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Daily Archives: January 26, 2015

Enrollees In Pa.’s Medicaid Expansion Locked Out Of Substance Abuse Services

A year before Healthy Pennsylvania’s rollout, Michael Harle, president and CEO of Gaudenzia, the drug and alcohol treatment center, was assured by top state Medicaid officials his clients would not see their health insurance change.

Harle has been around. So he asked for that guarantee in writing. He didn’t get it.

A high-placed executive “promised me that they would get it right,” he said.

But “they” didn’t.

PennsylvaniaAfter Medicaid recipients began shifting to the new program on Dec. 1, “all hell broke loose,” Harle said. A glitch in the system covered his clients and thousands of people across Pennsylvania in need of substance-abuse and mental-health services with private insurance instead of Healthy Plus, the new program for the medically frail.

The problem is most of those private plans don’t offer addiction and mental-health treatment, and those that do have less robust benefits than Healthy Plus.

The result is thousands of people have been locked out of treatment centers, risking their lives, said Deb Beck, president of the Drug and Alcohol Service Providers Organization of Pennsylvania, a statewide coalition of treatment programs.

“The problem with addiction is you can’t wait,” she said. “Alcohol and other addictions are progressive and are always fatal illnesses if they go untreated. You can’t wait.”

This copyrighted story comes from The Philadelphia Inquirer, produced in partnership with KHN. All rights reserved.PhiladelphiaInquirer213.jpg

In a letter sent two weeks ago to behavioral health providers, the Department of Human Services said it was working with drug and alcohol and mental-health groups to prevent interruption of service.

People shut out of care often end up in emergency rooms, jail, or on the street, Harle said. Some die. In 2011, Pennsylvania recorded more than 2,000 drug overdose deaths, ranking it seventh nationally, according to the federal government.

The lockout is also a financial burden on providers, especially smaller ones. How much of a burden is still unknown since many providers bill Medicaid a month or two after services are given.

“I suspect that, particularly for small outpatient programs that haven’t sent their bills in yet, it could be a shock,” Beck said.

Last year, Pennsylvania treated ።,000 people for substance-abuse disorders in a variety of settings. The larger programs appear to be continuing to treat patients without payments, Beck said. But the residential rehabilitation programs that serve the poor have been affected the most. They serveಙ,000 people a year, and December admissions were down 10 percent to 25 percent, Beck said.

At Gaudenzia, which has 900 beds in Southeastern Pennsylvania, December admissions fell by 247.

“They really botched this up,” Harle said.

The program was a signature health effort of former Gov. Tom Corbett, who had long resisted Medicaid expansion because he deemed it unsustainable. After losing his re-election bid in November, Corbett pushed a narrower version of expansion, called Healthy Pennsylvania, which cut benefits for all Medicaid recipients beginning Jan 1.

Problems began surfacing in the second week of December. That’s when Beck started getting calls from programs about their Medicaid clients. She spoke to state officials who told her there was a glitch in the system they were trying to figure out.

“I’m guessing that whoever did the data entry didn’t understand the addiction-treatment system and how it related to Medicaid,” Beck said. “And the misunderstanding became practice.”

When treatment programs realized what was happening, they had a choice. They could stop treating patients who didn’t have Medicaid coverage or continuing helping their clients. Harle and Gaudenzia decided to keep treating people.

“We get them treated and fight about it another day,” Harle said. “What is most important to us is the client.”

Gov. Wolf, who was sworn in last week, has pledged to scrap Healthy Pennsylvania for a more traditional Medicaid expansion program.

Estelle Richman, head of Wolf’s special transition team focused on human services, said the first thing on Secretary of Human Services Theodore Dallas’ to-do list was to “fix the drug and alcohol problem.”

“At the same time, we have to make sure that the providers are going to be paid,” she said. “Forcing providers to eat large sums of money only weakens them and their ability to provide comprehensive services to their clients.”

Richman said she would be in Harrisburg this week to continue working on the transition of Medicaid expansion. And though she didn’t want to speak for Dallas, she expected he would announce a plan that would unknot the problem.

“I will tell you that within the next couple of days we will have a plan and we will be communicating back out to the counties and people like Mike [Harle] how we plan to remedy this very quickly,” Richman said.

From Harle’s vantage point, the fix is really pretty simple. “There is a system in Pennsylvania that works,” he says. “It’s called HealthChoices and has been in place since the ’90s. It has rules and a system and a common language that people understand.”

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HHS Pledges To Quicken Pace Toward Quality-Based Medicare Payments

The Obama administration Monday announced a goal of accelerating changes to Medicare so that within four years, half of the program’s traditional spending will go to doctors, hospitals and other providers that coordinate their patient care, stressing quality and frugality.

The announcement by Health and Human Services Secretary Sylvia Burwell is intended to spur efforts to supplant Medicare’s traditional fee-for-service medicine, in which doctors, hospitals and other medical providers are paid for each case or service without regard to how the patient fares. Since the passage of the federal health law in 2010, the administration has been designing new programs and underwriting experiments to come up with alternate payment models.

Last year, 20 percent of traditional Medicare spending, about $72 billion, went to models such as accountable care organizations, or ACOs, where doctors and others band together to care for patients with the promise of getting a piece of any savings they bring to Medicare, administration officials said. There are now 424 ACOs, and 105 hospitals and other health care groups that accept bundled payments, where Medicare gives them a fixed sum for each patient, which is supposed to cover not only their initial treatment for a specific ailment but also all the follow-up care. Other Medicare-funded pilot projects give doctors extra money to coordinate patient care among specialists and seek to get Medicare to work more in harmony with Medicaid, the state-federal health insurer for low-income people.

Burwell’s targets are for 30 percent, or about $113 billion, of Medicare’s traditional spending to go to these kind of endeavors by the end of President Barack Obama’s term in 2016, and 50 percent — about $215 billion — to be spent by the end of 2018.

The administration also wants Medicare spending with any quality component, such as bonuses and penalties on top of traditional fee-for-service payments, to increase, so that by the end of 2018, 90 percent of Medicare spending has some sort of link to quality. These figures do not include the money that now goes to private insurers in the Medicare Advantage program, which enrolls about a third of all Medicare beneficiaries.

This KHN story can be republished for free (details).

Monday’s announcement did not include any new policies or funding to encourage providers, but Burwell said setting a concrete goal alone would prompt changes not only in Medicare but also by private insurers, which are also trying some of these alternative models. Leavitt Partners, a consulting firm, counts 317 commercial ACOs and 40 in the Medicaid program.

“For the first time we’re actually going to set clear goals and establish a clear timeline for moving from volume to value in the Medicare system,” Burwell said at an announcement at the department’s headquarters, where she was joined by leaders from insurance, hospitals and doctors. “So today what we want to do is measure our progress and we want to hold ourselves in the federal government accountable.”

Some providers have eagerly embraced the new payment models, some with success. Roughly a quarter of ACOs saved Medicare enough money to win bonuses last year. Others are wary, particularly since they could lose money if they fall short on either saving Medicare money or achieving the dozens of quality benchmarks the government has established.

“ACOs are quite expensive to set up,” said Andrea Ducas, a program officer at the Robert Wood Johnson Foundation, a New Jersey philanthropy that is funding research into ACO performance. “There’s a significant upfront investment and if you’re not sure you’re going to make it back, there’s a pause.”

In the largest ACO experiment, the Medicare Shared Savings Program, 53 ACOs saved enough money in 2013 to get bonuses from the government, but 41 spent more than the government estimated they should have. Those ACOs did not have to repay any money, but in future years Medicare intends to require reimbursements from those who fall short. Providers have been pushing Medicare to increase the cut they get from these programs and lessen the financial risks in ACOs and the other programs.

“Government needs to do more to make sure there’s more shared savings going back to the providers,” said Blair Childs, an executive with Premier, a company that assists hospitals and providers in establishing ACOs and other models.

It is still too early to know whether these alternate payment models actually improve the health of patients and whether the savings that have been achieved so far — often by focusing on the most expensive patients — will plateau. Studies on the success of these programs have shown mixed results.

“We still have very little evidence about which payment methods are going to be successful in getting the results we want, which are better quality care and more affordable care,” said Suzanne Delbanco, executive director of Catalyst For Payment Reform, a California-based nonprofit that has been tracking the spread of alternative payment models in the private sector.  “We’re just wanting to avoid a situation where a few years from now, where we’ve completely gotten rid of fee-for-service, we don’t want to wake up and say, ‘Oh my gosh, we did it and we’re no better off.’”

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State Highlights: Calif. Bill Advanced To Address Doctor Network Concerns; KanCare May Go Without IG

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Governors’ Budget Plans Touch State Employee Health Benefits, Medicaid

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Measles Outbreak Fails To Move Vaccine Opponents

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WHO Works To Reform Its Capacity To Respond To Global Health Emergencies

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Hospitals See $46B In Unpaid Bills Before Health Law’s Insurance Expansions

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Viewpoints: Ending Health Law Is Not Immoral; ‘Revolution’ In Hep C Drug Prices

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Iowa Insurance Commissioner Will Seek Liquidation Of CoOportunity

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Ark. Governor’s Choice On Medicaid Is A Risky One

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