Plugged Into Health @ Hinman Straub – October 9, 2018

VBP Updates

Last Thursday, the full VBP Reform Workgroup met in Albany.  The purpose of the meeting was to review the 2019 VBP Quality Measure Set and Clinical Advisory Group (CAG) recommended changes; MACRA VBP Alignment; “Member Churn” in MMC; hospital concerns related to MCO risk adjustment; MLTC VBP arrangements for Skilled Nursing Facilities (SNF); update on progress toward VBP implementation; and social determinants of health & community based organization update.

DOH is welcoming comments on all recommended changes and discussion points by October 18, 2018. In particular, MCO feedback is requested as to whether it is feasible/problematic for DOH to require a single standardized form of risk adjustment to be used for risk adjusting VBP arrangements with downstream providers. Providers have complained that plans using multiple forms of risk adjustment is problematic. The recommendation was made that all plans should use a single risk adjustment methodology. Presumably, this would be whatever version of the CRG DOH is using for MMC rate setting. Plan representatives indicated they would need to discuss this with their members.

Highlights from of the meeting include:

Measures

  • MMC Measure Changes:
    • High Value Measures
      • DOH is looking for feedback on what the right outcomes are for a set of “high value” quality measures that are currently P4R, as they attempt to turn these measures into P4P and make them part of the core list.  These measures include HbA1c poor control; controlling high blood pressure; maintenance of stable or improved housing; no or reduced criminal justice involvement; maintaining or improving employment or higher education status; HIV Viral Load Suppression; Depression Remission or Response for Adolescents and Adults (new measure); Preventive Care and Screening: Tobacco Use Screening and Cessation Intervention; Asthma Medication Ratio; Initiation and Engagement of Alcohol and Other Drug Dependence; Childhood Immunization Status, Combination 3; Immunization in Adolescents, Combination 2; Developmental Screening in first 3 years of life; and preventive care and screening, screening for clinical depression and follow-up plan.
    • Changes for 2019
      • The CAGs continue to recommend new measures and that existing process-based measures be retired, as the State works towards its ultimate goal of establishing a limited set of core outcomes-based measures for use in VBP and QARR and ultimately across all payers.  Specifically, the CAGs propose to add “asthma medication ratio” and a selection of maternity measures to the TCGP.
      • New Depression Measure: A new measure, “Depression Remission or Response for Adolescents and Adults” was added as a Category 2 measure following strong support for such a measure from the Behavioral Health CAG.  This measure currently has no “measure steward” and is unendorsed, though it appears this will change eventually and become Category 1 once the Department determines how measurement data will be collected.
      • Several diabetes related process measures (foot exam, Hemoglobin A1c (HbA1c) good control <8.0%, HbA1c testing performed, and Statin Therapy for Patients with Diabetes) were recommended for removal.
      • The Workgroup discussed that low use of the maternity bundle has occurred for a variety reasons, including need to devote resources towards arrangements with greater dollar impact.  DOH said they would be open to allowing a maternity bundle to occur within a TCGP arrangement.
      • IPC Split from TCGP: The IPC measure set has been split from the TCGP measure set due to the inclusion of maternity measures to cover the general population, which may not be applicable to certain PCPs.
    • MLTC Measure Changes
      • SNF VBP Proposal: Pending CMS approval of the change to the nursing home benefit within MLTC partial cap, DOH proposes to use a short-stay successful community discharge measure for SNF VBP.  This would apply both to permanent placement and community-based SNF admissions.  This would replace the PAH measure for SNFs in VBP.  DOH proposes to use $50 million to fund this.  They have not determined whether this arrangement would qualify as Level 1 or Level 2.

Risk Adjustment

  • As noted above, providers asked DOH to establish a uniform risk adjustment standard for all  MCOs to use. The specific recommendation was to use the  CRGs or some standard version of risk adjustment for risk-adjusting arrangements with VBP contractors.  According to one provider representative, use of multiple risk-adjustment methodologies has become a “data transparency” issue for VBP Innovators. Plans noted it may be complicated to standardize as some methodologies may apply across multiple business lines, but agreed to take this back for consideration.

 

MACRA

  • The State continues to discuss aligning Medicaid VBP with Medicare MACRA. There is an opportunity for providers to apply to cross-certify arrangements.  If the state applied for an arrangement to be certified by MACRA, it would not take effect until 2020. Some PPSs noted they are using MACRA as a “hook” to get smaller practices to join their IPAs.

 

Churn

  • Providers complained that PCP changes, MMC plan changes, and enrollment and eligibility issues are creating problems for VBP contractors. Provider representatives asked if high-level VBP contractors can receive information from plans about member enrollment and eligibility. Plans responded there are a litany of rules governing outreach to members about enrollment, making it difficult to simply share this information.  They also noted plans have experienced their own enrollment reconciliation issues and a process has been implemented to hopefully alleviate the enrollment discrepancies on a prospective basis.

VBP Progress Update

  • 9% of all MMC contracts are in some form of VBP Level 1-3 payments as of March 31, 2018.  This puts the State ahead of its Roadmap goal of 50% VBP by April 1, 2019, though plans are still held individually responsible for attaining the Roadmap’s Level 1 and 2 goals on their own.  $13 billion remains in FFS, including 33% of MMC and 26% of MLTC arrangements, which the Department said suggests there is still room for more VBP penetration. The “virtual model” of VBP was discussed as a possibility to collect the remaining arrangements. Some providers mentioned they were “philosophically opposed” but the State has to achieve 80% VBP contracting by April 1, 2020 to avoid forfeiting a percentage of DSRIP funds. Of course, these funds may be forfeited regardless if the State fails to meet certain DSRIP targets.

 VBP Attribution

  • One behavioral health provider representative commented that the rules around attribution need to be revised to give behavioral health providers some control over their own fate in VBP.  The State has long assumed physical health providers would seek to incorporate behavioral health providers within their arrangements in meaningful ways that are agreeable to BH providers, due to the fact that many hospitalizations are attributable to the BH population, but this has not been the case so far.  OMH  noted that  they were surprised by the lack of linkages to behavioral health providers in the SOMOs Innovator application and what they perceived as a lack of awareness among PPSs at a recent meeting about the rate of behavioral health hospitalizations, though PPSs at the meeting said this was not the case.  Provider groups countered that the savings for VBP come from ED and inpatient divergence, suggesting that behavioral health providers should accept their position in the chain.

The takeaway from the meeting was is there a role for the State to play in bringing together physical health and behavioral health providers who should be engaged in relationships.

ACF 3rd Quarter Statistical Information Report

The DOH Division of Adult Care Facility and Assisted Living Surveillance recently issued a Dear Administrator Letter (DAL 18-22: Adult Care Facility 3rd Quarter Statistical Information Report) reminding adult care facility (“ACF”) operators that they are required to complete the 2018 ACF 3rd Quarter Statistical Information Report, encompassing the time period from July 1, 2018 to September 30, 2018. The DAL also specifies additional requirements for facilities with a certified bed capacity of 80 beds or more, in which 20% or more of the resident population are persons with serious mental illness.

The 2018 ACF 3rd Quarter Statistical Information Report (and Roster of Adult Home Residents, if applicable) must be submitted to the Department no later than October 31, 2018.  Operators will be able to access and complete these reports on the HCS effective July 2, 2018.  The survey forms can be accessed by logging onto HCS, here.  To assist reporters, this DAL includes Data Entry Instructions and Definitions of Terms.

OMIG Issues 2017 Annual Report

The Office of the Medicaid Inspector General (OMIG) has issued its 2017 Annual Report, which details New York’s Medicaid program integrity efforts for calendar year 2017.

Highlights from the Report include:

  • OMIG claims more than $2.1 billion in cost savings to the Medicaid program. The overwhelming majority of this appears to be attributable to NYS’s third party liability vendor, HMS.  HMS uses rosters of insured individuals from many insurance carriers across the country to match coverage against Medicaid beneficiaries to ensure that medical services are first billed to the other insurance, ensuring that Medicaid is the payer of last resort.  According to the report, this pre-payment insurance verification resulted in cost savings of over $1.9 billion in 2017.
  • OMIG initiated 2,124 audits in 2017, and finalized 2,077 audits. These audits resulted in over $295 million in overpayment recoveries
  • Total recoveries of more than $501 million; and
  • Over $7.1 billion in combined Medicaid recoveries and cost-savings efforts over the last three years.
  • OMIG is reviewing solutions to address fraud under the Consumer Directed Assistance Program (“CDPAP”), including requiring all home health caregivers to obtain an NPI
  • OMIG is required by law to refer suspected fraud and criminal conduct to the Attorney General’s Medicaid Fraud Control Unit (“MFCU”).  In 2017, OMIG referred 287 providers to MFCU. OMIG also referred 629 providers to other outside state, city, and federal agencies.

The report includes a summary of audit activities across program lines.  Highlights include:

  • Mainstream Managed Care Plan audits: 543 finalized audits with over $131 million in identified premium overpayments, including more than $17.1 million in inappropriate payments to MCOs for foster care children whose services were provided by the foster care agencies, and more than $51 million in overpayments due to retroactive disenrollments.
  • Provider Audits: OMIG finalized 585 FFS audits in 2017, resulting in identified overpayments of over $21 million.  OMIG issued 485 audit summation letters (“Positive Reports”) advising entities under audit that they have generally adhered to Medicaid billing rules and no further action is required.
  • Personal Care Audits:  OMIG finalized 21 audits with identified overpayments of more than $9 million.  These audits reviewed certified home health agencies, personal care, and traumatic brain injury providers.  The most common findings included:
    • Billing Medicaid before services were authorized;
    • Supervision visits not performed within the required timeframe;
    • Failure to maximize third-party or Medicare benefits;
    • Failure to document tasks;
    • Personal care aide not present at nursing supervision visit;
    • Missing plan of care;
    • Missing documentation of service;
    • Failure to complete health requirements; and,
    • Failure to complete required training.
  • Nursing Home Audits
    • MDS Reviews:  OMIG finalized 364 reviews of nursing home Minimum Data Set (“MDS”) submissions resulting in identified overpayments of more than $31.7 million. The reviews identified upcoding errors in the activities of daily living (“ADLs”) and the number of physician orders and visits. The reviews also identified instances where skilled therapy were not medically necessary.
    • Base Year and Notice of Rate Change Audits:  OMIG finalized 46 base year and notice of rate change audits, with identified overpayments of more than $9 million. Examples of where improper expenses were included in the rate calculation include those not related to patient care, undocumented expenses, duplicated expenses, and non-allowable expenses.
    • Capital Component Audits:  OMIG finalized 52 capital audits were finalized, resulting in identified overpayments of more than $18 million. Examples of improper expenses that were included in the rate calculation include working capital interest expense disallowances, sales tax disallowances, mortgage expense disallowances; and depreciation disallowances.

Regulatory Updates

Education Department

Advanced Home Health Aides

The NYS Education Department recently issued a notice of adopted rulemaking to implement the Advanced Home Health Aide (“AHHA”) legislation passed and signed in 2016. The regulations define AHHA related terms, establish criteria for RN supervision of AHHAs, establish criteria for AHHA certification, establish criteria for AHHA training programs, and establish AHHA training and competency requirements.

The adopted rulemaking contains no changes from the proposed rulemaking that was published in the June 27, 2018 edition of the NYS Register.  A summary of the proposed rule was included in the June 18 edition of Plugged In To Health.

These new regulations complement the proposed regulations that were advanced by the Department of Health in the May 30, 2018 edition of the NYS Register.  It is important to note that during its September 17 meeting, the NYS Board of Regents approved these proposed regulations following the public comment period.  In its response to public comments, the Education Department appears to interpret the regulations to allow Licensed Home Care Services Agencies (“LHCSAs”) providing services to Assisted Living Program (“ALP”) residents to use AHHAs.  The Department of Health has not yet opined on whether or not they concur with this interpretation.

Department of Financial Services

Minimum Standards for Form, Content and Sale of Health Insurance, Including Standards of Full and Fair Disclosure

The Department of Financial Services recently issued a notice of adopted rulemaking that requires every small and large group and individual accident and health insurance policy or contract (other than a grandfathered health plan) that provides hospital, surgical, or medical expense coverage and every student accident and health insurance policy or contract provide coverage of at least the enumerated 10 categories of Essential Health Benefits (“EHBs”) if the EHB provisions in 42 U.S.C. § 18022 and 45 C.F.R. 156.100 et seq. are no longer in effect or are modified as determined by the Superintendent.

The Department has adopted these regulations to mitigate the impact of any Affordable Care Act (“ACA”) repeal and replace efforts enacted on the federal level.  The rulemaking would ensure that, if the Superintendent of DFS determines that EHB and anti-discrimination provisions (42 U.S.C. § 18022 and 45 C.F.R. 156.100 et seq.) included in the federal Affordable Care Act (“ACA”) are no longer in effect or are modified, these provisions will remain in place in NYS.

The adopted rule contains no changes from the revised proposed rule, which was published in the July 11, 2018 edition of the NYS Register.  A summary of the proposed rule was included in the July 16 edition of Plugged In To Health.  The Department’s assessment of public comments can be viewed here.

Legislative Spotlight

Now that the 2018 Legislative session has adjourned, bills that have passed both houses of the Legislature will be delivered to the Governor in “batches” over the next several months.  Once a bill has been delivered to the Governor, he has 10 days (excluding Sundays) to either sign the bill into law or veto the bill.

The following bill was recently signed into law by the Governor.

  • 10938 Gunther/S.8632 Ortt: This bill amends the Geriatric Service Demonstration Program to add Mental Health‐Home Care collaboration for the purpose of coordination, integration and improved access of health and mental health services for individuals with co‐occurring mental health and physical health needs.

Upcoming Calendar

Tuesday, October 9, 2018 State Health Innovation Plan Council

10:30 a.m. to 2:30 p.m.
Thursday, October 11, 2018 Public Health and Health Planning Council

9:30 a.m.

New York State Department of Health, 90 Church Street, 4th Floor, Rooms 4A and 4B, New York, NY
Thursday, November 29, 2018

 

 DSRIP PAOP & Downstate MRT Public Comment Day

1:00 p.m. to 4:00 p.m.

New York Academy of Medicine, 1216 5th Ave, Reading Room, New York, NY