HealthCare Roundtable e-News – June 10, 2024

 

Top News

Judge Rules in Favor of SCAN Health Plan in CMS Medicare Advantage Rating Dispute

A federal judge ruled that the federal government improperly lowered SCAN Health Plan’s 2024 Medicare Advantage star ratings, costing the California-based insurer hundreds of millions in government bonuses. This decision mandates over $250 million to be restored to SCAN, which insures 270,000 Medicare Advantage members, and could pave the way for other insurers to reclaim significant bonus amounts. The Centers for Medicare and Medicaid Services (CMS) did not comment on the case. SCAN’s CEO Sachin Jain highlighted that star ratings directly impact the benefits and payments to healthcare providers, stressing that the unexpected drop from 4.5 to 3.5 stars would have had severe repercussions.

The star rating system for Medicare Advantage plans, which influences substantial government bonuses, has faced criticism for being flawed. Independent experts and the Medicare Payment Advisory Commission argue that the system can be manipulated and does not accurately reflect care quality, particularly for lower-income and at-risk populations. Despite previous adjustments intended to stabilize ratings, insurers like SCAN have claimed improper application of these changes led to drastic rating fluctuations. The judge’s ruling against the government for not adhering to its regulations marks a significant precedent for ongoing and future litigation by other insurers similarly affected by rating recalculations.

 

Senators Send Letter Urging Departments to Finalize Mental Health Parity Rules

U.S. Senators Chris Murphy (D-CT), Alex Padilla (D-CA), Peter Welch (D-VT), Edward Markey (D-MA), Tina Smith (D-MN), Amy Klobuchar (D-MN), and Ben Ray Lujan (D-NM) sent a letter to Secretary Xavier Becerra of the Department of Health and Human Services (HHS), Assistant Secretary Lisa Gomez of the Department of Labor, and Deputy Commissioner Douglas O’Donnell of the Department of the Treasury, urging them to finalize the proposed rules that would strengthen the Mental Health Parity and Addiction Equity Act of 2008. The letter emphasizes that these rules are critical to addressing the mental health and substance use disorder (MH/SUD) crisis, noting that more than two-thirds of Americans with mental health conditions do not receive treatment. The letter also highlights how current insurance practices, such as low reimbursement rates, limited provider networks, and higher denials of mental health care compared to primary care services, hinder access to care.

Administrative Action

  • In response to rising temperatures due to the climate crisis, the U.S. Department of Health and Human Services (HHS) recently released its new tool to help communities prepare for extreme heat and prevent heat-related illness. The tool, known as the Heat and Health Index (HHI), is the first nationwide tool to provide heat-health outcome information at the ZIP code level. The HHI aims to help local officials identify communities most likely to experience adverse health outcomes and ensure that outreach and medical aid can reach those who need it most. HHS incorporated historic temperature data and Emergency Medical Services (EMS) data on heat-related emergency responses over the past three years, in addition to data on community characteristics, pre-existing health conditions, socio-demographic information, and characteristics of the environment, into the HHI to provide a final heat and health index ranking by ZIP code. The tool’s announcement follows the most recent National Climate Assessment, which highlighted the scale at which climate change is driving record-breaking high temperatures and dangerous heat waves across the country and world, contributing to an estimated 1,220 heat-related deaths in the U.S. per year.

 

  • The Centers for Medicare & Medicaid Services’ (CMS) Center for Medicare & Medicaid Innovation (CMMI) recently provided an update on its initiative to build a health system that ensures equitable outcomes through high-quality, affordable, person-centered care, with health equity as a central objective. CMMI tests value-based healthcare payment and service delivery models aimed at reducing costs while maintaining or improving care quality for Medicare and Medicaid beneficiaries. Recent models, such as the Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH), the Transforming Maternal Health (TMaH), and the Making Care Primary (MCP) models, mandate sociodemographic data collection, health equity plans, and health-related social needs (HRSNs) screening and referrals. These models also incorporate innovative payment policies and provider supports, especially for underserved populations. In 2023, CMMI reported on its health equity initiative, highlighting progress in safety-net provider participation, data collection for whole-person care, and payment innovations to reduce disparities. New models ensure diverse provider participation, readiness support, and lower financial risks, focusing on improving care for Medicaid beneficiaries and including safety-net providers. For instance, the MCP Model and the Innovation in Behavioral Health (IBH) Model aim to include Federally Qualified Health Centers (FQHCs) and community-based behavioral health providers in their programs. Insights from these initial steps to embed health equity in model design will guide future CMMI efforts to enhance whole-person care, address HRSNs, and strengthen workforce communication with the continued goal of advancing health equity.

 

  • The National Institutes of Health (NIH) announced an investment of $30 million over fiscal years 2024 and 2025 to launch a national primary care research network called Communities Advancing Research Equity for Health (CARE for Health). This initiative aims to integrate clinical research with community-based primary care to enhance access to medical research and improve patient outcomes, particularly for underserved and historically underrepresented communities. CARE for Health will utilize existing NIH-funded networks and community partners to establish infrastructure at select primary care sites, initially focusing on rural areas. The program will enable participating clinical sites to choose research studies based on local health priorities and involve patients in generating and utilizing meaningful clinical data. The program is designed to expand research participation and ensure diverse representation in clinical trials, addressing common health issues and disease prevention. As CARE for Health develops, it will introduce new studies, enhance training and data management, and integrate research findings into clinical practice, aiming to create a learning health system that continuously improves patient care based on community-driven research.

Research

In a recent study published by the Center on Budget and Policy Priorities, the repercussions of premium tax credits expiring were analyzed. The American Rescue Plan and the Inflation Reduction Act have temporarily improved premium tax credits (PTCs), making health coverage in the Affordable Care Act (ACA) marketplaces more affordable for millions. These enhancements, set to expire after 2025, have significantly reduced premium costs, with 92% of enrollees qualifying for PTCs in 2024, saving an average of $700 and lowering premiums by 32% since 2021. Enhanced PTCs have expanded coverage, especially among Black and Latino populations, and doubled enrollment for those with incomes between 100-200% of the poverty level. Without congressional action to extend these enhancements, nearly all enrollees will face higher premiums, and 3.8 million people will become uninsured. Premium costs would rise across all states, ages, and income levels, with substantial increases for those with lower incomes and those above 400% of the poverty level. For example, a family of four earning $60,000 would see their annual premium increase by about $2,700, and a 60-year-old couple in West Virginia earning $80,000 could face a premium hike from $6,800, to over $43,000 if the enhancements are not extended.


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