How Hospitals Can Meet the Needs of Non-Covid Patients During the Pandemic
As there has been many waves of coronavirus cases for many months, health care has seemed to only point to helping those who have been impacted by the virus. Although there are still many cases that test positive for the virus, there has been a dramatic decline in other non-COVID related health issues. Read this blog post to learn more.
During the initial wave of the Covid-19 pandemic, hospitals worldwide diverted resources from routine inpatient critical care and outpatient clinics to meet the surge in demand. Because of the resulting resource constraints and fear of infection, clinicians and non-Covid patients deferred “non-urgent” visits, evaluations, diagnostics, surgeries and therapeutics. Indeed, early in the pandemic physicians and leading public health officials noted a dramatic decline in non-Covid-related health emergencies, including upwards of a 60% decrease in patients with acute myocardial infarctions and strokes.
Drawing on key principles from operations management and applying a health-systems perspective, we propose four strategies to facilitate care of non-Covid patients even as hospitals are stretched to absorb waves of patients with Covid-19.
1. Innovate outpatient management to reduce demand at downstream bottlenecks.
To reduce future bottlenecks in emergency departments (EDs) and hospitals, outpatient clinicians should expand their proactive management of patients at high risk of needing acute or inpatient services, such as those with poorly managed hypertension or diabetes, and triage patients with acute needs to EDs now in order to reduce more serious complications later. This will help reduce potential future spikes in demand on EDs and inpatient beds from non-Covid patients.
While most clinicians have rapidly adopted some form of telemedicine, they will need to increase their digital engagement with high-risk patients in a more targeted fashion. Clinicians should evaluate their patient panels to identify high-risk individuals and initiate telemedicine visits, rather than relying on patients to initiate contact, similar to the process for proactive disease management used by several community health care organizations.
Although high-risk patients will vary by specialty, targeted populations may include patients recently discharged from the hospital and those at high risk for hospitalization, including those with uncontrolled heart failure or active malignancy. To facilitate remote patient monitoring of high-risk patients, clinicians may opt to send telehealth kits tailored to patients’ medical and technological needs. These kits may include connected health devices such as blood pressure monitors, pulse oximeters, and heart rate monitors, and even mobile technology devices such as tablets or smart phones. To most effectively leverage telemedicine during the pandemic, clinicians must also promote multidisciplinary virtual collaboration across primary care clinicians, specialists, social workers, home health clinicians, administrative support, and patients and their caregivers.
2. Combine essential non-Covid inpatient services across hospitals.
To balance demand across hospitals, public health officials should apply a version of the logistics strategy known as “location pooling,” combining demands from multiple locations. Rather than each hospital in a region redundantly providing the full suite of essential inpatient non-Covid clinical services, each of these services should be concentrated at one location. For example, each region should have a single designated cancer center, transplant center, stroke center, and trauma center. Implementing this strategy is fraught with challenges as hospitals are currently organized independently and compete with one another for patients and revenue. Nevertheless, during the initial Covid-19 wave, several hospitals in Boston collaborated to share data on the availability of hospital beds to efficiently route patients based on their clinical need and the available capacity. And centralization of acute stroke care, in which patients are taken to central specialty hospitals rather than the nearest hospital, demonstrates both the feasibility and potential improved outcomes of utilizing this approach in several countries including the United States, Canada, the Netherlands, Denmark, and Australia.
Crises require all possible realizations of economies of scale. Location pooling mitigates variability in service-specific demand faced by each hospital. As demand falls for specific non-Covid services at an individual hospital (e.g., for acute stroke care), hospital administrators can close those services and repurpose the specialty capacity to care of Covid-19 patients with underlying conditions, as discussed below. If all hospitals implement this strategy, not all non-Covid services will be available at every hospital. However, location pooling draws demand from across hospitals, ensuring that as a given hospital loses some patients it gains others, allowing it to maintain sufficient census to remain fiscally viable.
Centrally coordinated regional organization, similar to mass casualty planning, is critical to ensure that each essential service remains fully operational for routine emergencies, while adapting to dynamic changes in the region’s hospital capacity. The number of hospitals to include in location pooling should be determined by weighing the tradeoff of efficiency gains from pooling across more locations versus inefficiencies from increased travel time incurred by patients and emergency medical services.
3. Group hospitalized Covid-19 patients by their underlying clinical conditions.
At the same time that hospitals should be location-pooling specialty services for non-Covid patients, to the extent possible they should place their Covid-19 patients who have serious underlying health issues (e.g., cardiac conditions) with other Covid-19 patients with the same condition. In each of these “cohorted wards,” redeployed clinical staff from the relevant specialty service, such as cardiology, can provide essential specialty care alongside clinicians addressing patients’ Covid-specific care needs.
While such cohorting limits efficiency gains from pooling all Covid-19 patients in one ward, it maintains specialty care for patients who still need it while reducing the additional inpatient capacity strain resulting from patients being dispersed across the hospital. Indeed, prior research demonstrates that displacing patients from cohorted specialty units is associated with prolonged hospital length of stay and more frequent readmissions.
4. Discharge patients into post-acute care based on Covid-19 status.
Nursing home, rehabilitation hospital, and long-term acute care facility leadership should collaborate to establish separate regional, specialized, post-acute care facilities for Covid-19 and non-Covid patients. Sending patients to specialized post-acute care facilities based on their Covid-19 status will facilitate discharge planning, improving patient flow out of the hospital for Covid-19 and non-Covid patients alike. This will relieve strain at ED and hospital bottlenecks while maintaining care quality. Furthermore, having dedicated post-acute care facilities for Covid-19 patients will preserve post-acute care capacity for those recovering from non-Covid illnesses, while lowering their risk of becoming infected.
Challenges to this model include ensuring timely access to Covid-19 testing and rapid test results to guide appropriate patient routing. To prevent discharge delays due to testing constraints, hospitals need to implement rapid tests more widely, and post-acute care facilities should designate quarantine areas for patients to receive care while awaiting results.
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These strategies will undoubtedly be challenging to implement. But now is the time to rethink health care delivery and adopt operations management strategies with demonstrated success that are most promising. This will allow us to be better prepared for future waves of the Covid-19 pandemic.
SOURCE; Song, H.; Ezaz, G.; Greysen, S. Ryan.; Halpern, S.; Kohn, R. (14 July 2020) "How Hospitals Can Meet the Needs of Non-Covid Patients During the Pandemic" (Web Blog Post). Retrieved from https://hbr.org/2020/07/how-hospitals-can-meet-the-needs-of-non-covid-patients-during-the-pandemic
Medicare 101: A Quick Guide For Employers
Medicare is a governmentfunded health insurance program for those aged 65 and above, those under 65 with certain disabilities, and those with End State Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS). Employers that offer group health insurance plans to their employees have an interest in learning how employees’ entitlement to Medicare benefits can affect the administration of those plans. We sat down to speak with Olivia Childs, a Senior Solutions Licensed Agent at Saxon Financial Services, to get some more information on Medicare for beginners.
When asked about the number one thing to keep in mind when trying to figure out your first steps with Medicare, Olivia commented, “Ask a licensed agent for assistance. Advertisements can be confusing, and everyone wants to make the right choice. Using my expertise, I take the fear out of the decision making, so my clients can make an informed decision concerning their healthcare.”
What are the different parts of Medicare?
- Part A is hospital insurance that helps cover inpatient care in a hospital, skilled nursing facility care, inpatient care in a skilled nursing facility (not custodial or long-term care), hospice care, and home health care. Most U.S. citizens qualify for zero premium Medicare Part A upon attainment of age 65.
- Part B is the actual ‘health’ coverage under Medicare. It helps cover physician visits, screenings and other aspects of out-patient medical care. Medicare Part B has a monthly premium to cover outpatient care which increases annually.
- Part C is a Medicare Advantage Plan. This is a plan that offers all of the benefits of Parts A and B, sometimes with Part D, through a private health insurer.
- Part D was established in 2003. Part D of the Medicare Program provides prescription drug coverage to Medicare beneficiaries. This drug coverage may be available in a standalone Prescription Drug Plan (PDP) or integrated with a Medicare Advantage Plan.
What is Original Medicare?
With original Medicare, your coverage is through Parts A and B. Part A includes inpatient and/or hospital coverage, while Part B includes outpatient and/or medical coverage. Through this type of Medicare, you are provided a red, white and blue card to show your providers when receiving treatment. While most doctors take Original Medicare coverage, it is important to check whether your provider participates. If you visit one that does,
then your Medicare card will limit how much you can be charged.
Through Original Medicare, you are responsible for a 20% coinsurance if you see a participating provider and after meeting your deductible. Some basic, key things to know about Original Medicare include that:
- For Medicare Supplement Insurance, you have the choice to pay an additional premium for a Medigap to cover Medicare cost-sharing.
- You do not need referrals to see a specialist.
- For drug coverage, you must sign up for a standalone prescription drug plan.
- It does not cover vision, hearing, or dental services.
What is Medicare Advantage?
Unlike Original Medicare, Medicare Advantage are private plans that contract with the federal government to provide Medicare benefits. These plans are also known as Medicare private health plans or Part C. Some of the most common types of plans are:
- Health maintenance Organizations (HMOs)
- Preferred provider Organizations (PPOs)
- Private Fee-For-Service (PFFS)
If you join a Medicare Advantage Plan, you will not use the red, white, and blue card when you go to the doctor or hospital. Instead, you will use the membership card your plan sends you to get health services covered. Plans must provide the same benefits offered by Original Medicare, but they may apply different rules, costs, and restrictions. They also may offer certain benefits that Medicare does not cover. Just like Original Medicare, there are some key items to be aware of:
- Your cost-sharing varies depending on plan. Usually pay a copayment for in-network care. Plans may charge a monthly premium in addition to Part B premium.
- You cannot enroll in a Medigap plan.
- You can typically only see in-network providers.
- You will also typically need a referral to see a specialist.
- For drug coverage, in most cases, the plan provides prescription drug coverage (you may be required to pay higher premium).
- It may cover additional services, including vision, hearing, and/or dental (additional benefits may increase your premium and/or other out-of-pocket costs).
- You will have an annual out-of-pocket limit. Plan pays the full cost of your care after you reach the limit.
If you sign up for Original Medicare and later decide you would like to try a Medicare Advantage Plan–or vice versa–be aware that there are certain enrollment periods when you are allowed to make changes.
Employer Requirements
Employers are required to file annual Centers for Medicare and Medicaid Reporting and Employee-Notice Distribution letters even if one employee has coverage under Medicare Parts A, B, or C. Usually companies receive letters from their insurance companies asking for a Federal Tax Identification number and the group size of employees each year.
If your company has 19 or fewer full- and part-time employees, Medicare is almost always primary. Here, it is essential that employees turning 65 enroll in Medicare Parts A and B. If they do not, generally they will have to pay anything that Medicare would have covered. If your company is larger, various rules determine whether your group plan is the primary or secondary payer. MSP requirements also apply for Medicare-eligible employees who are disabled or have end-stage renal disease.
Once per year, written notice distribution is required to all Medicare-eligible employees. This must inform the employee whether the employer’s prescription drug coverage is ‘creditable’ or ‘noncreditable.’ Notice can be sent electronically, but it is often easier to distribute in written format. These need to be sent before October 31.
It is a good idea for employers to provide employees with written details about their employer-provided coverage, which will help them decide how to handle their Medicare choices.
How does it work with COBRA?
COBRA coverage is usually offered when leaving employment; if the employee has COBRA and Medicare coverage, Medicare is the primary payor. If an employee has Medicare Part A only, signs up for COBRA coverage and waits until the COBRA coverage ends to enroll in Medicare Part B, he or she will have to pay a Part B premium penalty.
Employees should be disenrolled in COBRA once they turn 65. A number of Medicare beneficiaries have delayed enrolling in Medicare Part B, thinking that because they are paying for continued health coverage under COBRA, they do not have to enroll in Medicare Part B. COBRA-qualified beneficiaries who have delayed enrollment in Medicare Part B do not qualify for a special enrollment period to enroll in Part B after COBRA coverage ends.
According to the Department of Labor Bureau of Labor and Statistics, the number of workers age 65 and older has increased dramatically since the late 1990s. With that trend expected to continue, companies have an excellent opportunity to assist employees in their health insurance decisions. Navigating the ever-changing Medicare rules can be tricky.
However, with the help of a qualified Medicare specialist, the process can be rewarding for the employer and employees.
Positioning for Long-Term Success
Offering Medicare coverage to your employees can be a daunting, confusing, and tiring task – especially when you go about it alone. While articles like this one can be helpful in understanding what Medicare is, the logistics of actually implementing it as a solution for your employees is a whole other story.
Saxon Financial Advisors creates strategies that are built around you and your vision for the future. The key is to take the first step of reaching out to a professional and then letting us guide you along the path to a confident future. We don’t stop at just a plan. We take the journey with you, reassessing your life situation, changing needs and goals and ensuring that your plan continues to meet your future needs in an ever-changing world. We offer several helpful services to businesses, just like yours, including:
- Risk Management
- Tax Planning
- Education Planning
- Retirement Planning
- Estate Planning
- Business Planning
People are your most valued asset and our greatest reward. Our compassion for people drives us to operate differently, assessing the needs of the population alongside the vision and goals of your organization. At Saxon, we truly listen, engage, understand and advise solutions to help meet your overall company goals. Employee Benefits will have an impact on your organization from recruitment, retention and population wellness to productivity and your bottom line. To us, it isn’t the size of your organization that matters most, but rather the needs of the people within it.
For more information, contact Olivia Childs, a Senior Solutions Licensed Agent, at (513)904-5955 or ochilds@gosaxon.com.
About Your Advisor
Olivia Childs is a Senior Solutions Advisor at Saxon Financial. She graduated from the University of Cincinnati with a degree in Organizational Leadership. She was involved in the Human Resources department and a member of HR Succeeds, a mentor program with professionals and students. In her free time, Olivia volunteers at the Cincinnati Epilepsy Foundation. When it comes to helping her clients with Medicare, Olivia pointed out, “Healthcare is personal. I love being a resource for my clients to use to help them make the best decision concerning a Medicare plan.”
Not Connected with or endorsed by the U.S. government or the federal Medicare program.
Reminder: Medicare Part D Notices Are Due to CMS by Feb. 29
The federal Centers for Medicare & Medicaid Services (CMS) require disclosures regarding coverage that is either "creditable" or "non-creditable" each calendar year. The notice and disclosure deadline for those who provide prescription drug coverage is due February 29, 2020. Read this blog post to learn more about the Medicare Part D notice.
Each year, group health plan sponsors that provide prescription drug coverage to individuals eligible for Medicare Part D must disclose to the federal Centers for Medicare & Medicaid Services (CMS) whether that coverage is "creditable" or "non-creditable." Prescription drug coverage is "creditable" when it is at least actuarially equivalent to Medicare Part D prescription drug coverage.
The disclosure obligation applies to all plan sponsors that provide prescription drug coverage, even those that offer prescription drug coverage only to active employees and not to retirees. Calendar year plans must submit this year's disclosure by Feb. 29, 2020.
Background
Individuals who fail to enroll in Medicare Part D prescription drug coverage when first eligible may be subject to late enrollment penalties if they go 63 consecutive days or longer without creditable prescription drug coverage. Because of this potential penalty, both Medicare Part D-eligible individuals and the CMS need to know whether a group health plan's prescription drug coverage is creditable or non-creditable.
Plan sponsors that provide prescription drug coverage must furnish Part D-eligible individuals with a notice disclosing the creditable or non-creditable status of their coverage before the beginning of the Medicare Part D annual enrollment period and at certain other times.
Plan sponsors must also disclose to CMS, on an annual basis and at certain other times, whether the coverage they provide is creditable or non-creditable. The submission deadline for this year's disclosure to CMS by calendar year plans is approaching.
Creditable Coverage Disclosures to CMS
Plan sponsors generally must disclose creditable coverage status to CMS within 60 days after the beginning of each plan year. Disclosure is made using the Disclosure to CMS Form on the CMS website. An entity that does not offer outpatient prescription drug benefits to any Part D-eligible individual on the first day of its plan year is not required to complete the CMS disclosure form for that plan year. Plan sponsors that contract directly with Medicare as a Part D plan or that contract with a Part D plan to provide qualified prescription drug coverage are also exempt from the CMS disclosure requirement for individuals who participate in the Part D plan.
In addition to the annual disclosure, plan sponsors must submit a new disclosure form to CMS within 30 days following any change in the creditable coverage status of a prescription drug plan. This includes both a change in the coverage offered so that it is no longer creditable (or non-creditable) and the termination of a creditable coverage option. A new disclosure form must also be submitted to CMS within 30 days after the termination of a prescription drug plan.
The disclosure requirement applies to all plan sponsors that provide prescription drug coverage to Part D-eligible individuals, even those that do not make prescription drug coverage available to retirees.
Calendar year plans must submit this year's disclosure to CMS by Feb. 29, 2020.
| Is disclosure required If an employer doesn't offer retiree coverage? | ||
| All Part D-eligible individuals covered under an employer's prescription drug plan — regardless of whether the coverage is primary or secondary to Medicare Part D — should be included in the disclosure. "Part D-eligible individuals" are generally age 65 and older or under age 65 and disabled, and include active employees and their dependents, COBRA participants and their dependents, and retirees and their dependents. Even employers without retiree coverage may need to file the disclosure. |
Information Needed to Complete Disclosure
In preparing the disclosure to CMS, plan sponsors need to:
- Identify the number of prescription drug options offered to Medicare-eligible individuals. This is the total number of benefit options offered, excluding any benefit options the plan sponsor is claiming under the retiree drug subsidy (RDS) program (i.e., benefit options for which the plan sponsor is expected to collect the subsidy) or that are employer group waiver plans (EGWPs).
For example, a plan sponsor with a PPO and an indemnity option covering actives and an option for retirees for which it is receiving RDS would report two prescription drug options. - Determine the number of benefit options offered that are creditable coverage and the number that are non‑creditable.
- Estimate the total number of Part D-eligible individuals expected to have coverage under the plan at the start of the plan year (or, if both creditable and non-creditable coverage options are offered, estimate the total number of Part D-eligible individuals expected to enroll in each coverage category). This includes Part D-eligible active employees, retirees, and disabled individuals and any of their Part D-eligible dependents and any individuals on COBRA who are Part D eligible.
The estimate should not include any Part D-eligible retirees being claimed under the RDS program or retirees in an EGWP (because that coverage is Medicare Part D coverage).
Individuals who will become Part D eligible after the start of the plan year should not be included in the count for that year. However, they must be provided a notice of creditable or non-creditable coverage prior to their initial Part D enrollment period. - Provide the most recent calendar date on which the required notices of creditable or non-creditable coverage were provided.
| Why doesn't the disclosure requirement apply to EGWPs or retiree plans where employer is receiving RDS payments? | ||
| Employers that provide prescription drug coverage through a Medicare Part D employer group waiver plan are exempt from the disclosure requirement because an EGWP is Medicare Part D coverage.
An employer participating in the retiree drug subsidy program must have already certified to CMS that its drug coverage is creditable. |
In Closing
Plan sponsors should review the instructions carefully before completing the Disclosure to CMS Form to make sure that they have all necessary information, and calendar year plans should report the information by Feb. 29, 2020.
Richard Stover, FSA, MAAA, is a principal at HR advisory firm Buck. Leslye Laderman, JD, LLM, is a principal in the Knowledge Resource Center at Buck. This article originally appeared in the Feb. 5, 2020 issue of Buck's For Your Information. © 2020 Buck Global LLC. All rights reserved. Republished with permission.
SOURCE: Stover, R.; Laderman, L. (06 February 2020) "Reminder: Medicare Part D Notices Are Due to CMS by Feb. 29" (Web Blog Post). Retrieved from https://www.shrm.org/resourcesandtools/hr-topics/benefits/pages/reminder-medicare-part-d-notices-due-to-cms.aspx
New drug plan would curb exorbitant pharmaceutical costs
California Governor, Gavin Newsom has proposed a pharmaceutical plan to cut costs of pharmaceutical prescriptions. It was suggested that using low prices obtained by the state, could help other buyers. Read this blog to learn about how California Governor is purposing an attempt to lower costs for California residents.
California’s governor unveiled plans to establish a state-run generic-drug wholesaler, as part of a series of measures that together would constitute one of the furthest-reaching attempts to curb pharmaceutical costs in the U.S.
Gov. Gavin Newsom on Thursday also proposed creating a single market that would allow drug buyers to pool their bargaining power to drive down costs. And Newsom suggested using low prices obtained by the state’s Medicaid program to aid other buyers, among other steps.
The most populous U.S. state, California has a history of using its economic muscle to try to influence national policy on everything from auto emissions to health care. The drug-pricing proposals, which in some cases appear to require new law, are likely to be opposed by a pharmaceutical industry that has formidable economic and legal wherewithal of its own.
“These nation-leading reforms seek to put consumers back in the driver seat and lower health care costs for every Californian,” Newsom, a Democrat, said in a statement.
The plans, released as part of the state’s proposed 2020-2021 budget, are almost certain to face substantial practical, political and legal hurdles. For example, the proposal to create a state-run drug label would rely on drug companies to supply inventory on a contract basis.
Companies could balk at that notion if it stands to further compress their margins. Major generic manufacturers, including Mylan NV and Teva Pharmaceutical Industries, have struggled to turn a profit on some widely used medications. For higher-cost generic drugs, there can be few competing manufacturers with the licenses to produce the pills for the U.S. market.
Creating a single buying pool could run into difficulties, as well. Newsom’s proposal says state programs, health insurers and private employers would band together as a sole buyer, and that drugmakers would have to offer their products at one price to the entire market.
But that could limit patient access to medications if pricing disputes lead drug companies to withhold their products. In Europe, negotiations between drugmakers and government health programs have resulted in some expensive drugs not being available, one of the trade-offs for the continent’s typically lower costs. It’s unclear if California could successfully hold together a large pool of independent buyers in the face of pressure from patients unable to access treatments.
SOURCE: Bloomberg News (09 January 2020) "New drug plan would curb exorbitant pharmaceutical costs" (Web Blog Post). Retrieved from benefitnews.com/articles/new-c-a-drug-plan-would-curb-exorbitant-pharmaceutical-costs
A look at how the opioid crisis has affected people with employer coverage
The opioid crisis is affecting more and more people each day. Discover how the opioid crisis affects you with this study on employer coverage.
With deaths from opioid overdose rising steeply in recent years, and a large segment of the population reporting knowing someone who has been addicted to prescription painkillers, the breadth of the opioid crisis should come as no surprise, affecting people across all incomes, ages, and regions. About four in ten people addicted to opioids are covered by private health insurance and Medicaid covers a similarly large share.
Private insurance covers nearly 4 in 10 non-elderly adults with opioid addiction
In this analysis and a corresponding chart collection, we use claims data from large employers to examine how the opioid crisis has affected people with large employer coverage, including employees and their dependents. The analysis is based on a sample of health benefit claims from the Truven MarketScan Commercial Claims and Encounters Database, which we used to calculate the amounts paid by insurance and out-of-pocket on prescription drugs from 2004 to 2016. We use a sample of between 1.2 and 19.8 million enrollees per year to analyze the change from 2004 to 2016 in opioid-related spending and utilization.
We find that opioid prescription use and spending among people with large employer coverage increased for several years before reaching a peak in 2009. Since then, use of and spending on prescription opioids in this population has tapered off and is at even lower levels than it had been more than a decade ago. The drop-off in opioid prescribing frequency since 2009 is seen across people with diagnoses in all major disease categories, including cancer, but the drop-off is pronounced among people with complications from pregnancy or birth, musculoskeletal conditions, and injuries.
Meanwhile, though, the cost of treating opioid addiction and overdose – stemming from both prescription and illicit drug use – among people with large employer coverage has increased sharply, rising to $2.6 billion in 2016 from $0.3 billion 12 years earlier, a more than nine-fold increase.
Trends in prescription opioid use & spending among people with large employer coverage
Opioid prescription use among people with large employer coverage is highest for older enrollees: 22% of people age 55-64 had at least one opioid prescription in 2016, compared to 12% of young adults and 4% of children. Women with large employer coverage are somewhat more likely to take an opioid prescription than men (15% compared to 12%). Opioid prescription use among people with large employer coverage is also higher in the South (16%) than in the West (12%) or Northeast (11%).
Among people with large employer coverage, older enrollees are more likely to have an opioid prescription
Among people with large employer coverage, the frequency of opioid prescribing increased from 2004 (when 15.7% of enrollees had an opioid prescription) to 2009 (when 17.3% did). After reaching a peak in 2009, the rate of opioid prescribing began to fall. By 2014, the share of people with large employer coverage who received an opioid prescription (15.0%) was lower than it had been a decade earlier, and by 2016, the share was even lower, at 13.6% (a 21% decline since 2009).
The share of people with large employer coverage taking opioid prescriptions is at its lowest levels in over a decade
Among people with large employer coverage, this pattern (of increasing opioid prescription use through the late 2000s, followed by a drop-off through 2016) is similar across most major disease categories. Some of the steepest declines in opioid prescription use since 2009 were among people with complications from pregnancy or childbirth, musculoskeletal conditions, and injuries. The share of people experiencing complications from pregnancy or childbirth who received an opioid prescription peaked in 2007, when 35% received an opioid prescription, but this share dropped to 26% in 2016. Similarly, in 2007, 37% of people with large employer coverage who had a musculoskeletal condition received an opioid prescription, but the share dropped to 30% by 2016. The same decline can be seen among people with large employer coverage who experienced injuries and poisonings (37% in 2009, down to 30% in 2016).
Opioid use declined across disease categories, particularly pregnancy, musculoskeletal diseases, and injuries
We also see a sharp decline in the use of opioid prescriptions among people with cancer diagnoses, particularly in the most recent couple of years. In 2016, 26% of people with large employer coverage who had a cancer diagnosis received at least one opioid prescription, down from 32% in 2007. Despite declines in opioid prescribing for musculoskeletal conditions, people with large employer coverage who have musculoskeletal diagnoses still receive opioid medications more frequently (30%) than those with cancer diagnoses (26%).Overall in 2016, among those receiving an opioid prescription, a slightly larger share received only a single prescription in that year (61%) than did in 2006, a decade earlier (58%). The average number of prescriptions each person received also rose from 2004 until 2010 and then fell again, but this measure is imperfect because it does not adjust for the length of the supply or the strength of the drug received.
In total, large employer plans and their enrollees spent $1.4 billion in 2016 on opioid prescription painkillers, down 27% from peak spending of $1.9 billion in 2009. In 2016, $263 million, or 19% of total opioid prescription drug spending was paid out-of-pocket by enrollees.
Spending on opioid prescriptions peaked in 2009
Opioid prescriptions have represented a small share of total health spending by large employer plans and enrollees.
Treatment for Opioid Addiction & Overdose among People with Large Employer Coverage
In 2016, people with large employer coverage received $2.6 billion in services for treatment of opioid addiction and overdose, up from $0.3 billion in 2004. Of the $2.6 billion spent on treatment for opioid addiction and overdose in 2016 for people with large employer coverage, $1.3 billion was for outpatient treatment, $911 million was for inpatient care, and $435 million was for prescription drugs. In 2016, $2.3 billion in addiction and overdose services was covered by insurance and $335 million was paid out-of-pocket by patients. (This total only includes only payments for services covered at least in part by insurance, not services that are paid fully out-of-pocket and not billed to insurance, so it is likely an undercount of opioid addiction and overdose treatment expenses by this population.)
The cost of treating opioid addiction and overdose has risen even as opioid prescription use has fallen
Spending on treatment for opioid addiction and overdose represents a small but growing share of overall health spending by people with large employer coverage. In 2016, treatment for opioid addiction and overdose represented about 1% of total inpatient spending by people with large employer coverage and about 0.5% of total outpatient spending. In 2004, treatment for opioid addiction and overdose represented about 0.3% of total inpatient spending and less than 0.1% of total outpatient spending. On average, inpatient and outpatient treatment for opioid addiction and overdose added about $26 per person to the annual cost of health benefits coverage for large employers in 2016, up from about $3 in 2004.
The bulk of the total $2.6 billion in spending for treatment of opioid addiction and overdose among people with large employer coverage was treatment for young adults, totaling $1.6 billion in 2016, even though young adults are prescribed opioids less often than older adults. Males also used more treatment than women ($1.6 billion vs $1.0 billion).
Spending on opioid addiction and overdose treatment is mostly concentrated among younger people
The bulk of spending by people with large employer coverage on inpatient and outpatient treatment for opioid addiction and overdose was for employees’ children (53%) or spouses (18%), while just under a third (29%) was for employees themselves.
Among people with large employer coverage who had outpatient spending on treatment for opioid addiction and overdose, their average outpatient expenses totaled $4,695 (of which $670 was paid out-of-pocket) in 2016. Among those with inpatient spending on treatment for opioid misuse, their average inpatient expenses totaled $16,104 (with $1,628 paid out-of-pocket) in 2016. On average, inpatient expenses have risen sharply, up from $5,809 in 2004.
In 2016, 342 people per 100,000 large group enrollees received treatment for opioid overdose or addiction, including 67 people per 100,000 who received treatment in an inpatient setting.
Discussion
Among people with large employer coverage, utilization of opioid prescription painkillers has declined somewhat in recent years. Use of and spending on prescription opioids by this group peaked in 2009 and has since dropped to the lowest levels in over a decade. Across most major disease categories, we see a similar pattern of the frequency of opioid prescription use rising until the late 2000s and then declining through 2016.
Despite declining rates of opioid prescribing to those with employer coverage, spending on treatment for opioid addiction and overdose has increased rapidly, potentially tied to growing illicit use and increased awareness of opioid addiction. Opioid addiction and overdose treatment – the bulk of which is for dependents of employees – represents a small but growing share of overall employer health spending.
Methods
We analyzed a sample of claims obtained from the Truven Health Analytics MarketScan Commercial Claims and Encounters Database (Marketscan). The database has claims provided by large employers (those with more than 1,000 employees); this analysis does not include opioid prescription or addiction treatment for other populations (such as the uninsured or those on Medicaid or Medicare). We used a subset of claims from the years 2004 through 2016. In 2016, there were claims for almost 20 million people representing about 23% of the 85 million people in the large group market. Weights were applied to match counts in the Current Population Survey for large group enrollees by sex, age, state and whether the enrollee was a policy holder or dependent. People 65 and over were excluded.
Over 14,000 national drug codes (NDC) were defined as opiates. In general, we defined “prescription opioids” as those with a primary purpose of treating pain. Only prescriptions classified under the controlled substance act are included. We excluded from this category Methadone, Suboxone (Buprenorphine with Naloxone), and other drugs commonly used to treat addiction. We also excluded medications not commonly prescribed (such as Pentazocine). Each opiate script was counted as a single prescription regardless of the quantity or strength of that prescription. The Marketscan database only includes retail prescriptions administered in an outpatient setting. Disease categories are defined by AHRQ’s chronic condition indicators, and based on the diagnosis an enrollee receives.
In our analysis of opioid addiction and overdose treatment, we include medications used to treat overdose (e.g. Naloxone) and drugs used to treat addiction (e.g. Methadone and Suboxone). We also include inpatient and outpatient medical services to treat opioid addiction or overdose, identified by ICD-9 and ICD-10 diagnosis codes. Midway through 2015, Marketscan claims transitioned from ICD-9 to ICD-10. While both systems classify diagnoses, there is no precise crosswalk between the two. In consultation with a clinician, we selected both ICD-9 and ICD-10 codes which are overwhelmingly used for opioid addiction or signify misuse. A list of these ICD codes is available upon request. Because of the change in coding systems, it is not possible to tracks trends between 2014 and 2016. Diagnoses related to heroin abuse were included as opiate abuse.
Because there is no precise way to identify costs associated with opioid addiction and overdose treatment, some of our rules for inclusion lead to an underestimate, while others lead to an overestimate. In general, we elected a conservative approach. For example, in some cases, opioid abuse diagnoses may be classified under a broader drug abuse diagnosis and therefore are not captured. Additionally, we do not include the costs associated with diagnoses that commonly arise from opioid abuse, such as respiratory distress or endocarditis, unless an opioid abuse diagnosis was also present. However, if a claim included an opioid abuse diagnosis along with other diagnoses, we included spending for all procedures during that day, even if some of those interventions were to treat concurrent medical conditions unrelated or indirectly related to opioid abuse. If an enrollee paid fully out-of-pocket and did not use their insurance coverage, this spending is also not included. Overall, we think these assumptions lead to an underestimate of the costs associated with opioid addiction and overdose treatment for the large employer coverage population.
SOURCE:
Cox C (24 May 2018). "A look at how the opioid crisis has affected people with employer coverage" Web Blog Post]. Retrieved from address https://www.healthsystemtracker.org/brief/a-look-at-how-the-opioid-crisis-has-affected-people-with-employer-coverage/#item-start
The Opioid Epidemic and Medicaid’s Role in Facilitating Access to Treatment
The Kaiser Family Foundation has released the key findings in Medicaid's role in the opioid epidemic. Get the facts, statistics, and visual charts here.
Key Findings
In 2016, 1.9 million nonelderly adults in the United States had an opioid addiction. Medicaid covers 4 in 10 nonelderly adults with opioid addiction. This brief examines Medicaid’s role in facilitating access to treatment for opioid addiction. Key findings include:
- Among nonelderly adults with opioid addiction, those with Medicaid were twice as likely as those with private insurance or no insurance to have received treatment in 2016.
- Medicaid facilitates access to treatment by covering numerous inpatient and outpatient treatment services, as well as medications prescribed as part of medication-assisted treatment.
- States use Medicaid Section 1115 waivers and other program authorities to expand treatment options for enrollees with opioid addiction.
While additional states expanding Medicaid could increase coverage and access, support for new work and premium requirements could impose barriers to obtaining and maintaining Medicaid coverage that may compromise efforts to address the opioid crisis.
Introduction
The opioid epidemic continues to escalate, with 1.9 million nonelderly adults having an opioid addiction in 2016.1 Opioid addiction is often associated with comorbid physical and mental health conditions and high levels of health care services utilization. These issues have worsened throughout the past decade as the opioid epidemic has escalated. In 2016, there were 42,249 opioid overdose deaths in the United States, more than quadruple the number in 2001, and the number of deaths from heroin and fentanyl have surpassed the number due to prescription opioids. The Trump administration has stated that addressing the opioid epidemic is a key priority.
Medicaid has historically filled critical gaps in responding to public health crises, such as the AIDS epidemic in the 1980s, the Flint water crisis, and numerous natural disasters since the program originated. As with these other public health crises, Medicaid helps to address the opioid epidemic by providing access to coverage and necessary health care. The program covers a disproportionate share of individuals with opioid addiction and facilitates access to numerous treatment services. Additionally, as of February 2018, 33 states have adopted the Medicaid expansion, with enhanced federal funding, to cover adults up to 138% of the federal poverty level ($16,753/year for an individual in 2018). All Medicaid expansion benefit packages must include behavioral health services, including mental health and substance use disorder services, which has increased access to care for many people with opioid addiction.
Based on data from the 2016 National Survey on Drug Use and Health, this brief describes nonelderly adults with opioid addiction, including their demographic characteristics and insurance statuses, and compares receipt of various treatment services among those with Medicaid to those with private insurance and those who are uninsured. It also describes Medicaid financing for opioid treatment and the ways in which Medicaid promotes access to treatment for enrollees with opioid addiction.
Characteristics of Nonelderly Adults with Opioid Addiction
Individuals with opioid addiction are predominantly white, male, and young. In 2016, nearly 3 in 4 (74%) nonelderly adults with opioid addiction were white (Figure 1). Those with opioid addiction were also more likely to be male (58%), although the epidemic has touched an increasingly large share of women in recent years, including many pregnant women.2,3 Additionally, nearly half (48%) were between ages 18 and 34, and another one-third (32%) were between ages 35 and 49. This age distribution is comparable to those for other types of addiction, including addictions to both drugs and alcohol, which generally affect young adults more than they affect other age groups.4
Figure 1: Race, Gender, and Age of Nonelderly Adults with Opioid Addiction, 2016
The majority of nonelderly adults with opioid addiction are employed, but many have low incomes. In 2016, nearly 6 in 10 (56%) were employed; however, there was wide variability with regard to the types of jobs and industries in which they work, their salaries, and the number of hours they worked each week (Figure 2). Of those who were employed, about 7 in 10 (72%) reported working at a full-time job during the previous week.5 One in ten were unemployed and an additional 13% were unable to work because of a disability, reflecting the complicated health needs of individuals with opioid addiction, many of whom may have developed an addiction to opioids after using opioids to treat their chronic pain.6 Adults with opioid addiction are also more likely than other adults to have many other health conditions, including hepatitis, HIV, and mental illness,7 all of which may hinder their ability to work. As a result of these and other factors, more than half of nonelderly adults with opioid addiction had low incomes in 2016, and over a quarter (28%) lived below the poverty line (Figure 2).
Figure 2: Employment Status and Income of Nonelderly Adults with Opioid Addiction, 2016
Medicaid covers a disproportionate share of nonelderly adults with opioid addiction, and an even greater share of those with low incomes. In 2016, nearly 4 in 10 (38%) were covered by Medicaid and a similar share (37%) had private insurance. Approximately 1 in 6 (17%) was uninsured (Figure 3). Low-income nonelderly adults with opioid addiction are typically less likely than adults with higher incomes to have jobs that offer health insurance.8 In 2016, over half (55%) were covered by Medicaid, while only 13% had private insurance. Nearly 1 in 4 (24%) were uninsured (Figure 3), although if they lived in states that expanded Medicaid, they would likely be eligible for coverage.
Figure 3: Insurance Status of Nonelderly Adults with Opioid Addiction, 2016
Utilization of Opioid Addiction Treatment Services
Overall receipt of treatment for opioid addiction is low. In 2016, fewer than 3 in 10 (29%) adults with opioid addiction received any treatment for their addiction (Figure 4).9 Opioid addiction treatment can be delivered in an inpatient or outpatient setting and can be provided in numerous types of facilities, including hospitals, drug or alcohol rehabilitation facilities (for either inpatient or outpatient services), mental health centers, or private doctors’ offices. Depending on the severity of their addictions, some patients begin in an inpatient facility and then later transition to an outpatient setting, while others require only outpatient treatment. Overall, in 2016, 16% of nonelderly adults with opioid addiction received inpatient treatment, while 25% received outpatient treatment.
Figure 4: Past-Year Opioid Addiction Treatment Among Nonelderly Adults with Opioid Addiction by Insurance Status, 2016
Among nonelderly adults with opioid addiction, those with Medicaid are significantly more likely than those with private insurance or those who are uninsured to receive treatment. In 2016, those with Medicaid were twice as likely as those with private insurance or no insurance to receive any treatment for their addiction (43% vs. 21% and 23%). Nearly a quarter of adults with opioid addiction who had Medicaid coverage received inpatient care, while nearly 4 in 10 received outpatient care. In contrast, just over 1 in 10 (13%) of those with private insurance received any inpatient treatment and only 17% received any outpatient treatment. Those who were uninsured received treatment at rates similar to those with private insurance. These differences in utilization highlight the significant role Medicaid plays in increasing access to treatment.
Figure 5: Past-Year Outpatient Addiction Treatment Among Nonelderly Adults with Opioid Addiction by Insurance Status, 2016
Adults with opioid addiction who were covered by Medicaid were significantly more likely to have received treatment at an outpatient rehabilitation center or at an outpatient mental health center than those with private insurance or those who were uninsured (Figure 5). In 2016, adults with opioid addiction covered by Medicaid were three times more likely to have received treatment at these facilities than privately insured or uninsured adults. At the same time, utilization of services at private physician’s offices did not differ significantly across the three groups. Higher rates of utilization of outpatient treatment services by those with Medicaid may reflect the greater push for outpatient community-based behavioral health treatment in recent decades.10
Medicaid’s Role in Covering Opioid Addiction Treatment Services
State Medicaid programs cover numerous addiction treatment services that fit into several state plan categories, including outpatient treatment, inpatient treatment, prescription drugs, and rehabilitation. The standard of care for opioid addiction is medication-assisted treatment (MAT), which combines one of three medications (methadone, buprenorphine, or naltrexone) with counseling and other support services. All state Medicaid programs cover at least one medication used as part of MAT,11 and most cover all three of these medications. State Medicaid programs also cover many counseling and other support services, delivered either as part of MAT or separately. Most of these services are delivered at state option and include detoxification, intensive outpatient treatment, psychotherapy, peer support, supported employment, partial hospitalization, and inpatient treatment.12
Several policy changes have allowed states to obtain waivers to allow Medicaid funding of substance use treatment services at institutions for mental disease (IMDs). Federal law has historically prohibited Medicaid payments for services provided to adults age 21-64 in IMDs as a way to preserve state financing of these services. However, in April 2016, CMS issued final Medicaid managed care regulations that allow federal matching funds for managed care capitation payments for services in an IMD for up to 15 days in a month in lieu of services covered under the state plan and at the enrollee’s option.13 Additionally, in July 2015, the Centers for Medicare & Medicaid Services (CMS) released guidance stating that states could request federal funding for substance use disorder services delivered to nonelderly adults in IMDs through Section 1115 demonstration waivers. On November 1, 2017, CMS issued revised guidance that continues to allow states to seek Section 1115 waivers to pay for services provided in IMDs, including substance use disorder services. A number of states have sought waivers of the IMD exclusion specifically to expand treatment options for substance use disorder services. As of March 2018, CMS has approved waiver requests in 10 states to provide substance use disorder services in an IMD, and 10 states have waiver applications pending with CMS.14
Many states have also applied for other Medicaid Section 1115 behavioral health waivers focused on treating individuals with addiction, including opioid addiction. CMS has approved community-based benefit expansions proposed in Section 1115 waivers, which enable states to provide additional services to individuals with addiction, such as supportive housing, supported employment (such as job coaching), and peer recovery coaching. Additionally, CMS has approved waivers that allow states to expand Medicaid eligibility to cover additional populations with behavioral health needs, to provide home and community-based services, and to implement certain delivery system reforms, such as physical and behavioral health integration and alternative payment models.
Because of the large number of Medicaid enrollees with opioid addiction and the breadth of treatment services that Medicaid covers, Medicaid finances a substantial proportion of addiction treatment. In 2014, Medicaid financed 21% of all addiction treatment, which was more than the share covered by all private insurers combined (18%). Nine percent of all spending on addiction treatment came from out-of-pocket payments (Figure 6).15
Figure 6: Proportion of Total Spending on Addiction Treatment Services in 2014, by Payer
Looking Ahead
Medicaid plays a major role in facilitating access to inpatient and outpatient treatment services for individuals with opioid addiction. Nonelderly adults with Medicaid were more likely than those without insurance to receive various types of opioid addiction treatment and had better access to treatment than those with private insurance. Furthermore, despite the IMD payment exclusion, individuals with Medicaid were more likely than privately insured individuals to receive inpatient treatment.
As the opioid epidemic continues to worsen, particularly as fentanyl has become more pervasive,16 states are increasingly looking to Medicaid to expand treatment options to stem the crisis. In addition to covering MAT medications and numerous other treatment services, states are seeking waivers to allow payment for opioid treatment services provided in IMDs, to expand coverage of community-based benefits to support treatment and recovery, and better integrate behavioral health services, including substance use disorder services, with physical health services.
Non-expansion states can improve access to treatment by expanding Medicaid, which would enable them to cover many people with opioid addiction who are currently uninsured. At the same time, using 1115 waivers to impose new requirements in Medicaid, including work requirements and premiums, could compromise efforts to address the opioid epidemic. Although some states exempt people in addiction treatment from work requirements and other states count treatment as work hours, other states do not have such exemptions. Additional reporting requirements coupled with new premium requirements may also make it more difficult for eligible individuals to enroll in Medicaid and for those currently enrolled to keep their coverage. Utilization of treatment by adults with an opioid addiction is already low; imposing new barriers to obtaining and maintaining Medicaid could further impede those battling opioid addiction from getting the care they need.
This article was brought to you from the Kaiser Family Foundation on April 11,2018.
Medicare Advantage payments to see 3.4 percent increase next year
The U.S. agency that oversees Medicare said it will increase payments to privately run health plans for the elderly by an average of 3.4 percent next year, almost double the amount it had previously estimated.
That’ll be a boon for insurers such as UnitedHealth Group Inc. and Humana Inc. that have big businesses selling the private plans, known as Medicare Advantage. Including changes based on how sick or healthy people are, the total increase in payments to insurers is estimated to be about 6.5 percent, on average, the Centers for Medicare and Medicaid Services said in a statement Monday.
Medicare Advantage is an important source of growth for health insurers as the U.S. population ages and more people opt for the private plans, rather than the traditional Medicare program. About 21.4 million people are enrolled in the private plans, while 37.7 million rely on standard Medicare.
Medicare Advantage has drawn plenty of interest from both startups and established firms. Walmart Inc. may be seeking a broader partnership with Humana Inc. in part to benefit from growing enrollment in the plans, Bloomberg reported late last week. CVS Health Corp. agreed to acquire Aetna Inc. late last year in a bet in part on providing better care for seniors.
Source: Tracer Z. (3 April 2018). "Medicare Advantage payments to see 3.4 percent increase next year" [Web Blog Post]. Retrieved from Benefits Pro.
Understanding the Intersection of Medicaid and Work
Sometimes, healthcare is confusing. We know this, which is why today we are focusing on Medicaid and work. Check out the snippet below, and check out the link for the full article.
Medicaid is the nation’s public health insurance program for people with low incomes. Overall, the Medicaid program covers one in five Americans, including many with complex and costly needs for care. Historically, nonelderly adults without disabilities accounted for a small share of Medicaid enrollees; however, the Affordable Care Act (ACA) expanded coverage to nonelderly adults with income up to 138% FPL, or $16,642 per year for an individual in 2017. As of December 2017, 32 states have implemented the ACA Medicaid expansion.1 By design, the expansion extended coverage to the working poor (both parents and childless adults), most of whom do not otherwise have access to affordable coverage. While many have gained coverage under the expansion, the majority of Medicaid enrollees are still the “traditional” populations of children, people with disabilities, and the elderly.
Some states and the Trump administration have stated that the ACA Medicaid expansion targets “able-bodied” adults and seek to make Medicaid eligibility contingent on work. Under current law, states cannot impose a work requirement as a condition of Medicaid eligibility, but some states are seeking waiver authority to do so. These types of waiver requests were denied by the Obama administration, but the Trump administration has indicated a willingness to approve such waivers. This issue brief provides data on the work status of the nearly 25 million non-elderly adults without SSI enrolled in Medicaid (referred to as “Medicaid adults” throughout this brief) to understand the potential implications of work requirement proposals in Medicaid. Key takeaways include the following:
- Among Medicaid adults (including parents and childless adults — the group targeted by the Medicaid expansion), nearly 8 in 10 live in working families, and a majority are working themselves. Nearly half of working Medicaid enrollees are employed by small firms, and many work in industries with low employer-sponsored insurance offer rates.
- Among the adult Medicaid enrollees who were not working, most report major impediments to their ability to work including illness or disability or care-giving responsibilities.
- While proponents of work requirements say such provisions aim to promote work for those who are not working, these policies could have negative implications on many who are working or exempt from the requirements. For example, coverage for working or exempt enrollees may be at risk if enrollees face administrative obstacles in verifying their work status or documenting an exemption.
Get the full report and findings.
SOURCE: Kaiser Family Foundation (5 January 2018). "Understanding the Intersection of Medicaid and Work" [Web Blog Post]. Retrieved from address https://www.kff.org/medicaid/issue-brief/understanding-the-intersection-of-medicaid-and-work/
Some States Roll Back ‘Retroactive Medicaid,’ A Buffer For The Poor — And For Hospitals
From Kaiser Health News, let's take a look at the latest regarding Medicaid.
If you’re poor, uninsured and fall seriously ill, in most states if you qualify for Medicaid — but weren’t enrolled at the time — the program will pay your medical bills going back three months. It protects hospitals, too, from having to absorb the costs of caring for these patients.
But a growing number of states are rescinding this benefit known as “retroactive eligibility.” On Nov. 1, Iowa joined three states that have eliminated retroactive coverage for some groups of Medicaid patients since the Affordable Care Act passed. Each state had to secure approval by the federal government.
Retroactive eligibility has been a feature of Medicaid for decades, reflecting the program’s emphasis on providing a safety net for poor, disabled and other vulnerable people. In contrast to private insurance, determining Medicaid eligibility can be complex and the application process daunting, advocates say. A patient’s medical condition also may keep families from applying promptly for coverage.
All four states — Arkansas, Indiana and New Hampshire, in addition to Iowa — have expanded Medicaid under the health law, which allowed states to include adults with incomes up to 138 percent of the federal poverty level, or about $16,000 for one person. So, in theory, most adults are required to have insurance under the ACA. In practice, each state still has a significant number of uninsured, ranging from 5 to 8 percent of the population.
The retroactive coverage “can compensate for the sorts of errors and lapses that can so easily occur on the part of both the applicant and the government bureaucracy” that delay applications, said Gordon Bonnyman, staff attorney at the Tennessee Justice Center, a public interest law firm that represents low-income and uninsured residents.
State and federal officials say eliminating the retroactive coverage helps encourage people to sign up for and maintain coverage when they’re healthy rather than waiting until they’re sick to enroll. It also fits into federal officials’ efforts to make Medicaid, the federal-state program that provides health care for low-income adults and children, more like private insurance.
But consumer advocates and health care providers say the shift will saddle patients with hefty medical bills and leave hospitals to absorb more uncompensated care when patients can’t pay. Some worry this could be the start of a trend.
In Iowa, the change applies to just about anyone coming into Medicaid — except for pregnant women and children under age 1. The change will affect up to 40,000 residents annually and save the program more than $36 million a year.
“We’re making it a lot more likely that Medicaid-eligible members are going to incur significant medical debt,” said Mary Nelle Trefz, health policy associate at the Child & Family Policy Center in Des Moines, whose organization opposed the change.
When someone has a traumatic health event, the initial focus is to get them stabilized, not figure out how to pay for it, said MaryBeth Musumeci, associate director of the Program on Medicaid and the Uninsured at the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)
Patients may neglect to apply immediately for Medicaid, leaving them financially responsible for days or months of care they received before they got in their application, even though they may have been eligible for Medicaid all along.
That’s not the only issue, advocates say. Unlike the commercial insurance market where re-enrollment through someone’s employer is routine, Medicaid requires that beneficiaries’ eligibility be reassesed every year.
“People fall through the cracks,” said Andrea Callow, associate director of Medicaid initiatives at Families USA, a consumer advocacy group.
In addition, complications can arise for people who might need Medicaid coverage for long-term care services. “The criteria are complicated. For a layperson to find those criteria and figure out if they’re eligible” is challenging and they may need extra time, said Musumeci. Once patients have secured coverage, they may already have accrued hefty expenses.
Maybe so, but some people argue that a 90-day retroactive eligibility guarantee is counterproductive.
“We’re trying to get people to behave more responsibly, not less responsibly,” said Gail Wilensky, an economist who oversaw the Medicaid and Medicare programs in the early 1990s under President George H.W. Bush. “That is not the signal you’re sending” with three months of retroactive eligibility. A 30-day time frame is more reasonable, Wilensky said.
In contrast to Iowa, the waivers in Arkansas, Indiana and New Hamsphire generally apply only to adults who gained coverage under the law’s Medicaid expansion. (Indiana’s waiver also applies to other groups.)
Kentucky has a request pending that, like Iowa, would eliminate retroactive Medicaid eligibility except for pregnant women and children under 1, according to KFF.
Under federal law, officials can waive some Medicaid coverage rules to give states flexibility to experiment with different approaches to providing services. And retroactive eligibility waivers in Medicaid are hardly new. A few states like Tennessee have had them in place for years. Tennessee officials eliminated retroactive eligibility for all Medicaid beneficiaries in 1994 when the state significantly expanded coverage under TennCare, as Medicaid is known there. At the time, the state even allowed uninsured people to buy into the program who wouldn’t otherwise qualify based on income, said Bonnyman.
“There was no reason for anybody to be uninsured except undocumented immigrants,” said Bonnyman. “It didn’t seem to have the potential for harm.”
But state officials revamped that program after serious financial problems. Eligibility for TennCare has become more restrictive again.
Other states that waived retroactive coverage for at least some Medicaid groups include Delaware, Maryland, Massachusetts and Utah, according to the Kaiser Family Foundation.
Bonnyman said his group frequently works with Medicaid beneficiaries who have medical bills they can’t afford that accumulated during the months before they applied for Medicaid.
“If you’re a moderate- to low-income working family, one or two days in the hospital is enough to ruin you financially,” he said.
You can read the original article here.
Source:
Andrews M. (14 November 2017). "Some States Roll Back ‘Retroactive Medicaid,’ A Buffer For The Poor — And For Hospitals" [Web blog post]. Retrieved from address https://khn.org/news/some-states-roll-back-retroactive-medicaid-a-buffer-for-the-poor-and-for-hospitals/