Bill Dombi

New CMS Rules Hope to Curb Consumer Fraud! KFF Health News reports, “Unauthorized switching of Affordable Care Act plans appears to have tapered off in recent weeks based on an almost one-third drop in casework associated with consumer complaints, say federal regulators.” CMS “credits steps taken to thwart enrollment and switching problems that triggered more than 274,000 complaints this year through August.” But “now, the annual ACA open enrollment period that began Nov. 1 poses a real-world test: Will the changes curb fraud by rogue agents or brokerages without unduly slowing the process of enrolling or reducing the total number of sign-ups for 2025 coverage?” The article says “the clampdown could add complexity to enrollment and slow the process.”

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There is a bit of a black hole when it comes to the incoming Trump Administration and what they may do with Medicaid, which I why I think the more information and different analysis the better-and I find this piece interesting when looking at Colorado’s administrative spend. For a state that claims to run an efficient program, while staring at a close to $1 Billion state budget deficit, a 43% administrative share seems like something we should be able to improve.

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CMS’ “Year 2” IRA Guidance Concedes Agency Patient Engagement Has Been a Bust A number of patient groups have quietly expressed frustration with #CMS’ “listening sessions” on the #InflationReductionAct “fair price” negotiations. If you read CMS’ “year 2” guidance carefully, it effectively admits the patient complaints are real and legitimate. The Complaints: Patient groups sat on the sidelines in the litigation challenging the constitutionality of the IRA, at least in part, because they believed that they could shape IRA implementation through agency engagement. But some groups are now expressing frustration. They expected CMS to explain how it was approaching negotiation and the underlying evaluation of the selected drugs. With that context, they expected to be able to provide meaningful feedback to CMS’ plans and preliminary assessments. According to the groups I have spoken to, that is not how things have gone. CMS is tight-lipped—in “listen only” mode. Unclear what CMS is considering and how it sees the “value” question, “patient interaction” on the IRA has devolved into CMS and patient groups staring at each other blankly. Confirmation: When you read the “year 2” guidance, it confirms the patient complaints. Deploying diplomatic “regulatory speak”, CMS says it “intends to improve upon the design of the patient-focused listening sessions”. Note the reference to “listening sessions”—confirming the agency has been in “listen only” mode. CMS admits the need for change, saying it “is soliciting comments from interested parties on event format, scope, and logistics”; it then indicates it “is considering events where there is discussion among speakers and in which CMS may ask clarifying questions”. But even this proposal isn’t getting to the core of the problem—patient groups shouldn’t have to be expert mind readers regarding CMS’ intent based on a few interspersed “clarifying questions”. CMS offers some other alternatives, too: “CMS is also weighing different event formats, such as round table sessions on broader topics with a mix of speaker types (e.g., patients, providers, and health data experts) or focus groups on targeted topics with one speaker type (e.g., patients or caregivers)”. But all that doesn’t commit CMS to doing any speaking. Just that others—patients, providers, and “experts” will be asked to speak. Patient groups can’t react in, or to, a vacuum. No Time: The guidance concedes that they can’t fix the problem for “year 1”. After all, July 31, 2024 is the deadline for manufacturers of selected drug to accept or reject CMS's final MFP offer. Indeed, CMS acknowledges that its proposed changes in patient engagement will be effective only “for…price…year 2027”. So, in another words, at least for “year 1”, we are going to get “fair prices” that don’t reflect meaningful patient input. #drugdevelopment #drugpricing #Medicare #managedcare #rarediseases #patientsfirst #lifesciences

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We're excited to share that Jack Rollins, Director of Federal Policy at the National Association of Medicaid Directors (NAMD), recently participated in a high-profile panel discussion at the Medicaid Health Plans of America (MHPA) annual conference. The panel, titled "2024 CMS Regulatory Sprint: A Panel Discussion on the Medicaid Impacts of Recently Finalized Rulemaking," brought together key industry leaders to discuss the implications of recent CMS regulations on Medicaid programs. Jack shared the stage with distinguished experts: Andrea Bennett, Kate Paris and Nicolas Wilhelm. The discussion covered critical areas affecting Medicaid programs: ▪️ Implementation Challenges: Jack highlighted the complexities Medicaid programs face in managing multiple significant regulations simultaneously. ▪️ Collaboration Opportunities: He emphasized the potential for partnerships between Medicaid programs and managed care plans to support effective implementation. ▪️ Financing Changes: Jack provided an in-depth analysis of the financial implications in the new managed care rule. ▪️ Access Standards: Andrea Bennett offered insights on evolving access standards in managed care for Medicaid beneficiaries, including home- and community-based services and required use of secret shopper surveys. ▪️ Eligibility and Integration: Kate Paris discussed important changes to eligibility criteria and efforts to integrate dual-eligible beneficiaries. ▪️ IT Systems Impact: Nicolas Wilhelm underscored the significant technological implications these new rules have across Medicaid systems. NAMD continues to be at the forefront of Medicaid policy discussions, ensuring that state Medicaid directors' perspectives are heard and considered in national forums. We're grateful for the opportunity to contribute to this important dialogue and remain committed to fostering collaboration between Medicaid programs and managed care organizations.

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𝗜𝗻𝘀𝗶𝗴𝗵𝘁𝘀 𝗳𝗿𝗼𝗺 𝗘𝗹𝗶𝘇𝗮𝗯𝗲𝘁𝗵 𝗠𝗶𝘁𝗰𝗵𝗲𝗹𝗹, 𝗖𝗘𝗢 𝗮𝘁 𝗣𝘂𝗿𝗰𝗵𝗮𝘀𝗲𝗿 𝗕𝘂𝘀𝗶𝗻𝗲𝘀𝘀 𝗚𝗿𝗼𝘂𝗽 𝗼𝗻 𝗛𝗲𝗮𝗹𝘁𝗵 As the CEO of PBGH, Elizabeth has line of sight on $350 Billion of annual healthcare spending by member employers. She sees what's broken and where the opportunities exist. Elizabeth was recently interviewed on the Relentless Health Value Podcast by the always great Stacey Richter. Full episode is linked. Below are a just a few of the highlights... 𝗢𝗻 𝗗𝗶𝗿𝗲𝗰𝘁 𝗖𝗼𝗻𝘁𝗿𝗮𝗰𝘁𝗶𝗻𝗴... "[Employers] are going to be moving more and more into these direct relationships where they understand exactly what's going on. It's all visible and transparent and they have more control because one of the key changes under the CAA is they are now being held to an expert standard. They can't say, well, my consultant told me to do it or my health plan said it was a good idea. They are being held to an expert standard. They have to take this in house. They have to really dive into what is happening, where the money is going, what are the outcomes that they are getting, and they've got to own it. This is going to be a very different dynamic going forward. They are accountable and that accountability will be passed on to all of their partners." 𝗢𝗻 𝗧𝗿𝗮𝗻𝘀𝗽𝗮𝗿𝗲𝗻𝗰𝘆 𝗮𝗻𝗱 𝗖𝗼𝗻𝗳𝗹𝗶𝗰𝘁𝘀 𝗼𝗳 𝗜𝗻𝘁𝗲𝗿𝗲𝘀𝘁... "Brokers, consultants, health plans, PBMs, now with this newly transparent information, [employers] are realizing [vendors] were not always working on their behalf. They have said, well, my consultant advised this, I really trust them, I like them, I've known them for years. I'm paying them $20 to $30 PMPM so they should be giving me the best ideas and the best deals. And as this starts to come to light, it is really unnerving for the purchasers who thought they were doing the right thing. They trusted people who weren't aligned with their needs. So, we have [employer] members right now saying, I don't know who to get unconflicted, trusted guidance from." 𝗢𝗻 𝗗𝗼𝗰𝘁𝗼𝗿𝘀 𝗜𝗻𝘁𝗲𝗿𝗲𝘀𝘁𝗲𝗱 𝗶𝗻 𝗗𝗶𝗿𝗲𝗰𝘁 𝘁𝗼 𝗘𝗺𝗽𝗹𝗼𝘆𝗲𝗿 𝗥𝗲𝗹𝗮𝘁𝗶𝗼𝗻𝘀𝗵𝗶𝗽𝘀... I can't describe the number of times we are approached by providers who want to work directly with employers. Maybe not all of them, but there are a lot of them out there who are ready for that type of relationship.

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some key takeaways for telehealth in the MPFS. bottom line: some good things but congress needs to extend the flexibilities or CMS will be stuck.

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The key to the new guidance, in my opinion, is it solves the debate about whether a peer can supervise another peer. This clarification makes it possible for states to add peer-run organizations to their provider networks without stipulation that a clinician must be in a supervisory role. It's a big deal for workforce and recovery-oriented care.

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Carefully consider this proposal and tie through related to VBP transitions and AI tools.

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The Association of Healthcare Value Analysis Professionals (AHVAP) celebrates Elizabeth Eisenberg, MSN, RN, CVAHP from Scripps Health for commitment to excellence in the specialty of healthcare value analysis! Liz has signified this commitment by signing the official Association of Healthcare Value Analysis Professionals (AHVAP) healthcare value analysis pledge. To learn more about the Association of Healthcare Value Analysis Professionals (AHVAP) Commitment pledge: https://lnkd.in/gqEWPBue. #AHVAP #valuebasedcare #excellenceincare #valueanalysis

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#Chevron’s Demise and the #340B Program: What’s the Impact? This 340B Report article explores the question, with different sources providing very different takes. I’m quoted. My take? I think #Loper puts #HRSA in an even worse position—as difficult as that is to imagine. Both #drug #manufacturers and #coveredentities will be further encouraged to develop “self-help” solutions, more confident that, even if the Health Resources and Services Administration (HRSAgov), HHS tries to intervene, its enforcement efforts can be beaten back. Though it didn’t make the cut for this article, I also think a DIFFERENT #SupremeCourt case, #Jarkesy, spells the demise of HRSA’s ability to impose #civilmonetarypenalties (#CMPs). You can see my separate post exploring that issue. If I’m right, that, too, will encourage manufacturers to pursue more self-help solutions. Buckle up, people. #lifesciences #drugpricing #Protect340B #adlaw #administrativelaw #HHS

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Great defense of “private equity medicine” from former CMS administrator Leslie Norwalk. Though few clinicians fully understand it, PEM has become a popular bogeyman for a wide range of complaints about US health care. A few key takeaways: ·      All health care organizations require working capital. They should be judged on their behavior, rather than their source of capital. ·      Pushing health care organizations to more expensive sources of capital (e.g,, high interest loans) doesn’t serve anyone’s interests (except the banks). ·      The financial successes of private equity-backed companies accrue to everyone with a 401K or a mutual fund, not just a small number of wall street elites. ·      Reducing competition in health care (based on investment class) only accelerates market consolidation by integrated health systems, and the higher prices that come with it.

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CMS has again proposed a negative Medicare physician fee schedule update for 2025 with dangerous implications for beneficiary access to care. A 2.8% reduction to the conversion factor would be alarming in the best circumstances, but to propose doing so at a time when 92% of medical groups report increased operating costs and are otherwise struggling to remain financially viable is critically short-sighted. Medicare physician reimbursement is on a dire trajectory and these ongoing cuts continue to undermine the ability of medical practices to keep their doors open and function effectively — the need for comprehensive reform is paramount. MGMA is once again calling on Congress to pass the Strengthening Medicare for Patients and Providers Act to implement an annual inflation-based physician payment update tied to the Medicare Economic Index, and modernize Medicare’s antiquated budget neutrality policies by enacting the Provider Reimbursement Stability Act.” https://lnkd.in/edh_sS5t

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Another section of the #FinalRule has been released by #CMS aimed at enhancing #access to and #transparency of #Medicaid services, including #HCBS. This rule pairs with two other final rules published in April 2024 that focus on improving Medicaid #eligibility and access to Medicaid services. This rule is focused on an #FFS system, but the impact could involve changes to underlying FFS rates in base #data for #ratesetting and program #oversight in #MLTSS. Dianne Heffron and Meredith Mayer of Mercer US Government have conducted a review of the proposed and finalized rules. https://bit.ly/3QuGRXe

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This Thursday the Energy and Commerce Committee will hold a hearing on the Centers of Medicare and Medicaid Improvement (CMMI). Members of the Committee are expected to raise concerns and praise for the agencies' efforts to test and achieve savings in value-based payment models over the years. Since its inception in 2010, CMMI has tested many new payment models including bundled payments, multiple accountable care organization offerings, and the making care primary model. The agency continues to face challenges, such as finding ways to engage rural providers and solo or small physician specialty practices. Reps. Michelle Steel and Susie Lee and Sens. Markwayne Mullin, Kyrsten Sinema and Thom Tillis introduced the EASE Act (HR 7149 / S.4078) to encourage CMMI to create a new payment model for rural and underserved communities to reduce long wait times that many seniors and residents face in these communities when seeking care from a specialist. The bill was developed based on years of data collected and reviewed by OCHIN to help community health centers and rural hospitals improve care integration and create a new value-based payment model. While Congress looks for ways to improve outcomes and reduce costs; and medical schools continue to look for ways to grow the physician workforce, one pathway that would fill the needs of communities (especially rural areas) and prevent avoidable hospital admissions is the EASE Act which looks to utilize telehealth or e-consults to help our most vulnerable populations receive timely care

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So important to have state Medicaid and I/DD agencies collaborate to serve individuals with I/DD and their families! This rule highlights many of the important steps that states will need to take to further align and integrate care and services to meet self-advocate percent centered planning need and goals.

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The Double Standard that Protects #CMS, #MAPlans, and #PBMs In 2007, 17 years ago, Judge Saris, in the #AWP case, took #drug makers to the watershed for EXACTLY what #CMS, #MedicareAdvantage plans, commercial payers, and #PBMs do to patients EVERY day. What was bad for the goose (manufacturers) is perfectly fine for the many ganders out there. It’s time to throw a flag on this ridiculous double standard. The Case: I’m rereading In re: AWP for the law school course I’m teaching in the Fall, and, as happens each time I read it, my head explodes. Judge Saris was merciless in her criticism of how Average Wholesale Price, because it did not reflect rebates and other discounts, affected patients. “Disturbingly”, Saris wrote, “the patient was a vulnerable victim” of AWP as the means to peg both #reimbursements and #copays. This was so, she said, because the “inflated” AWPs that did reflect rebates and discounts, meant that “the Medicare patient was required to make a co-payment” that was itself “inflated”. With obvious disgust, she concluded her rant by intoning that ”manufacturers understood well the harmful impact that publishing inflated AWPs had on the elderly cancer patient” through the inflated copays they paid. I wish that some of Judge Saris’ outrage could now be turned towards #Congress, #HHS, #CMS, MA plans, and their #PBMs. All of these “ganders” are responsible for inflated Part D “negotiated prices” that impose the very same kind of inflated #costsharing “percentages” on vulnerable patients. The “ganders” know that—but they have enshrined inflated prices in Part D “negotiated price” and profit of off it. The same dynamic exists in the commercial insurance market. The ganders don’t care. #InflationReductionAct supporters will say: “Ah ha—but that is the beauty of the the IRA. It will mean truly negotiated prices where a net price will be the basis of the cost share.” Well, I fear that is doubly wrong. First, that only applies, if it applies at all, to #IRA “selected drugs”. So many patients using so very many other #drugs are necessarily subjected to exactly the kind of inflated copays that Judge Saris decried under the #PartD statute’s “negotiated price” deception. Second, I’m skeptical that patients even get the benefit, at least in the early years of the IRA, of “select drug” copay rates, which, on paper, will be lower. Why’s that? As I have said before, I’m not understanding why plans and PBMs won’t push patients using those select drugs to high list/high rebate alternatives—forcing patients to continue to pay the inflated copays Judge Saris found “[d]isturbing”. Lower copays on paper that aren’t actually accessed don’t mean nothin’. Why hasn’t 17 YEARS been sufficient to systematically fix this #patientharm? Senator Sanders, let’s stop the finger pointing exercise, and just fix this problem. #lifesciences #drugpricing #managedcare #healthcare

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Following the end of the COVID-19 public health emergency and Medicaid continuous coverage, many states have routed people who have lost Medicaid benefits to the Affordable Care Act (ACA) Marketplace. In the July issue of Health Affairs, Mark Meiselbach and colleagues at Johns Hopkins University explore county-level overlap in carriers and networks in Medicaid managed care and the Marketplace in 2021. They find significant variation in “the share of Medicaid managed care beneficiaries covered by carriers that offered ACA individual Marketplace plans in their county in 2021.” Also, on average, 52.1 percent of Medicaid managed care enrollees were enrolled by a carrier that also had a plan on the Marketplace in the same county.” Read the full paper: https://bit.ly/3Sw0LlA

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