Sellers Dorsey Digest

Federal Updates

News

National Committee for Quality Assurance (NCQA) Updates Healthcare Effectiveness Data and Information Set (HEDIS) Measures for 2025

• Health plans will be required to report on three new measures starting in 2025: rates of documenting mammogram results; following up with patients after abnormal breast cancer assessments; and controlling blood pressure for individuals with hypertension. NCQA also intends to remove four measures, including the pain assessment indicator and antidepressant medication management, and will make changes to current measures. The new measures aim to better support minority populations that are at a higher risk for missing follow-up care after diagnosis or treatment for a health issue. Additionally, among the changes in other measures, NCQA has opted to remove the data source reporting requirement for measures stratified by race and ethnicity for 2025 due to the administrative burden it places on health plans, though plans scored high on this measure in 2024, the first year it was included (Modern Healthcare, August 2).

Former HHS Secretaries Sebelius and Azar Advocate for Medicare Site-Neutral Policies

• Medicare site-neutral payment reforms could fund major policy priorities for either political party according to previous HHS secretaries speaking at an event hosted by the Paragon Health Institute. Previously, the Committee for a Responsible Federal Budget (Committee) estimated that site-neutral payment reforms could reduce Medicare spending by $153 billion and reduce cost sharing and premiums for beneficiaries by $94 billion. Additionally, the Committee stated that these reforms could reduce the federal budget deficit by $117 billion and disincentivize consolidation and facility fee bills. Former HHS Secretaries Sebelius and Azar wrote a joint opinion piece earlier this year in support of site-neutral requirements, though both expressed doubt that Congress would pass stand-alone legislation on the topic for several reasons including strong hospital provider opposition to site-neutral policies (Inside Health Policy, July 30; C-SPAN, July 29).

Health Resources and Services Administration (HRSA) Releases Top 10 Accomplishments for Health Centers

• The HRSA reviewed four years of health center outcomes in August 2024 and developed a top 10 achievements list. Health centers serve patients whether they have insurance or are able to pay for their care. The data found that 90% of patients seen had incomes of less than 200% federal poverty level (FPL). In 2023 alone, community health centers (CHCs) served over 31 million individuals, the highest number ever recorded and an increase of more than 2.2 million people since 2020. In addition to record patient growth, there has been an increase in school-based care, public housing outreach, and prenatal care expansions. These, coupled with increases in community health workers and healthcare training, cancer screening strides, HIV testing breakthroughs, mental health advancement, and clinical quality improvements round out the list of achievements CHCs have seen over the past four years (POLITICO Pro, August 6).

Federal Legislation

Senate Appropriations Bill Focused on SDOH and Rural Health Advances

• On August 1, the Senate Appropriations Committee advanced its FY2025 HHS spending bill on a bipartisan basis. The bill includes a focus on social determinants of health (SDOH) and funding for initiatives to diversify the healthcare workforce. Specifically, the health workforce budget for HRSA would increase from $1.40 billion to $1.41 billion and support programs at HRSA that improve the diversity of the healthcare workforce. The bill also includes $71 million for CDC public health workforce efforts including potential investment in fellowship and training programs for various types of professionals; $12.5 million for firearm injury and mortality prevention research; and a $21 million increase above the FY2024 enacted amount for various rural health initiatives (Inside Health Policy, August 5).

Federal Regulation and Guidance

CMS Releases Skilled Nursing Facility Prospective Payment System (SNF PPS) Final Rule

• On July 31, CMS released its SNF PPS final rule, which includes a 4.2% pay increase for skilled nursing facilities (SNF), amounting to $1.4 billion. Many stakeholders have expressed mixed feelings about the pay hike and their dissatisfaction with the additional civil monetary penalties (CMPs) tied to health and safety violations, arguing that CMPs take away from resources needed to improve support and address root causes that their residents need. The rule also adds four new SDOH reporting requirements to the SNF Quality Reporting Program for FY2027, including living situation, two food related measures and utilities (Inside Health Policy, August 1).

CMS Releases Final Rule on PPS, Finalizes TEAM Model

• On August 1, CMS released for public inspection its final rule, governing Medicare prospective payments for inpatient acute care hospitals and long term care hospitals. Inpatient acute care hospital payments will increase by 2.90% in FY2025, totaling a net $2.90 billion, up from the 2.60% originally proposed. Stakeholders remain critical, believing that the slight increase still does not adequately address rising costs and operational challenges. CMS also finalized the TEAM model, a five-year program aimed at improving care coordination during and after surgeries through bundled payments for five different surgical episodes, despite stakeholder concerns. Long term care hospitals will receive a 3% increase to the standard payment rate with payments expected to increase by $45 million. CMS will also implement a higher than normal increase in outlier thresholds to align with statutory requirements that payments are 8% of the total. Other proposals finalized in the rule are the extension of a 2020 policy to address wage index disparities affecting low-wage hospitals for an additional three years; a separate payment for small, independent hospitals to maintain and support their stock of essential medicines; an additional payment for housing insecurity; and an additional 200 residency positions funded by Medicare, half of which will be specifically for psychiatry or its subspecialties (Inside Health Policy, August 2).

State Updates

News

North Carolina Medicaid Beneficiaries Will Now Have Access to Free OTC Birth Control

• Starting August 8, the over-the-counter contraceptive Opill will be available at more than 300 local and retail pharmacies throughout North Carolina. The birth control pill will be available without a prescription and at no cost for Medicaid beneficiaries. The coverage was initiated in HB 96, a 2021 law that permits pharmacists to prescribe contraceptives in compliance with state regulations (MSN, August 1).

New Hampshire’s New Medicaid Program Expands Coverage for Community Re-entry for Incarcerated Individuals

• New Hampshire’s newly approved expansion of Medicaid services will allow the state to provide insurance coverage to incarcerated people who have a diagnosis of mental illness or substance use disorder (SUD) 45 days prior to their release. The new program, called Community Re-Entry, will allow incarcerated individuals to see community-based providers of mental health and SUD treatment twice within 45 days before leaving the justice system. During that period, individuals will also have access to two meetings with peer support specialists and up to 30 days of medication, if needed. Community Re-Entry is expected to take effect January 1, 2025, at state prisons with the future goal to bring the program to county jails eventually (The Keene Sentinel, August 4).

Steward Health Care to Lay Off 1,200 Employees Across Two Massachusetts Hospitals

• Steward Health Care (Steward), a physician led-healthcare network in Massachusetts, plans to lay off 1,200 employees across two hospitals. The decision comes after approval from a federal court to close its facilities on August 1, due to monetary loss and low patient volumes. Steward entered Chapter 11 Bankruptcy restructuring back in May and attempted to begin the sale process but has had a hard time finding a qualified buyer and fair bid for Carney Hospital and Nashoba Valley Medical Center, its lowest performing hospitals. Massachusetts Governor, Maura Healey, has assured state residents that she’s determined to aid in the facilitation of a smooth transition of patients and employees of the health network. Healey also spoke on the state’s statutory 120-day notice period for hospital closures, for which Steward’s plan falls short of, giving the state the ability to require the network to keep its facilities open if it chooses to ensure a proper transition timeline. A spokesperson for the health system, says that Steward intends to find roles for employees impacted by this layoff at Steward-run hospitals throughout the state (Healthcare Dive, August 5).

UnitedHealthcare Files Lawsuit Against New For-Profit HMO Ban in Minnesota

• UnitedHealthcare has filed a lawsuit challenging a new Minnesota state law set to become effective next year prohibiting for-profit HMOs from participating in its Medicaid managed care program. UnitedHealthcare alleges that the bill which included the provision violates the state Constitution’s single subject clause and claims that there was not adequate time to debate the for-profit HMO ban provisions within the bill. Minnesota previously banned for-profits from the state Medicaid managed care program until 2017. UnitedHealthcare manages care for about 32,000 Medicaid beneficiaries and has two additional health plans for dual eligible beneficiaries that will also be impacted by the for-profit HMO ban according to the lawsuit (Minnesota Star Tribune, August 5).

SPA and Waiver Approvals

Waivers

• 1115
  • Virginia
    • On July 26, Virginia submitted an extension request for its Building and Transforming Coverage, Services, and Supports for a Healthier Virginia (BTCSSHV) 1115 waiver to extend the substance use disorder program and continue coverage for former foster care youth (FFCY). The extension request also proposes to remove the High Needs Supports component of the waiver demonstration. The federal public comment period is open from August 5, 2024, through September 4, 2024.

SPAs

• Payment SPAs
  • District of Columbia (DC-24-0008, effective July 1, 2024): Updates the fee schedule rate for Medication Therapy Management (MTM) services.
  • Missouri (MO-23-0027, effective July 1, 2024): Adds incentive payments for targeted care management providers under the Division of Developmental Disabilities for completing Person Centered Thinking (PCT) and Fatal Five for Case Managers trainings.
  • Oregon (OR-24-0011, effective July 1, 2024): Increases the rate for air ambulance services to 80% of 2024 Medicare rates.

Private Sector Updates

News

Investigation Published by the Wall Street Journal Finds Unreliable Medicare Advantage Home Visit Diagnoses

• An investigation published by the Wall Street Journal (WSJ) found that insurers have made billions of dollars from diagnoses added to patients’ medical records during home visits for Medicare Advantage (MA) beneficiaries. The Medicare Payment and Advisory Commission (MPAC) has recommended insurers not be paid for diagnoses added during home visits. According to a CMS spokesperson, the agency is working to better audit insurers to verify diagnoses and also plans to eliminate some diagnoses that quality for additional payments (Becker’s Payer Issues, August 5).

Epic Introduces Individual Access Services (IAS), Making It Easier for Patients to Release Medical Records to Health and Wellness Apps

• In December, the Trusted Exchange Framework and Common Agreement (TEFCA) network became usable, making it easier to share patient data nationwide. TEFCA included six exchange purposes: individual access services, treatment, payment, healthcare operation, government benefits determination, and public health. Epic opted to build on the individual access services capability, allowing members to have secure access to their health data when and where they need it. Now, should patients choose to use health and wellness apps on their phones, their medical records can be linked as appropriate. This new capability is part of a significant effort by the healthcare sector to expand data-sharing and was accelerated by new health tech policies enacted by the federal government (Fierce Healthcare, August 5).

Humana Expected to Drop Unprofitable MA Plans

• Humana expects to lose a “few hundred thousand members” as the payer adjusts to changes in MA, according to its CFO. Additionally, the CEO stated that the company intends to exit MA plans that are not turning a profit with no viable plans to become profitable. Individuals enrolled in these plans may have access to alternative coverage through Humana. This comes as the company experiences reduced profits compared to the prior-year quarter and an increased medical loss ratio (MLR) of 89.50% (Fierce Healthcare, July 31).

JAMA Analysis Finds Healthcare Workers Have Higher Educational and Medical Debt

• On July 26, the JAMA Health Forum published an analysis that used 2018 through 2021 data from the U.S. Census Bureau’s Survey of Income and Program Participation and found that extensive training requirements and lower wages lead healthcare professionals and non-professionals to accrue more debt than workers in other industries. Specifically, physicians and registered nurses are more likely to have student loan debt while nursing aides and environmental services workers have more medical debt. Overall, almost 14% of healthcare workers have some form of medical debt compared to 11% of workers in other industries. Other industry workers are also less likely to have educational debt, with only 17% having student loan debt compared to 27% of healthcare professionals. Additionally, the analysis noted that debt impacts health outcomes, and healthcare workers with educational and medical debts are at risk for worse mental health issues and chronic physical conditions (Modern Healthcare, August 5).

Commonwealth Fund Survey Finds Few Know They Can Challenge Their Insurer

• On August 1, the Commonwealth Fund published a survey with findings demonstrating that fewer than half of people who receive an unexpected bill from their insurer will challenge the charges. The survey was taken by 4,803 adults who were asked if they had received an unexpected medical bill in the past year. The following are the top 5 findings of the survey:
  • Individuals with marketplace coverage were more likely to say they received an unexpected bill, while Medicaid beneficiaries were least likely to report receiving an unexpected bill.
  • Among those who did not challenge an unexpected bill, the most reported reason was they did not know they had the right to appeal.
  • Around 1 in 5 respondents reported they or a family member were denied coverage for a screening, procedure or medication recommended by their physician.
  • Of those who had a service denied by an insurer, 43% said they challenged the decision. Of those who did not challenge the denial, 45% said they weren’t sure they had the right to appeal.
  • Of the survey respondents who reported challenging denied care, 50% reported the service was ultimately approved by their insurer (Becker’s Payer Issues, August 2).

Sellers Dorsey Updates

New Blog: Addressing Health Equity for System-Involved Youth

• All children deserve access to quality healthcare including those involved with foster care and the juvenile justice system. For optimal health outcomes, healthcare, child welfare, and other important stakeholder agencies must operate in unison and work toward the same goal, enhancing quality, equity, and access for system-involved youth. In her latest blog, Sellers Dorsey Senior Director and Child and Family Well-Being expert, Katie Renner Olse, shares her insights on innovative approaches that can help advance health equity for children to live healthy and full lives. Click here for Katie’s blog.