At the agencies
On April 11, the Centers for Medicare and Medicaid Services (CMS) announced plans for Comprehensive Primary Care Plus (CPC+), a new model designed to align primary care payments among government healthcare programs, private insurers, and large employers. The new model will begin in January and will run for five years. Twenty states or regions will adopt the new model which will encompass 5,000 physician practices that serve 25 million patients.
The participating states and regions will be selected based on the interest expressed by various stakeholders such as Medicaid agencies, commercial insurance plans, and self-insured corporations during the application period that ends June 1, 2016. Primary care doctors in the selected areas will be able to then apply for CPC+ from July 15 through September 1, 2016. Eligibility for the program will be based on practice structure, payer interest, use of electronic health records, and existing delivery capabilities. Providers who already take part in other initiatives, such as accountable care organizations, will not be able to participate in CPC+.
The model’s multi-payer approach is aimed at making Medicare’s alternative payment structures feasible by adopting them across a broader spectrum of entities from which doctors receive reimbursement. The model offers two tracks for providers to follow. Both will offer monthly “care management fees” that vary according to a patient’s health status, and physicians on both tracks are eligible for incentive payments for hitting certain quality of care objectives. One track will continue to provide traditional fee-for-service payments along with a monthly $15 fee-per-patient. The second track will feature a hybrid payment system where CMS will pay practices $28 per patient along with reduced fee-for-service and up-front comprehensive primary care payments. This method intends to promote flexibility since it would reduce financial incentives to order unnecessary services while giving doctors money for services traditionally not covered, such as telemedicine. This track is optimistically projected to save around $2 billion over a five year period.
On April 4, CMS finalized policies amending Medicare Part D plans that are aimed at reducing opioid overdoses and high drug costs. The new policies require implementing a system by 2018 which will reject claims for opioid prescriptions at the pharmacy for patients who reached the painkiller threshold and rejecting plan formularies that hinder access to medication assisted treatment for substance use disorder. In an effort to cut drug costs, CMS will encourage plans to notify patients about drugs that are added to formularies mid-year that could provide better value than existing options.
On the Hill
On April 7, the Medicare Payment Advisory Commission (MedPAC) voted to include proposals regarding post-acute care and the Part D program in its next report to Congress. The MedPAC post-acute care proposal would tie rates to specific patient settings as opposed to the current system of tying rates to the specific facility in which care is delivered. This would change Medicare reimbursements for skilled-nursing facilities, home health agencies, inpatient rehabilitation facilities, and long-term care hospitals.
Members of MedPAC also agreed to include nine Part D policy changes in its next report. According to the Congressional Budget Office, if Congress were to pass these recommendations it could save as much as $10 billion over five years. One of the key policy recommendations would be to limit the drugs that could be part of the protected class of Part D, specifically antidepressants and immunosuppressants used for post-transplant care. MedPAC also recommends that providers would need to provide standardized justifications when applying for exemptions. The next MedPAC report to Congress will be submitted in June, and a thorough review of MedPAC’s policy recommendations will be conducted.
In the courts
On April 5, the state of Florida reached a settlement over access to providers for children enrolled in Medicaid, after a 10 year class action suit. While the state admitted no wrongdoing, it did agree to pay $12 million in attorneys’ fees for the plaintiffs, Florida Pediatric Society and the American Academy of Pediatrics. The Florida Agency for Health Care Administration (AHCA) has 30 months to reach specific thresholds for provider participation in the Medicaid program. If it fails to meet its goal, the state will be required to create a “corrective action plan” in collaboration with the plaintiffs. As part of the agreement, AHCA will increase payments to the state’s Medicaid managed care plans in the event it fails to meet provider participation goals. AHCA also agreed to evaluate what changes should be made to the 2016 Medicaid contracts to improve children’s access to dental services and to improve outreach efforts to enroll more children in Medicaid.
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