november 20, 2017 acting director center for medicare & … · 2018. 1. 24. · and medicaid....

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November 20, 2017

Amy Bassano

Acting Director

Center for Medicare & Medicaid Innovation

Centers for Medicare & Medicaid Services

7500 Security Boulevard

Baltimore, Maryland 21244

RE: CMS Innovation Center -- New Direction Request for Information (RFI)

Dear Ms. Bassano:

America’s Health Insurance Plans (AHIP) appreciates the opportunity to submit comments to the

Centers for Medicare & Medicaid Services (CMS) in response to its Request for Information on

a new direction for the CMS Center for Medicare & Medicaid Innovation (Innovation Center).

AHIP is the national association whose members provide coverage for health care and related

services. Our members offer coverage across the entire spectrum of private-sector and public

programs. We are committed to market-based solutions and believe that every American

deserves affordable coverage that provides them with access to high quality care.

We applaud CMS for seeking public input on the development of priorities and guiding

principles for the Innovation Center. AHIP encourages CMS to move forward in directing

Innovation Center resources toward model designs most likely to encourage modernization of the

Medicare and Medicaid programs and to lower costs, increase quality, and improve outcomes.

We are aligned with CMS in our belief that achieving such objectives is best accomplished

through models focused on market-based reforms that promote patient-centered care, expand

competition and choice, and reduce unnecessary burdens.

To achieve these objectives, AHIP strongly recommends that the Innovation Center design and

test new models focused on Medicare Advantage (MA), Medicare Prescription Drug Coverage

(Part D), and Medicaid health plans. We are encouraged that the RFI specifically identifies these

three programs as potential areas for testing and have attached several recommended models.

These models would modernize benefits, better prevent and treat addiction to opioids and other

substance use disorders, promote better care integration for dual eligible beneficiaries, allow

plans to address social determinants of health, leverage technologies to improve the beneficiary

experience, better align drug coverage within Medicare, and provide plans with tools and

flexibility to contain rising prescription drug costs. We also encourage CMS to work closely

with health plans and other relevant stakeholders in model development and design.

Health insurance providers have a proven track record of success they can bring to bear on

Innovation Center models. Our members specialize in integrating and coordinating care for

beneficiaries; mitigating the harm of chronic diseases by focusing on prevention, early detection,

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and care management; addressing the needs of vulnerable individuals, including low-income

beneficiaries and individuals with disabilities; applying evidence-based clinical practices to

increase patient safety and to limit unnecessary utilization of services; reducing medication

errors; and promoting clinically sound drug usage. Through collaboration with physicians,

hospitals, and other clinicians, health plans provide better care, achieve better outcomes, and

lower costs for beneficiaries. While these achievements are important, statutory and regulatory

restrictions continue to limit the potential for further innovation and improvement in Medicare

and Medicaid. We believe health plans are an ideal laboratory for testing new innovative

strategies and practices.

The Value of Medicare Advantage and Part D

Today nearly 19 million Americans, or nearly one in three Medicare beneficiaries, have chosen

to enroll in the MA program. Since 2010, MA enrollment has increased by more than 60

percent. The MA program has a beneficiary satisfaction rate of 90 percent for plans, preventive

care coverage, benefits, and choice of provider.1

Unlike traditional Medicare, whose benefit package is largely stuck in time and reflects its 1960s

origins, MA plans often offer additional, comprehensive benefits such as vision, dental, and

hearing coverage, as well as a cap on out-of-pocket spending, and many plans offer drug

coverage as well for no additional cost to beneficiaries. In comparison to the traditional

Medicare program, which is built upon a fee-for-service chassis that rewards volume over value,

MA has been shown to reduce hospital readmissions2 and institutional post-acute care

admissions3, and increase rates of annual preventive care visits4 and screenings.5

The benefits of the MA program accrue to taxpayers as well. For many years, average MA plan

bids for delivering the basic Medicare benefit have been below traditional Medicare costs and, in

2017, average MA payments are equivalent to traditional Medicare according to the Medicare

Payment Advisory Commission. Furthermore, in many geographies, increases in MA enrollment

have led to decreases in traditional Medicare spending growth due to changes in practice patterns

and care guidelines that have positive “spillover” effects by reducing Medicare fee-for-service

spending.6 In fact, private MA plans pioneered many payment and delivery reforms being tested

in the traditional Medicare program. Moreover, recent studies have shown that alternative

1 Morning Consult National Tracking Poll. March 11-16, 2016. 2 Lemieux, Jeff, Sennett, Cary, Wang, Ray, Mulligan, Teresa, Bumbaugh, Jon. Hospital readmission rates in

Medicare Advantage plans. American Journal of Managed Care 18(2): 96-104. February 2012. 3 Huckfeldt, Peter J., Escarce, Jose J., Rabideau, Brendan, Karaca-Mandic, Pinar, Sood, Neeraj. Less intense post-

acute care, better outcomes for enrollees in Medicare Advantage than those in fee-for-service. Health Affairs 36(1):

91-100. January 2017. 4 Sukyung, Chung, Lesser, Lenard I., Lauderdale, Diane S. et al. Medicare annual preventive care visits: Use

increased among fee-for-service patients, but many do not participate. Health Affairs 34(1): 11-20. January 2015. 5 Ayanian, John Z., Landon, Bruce E., Zaslavsky, Alan M., et al. Medicare beneficiaries more likely to receive

appropriate ambulatory services in HMOs than in traditional Medicare. Health Affairs 32(7): 1228-1235. July 2013. 6 Johnson, Garret, Figuero, Jose F., Zhou, Xiner, Orav, E. John, Jha, Ashish K. Recent growth in Medicare

Advantage enrollment associated with decreased fee-for-service spending in certain US counties. Health Affairs

35(9):1707-1715. September 2016.

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payment models within MA lead to the delivery of care that is of higher quality and lower cost

than other types of payment arrangements.7

Part D covers most medications – including many biologics and vaccines – that are not otherwise

covered by Medicare Part A (hospital insurance) or Part B (medical insurance). Over the past 10

years, Part D has been a model of consumer choice and market competition that has improved

access to prescription drugs and reduced out-of-pocket costs for tens of millions of beneficiaries.

Today, 43 million seniors and individuals with disabilities are covered by private plans

participating in the program, and enrollees are overwhelmingly pleased with their coverage and

benefits. The program is highly popular, as nearly 90 percent of seniors are satisfied with the

Part D program.8 Part D premiums also have been relatively stable over time. For 2018,

according to CMS, the average Part D premium is projected to fall 3 percent, from $34.70 to

$33.50, which is the first projected premium decrease since 2012.

The Value of Medicaid Managed Care

Medicaid health plans are at the forefront of implementing systems and programs across the

country that promote high-quality, coordinated care for millions of our most medically-

vulnerable citizens, including lower-income individuals, people with disabilities, and pregnant

women and children. More than 52 million low-income individuals – representing over 70

percent of total Medicaid enrollment – rely on private health plans for their Medicaid coverage.

Thirty-nine states have adopted Medicaid managed care and 26 states have adopted managed

long-term services and supports (MLTSS), a six-fold increase since 2004.

AHIP members have a proven track record in addressing the needs of Medicaid beneficiaries

with complex needs, including individuals with physical or developmental disabilities, people

with multiple chronic conditions, older adults, foster children, and those in need of long-term

services and supports and/or home and community based services. Medicaid health plans’ focus

on chronic care and disease management and delivery of patient-centered care improves quality

and care coordination for these vulnerable populations.

Moreover, Medicaid health plans remain committed to the success and sustainability of the

Medicaid program. Medicaid health plans help states – and, by extension, the federal

government – control escalating program costs and achieve high value for their scarce health

care dollars. By coordinating medical and pharmacy benefits, Medicaid health plans saved $2.06

billion in state and federal expenditures in 2014 alone.9 In many states, Medicaid health plans

have provided savings of up to 20 percent compared to Medicaid fee-for-service and between 10

and 15 percent lower per-member per-month drug costs.10 In addition, a report from the Ohio

Association of Health Plans shows that Ohio’s Medicaid health plans saved the state Medicaid

7 Mandal, Aloke K., Tagomori, Gene K., Felix, Randell V., Howell, Scott C. Value-based contracting innovated

Medicare Advantage healthcare delivery and improved survival. American Journal of Managed Care 23(2): e41-

e49. January 2017. 8 Morning Consult for Medicare Today, “Ten Years After Implementation, Nearly Nine in 10 Seniors are Satisfied

with Part D” (July 2016). 9 The Menges Group, “Comparison of Medicaid Pharmacy Costs and Usage in Carve-In Versus Carve-Out States,”

April 2015. 10 The Lewin Group, “Medicaid Managed Care Cost Savings: A Synthesis of 24 Studies,” March 2009.

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program as much as $2.5 to $3.2 billion compared with the fee-for-service Medicaid program

from 2013 to 2015.11

Potential Model Considerations

As noted above, we have developed a variety of recommendations for pursuing innovations in

MA, Part D, and Medicaid programs. Brief summaries of these proposals are attached. They

reinforce the guiding principles in the RFI that are aimed at increasing beneficiary choices in the

marketplace and testing new payment and delivery models to improve quality and decrease costs.

By focusing more models on opportunities and added flexibility for health plans to implement

innovative programs and services, the Innovation Center will be able to identify and test new

approaches and develop best practices that could provide greater value to Medicare and

Medicaid beneficiaries in managed care and ultimately be implemented in the traditional fee-for-

service programs. At the same time, these approaches may better align health plan practices and

quality standards in commercial and public programs, reduce burden for providers participating

in health plan networks across multiple products, and reinforce efforts to improve quality and

reduce costs across the health care system.

In our comments submitted to the Agency earlier this year regarding transformational ideas in

the RFI within the 2018 Advance Notice for MA and Part D, we recommended several changes

to transform and modernize the MA and Part D programs. We have included several of those

proposals as potential Innovation Center models. We strongly urge CMS to implement those

suggestions as permanent program changes by exercising its interpretive regulatory authority.

However, we have included these suggestions in this RFI response to the extent CMS may have

questions about the Agency’s regulatory authority or CMS is otherwise hesitant to implement the

suggested changes through regulation.

We also want to address several other elements in the RFI. First, CMS requests input on the

possibility of developing models that would test alternatives to traditional Medicare and MA,

presumably through new types of risk bearing entities. We have serious concerns with such an

approach. The traditional Medicare and MA programs already provide robust, alternative forums

for the Innovation Center to explore different models in pursuit of the principles in the RFI.

Introducing alternative financing programs that require providers to assume substantial new

levels of financial risk would divert significant government and private sector attention and

resources. For example, such an approach could lead to the financial insolvency of providers

and other entities that lack the capacity to effectively manage risk. This would, in turn,

invariably create confusion for beneficiaries and potential harm as a result of provider challenges

and potential failures. Based on their track record, plans in the MA program are in the best

position to test and implement innovative models that offer long-term value to beneficiaries and

taxpayers. We urge the Innovation Center to focus on working with stakeholders to identify and

solve specific problems within traditional Medicare and MA.

11 Ohio Association of Health Plans, “The Impact of Private Industry on Public Health Care: How Managed Care is

Reshaping Medicaid in Ohio,” January 2017.

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Second, the RFI indicates potential CMS interest in an MA demonstration “that incentivizes MA

plans to compete for beneficiaries, including those beneficiaries currently in Medicare fee-for-

service (FFS), based on quality and cost in a transparent manner.” We note that existing

competition in the MA and Part D programs is robust. Enrollment continues to increase despite

significant changes that have been made to these programs over the past decade. However, we

believe CMS can take steps to enhance beneficiary understanding of their choices, including the

additional value that MA plans offer. For example, we recommend that CMS work with

stakeholders to develop a way to measure the quality of care received by beneficiaries in

traditional Medicare. Beneficiaries could then have more information available to compare the

performance of traditional Medicare against MA plan options in their service areas. We also

recommend that CMS work with stakeholders to improve the Medicare Plan Finder so that

beneficiaries have a clearer and better understanding of their Medicare coverage options.

Third, we support CMS’s interest in further exploring the voluntary use of value-based contracts

(VBCs) for new high cost drug therapies. We encourage CMS to prioritize VBC arrangements

that include independently-developed outcome measures, appropriate and adequate safeguards

and guarantees for the promised impact and length of therapeutic effects and to explore

alternatives to traditional end of the year payment reconciliations. We believe these types of

arrangements can ensure the maximum value for patients and taxpayers.

Finally, we would like to take this opportunity to recognize and support the work of the

Medicare-Medicaid Coordination Office (MMCO). The MMCO was created to serve

individuals who are dually eligible for Medicare and Medicaid, with a focus on integrating

program benefits and improving federal and state coordination. Achieving these goals is critical

to reducing avoidable costs and enhancing quality for these often-vulnerable beneficiaries.

AHIP believes the MMCO has been extremely successful in furthering those objectives, as

reflected in the implementation of the Medicare-Medicaid Plan (MMP) demonstrations and the

office’s role in resolving broader issues for dually eligible beneficiaries. The MMP

demonstrations are a crucial laboratory for testing the impacts of eliminating regulatory conflicts,

increasing stakeholder engagement, and implementing other activities to achieve the highest

value care for dual eligibles. Therefore, as indicated in our attached recommendations, AHIP

strongly urges CMS to continue and expand the MMP demonstrations. We also encourage

enhanced intra-agency coordination in the design and oversight of programs impacting dual

eligibles, under the leadership of the MMCO, so that decisions affecting these programs are

made through the lens of an integrated program that considers the impact on beneficiaries, as

well as coordination with state partners.

We look forward to providing any additional information you may need and to continue working

with you to promote innovation and strengthen the Medicare and Medicaid programs for the

beneficiaries they serve.

Sincerely,

Matthew Eyles

Senior Executive Vice President & Chief Operating Officer

AHIP List of Model Ideas for Innovation Center RFI

* Innovation Center Guiding Principles: “CC” is choice and competition in the market; “PC&T” is provider choice and incentives; “PCC” is patient-centered care; “BD&PT” is

benefit design and price transparency; “TMD&E” is transparent model design and evaluation; and “SST” is small scale testing.

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MA Innovation Models

Model name Current Landscape and Challenges Model description Innovation Center Guiding Principles* CC PC&T PCC BD&PT TMD&E SST

Medicare Access and

CHIP

Reauthorization Act

(MACRA) Medicare

Advantage (MA)

Advanced APM

Demonstration

Under the current MACRA rule, MA

plans are treated as ‘Other Payers’

and payments and members

attributable to MA plans are not

counted toward qualifying alternative

payer model (APM) determinations

under the Medicare Option.

Clinicians taking risk in a contract

with an MA plan are only eligible to

receive credit for their participation

through the All-Payer Combination

Option beginning in payment year

2021.

Test whether including provider risk

arrangements with MA plans as qualifying

APM arrangements under the Medicare Option

will expand the adoption and impact of value

based arrangements. Additional details about

this recommended model were submitted to

CMS as part of AHIP comments on the

proposed 2017 MACRA rule. We note and

appreciate that the MACRA CY2018 final rule

confirms CMS interest in moving forward with

a demonstration.

✓ ✓ ✓ ✓ ✓

Telehealth

demonstration

The original Medicare fee-for-service

(FFS) program restricts the covered

services that can be delivered via

telehealth to a limited list of

geographies, covered services, and

provider types. MA plans can only

provide coverage for telehealth

services beyond those restrictions

through supplemental benefits.

Test whether permitting MA plans to

incorporate telehealth costs in the basic MA

benefit, and thereby expand the use of telehealth

and remote patient monitoring, will reduce costs

and enhance quality and access to care for

Medicare plan enrollees. ✓ ✓ ✓ ✓ ✓

Expansion of MA

Value Based

Insurance Design

(VBID) Model

CMS is currently testing a model

allowing MA plans to offer VBID,

but the model is limited to 10 states

and to certain types of clinical

conditions.

Enhance testing of the cost and outcomes

impacts of VBID by expanding the model

nationwide and providing plans with more

flexibility to identify clinical conditions eligible

for VBID and consider expanding to other plans

types.

✓ ✓ ✓ ✓

Expanded

Supplemental MA

Benefits

CMS rules restrict the types of items

and services that MA plans can offer

as supplemental benefits to those that

are “primarily health related,” defined

by CMS as having a “primary”

Test the cost and quality impacts of allowing

MA plans to cover a broader range of assistive

devices, items and services that help

beneficiaries compensate for physical

disabilities, diminish the impacts of an illness or

injury, and enhance quality of life. We note, for

✓ ✓ ✓ ✓ ✓




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purpose to prevent, cure or diminish

an illness or injury.

example, that CMS permits certain D-SNPs to

offer supplemental benefits for enrollees

needing assistance with activities of daily living

(Medicare Managed Care Manual, Chapter 16b,

Sec. 20.2.6.2); a model could test the impacts of

extending similar flexibility to all MA plans.

Limited Home and

Community Based

Services (HCBS)

Benefit for “Near

Dual Eligibles”

CMS rules for home health services

require that the enrollee need

intermittent skilled nursing care. MA

plans cannot provide supportive home

health services to people who have

difficulty performing activities of

daily living (ADLs), except in

combination with skilled services,

and such services cannot be provided

as supplemental benefits. Many

individuals with ADL impairments

would qualify for nursing home level

care but have incomes too high to

qualify for Medicaid, and a

significant number of these “near dual

eligibles” spend down their resources

to eventually qualify for Medicaid.

Test whether allowing MA plans to cover a

limited HCBS benefit as a supplemental benefit

for this population reduces the number of

Medicare enrollees who progress to Medicaid

and dual eligibility, and whether such limited

HCBS would have positive impacts on use of

Medicare acute services, e.g. inpatient hospital

and ER.

✓ ✓ ✓ ✓

Hospice and

Palliative Care in

MA

MA members who elect to receive

hospice care receive such coverage

exclusively through Part A of the FFS

program. In addition, beneficiaries

receiving hospice care are generally

limited to the receipt of palliative

care, not additional curative care. The

Innovation Center is currently testing

a model that allows beneficiaries

receiving hospice benefits to also

receive curative care.

Test whether providing a more integrated

hospice benefit by including it as an MA

covered service can reduce costs and enhance

quality of life of MA beneficiaries. Further test

the cost and quality impacts of offering

concurrent palliative and curative care in this

MA benefit. ✓ ✓ ✓ ✓




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MA Rewards and

Incentives Program

CMS rules limit the types and

amounts of rewards and incentives

that are permissible under the MA

program for plans to provide to their

members.

Allow plans more flexibility to design

innovative reward and incentive programs for

beneficiaries, including innovative educational

outreach to targeted member populations, and

permit use of cash or monetary rebates as a

form of reward or incentive.

✓ ✓ ✓ ✓ ✓ ✓

MA Health Savings

Account (HSA)

Demonstration

Medical savings account (MSA)

plans, first offered as a demonstration

under the Balanced Budget Act of

1997, have been a permanent MA

option since the Medicare

Modernization Act of 2003.

However, enrollment in MSA plans

represents less than 0.1 percent of

total MA enrollment. The program

was developed before modern HSAs

and lacks features such as the ability

of beneficiaries to contribute their

own funds to an MSA. Other

restrictions that may affect enrollment

include a prohibition on mandatory

supplemental benefits.

Test whether modifying Medicare MSA rules to

be more consistent with commercial HSA

arrangements could increase Medicare

beneficiary interest and ultimately lead to

higher value utilization of Medicare services.

✓ ✓ ✓ ✓ ✓




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MA Coverage of

Home Infusion Drugs

The FFS program limits the coverage

of home infusion services. Some MA

plans provide broader coverage of

home infusion services, and have the

option of bundling Part D home

infusion drugs with equipment,

supplies, and nursing services as a

supplemental benefit. The Innovation

Center is currently testing a model in

the FFS program that provides

bundled payments for a specific type

of home infusion service that is

usually available only to homebound

members.

Test the program cost impacts and other

potential benefits of providing MA plans

additional incentives to offer services to

enrollees who are not homebound, and/or

including Part D home infusion coverage under

a bundled payment.

✓ ✓ ✓ ✓ ✓




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State-Based and Local Innovation, including Medicaid-Focused Models


Extension and

Expansion of the

Medicare-Medicaid

Plan Financial

Alignment

Demonstrations

The Financial Alignment

Demonstrations (FADs), which

currently serve more than 400,000

Medicare-Medicaid beneficiaries in

11 states, are highlighting interactions

between Medicare and Medicaid,

helping policymakers to understand

and bridge the disconnects between

the two programs. The FADs serve as

important laboratories in several

respects:

• Identifying and understanding

challenges and inconsistencies

between benefits, rules and

requirements of the two programs;

• Understanding state, provider and

beneficiary perspectives and

behavior toward integrated care

models; and

• Refining integrated delivery of

care and services to improve

outcomes, while working within

the existing statutory and

regulatory framework.

The Medicare-Medicaid Plans

(MMPs) operating in the capitated

FADs provide greater flexibility for

the delivery of services to these

vulnerable beneficiaries and reduced

administrative burden for the

providers and health plans serving

them.

To enable health plans and state Medicaid

agencies to continue investing in the

coordination and integration of benefits and

services for Medicare-Medicaid dual eligibles,

to allow sufficient time for evaluation reports

and other demonstration results to become

available, and to allow sufficient time for state

budget planning and CMS processes, AHIP

strongly recommends that the Innovation Center

work with all interested states to extend the

MMP FADs, consistent with the extensions

CMS previously offered to states with 2018

demonstration end dates. We also strongly

recommend that CMS expand opportunities for

additional plans and states to participate.

Moreover, we believe that there are additional

opportunities to further enhance the levels of

integration within the MMPs. Extending the

demonstrations will provide time to realize

those enhancements, for example, testing the

cost and quality impacts of allowing states

additional flexibility and permitting greater

integration and streamlining of Medicaid and

Medicare administrative processes in the FADs,

including network adequacy reviews, financial

and program reporting, appeals and enrollment.

The MMPs are the most integrated currently

available plan option for dual eligibles, and we

urge the Innovation Center to continue its

commitment to this important care delivery

model, partnering with states and the MMPs to

refine it as program evaluations and results

become available. We believe that there is much

more to be learned from the MMP

✓ ✓ ✓ ✓




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demonstrations, and allowing adequate time for

those insights and lessons learned to be realized

will contribute significantly to the long-term

outlook for person-centered, integrated care and

services for dual eligibles.

Unified Dual Eligible

Integration

Demonstration

Current Medicare and Medicaid

benefits and administrative processes

are independent and not aligned,

creating significant challenges for

beneficiaries in understanding and

navigating the two programs, and

challenges for providers and health

plans in coordinating care and

services. Non-alignment also creates

incentives to shift costs between

Medicaid and Medicare.

A Unified Dual Eligible Integration

Demonstration would take the evolution of

integration of care and services for Medicare-

Medicaid dual eligibles to the next level. The

Innovation Center could select up to ten states

to implement fully integrated programs in all or

part of the state. States would apply to

administer integrated funding and benefits for

full benefit dual eligibles, including Medicare

Parts A, B and D, and Medicaid covered

services such as behavioral health and MLTSS.

CMS would provide Medicare funds, along

with FFP for Medicaid, to demonstration states,

who would administer funds and provide

rigorous accounting of Medicare and Medicaid

attributable expenditures. States would contract

with qualified managed care organizations to

provide delivery systems, care management and

coordination. Beneficiary-centered processes

such as enrollment, continuous coverage,

benefits and appeals would be completely

aligned and integrated.

✓ ✓ ✓ ✓ ✓




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Enhanced Integration

for Medicare/

Medicaid Dual

Eligible Special

Needs Plans (D-

SNPs)

Special Needs Plans for Dual

Eligibles (D-SNPs) have been an

option under the Social Security Act

for more than ten years. They offer an

alternative approach to providing

integrated and coordinated benefits

for duals, and also provide flexibility

in CMS rules to enable more

simplified processes.

More recently, Fully Integrated Dual

Eligible (FIDE) SNPs were

developed to offer additional

integration with respect to benefits,

member facing processes and

materials.

There is still substantial work that can

be done in D-SNPs to further

integrate funding, benefits and

administrative processes, limit

challenges for beneficiaries, and

enhance the ability of SNPs to

achieve the most effective care and

service coordination. For example,

some states have been reluctant to

expend scarce state resources on

FIDE SNP participation because such

SNPs are not designed to provide

states with tangible financial benefits

that may be realized by the SNPs

through the delivery of higher quality,

more cost-effective care.

Test the cost and quality of permitting all D-

SNPs to use fully integrated member

correspondence, marketing and member

materials, for member-facing administrative

processes, such as enrollment, appeals and

medical management, with complete alignment

of Medicare and Medicaid requirements.

In addition, for FIDE SNPs, the Innovation

Center could test a model that allows states to

participate financially in savings that accrue to

Medicare through intensive coordination and

management of services provided to dual

enrollees through their Medicaid coverage, such

as Medicaid-covered long-term services and

supports that reduce use of Medicare-covered

inpatient and emergency room use.

✓ ✓ ✓ ✓




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Integrated Coverage

for Social

Determinant(s) of

Health

There is a growing body of evidence

about the impacts of social

determinants – such as employment,

food security and access to affordable

housing – on health costs and

outcomes for Medicaid beneficiaries

and other individuals. Yet

community, state and federal

programs aimed at these social issues

are not coordinated with public health

policies. For example, social

determinants clearly have impacts on

Medicaid utilization and costs, but

key aspects of federal programs, such

as funding criteria, eligibility

standards and benefit duration for

Medicaid, housing, nutrition and job

training programs vary significantly.

These differences severely limit the

ability of Medicaid health plans and

others to combine health and social

services to address the needs of

people with Medicaid in a holistic

manner.

Test the impacts of allowing Medicaid health

plans to coordinate the offering of a more

integrated and seamless set of medical and other

services.

For example, Medicaid “buy-in” (MBI)

programs are widely available for Medicaid

enrollees with disabilities, allowing participants

to work while retaining Medicaid coverage

within limits. A potential demonstration could

expand the MBI model to all adults with

Medicaid to test the long-term savings for

Medicaid and low-income assistance programs

by Medicaid coverage of job readiness,

placement, and retention services; for example,

similar to Ohio’s successful JobConnect

program. By allowing enrollees to retain

Medicaid eligibility for a period of time,

regardless of income, this would eliminate the

financial eligibility “cliff” that discourages

permanent employment. Such a demonstration

also could test expanded flexibilities, such as

eliminating upper age limits, and varying

premiums and cost sharing on a sliding scale

according to income.

Another example would be a model

incentivizing and testing the cost impacts on

Medicaid and other low-income programs of

providing coordinated and integrated health

services for people moved from chronic

homelessness into permanent supportive

housing, building on a study by the Providence

Center for Outcomes Research & Education and

work done by the Assistant Secretary for

Planning and Evaluation.

✓ ✓ ✓ ✓ ✓




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HCBS Infrastructure The practicality and viability of

HCBS programs in some states or

certain geographies within states may

be affected by a range of barriers,

including workforce attrition and

resistance/concerns from facility-

based providers to diversify into

HCBS. Some states are trying to

address these barriers but may not

have federal financial support.

Test the impacts on costs, availability of

services and institutionalization rates of making

state Medicaid and federal matching funds

available to address HCBS infrastructure

barriers through MLTSS health plans. Examples

include: training programs to improve the

number of direct care service workers;

increased support for direct care service worker

wages; and assistance for LTSS providers in

rural areas to diversify and convert facility-

based resources to the provision of meaningful,

bona fide HCBS that comply with the HCBS

settings rule.

✓ ✓ ✓ ✓ ✓

Medicaid Drug Costs Medicaid rules allow states and health

plans to develop formularies and

certain utilization management

processes such as prior authorization

common in commercial and other

programs for prescription drug

coverage, but they generally have less

flexibility to incentivize use of the

highest value drugs. At the same

time, MACPAC finds that

prescription drug spending has been a

key driver in rising Medicaid costs.

Test the cost impacts and clinical outcomes of

providing states – working with health plans –

with additional flexibility to develop medication

management policies for high cost drugs

targeted to the needs of a state’s population.

Any such model should ensure policies are

developed in consultation with clinicians and

other experts on pharmacy and therapeutics

committees or drug utilization review boards,

taking into account evidence (from scientific

literature, cost effectiveness studies and

specialty provider practice guidelines) and state-

specific factors (such as the availability of

specialists).

✓ ✓ ✓ ✓




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Prescription Drug Models


MA-VBID Model

Focused on Opioids

The Secretary has declared the opioid

crisis a nationwide public health

emergency. HHS released a five-point

strategy in April of 2017 to combat

the opioid crisis, including

improvement of access to prevention,

treatment, and recovery support

services. A large part of this strategy

relies on the full range of medication-

assisted treatments (MATs).

Currently, the MA-VBID model tests

the impact of providing plans with the

tools and flexibility to promote better

health and outcomes among

beneficiaries. However, CMS

currently limits MA-VBID to certain

specified clinical conditions.

In addition to expanding the geographic and

clinical scope of the MA-VBID model,

specifically test the public health impact of

leveraging innovative benefit designs centered

around improving access to prevention,

treatment, and recovery support services.

Models can include:

• Expanding coverage and reducing cost

sharing for non-opioid and non-medical

treatments for pain;

• Improving access to MATs by allowing

MA plans to reimburse Methadone

under Part D when used for treating

addiction; and

• Enhancing recovery support services by

giving plans the flexibilities to better

coordinate medical, behavioral, and

mental health services.

✓ ✓ ✓ ✓ ✓

Expand Enhanced

MTM Demonstration

Currently, CMS has limited the Part

D Enhanced MTM model test to five

out of 34 Part D regions (i.e., to only

11 states), preventing many plans that

are ready and willing to participate

nationwide from doing so. In fact,

only 6 standalone Part D plan

sponsors currently participate in the

program.

Enhance testing of the cost and outcomes

impacts of the Part D Enhanced MTM model by

expanding the model to nationwide testing and

providing more plans with the flexibility to

identify a wide array of targeting criteria,

intervention activities, and provider-beneficiary

engagement strategies allowed under the model.

✓ ✓ ✓ ✓




11

Prescription Drug Models


Aligning Part B and

D Drug Coverage

While the Part D program generally

covers outpatient prescription drugs

purchased at retail pharmacies, some

pharmacy drugs are covered by Part

B. This sometimes can create

confusion, including cases involving

delayed/inconsistent Part B Local

Coverage Determinations. In addition,

there can be significant differences in

payment rates, cost sharing, and other

matters for Part B and Part D drugs.

Test the cost and access impacts of applying

Part D to all drugs and supplies dispensed at a

retail pharmacy. These would include drugs and

supplies currently covered by Part B, such as

oral anticancer drugs and oral antiemetic drugs.

✓ ✓ ✓ ✓ ✓

Preferred & Non-

Preferred Specialty

Tiers

CMS has the authority to allow plans

to use preferred and non-preferred

specialty drug tiering in their Part D

plans. However, to date CMS has not

permitted this design.

Test the cost and outcomes impacts of preferred

and non-preferred specialty tiering.

✓ ✓ ✓ ✓ ✓

Flexibility in

Implementing the

Protected Class

Requirement

Part D plans generally are required to

cover all drugs in six protected

classes. The statute gives CMS

authority to modify the list of classes

but has not done so.

Test the cost and access impacts of providing

Part D plans with the flexibility to apply

common formulary management tools,

developed based on clinical evidence and best

practices via a Pharmacy and Therapeutics (i.e.,

P&T) committee process, for drugs in one or

more protected classes.

✓ ✓ ✓ ✓

Flexibility in

Implementing the

“Two Drugs Per

Class” Requirement

Though CMS has the authority to

allow for one drug per therapeutic

class to be covered by a plan, plans

are currently required to cover two

drugs for each class of drugs.

Test the cost and access impact of requiring the

coverage of one drug per therapeutic class.

✓ ✓ ✓ ✓




12

Mental and Behavioral Health Models


Early Identification

and Care

Coordination for

Behavioral Health

Conditions

Coordinating care for individuals

with behavioral health issues presents

a broad range of challenges for

providers, health plans, and other

stakeholders in the current legislative

and regulatory environment. These

challenges include:

• Federal rules limiting the sharing

of substance use information

among providers, affecting

coordination and integration of

care.

• A quality measurement

infrastructure that is less

developed than that for

medical/surgical care.

• A lack of validated evidence-

based quality standards and

certification/accreditation

standards for behavioral health

facilities, particularly inpatient or

24-hour residential care facilities.

There is significant ambiguity

and wide variation in what is

considered a residential treatment

facility.

• The laws and regulations

applicable to mental health and

substance use disorder treatment

are subject to multiple

jurisdictions and differing

interpretations.

Test the cost and access impacts of a proactive

identifying and conducting outreach to patients

with behavioral health concerns using care

managers and founded on quality metrics and

evidence-based care.

✓ ✓ ✓ ✓ ✓




13

Program Integrity Models


Explore Models of

Data Sharing and

Aggregation that

Allow for Improved

Efforts to Reduce

Fraud, Waste and

Abuse

Efforts to deter fraud, waste, and

abuse are often deterred by the failure

to collect and report information or

the fragmentation of information that

is reported.

Test models that allow for better sharing of data

and information related to fraud, waste, and

abuse to further improve efforts to reduce them.

The Healthcare Fraud Prevention Partnership

(HFPP) has demonstrated the important results

that can happen when information is collected,

analyzed, and (in an appropriate form) shared.

We encourage the Innovation Center to explore

incentives for enhanced collection and reporting

of information related to fraud, waste and

abuse, and also for enhanced processes for

utilizing such information including in

aggregated form if it is combined with

information from other entities.

✓ ✓ ✓ ✓

Enhancing Provider

Competition

CMS should ensure that all models

tested enhance, and in no case, reduce

provider competition.

Test actively promoting approaches that are

based upon provider competition and reject

approaches that rely upon a reduction in

provider competition. For example, the

Innovation Center should focus on ways in

which existing provider competition can be

enhanced, e.g., through reporting on common

data elements and reward structures based on

relative outcomes on those elements.

✓ ✓ ✓ ✓

november 20, 2017 acting director center for medicare & … · 2018. 1. 24. · and medicaid....

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