Author: Will Humble

February 5, 2018

Seema Verma

Administrator,

The Centers for Medicare and Medicaid Services

7500 Security Boulevard

Baltimore, MD 21244

RE: Arizona (AHCCCS) 1115 Waiver Application

Dear Administrator Verma:

I write on behalf of the Arizona Public Health Association (AzPHA) – one of Arizona’s oldest and largest membership organizations dedicated to improving the health of Arizona citizens and communities. An affiliate of the American Public Health Association, our members include health care professionals, state and county health employees, health educators, community advocates, doctors, nurses and students.

The Arizona Health Care Cost Containment System (AHCCCS) has requested permission through an 1115 Waiver Application to implement changes to its 1115 demonstration in response to its state legislation, (Senate Bill 1092). Through their amendment, AHCCCS requests to implement employment and community engagement requirements as a condition of Medicaid eligibility and bi-annual verification of compliance with employment and community engagement requirements as well as other changes in family income or other eligibility factors.  They have also asked for the authority to limit lifetime coverage for “able-bodied adults” to five years unless an individual is considered exempt by the state.

Section 1115 of the Social Security Act gives the Secretary of Health and Human Services authority to approve experimental, pilot, or demonstration projects that are found by the Secretary to be likely to assist in promoting the objectives of the Medicaid program. The purpose of these demonstrations, which give states additional flexibility to design and improve their programs, is to demonstrate and evaluate state-specific policy approaches to better serving Medicaid populations.

A core tenant of these waivers is to conduct a robust evaluation of demonstration projects to properly gauge their effectiveness.  We urge the Centers for Medicare and Medicaid Services to stay true to this commitment and withhold approval of the waiver.

until after AHCCCS submits an evaluation design that will satisfactorily measure the effectiveness of this waiver application in meeting the health and wellness needs of our nation’s vulnerable and low-income individuals and families. 

Because a comprehensive evaluation plan has not been submitted with this waiver application, it is unclear how the Administration will evaluate the plan’s effectiveness and meet the intent of the 1115 waiver requirements. 

For example, the application provides no insight into how AHCCCS will evaluate program impact on health outcomes and track and report on the number of individuals whose eligibility is discontinued due to failure to demonstrate compliance with the Waiver’s work/job training requirements.

It is unclear whether AHCCCS will track and report on the number of individuals who seek and obtain exemptions from the work requirement and how population impacts will be disaggregated by sociodemographic characteristics including age, sex, race, ethnicity and geography. The application does not discuss whether they will use external metrics such as hospital uncompensated care reports to provide early indicators of any potential provider impacts on changes in coverage that may result from the waiver.

AHCCCS identifies basic proposed evaluation methods such as the rate of employment, job seeking, education and employment support and development activities for able-bodied adults and state that they will track and report on the average household income.  However, their discussion does not constitute an evaluation plan. CMS guidance states that evaluations must assess program impact on health outcomes – a topic which is not addressed in the AHCCCS Waiver application.

We are aware the Secretary of Health and Human Services and the CMS Administrator are receptive to the kind of waiver request that AHCCCS is requesting, and that Section 1115 demonstrations are generally approved for an initial five-year period and can be extended for up to an additional three to five years, depending on the populations served. 

However, because of the large and challenging system changes that will be required by AHCCCS and members under this request, we strongly urge CMS to withhold any approval until the Administration submits a credible and robust evaluation strategy and plan.

We also urge CMS to limit any approval to 3 years, pending the results of an objective evaluation of the impact that these changes will have on vulnerable and low-income individuals and families.

Additionally, we urge CMS to ask AHCCCS for a complete and evidence-based rationale for how a 5- year limit on lifetime benefits could possibly further the mission of meeting the health and wellness needs of our nation’s vulnerable and low-income individuals and families. Many chronic medical conditions such as diabetes and asthma require continual chronic disease management.  Without connection to care these conditions become more challenging and more expensive. With a 5-year limit on benefits, former members will be disconnected from care, resulting in poor outcomes and increased compensated and uncompensated care.

Additionally, there are many unknowns about how the Administration will implement the 5-year limit. For example, how will the Administration keep track of exempt member months over time and how will they be able to apply and allocate those months toward the 5-year limitation? What mechanisms will be used to allow members to supply the needed data, and how will the communication loop be implemented and maintained.

Sincerely,

Will Humble, MPH

Executive Director,

Arizona Public Health Association

AHCCCS Submits Work Requirement Waiver

An AZ law (from 2015) requires AHCCCS to annually ask the Centers for Medicare and Medicaid Services (CMS) for permission to require work (or work training) and income reporting for “able bodied adults” as well as a 5-year lifetime limit on AHCCCS eligibility. 

The work requirement and 5-year limit requests that were turned in during the Obama Administration were denied, but the new administrator CMS has publicly said (and written) that they’re receptive to proposals from states to require work or community engagement for people who want to receive Medicaid.

This week AHCCCS submitted their official waiver request asking permission to implement the following requirements for certain adults receiving Medicaid services: 

• A requirement to become employed, actively seek employment, attend school, or partake in Employment Support and Development (ESD) activities (with exceptions below);
• A requirement to bi-annually verify compliance with the requirements and any changes in family income or other eligibility factors; and
• Limit lifetime coverage for able bodied adults to five years (with exceptions below).

Here are the proposed exempted groups:

• People who are at least 55 years old;

• American Indians;

• Women up to the end of the month in which the 90th day of post-pregnancy occurs;

• Former Arizona foster youths up to age 26;

• People determined to have a serious mental illness;

• People receiving temporary or permanent long-term disability benefits from a private insurer or from the government;

• People determined to be medically frail;

• Full-time high school students who are older than 18 years old;

• Full-time college or graduate students;

• Victims of domestic violence;

• People that are homeless;

• People who have recently been directly impacted by a catastrophic event such as a natural disaster or the death of a family member living in the same household;

• Parents, caretaker relatives, and foster parents; or

• Caregivers of a family member who is enrolled in the Arizona Long Term Care System.

Able-bodied adult members will be required to meet the following activities or combination of activities, for at least 20 hours per week to qualify for AHCCCS:

• Be employed;

• Attending school; or

• Attending an ESD program (e.g. English as a Second Language courses, parenting classes, disease management education, courses on health insurance competency, and healthy living classes. 

People looking for a job and meeting the requirements to receive unemployment benefits would be deemed as meeting the work requirements.

Community service hours may count toward the required 20 hours per week for people transitioning from the justice system, living in an area of high unemployment, or who otherwise face a significant barrier to employment.

The entire waiver request is 678 pages long- but don’t let that scare you off.  The meat of it is only 13 pages long.

P.S. I didn’t see a request to change the reimbursement scheme for community health centers or the limitations on non-emergency medical transportation in the waiver request.

New Tax Law Repeals Penalties for Not Having Health Insurance

The new federal tax law that will be signed shortly eliminates the penalties that people currently need to pay for choosing not to have health insurance. The penalty elimination begins on January 1, 2019…  so, there will still be a financial penalty for not having health insurance during 2018. 

The tax penalty for not having health coverage in 2017 is $695 per adult and $347 per child, or 2.5% of one’s household income, whichever is greater. About 4 million US taxpayers paid the penalty in 2016 (an 80,000 Arizonans paid the tax penalty that year).

The CBO estimates that eliminating of the mandate will result in 80,000 more Arizonans becoming uninsured during the first year of implementation (2019).  By 2027 they estimate that the number of uninsured will rise by 13 million people nationally (260,000 in Arizona).

The change is also expected to increase premiums on the Marketplace by an unknown amount in 2019 because younger and healthier people are expected to disproportionately elect not to buy health insurance.  Part of that increase may be mitigated if congress chooses to restore the Cost Sharing Reductions and if they authorize a reinsurance program

CDC Submits Much Smaller Budget Request

This week the CDC turned in their FY 18 budget request.  The overall request is 17% smaller than last year’s agency budget.  If enacted as requested, the funding cut would have big implications for state and county health departments.  The request is for $6B in budget authority which is $1.2B less than the FY 2017 Continuing Resolution (CR) level (a 17% reduction).  Here’s a link to the actual budget request. 

Here are the bullet’s identified as an introduction to the request from the CDC Director:

•  Creation of the new America’s Health Block Grant, reforming the model of existing state-based chronic disease programs to increase flexibility

• Reform of public health preparedness and response activities, including a greater emphasis on risk in the state grant program.

• Enhanced support for vector-borne disease outbreaks

• Critical investments to improve our laboratories and facilities

• Continued efforts to reduce deaths due to opioid abuse, misuse, and overdose

The budget request is too long and complicated to characterize fully here- but I’ve picked out a few highlights.

America’s Health Block Grant Program ($500 million)

The FY 2018 budget request includes a new $500 million “America’s Health Block Grant” to increase flexibility on the leading chronic disease challenges specific to each State, which could include preventing and better managing heart disease and diabetes—two of the most common and costly chronic diseases—as well as arthritis, the leading cause of disability in the United States. 

The request proposes to eliminate the following programs completely:

• Preventive Health and Health Services Block Grants (-$160.0 million)

• Racial and Ethnic Approaches to Community Health (-$51.0 million)

• Prevention Research Centers (-$25.4 million)

• Cancer Prevention and Control (-$18.1 million)

• Hospitals Promoting Breastfeeding (-$8.0 million

• National Early Child Care Collaboratives (-$4.0 million)

• Health Promotion (-$10.5 million)

• Occupational Safety and Health (-$138.5 million) – eliminating funding for state and academic partners for conducting, translating, or evaluating research

• Education and Research Centers (-$28 million)

The following programs would be significantly scaled back (but not eliminated in their entirety):

• Chronic Disease Prevention and Health Promotion (-$222 million) – the agency says that the America’s Health Block Grant could make up a portion of this cut if states prioritize these activities in their block grant

• Public Health Preparedness and Response (-$136.3 million)- with large reductions in the state cooperative agreements

• Immunization Program (-$89.5 million) – CDC would continue to provide funding to the 64 immunization awardees for state infrastructure awards, vaccine direct assistance, and laboratory capacity- but at a substantially reduced level.

• Emerging and Zoonotic Infections (-$64.9 million)

Remember that this is the agency’s budget request- not a final funding decision by congress.  In all likelihood, the agency was directed by the Executive to submit a budget that’s 17% smaller- reflecting the goals of the President’s budget.  As such- the CDC Director (Brenda Fitzgerald, MD) may not really want to make these cuts- but when you work for an Executive you gotta to follow their instructions (or quit- in which case someone else will).

You can weigh in regarding the proposed CDC budget with your Representative and Senators by sending a message via this: APHA FCDC Funding Action Alert Tool.

___________

Innovative Community Health Worker Strategies: Medicaid Payment Models for Community Health Worker Home Visits

By Tina Kartika December 19th, 2017

Due to mounting evidence that community health workers (CHWs) can improve health outcomes, increase access to health care, and control medical costs,[1] states are increasingly engaging their CHW workforce to replicate those successes at the state level. However, the policies and programs that regulate and pay for CHWs differ dramatically across states,[2] and states facing difficulties advancing CHW initiatives can gain insights from the experiences of other programs across the country.

The National Academy for State Health Policy (NASHP) recently updated its State Community Health Worker Models Map, and is currently identifying innovative state strategies that have helped CHW initiatives meet their goals. This case study, which explores payment models for CHWs conducting home visits in Minnesota, New York, Utah, and Washington State, is the second in a series of products that highlight those CHW program strategies.

Community Health Workers and Home Visits

Health outcomes are influenced by many factors, one of which is physical environment. Living in an unhealthy home environment can cause or exacerbate health issues. For example, exposure to lead in the home from lead paint or contaminated drinking water, “affects the brain’s ability to control impulses and process information,” which can lead to children’s underperformance in school and later in the workplace.[3] Exposure to dust mites, mold, and cockroaches can trigger asthma attacks.[4]

In addition to improving health outcomes and quality of life, addressing health hazards in the home environment can yield positive economic results. Remediating lead paint hazard in homes built before 1960 is estimated to generate $3.5 billion of earnings, health and education savings, and quality-adjusted life year benefits for 311,000 low-income children.[5] Home visiting services targeting asthma are estimated to generate $1.39 to $5 of savings for every dollar invested.[6] Assessing the home environment is a critical first step to reduce these hazards, and CHWs can be trained to conduct healthy home assessments,[7] educate, and connect patients to resources during home visits.[8]

Payment Models

Low-income households are more likely to live in unhealthy homes with significant lead-based paint hazards and indoor allergens.[9] Although Medicaid covers many low-income children and adults,[10] few state Medicaid programs directly reimburse CHWs to provide in-home services that address healthy home environments. The following are examples of payment models used by several states to finance home-based preventive services provided by CHWs:

§  Medical expenditure: In Minnesota, home-based preventive services provided by CHWs can be reimbursed under Medicaid as long as the services qualify as diagnostic-related patient education and the CHWs work under the supervision of a licensed medical professional. Beneficiaries can receive up to 12 hours of these services each month.

§  Administrative expenditure: Some accountable care organizations (ACOs) in Utah are covering the costs of home-based preventive services through administrative payments.[11] According to a National Center for Healthy Housing case study, Medicaid managed care organizations (MCOs) in New York can also choose to provide home-based asthma services and bill the services as administrative expenses.

§  Incentive payment: Under the authority of 1115 waivers, 12 states have implemented Delivery System Reform Incentive Payment (DSRIP) programs that “restructures Medicaid funding into a pay-for-performance arrangement in which providers earn incentive payments outside of capitation rates for meeting certain metrics or milestones based on state-specific needs and goals.”[12] New York’s and Washington’s DSRIP programs in particular include projects that incentivize participating provider entities to provide CHW home visits to their members.

§  In New York, 8 out of 25 participating Performing Provider Systems (PPSs) have implemented a project that expands asthma home-based self-management programs and includes home environment assessment, remediation, and education. During a meeting in February 2017, five of those eight PPSs reported engaging CHWs to meet the goals of the project.[13]

§  Similarly, Washington’s Accountable Communities of Health (ACHs) can choose to implement a DSRIP project on chronic disease prevention and control and pay CHWs to conduct home visits for asthma services using DSRIP funding.

Takeaways

Minnesota, New York, Utah, and Washington provide examples of using Medicaid dollars to finance CHW home-based services. States can enable providers to bill certain CHW home visits as medical expenses, encourage MCOs to cover these services as administrative expenses, and use incentive payments to fund these services. States seeking sustainable CHW programs can explore these models to determine what fits their needs and goals.

Acknowledgements: The author thanks Anna Guymon, the New York State DSRIP Team, Jill Rosenthal, and Amy Clary for their helpful comments and contribution to this case study. This case study was made possible by support from the National Center for Healthy Housing.