Syrtis Solutions publishes a monthly Medicaid news roundup to help you stay up-to-date. The monthly summary highlights developments, analysis, and legislation that relates to Medicaid program integrity, cost avoidance, coordination of benefits, third party liability, improper payments, fraud, waste, and abuse. Below is a list of last month's important Medicaid news.
Syrtis Solutions delivers a monthly Medicaid news roundup to help you stay informed. The monthly roundup highlights developments, analysis, and legislation that relates to Medicaid program integrity, cost avoidance, coordination of benefits, third party liability, improper payments, fraud, waste, and abuse. Below is a summary of last month's important Medicaid news.
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In March 2020, under former Governor Andrew Cuomo's administration, the New York Medicaid Redesign Team recommended that the state carve-out pharmacy benefits from the Medicaid program because of concerns pertaining to pharmacy spend and provider transparency. The reform essentially changes prescription drug reimbursement from a managed care model to a fee-for-service model, making the state responsible for the Rx benefit rather than MCOs and PBMs. To date, seven other states, including California, West Virginia, Wisconsin, Missouri, Ohio, Kentucky, and Tennessee, have carved-out pharmacy benefits from their Medicaid programs.
The state's decision was instantly met by opposition from safety net providers, 340B entities, community leaders, and nonprofits. They warned legislators of the harmful impact the move would have on the Medicaid prorgam and its beneficiaries' access to care. As a result, the carve-out was postponed in April 2021.
After a two-year postponement, the New York State Department of Health announced earlier this year that it would continue with the carve-out. Beginning April 1, 2023, Medicaid members will begin receiving their pharmacy benefits under the state's new delivery model, NYRx.
In spite of the state's decision, those in opposition to the change continue to make a concentrated effort to derail the carve-out as the April start date approaches. Save New York's Safety Net is a statewide coalition of providers and community organizations that represent vulnerable populations in the state. The coalition is fighting the transition because of its potential to disrupt access to specific drugs and its repercussions for community health centers.
For example, State officials that support the move to a fee-for-service model believe that it will increase program revenue by $250 million. That being said, under the current program framework, this money goes to safety-net providers around the state as a part of the 340B drug discount program. The program provides qualifying hospitals and clinics that treat low-income and uninsured patients with pharmaceutical drugs at a significantly lower cost. These savings help to fund programs such as vaccination clinics, housing assistance, transportation, outreach, and nutrition services. If the carve-out is carried out, it will divert these funds and lead to a reduction of services, clinic closures, and disruptions to the coordination of care.
Jacqui Kilmer, CEO of Harlem United, is amongst those in opposition to the state's decision. She expects the carve-out to drive up healthcare costs and views the measure as bad government from a policy and legal standpoint. However, the former business attorney is hopeful and strongly believes there is still a chance to convince Gov. Hochul to repeal the carve-out. According to Kilmer, "she can do that on her own without legislative approval, any kind of other oversight, budgetarily, or from the Department of Health."
Among lawmakers, several representatives sponsored bills in the former legislative session to repeal the pharmacy carve-out, but they were unsuccessful. These efforts are expected to be reintroduced this year, and legal challenges are anticipated if NYRx is implemented.
Along with the coalition's concerns surrounding the shift, there is also data that suggests New York and other states may want to reevaluate carving-out pharmacy benefits. In a 2018 report from the Association for Community Affiliated Plans (ACAP), the trade association found that when compared to fee-for-service models, managed care improves the quality of care and saves significantly more on brand name and generic drugs. ACAP analyzed Medicaid drug spending over a six year period and found the following:
Syrtis Solutions distributes a monthly Medicaid news summary to help you stay informed. The monthly summary highlights developments, analysis, and legislation that pertains to Medicaid program integrity, cost avoidance, coordination of benefits, third party liability, improper payments, fraud, waste, and abuse. Below is a summary of last month's significant Medicaid news.
Click this link to learn more.
Medicaid currently fails at providing a system that efficiently and accurately stores and utilizes member data. As Medicaid is a joint state and federally run program, there are many problems with coordinating data platforms. Different states have their own unique data processing and storing, and while federal Medicaid data can reveal a clearer picture of consistent problems across state lines, lack of communication and data sharing produces significant barriers. While technology has advanced, gaps in existing data or errors in computation have direct consequences to the swift identification of third party liability (TPL), resulting in costly reimbursement strategies for Medicaid. The lack of uniformity in these systems prevents Medicaid from functioning smoothly.
One of the major challenges facing Medicaid is the lack of quality TPL data. In testimony before Congress in 2012, HHS Regional Inspector General Ann Maxwell delivered an alarmingly unfavorable evaluation pertaining to the reliability of data federal and state authorities use to identify overpayments and fraud in the Medicaid program. She stated, "much of the data used to identify improper payments is not current, available, complete, [or] accurate." A decade later, the exact same issues with TPL data that Maxwell outlined in her testimony to congress exist today. Apart from simple mistakes at the point of service with providers, there are fundamental problems in the health care data used by the Medicaid program that result in the loss of literally billions of dollars a year.
Each state Medicaid agency (SMA) is responsible for delegation of funds and detecting TPL through their own data sources. That being said, states have differing policies and benefits for Medicaid enrollees, producing inconsistent results. State policies may have existing gaps in information or may be so complicated that they are virtually impossible to navigate, leading to administration frustration. The Medicaid Management Information System (MMIS) works to centralize information and uses patient identification numbers to help with payment delegation. That being said, because of the large Medicaid population, in addition to continual churn, these datasets can be cumbersome and create missing information that causes difficult identification of TPL. Furthermore, Medicaid information is not communicated across state lines, creating repetitive errors that could be avoided. Health care organizations may share patient data with Medicaid for payment purposes, but the various types of data management could be an issue when trying to translate to Medicaid-specific forms.
While states may send routine reports to federal Medicaid agencies, a working federal database may have a hard time deciphering the varying information from different SMAs. Data can be lost, infrequently collected, or incorrect across state lines. An individual in one state could move to an adjoining state and lose specific Medicaid benefits. Data might only show a small piece of the big picture and can not properly address the nuances of a social program and the problems that persist across states. Federal guidelines may only guide overarching procedures, and not have control over individual states' Medicaid programs and policies. This disjunction of administration proves difficult when trying to accurately find TPL data for not only individuals, but also states and federal overview.
Data sharing is therefore an efficient and effective way to decrease the number of inconsistencies between states and local organizations that require Medicaid payment. Nevertheless, a slew of issues stem from data sharing in totality. Even within states, health care organizations are hesitant to share patient data. Sacred protected health information (PHI) delegates immense responsibility to hospitals, providers, and care coordinators to handle data cautiously. Even if organizations are willing to share patient data, unique technology systems across health care do not always capture the same data or translate it in the same way. SMAs are responsible to intake this information and identify TPL, which increases difficulty when trying to smooth operations. This reluctance to share information translates to state and federal Medicaid agency issues. Sharing large amounts of diverse data has been troublesome and leads to inconsistent data and high costs to the Medicaid program.
For years Medicaid has struggled to effectively store and utilize program beneficiary data due to disparate data platforms and the inability to accurately share Medicaid data between states and the federal government. Moreover, much of the healthcare data that Medicaid plans do have access to is leading to billions of dollars in improper payments each year. Without having reliable, complete, and accurate TPL data, Medicaid plans will continue to make claims payments in error and rely on costly reimbursement strategies. Plan administrators must look to true TPL technology solutions for additional efficiency and cost avoidance opportunities to protect the program's valuable resources and ensure that plan members receive the care they need.
