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FEATURED TOPICS

Affordable Care Act (ACA)

Modern Healthcare: Tennessee Governor Continues to Push for Medicaid Expansion
Gov. Haslam continues to seek a Medicaid expansion plan that is amiable to HHS and the TN legislature. State lawmakers passed a law requiring their approval before the governor can expand Medicaid.
Commonwealth: Commentary: Grading ACA's Roll Out to Date
Commonwealth President and VP "grade" the ACA: marketplaces (need improvement), enrollment (good to excellent), underinsured (pending), healthcare utilization and cost (pending). Overall: progress.
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Employer Sponsored Insurance

NPR: Skinny Plans That Exclude Hospital Benefits Still Meet ACA Requirements
Calculator created to verify that plans meet the ACA's "minimum value" requirements approves plans that do not include inpatient care. Such plans have been purchased by low wage employers. Also: KHN
DOL: Excepted Benefits Rule Finalizes Dental, Vision, EAP Provisions
While deferring guidance on limited wraparound coverage to a future rule to account for the "extensive comments received on this issue," the IRS, DOL and HHS finalize excepted benefits regulations for dental, vision and employee assistance programs (EAPs). Among other provisions, the rule specifies that "consistent with the 2013 proposed regulations, these final regulations eliminate the requirement under the HIPAA regulations that participants pay an additional premium or contribution for limited-scope vision or dental benefits to qualify as excepted benefits." The rule also generally finalizes the proposal that EAPs qualify as excepted benefits if they meet 4 criteria. The Departments note that "in response to comments, these final regulations do not include the requirement set forth in the 2013 proposed regulations that EAP benefits cannot be financed by another group health plan in order to qualify as excepted benefits."
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Doctors

NYT: Narrow Networks Have Implications for Emergency Room Visits
Select ACA-compliant narrow network plans cover ER visits but not ER physicians. With 65% of ER doctors working as contractors rather than hospital employees, insurance networks are complex.
Modern Healthcare: Open Payment Website to Launch Tuesday, Sept. 30
CMS' Open Payments website is launching amid concerns. Created by the ACA Sunshine Act, it generates transparency on payments by device and Rx companies to doctors and hospitals. Also: CQ($)
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Prescription Drugs

HHS: Drug Funded to Address "Cytokine Storm"
HHS awarded Atox Bio, an Israeli biotechnology company, $4.4M to develop a drug to reverse "cytokine storm," a complication stemming from severe infection that can lead to patient death. The 1.5-year, BARDA-funded project may be extended for up to 3 more years.
Modern Healthcare: Open Payment Website to Launch Tuesday, Sept. 30
CMS' Open Payments website is launching amid concerns. Created by the ACA Sunshine Act, it generates transparency on payments by device and Rx companies to doctors and hospitals. Also: CQ($)
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Medicaid – General

Modern Healthcare: Tennessee Governor Continues to Push for Medicaid Expansion
Gov. Haslam continues to seek a Medicaid expansion plan that is amiable to HHS and the TN legislature. State lawmakers passed a law requiring their approval before the governor can expand Medicaid.
Modern Healthcare: California Governor Vetos Bill Protecting Deceased Medicaid Enrollees' Assets
Gov. Brown vetoed legislation limiting CA's ability to recover medical costs from the estates of Medi-Cal enrollees. CA collects for all medical expenses; bill would have limited to LTC. Also: KHN
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Health Information Technology (HIT)

Modern Healthcare: California's Health Information Exchange Moves Forward
The CA Integrated Data Exchange (Cal INDEX) was created in August '14 as a statewide health data exchange that will initially have approximately 9 million records. Two new board members just joined.
CMS: Resources: Health IT Week Infographic on eHealth Adoption; ICD-10 Education Tools
Following last week's observance of National Health IT Week, CMS highlights select resources on health IT adoption, including an infographic depicting quality and cost gains from Meaningful Use, ACOs, PQRS and administrative simplification. The agency also released resources on ICD-10, including opportunities to earn CME credit (see CMS resources here).
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Health Insurance Exchanges

WSJ: 300,000 Individuals Must Submit Documentation By September 30 or Lose Premium Subsidies
300,000 individuals must submit income documentation today, Sept. 30, to maintain their premium subsidies; 115,000 others had to provide citizenship or immigration documentation by Sept. 5. Also: KHN
GAO: Most Large Insurance Issuers Participated in 2014 Exchanges
GAO found that most of the largest health insurance issuers participated in the ACA Exchanges. In two-thirds of states, the health insurance issuer with the largest share of their 2012 individual or small group market participated in the ACA exchange for that market in 2014.   On average in 2014, exchanges had six participating issuers in their individual market and four in their small group market, representing 57% and 56% of the share of these markets in 2012, respectively. The total number of issuers participating in exchanges varied from one to 17 in individual markets and one to 13 in small group markets.   GAO provides additional detail regarding plan participation in 2014 exchanges in this comprehensive report.
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Hospitals

Health Affairs: Commentary: Exploring Who Saves When Palliative Care Costs are Reduced
Cassel notes the fragmented health system and the business case for "cost savings" for payers and hospitals. He urges policy makers to consider clinical and business motivations in policy development.
NYT: Narrow Networks Have Implications for Emergency Room Visits
Select ACA-compliant narrow network plans cover ER visits but not ER physicians. With 65% of ER doctors working as contractors rather than hospital employees, insurance networks are complex.
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Quality

NHPF: Forum Discussion: Sociodemographic Risk Adjustment to Protect the Safety Net
This forum summary provided a range of views on using socioeconomic status and other sociodemographic factors in risk-adjusting performance measurement for physicians.
E&C: Bipartisan House E&C, Senate Finance Letter Seeks Input on Medicaid Managed Care's Role, Best Practices
The chairmen and ranking members of the House Energy and Commerce and Senate Finance Committees said they had written to trade associations, the Medicaid Health Plans of America, the Association for Community Affiliated Plans and America’s Health Insurance Plans, requesting input on “best practices related to access to and quality of care” in Medicaid managed care. The Members, who include House E&C Chairman Fred Upton (R-MI) and Ranking Member Henry Waxman (D-CA) and Senate Finance Committee Chairman Ron Wyden (D-OR) and Ranking Member Orrin Hatch (R-UT), say they seek a “better understanding of the role of managed care plans in Medicaid and [to] learn from innovative methods used to serve different [covered] populations.” They ask for input on nine areas (see p. 2 of the letter):
  • Responsible Medicaid rate-setting processes that take into account different types of Medicaid managed care plans, including industry standards for assessing actuarial soundness;
  • Development of comprehensive provider networks that meet the full range of patient needs, including strategies for recruiting and retaining primary and specialty care providers;
  • Methods for evaluating quality of care, including clinical measures, or other metrics for evaluation;
  • Clinical and other interventions that coordinate care, especially related to the management and treatment of  chronic diseases for higher-risk, higher-cost enrollees, and enrollees requiring long-term services and supports;
  • Effective policies or programs to communicate with and provide services to vulnerable populations, such as enrollees with disabilities, those who speak English as a second language, those who live in rural or medically underserved areas, etc.
  • Collecting, using and reporting complete, accurate and reliable encounter data;
  • Effective strategies to enhance program integrity and prevent improper payments, including the use of data and analytics, information security protocols, billing standards, and drug abuse prevention and diversion strategies;
  • Accountable management culture and processes, including developing a workforce capable of responding to enrollee needs, implementing effective and responsive grievance procedures, and providing enrollees with access to relevant information about services and programs;
  • Constructive means of engaging and collaborating with states or other partners, including communications, legal, organizational or other strategies.
The groups’ responses are requested by Nov. 15, 2014. Also see a Committee press release.
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Legal

CMS: Slides: Sept. 9 Call on Inpatient Appeals Settlement Offer
CMS reviews the parameters for its offer to settle pending hospital inpatient status appeals for 68% of the net payable amount, discussing eligible providers and claims, as well as the validation and payment process. For audio, see this page. A transcript is available here.
KHN: Consumers Sue Two California Plans Regarding Narrow Networks
Enrollees have brought a lawsuit against Cigna and Blue Shield of California alleging that they misled consumers regarding the size of their networks and the specific hospitals and physicians included
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Delivery Reform

Inside Health Policy: House Bill Envisions Testing Capitated ACOs
A bill introduced by Reps. Black and Welch would require testing Medicare ACOs under a capitated payment model. ACOs could reduce seniors' co-pays for primary care. Also: press release  
NASHP: Report: State Efforts to Improve Care Delivery and EPSDT for Children
This policy brief is intended to share tools, resources and strategies to states working to improve care delivery and access to data on Early & Periodic Screening benefit for children in Medicaid.
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Prevention

Brookings: Commentary: Investing in Better Health, Not Better Health Care
Rivlin, founding director of CBO, former OMB director and former Federal Reserve Vice Chair, discusses the drivers in health care expenditures and opportunities to redirect spending to improve health.
Washington Post: CDC Investigating Enterovirus 68 Outbreak and Potential Paralysis Cases
Though not typically associated with paralysis, the CDC is investigating 9 cases of potential paralysis linked to the respiratory virus outbreak which has impacted 40 states and 277 people. Also: USA
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