision for Burwell may discourage states from establishing their own State-based marketplaces, HHS Secretary Burwell has vowed to continue to offer assistance to states wishing to shift towards a State-based marketplace. Burwell admits the administration still “has work to do” to make the ACA better, but remains optimistic on the administration’s chance to “build on the progress” the ACA has made. Following the decision, Burwell announced several new campaigns to improve the law, including a push to expand Medicaid in non-expansion states and reforms to payment systems to reflect quality not quantity of care.

Though the complete repeal of the ACA is unlikely at this point, the topic is almost guaranteed to resurface during the 2016 presidential campaign season. Although the ACA could take a beating during the upcoming race, President Obama remains confident in the future of his signature legislation. In a press conference on Thursday, President Obama heralded the decision remarking that “after nearly a century of talk, decades of trying, a year of bipartisan debate, we finally declared that in America, health care is not a privilege for a few but a right for all.” In his own words, it is becoming increasing clearer that “the Affordable Care Act is here to stay.”