November 2, 2020

The Centers for Medicare & Medicaid Services (CMS) released the third annual update to its Medicaid and Children’s Health Insurance Program (CHIP) Scorecard. The Scorecard is the signature Medicaid accountability initiative that highlights state and federal performance on the administration and health outcomes of the Medicaid and CHIP programs that collectively account for approximately $600 billion in annual spending and serve over 74 million Americans. For the first time, the Scorecard now provides identified per capita spending data across all states, highlighting variation in program costs alongside the quality and performance data. First released in 2018, the Medicaid and CHIP (MAC) Scorecard is a key part of President Trump’s efforts to ensure greater transparency and accountability of the nation’s largest health coverage programs.

“From the beginning of his administration, President Trump has made giving states more flexibility to provide high quality accessible care for our most vulnerable citizens on Medicaid and CHIP a priority,” said Administrator Seema Verma. “At the same time, we also recognize that with greater autonomy must come greater accountability. The Medicaid and CHIP Scorecard provides unprecedented transparency on cost and quality across state Medicaid and CHIP programs.”

This year’s release builds on the success of the previous Scorecards with a variety of updates and improvements for users, including the debut of a new way to view state-specific data on the Medicaid.gov State Profile “Quality of Care” section. CMS has also improved the overall design and navigation across the 2020 MAC Scorecard to enhance the user experience.

The Scorecard includes healthcare quality measures of asthma medication management for children and adults as well as a measure of follow-up care for adults after an emergency department visit for mental illness. It also contains new administrative accountability measures including CMS and state approval times for managed care contract reviews; and CMS approval times for enhanced federal funding to support states’ eligibility, enrollment and information technology systems.

The 2020 Scorecard provides per capita expenditure data across all states. For the 2018 T-MSIS based per capita expenditure data, seventeen states had a high level of data usability, and an additional eleven states showed a moderate level of data usability. The remaining states fell into the category of having a low level of data usability. The median per capita expenditures, based on CMS calculations, for all states in 2018 is $8,126, with a range of $1,807 in Puerto Rico to $14,387 in North Dakota.[1]  

This year, new data were added to the MAC Scorecard’s National Context page. For example, these new data show the percentage of each state’s population that is enrolled in Medicaid, which ranges from 9.0% to 36.3 % and that nationally, about half of those enrolled in Medicaid and CHIP are children. The National Context page also has new data on the national percentage of beneficiaries enrolled in Medicaid and CHIP by eligibility group and the national rate of improper payments in Medicaid and CHIP.

Further, the national context now provides information on the percentage of Medicaid beneficiaries currently enrolled in Medicare (i.e., dually eligible beneficiaries); the percentage of dually eligible beneficiaries in programs that integrate the delivery of Medicare and Medicaid benefits; and the approval status for states’ transition plans for home and community-based services. For example, nearly half of all states (23) have a Medicaid population where 11.8%-24.2% are dually eligible beneficiaries and 36 states now enroll dually eligible beneficiaries in integrated care programs. The addition of these new data in the Scorecard help to further underscore the importance of understanding the dually-eligible population’s role in the Medicaid program.

CMS continues to engage stakeholders in identifying enhancements to the MAC Scorecard, including receiving input from Medicaid agencies through a collaboration with the National Association of Medicaid Directors.

CMS analyzed trends in median state performance on a subset of Child and Adult Core Sets measures that are included in the MAC Scorecard’s State Health System Performance pillar. Under this pillar, five states reported all measures in Federal Fiscal Year (FFY) 19: Connecticut, Massachusetts, New Hampshire, Tennessee and Washington. Across all states that reported, performance improved from FFY 2017 to FFY 2019 on several measures, suggesting progress in the quality of care provided to Medicaid and CHIP beneficiaries. These measures include:

• Well-Child Visits in the First 15 Months of Life (performance improved from 60.2% to 65.1%)
• Adolescent Well-Care Visits (performance improved from 44.9% to 50.7%)
• Immunizations for Adolescents (performance improved from 74.5% to 79.2%)
• Percentage of Eligibles Who Received Preventive Dental Services (performance improved from 48.2% to 49.0%)
• Comprehensive Diabetes Care: Hemoglobin A1c Poor Control (performance improved from 40.9% to 38.3%). Lower rates are better for this measure.

Overall, under the State Health System Performance pillar, states that reported for FFY19 have opportunities to improve in measures such as: emergency department utilization rate for children and adolescents; the percentage of children ages 3 to 6 who had at least one well-child visit with a primary care provider; the percentage of women delivering a live birth who had a timely postpartum care visit; and inpatient hospital admission rates for short-term complications of diabetes (e.g., diabetic ketoacidosis, hyperosmolarity) in adults ages 18 and older.

The State and Federal Administrative Accountability pillar measures show, for example, that the percentage of State Plan Amendments and 1915 waivers approved in within the first 90 day review period has increased between 2016 and the second quarter of 2020.

When viewing data in the MAC Scorecard, CMS would caution against making direct state-to-state comparisons based solely on data presented. For example, for measures drawn from Child and Adult Core Set, reporting methods can vary among states. States have access to different data on populations covered under fee-for-service as compared to populations covered under managed care. This variation in data availability can impact measure performance. Users should review the state-specific measure notes to better understand states’ reported rates. CMS is committed to working with states to improve standardized measure calculation and reporting which will increase the ability to do direct state-to-state comparisons in the future.

CMS is committed to working with states to improve standardized measure calculation and reporting on measures across the Scorecard. As with other measurement-focused initiatives, CMS offers states technical assistance and quality improvement opportunities to assist states in collecting and reporting measures displayed in the Scorecard, as well as sharing best practices to support improved state performance.

To view the 2020 MAC Scorecard, please visit: https://www.medicaid.gov/state-overviews/scorecard/index.html  

For more information pertaining to the 2020 MAC Scorecard, please visit: 

https://www.medicaid.gov/media/file/2020-medicaid-chip-scorecard-factsheet.pdf

October 2, 2020

In June, CMS Administrator Seema Verma issued a call to action, noting that “the transition to a value-based system has never been so urgent. When implemented effectively, it encourages clinicians to care for the whole person and address the social risk factors that are so critical for our beneficiaries’ quality of life.”

As part of CMS’s focus on delivering better health care value, for the first time, CMS is sharing a fact sheet with a snapshot of the data from the Accountable Health Communities (AHC) Model, reflecting the agency’s most comprehensive collection of social needs data to date. One in three beneficiaries (33 percent) reported at least one core health-related social need. Food needs were the most commonly reported (67 percent of those reporting at least one need), followed by housing (47 percent), transportation (41 percent), and utility assistance (28 percent). Of those screened, 18 percent were eligible for community navigation services, and 76 percent of eligible beneficiaries accepted the navigation assistance.

The AHC Model addresses a critical gap between clinical care and community services in the current health care delivery system by testing whether systematically identifying and addressing the health-related social needs of Medicare and Medicaid beneficiaries’ through screening, referral, and community navigation services will impact health care costs and reduce health care utilization. The participants in the AHC Model include urban and rural communities and a variety of care settings, ranging from hospitals to primary care to behavioral health providers, with a shared commitment to addressing health-related social needs and connecting beneficiaries to community resources.   

The fact sheet provides information on how the model is implemented and a snapshot of data on demographics of beneficiaries participating in the model as well as their self-reported health-related social needs. The first AHC Model evaluation report is anticipated in 2021 and will include a more in-depth analysis of data from the AHC Model. This fact sheet is for informational purposes only. Learn more in the AHC Model Fact Sheet: First 750,000 Completed Screenings.

September 24, 2020

The U.S. Department of Health and Human Services (HHS), through the Health Resources and Services Administration (HRSA), released a notice of proposed rulemaking (NPRM) to increase access to affordable insulin and injectable epinephrine for low-income Americans in health centers nationwide.

“The Health Center Program provides preventive and primary care services to nearly 30 million medically underserved people annually, including more than 2.7 million people with diabetes,” said HRSA Administrator Tom Engels. “Expanding affordable access to lifesaving medications like insulin and injectable epinephrine can significantly improve the health status of patients with chronic diseases, ultimately reducing or even eliminating health disparities that acutely impact underserved and minority communities nationwide.”

Read the release.

Click to view Price Transparency Resources.

Click to view Price Transparency Information.

September 24, 2020

Click to view UPDATE.

September 2, 2020

Finalized policy changes expand new technology add-on payment pathway for certain antimicrobials

On September 2, CMS issued the FY 2021 Medicare Hospital Inpatient Prospective Payment System and Long Term Acute Care Hospital (LTCH) final rule, which includes important provisions designed to ensure access to potentially life-saving diagnostics and therapies for hospitalized Medicare beneficiaries. The changes will affect approximately 3,200 acute care hospitals and approximately 360 LTCHs. CMS estimates that total Medicare spending on acute care inpatient hospital services will increase by about $3.5 billion in FY 2021, or 2.7 percent.

“President Trump is committed to ensuring that seniors on Medicare have access to the latest life-saving diagnostics and therapies,” said CMS Administrator Seema Verma. “This rule is another critical step in our effort to modernize the program and strip away bureaucratic barriers between our seniors and the latest innovative treatments.”  

CMS’ rule creates a new Medicare Severity Diagnostic Related Group (MS-DRG) that provides a predictable payment to help adequately compensate hospitals for administering Chimeric Antigen Receptor (CAR) T-cell therapies. The current FDA-approved CAR-T-cell cancer therapies use a patient’s genetically modified immune cells to treat specific types of cancer.

Also in the final rule, CMS approved a record number of 24 New Technology Add-on Payments (NTAPs), which is an additional payment to hospitals for cases involving eligible new and relatively high cost technologies. Last year, to remove barriers to innovation, CMS established alternative streamlined pathways for FDA Breakthrough Devices and FDA Qualified Infectious Disease Products (QIDPs) to qualify for NTAPs. Among CMS’ approval of these 24 additional NTAPs are two technologies for new medical devices that are part of the FDA’s Breakthrough Devices Program and six technologies that received FDA QIDP designation. This will provide additional Medicare payment for these technologies while real-world evidence is emerging, giving Medicare beneficiaries timely access to the latest innovations.

CMS is also expanding the add-on payment alternative pathway for antimicrobial products approved under FDA’s Limited Population Pathway for Antibacterial and Antifungal Drugs (LPAD pathway), which encourages the development of safe and effective drug products that address unmet needs of patients with serious bacterial and fungal infections. Specifically, an antibacterial or antifungal drug approved under the LPAD pathway is used to treat a serious or life-threatening infection in a limited population of patients with unmet needs.

CMS is also taking steps to ensure that the Medicare Fee-for-Service (FFS) program adopts pricing strategies based on real world market forces. Medicare generally pays hospitals a rate that is weighted by the relative cost of providing certain services based on a patient’s diagnosis. These weights are currently based in large part on the charges that hospitals report to the federal government, which often have little relevancy to the actual rates paid by insurance companies. Hospitals are already required to report these negotiated rates as part of the Trump Administration’s efforts to promote price transparency, and CMS is now finalizing a requirement for hospitals to report to CMS the median rate negotiated with Medicare Advantage Organizations for inpatient services to use instead of the charge based data. CMS will begin to collect this data in 2021 and will use it in the methodology for calculating inpatient hospital payments beginning in 2024. These provisions will introduce the influences of market competition into hospital payment and help advance CMS’s goal of utilizing market- based pricing strategies in the Medicare FFS program.

For More Information:

• Final Rule
• Fact Sheet