Wednesday, October 7, 2015

Health Reform Task Force releases consultant's report; recommends continuing private option, with tweaks

Posted By on Wed, Oct 7, 2015 at 9:33 AM

click to enlarge THE STEPHEN GROUP: Keep the private option, make some tweaks and adjustments, re-name. - BRIAN CHILSON
  • THE STEPHEN GROUP: Keep the private option, make some tweaks and adjustments, re-name.

: The report is now out. Here is the executive summary. Findings and appendices here and here. Recommendations here. Recommendations specific to contracts here

As expected, the Stephen Group's report, in broad strokes, recommends continuation of the private option, but with tweaks. And it even has a re-branding suggestion: the Transitional Health Insurance Program (or T-HIP). I think it's fair to say that the Stephen Group is pretty solid at wonky analysis but unspeakably bad at branding. T-HIP sounds like the name of a geriatric rapper. Anyway, T-HIP retains the same basic structure of the private option but adds some tweaks, some to give it a more "conservative" veneer and some simply geared toward making the policy more efficient. TSG is also pushing hard for the state to move toward managed care. Oh, and it is going to say "ladder of opportunity" and "personal responsibility" as much as possible. The big picture: This is a recommendation that the Obamacare-funded coverage expansion continue.

Below, you can see a quick-hit list of TSG's suggestions for tweaks and adjustments to the private option. The most notable: It suggests requiring beneficiaries to comply with certain practices for health wellness and preventative care. If beneficiaries do not comply, they could be hit with small premiums (no one who did comply would have to pay premiums). If those premiums aren't paid, beneficiaries could be booted from the program for six months (again, this would only come up if beneficiaries failed to comply with the wellness requirements, such as seeing a primary care physician in the first six months, etc.). TSG also suggests requiring work training for beneficiaries who are unemployed or underemployed (note: this is not a work requirement, but rather a requirement that beneficiaries participate in work training/encouragement programs). Again, if those beneficiaries failed to comply with work training, they could be hit with small premiums, with the threat of being locked out of the program for six months if they don't pay.  

TSG offered both "in the box" recommendations — policy tweaks like those mentioned above that the feds would actually approve — and "out of the box" ideas — changes that would likely only be possible under a different presidential administration. Again, in broad strokes, here are its "in the box" recommendations for the private option, or whatever you want to call it: 

* Mandatory "work referral." This would require beneficiaries who are unemployed or underemployed to participate in job training programs. Note that this would not require having a job or working in order to get benefits, a red line in the sand for the feds. 

* Offer vision and dental benefits to beneficiaries (this is an additional benefit not required by Medicaid and not currently offered to private option beneficiaries).  

* Small premiums and co-payments — but only if beneficiaries do not follow wellness practices and work training programs. Require a membership agreement that requires the beneficiary to visit a primary care physician within six months of signing and to comply with follow-up instructions (and work training programs if relevant). If beneficiaries don't comply, they would be hit with small premiums and cost-sharing, as well as losing vision and dental benefits. 

* "Member lockout" if beneficiaries don't pay required premiums. Again, the small premiums would only be initiated if beneficiaries don't comply with the wellness requirements in their membership agreement. But in that scenario, if a beneficiary then failed to pay the nominal premium, he or she would be given a 30 day notice to come into compliance before being removed from the program, and unable to regain eligibility for six months. (Again, if a beneficiary meets wellness requirements, there would be no premiums and thus no lockout. 

* Co-payments to encourage appropriate use of services. SG suggests a $20 co-pay for use of the ER in non-emergencies. Failure to pay would be subject to the six-month lockout mentioned above.

* Create a Wellness Report Card for each beneficiary, which would track critical health factors, like primary care physician visits, flu shots, etc. The insurance companies would send these report cards to beneficiaries annually, as part of fulfilling the "membership agreement." 

* Improve the eligibility verification process.

* Include mandatory Health Insurance Premium Program, using Medicaid funds to offer premium assistance to employees offered employer-sponsored coverage (a version of this was one of the governor's suggestions), so they get insurance from their job instead of moving to the PO (I mean, THIP, whatever). 

* Including an asset test that would require enhanced cost-sharing for beneficiaries with a house worth more than $200,000 or cash-equivalent assets of $50,000 or more.

* End the Healthcare Independence Account program. This was a new wrinkle this year, pushed heavily by Sen. David Sanders, which ostensibly was a version of Health Savings Accounts, but in practice amounted to a confusing and bureaucratically complicated program that had no impact on how beneficiaries actually utilized health care services. TSG's take: "Acknowledge when things don’t work."

* Establish publicly available health scorecards and rating system to analyze how well the program (and the insurance carriers) are doing in terms of wellness and prevention. 

* Require the health insurance companies to offer education about the "appropriate and proper use of health care." 

* Improve care coordination for the "medically frail." Right now, people likely to need additional medical care are identified by a medical screener; TSG suggests that they be required to visit a medical provider for a clinical determination of "medically frail." TSG: "This will serve two purposes: ensuring that those who should not be classified as frail stay in the exchange-based plans and confirming that those who are frail get into a care coordination program quickly. Making sure that Medically Frail individuals have coordinated care is essential both to improving their health and reducing associated health care costs." 

* Offer employer support. Give employers a one-time payment of $1,000 to businesses that offer employer-sponsored insurance and hire people who are currently private option beneficiaries. 

* Eliminate 90-day retroactive eligibility. Right now, people are covered for services in the three months prior to signing up. SG suggests eliminating that benefit, so coverage would only start once they signed up. 

* Improve the redetermination process. This, of course, was an unmitigated disaster for DHS this year. SG recommends: “an automated system that regularly checks for changes in address and income using state databases and additional date sources from national vendors. These represent a ‘change in circumstance’ that would then require a 30-day notice letter as required by the federal government. In essence, this turns the process into a real-time, data-driven function, operated in the background, as opposed to a batch process that can overwhelm DHS.”

* Require health wellness and outcome scorecards for the insurance companies. These would be developed by the Insurance Department and offer "data to policy makers and the public on important health care program indicators such as the percentage of individuals who have visited a primary care physician within 90 days, the percentage that have obtained flu shots, reductions in hospital admissions for asthma, diabetes, and other preventable conditions, and other outcomes that further the health and wellness of the entire beneficiary population."

* Create a Legislative Oversight Panel that would monitor outcomes and approve any substantial policy changes proposed by state agencies. Wow, just think of the grandstanding opportunities.

Our original preview post on the report is below: 

At 10 a.m., the state's Health Reform Legislative Task Force will meet to discuss the final report from the Stephen Group (TSG), the million-dollar consultant hired by the task force to provide analysis and recommendations on the future of health care in Arkansas, including the private option (the state's unique version of Medicaid expansion). 

TSG released a preliminary report in August, which found that the private option saved the state more than $400 million between 2017 and 2021 (the state saves even more in 2015 and 2016, when the feds pick up the full tab — the key finding from TSG was that the private option is a good deal for the state budget even when the state has to start chipping in for costs). The preliminary report also covered possible Medicaid waivers the state might pursue for additional flexibility; the Community First Choice Option (CFCO), a federal initiative — which has been blocked by the legislature so far — that provides additional federal Obamacare funds to states that commit to providing home/community based services as an option for families of the elderly and the disabled; and the state's purge of Medicaid beneficiaries for failure to respond to income-verification letters within 10 days. (It should be noted that TSG recommended that Gov. Asa Hutchinson extend the response window; the governor finally did so after the feds forced his hands because the state was acting in violation of federal regs, a problem flagged by both TGS and the Arkansas Times.)

This final report will be much more detailed (it's likely to run in the hundreds of pages). Most observers predict that it will recommend some form of the following:

1) a continuation of the private option, potentially with some tweaks to implementation or policy details

2) opposition to the governor's bizarre idea to split the expansion population between traditional Medicaid and private plans, based on income, making the private option more bureaucratically complicated for no coherent reason

3) small premiums for some beneficiaries, which could be waived if beneficiaries follow certain practices regarding preventative care

4) reforms to nursing home and disabled care (potentially including implementation of CFCO)

5) reforms to contract procurement, which has been an ongoing fiasco at DHS (and potentially shifts to more in-state project management as opposed to out-of-state consultants)

6) potentially shifting some or all of the private option population to managed care

I'll update this post once the report is out, and offer some liveblog commentary of the meeting once it starts. 

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