Quality Health Care Trumps Volume

The federal government’s drive to reshape health care in America continues to take shape with the latest shift to value-based payment.

The Centers for Medicare and Medicaid Services (CMS) recently set a time line for having half of all Medicare payments based on the value of the care provided, not simply the volume of services. While CMS is often the leader in setting quality and value metrics, health plans have also set pay-for-performance metrics for their policy holders, and, most recently, the New York State Department of Health has set value metrics for Medicaid under the Delivery System Reform Incentive program.

States Watch 2015 Health Care Issues

Much of the health-care conversations this year will concentrate on two issues with major budgetary and insurance coverage implications that Governing has previously covered. Those are the upcoming U.S. Supreme Court decision that could end federal subsidies in the 30-some states that don’t operate their own exchange, making insurance unaffordable for many, and whether Congress reauthorizes the Children’s Health Insurance Program, which covers 8 million kids from low-income families through state and federal funding.

Unfortunately for states, those are also both issues over which they have little control. There are, however, several other areas to watch over which states do have greater control and still others worth keeping an eye on where federal policymakers remain in the driver’s seat.

Half of Medicaid Providers Not Available to Treat Patients, Report Finds

WASHINGTON — Large numbers of doctors who are listed as serving Medicaid patients are not available to treat them, federal investigators said in a new report.

“Half of providers could not offer appointments to enrollees,” the investigators said in the report, which will be issued on Tuesday.

Many of the doctors were not accepting new Medicaid patients or could not be found at their last known addresses, according to the report from the inspector general of the Department of Health and Human Services. The study raises questions about access to care for people gaining Medicaid coverage under the Affordable Care Act.

Rehab and Habilitation to Be Covered Under ACA

“To rehabilitate,” according to the Merriam-Webster dictionary, means “to restore to a former capacity.”

But what if that capacity — be it walking or talking or brushing one’s teeth — was never there in the first place?  In that case, you aren’t talking about “rehabilitation” but “habilitation.”

People need habilitation when they have a congenital defect or disease that impairs the development of basic life skills. For example, autism may leave a child unable to speak. Cerebral palsy may result in language deficits and severe physical limitations. Birth defects may leave a child deaf.

Thanks to the Affordable Care Act (ACA), habilitation services will now be widely covered for the first time in private insurance plans. Rehabilitative and habilitative services are among the 10 “essential benefits” that must be provided by all plans sold on all the state and federally run health insurance exchanges. 

Oregon Families Fight New Provision of Affordable Care Act

SALEM, Ore. — Deana Copeland has cared for her 22-year-old, medically fragile daughter since she was born, but she's afraid that a new provision of the Affordable Care Act could force her to place her daughter in foster care.

Deana Copeland, right, has cared for
her daughter, Andrea Hood, since
she was born.

Her daughter, Andrea Hood, suffers from cerebral palsy, spina bifida and autonomic dysreflexia, a potentially life-threatening condition, and requires around-the-clock care. Copeland is both Hood's legal guardian and paid service provider, for which she receives $1,400 a month.

"I could never expect somebody else to address her needs the way I do," said Copeland, a Cornelius resident. "In our specific situation, it is going to cost the state exponentially more to do less care for Andrea if Andrea has to be cared for in a center."

That's because a new provision of the Affordable Care Act set to go into effect Jan. 1, 2014, would largely prohibit guardians from serving as the paid caregiver of an adult child with developmental disabilities. Disability rights advocates and state officials are fighting the provision and say it could restrict family flexibility and choice, especially for single parents who serve as guardians and use the caregiving allowance to stay at home.

Florida Governor Presses Feds on Medicaid

TALLAHASSEE -- After emerging from a meeting with U.S. Health and Human Services Secretary Kathleen Sebelius, Gov. Rick Scott said Monday he asked for the federal government to “expedite” approval of Florida’s controversial proposals to shift most Medicaid beneficiaries into managed-care plans.
But Scott offered few details about their discussion on another major issue — how, or if, the state will carry out key parts of the federal Affordable Care Act.

Higher Payments May Prompt More New Jersey Doctors to Accept Medicaid Patients

A two-year project is under way to encourage primary care doctors to accept Medicaid-eligible patients by paying for many services at the same level as Medicare.
Many poor or disabled patients have limited access to healthcare because so few doctors have been willing to accept the low Medicaid reimbursement rates.
The federal government will cover the difference between Medicare and Medicaid reimbursements for 146 primary-care services from Jan. 1 through the end of 2014. The increased payments will be made to family physicians, pediatricians and internal medicine doctors who specialize in primary care.