State News

Legislation aimed at overhauling Massachusetts’ healthcare system was introduced this month, according to the Boston Globe. Among other things, the legislation would require an increase in spending by hospitals and insurers of 30 percent over three years for primary care and behavioral health, without increasing overall spending. This move to reshape the delivery of services reflects the concern that less than 15 percent of total medical expenses are spent on primary care and behavioral health combined. In addition, this legislation would streamline the behavioral health provider credentialing process. Also of note, this legislation would seek to create more extensive state oversight of drugs that cost over $50,000 per person per year, even if bought through the private market.

A report from Massachusetts’ Attorney General finds that alternative payment models did not shift care to lower cost providers, as frequent plan-switching by patients and the administrative complexity of the arrangements limited the effectiveness of the models, according to RevCycleIntelligence.

Recently released data from the New York Department of Financial services has revealed that the state’s arbitration process, created through legislation in 2018, may substantially increase what New Yorkers pay for healthcare, according to a report by USC-Brookings Shaeffer Initiative for Health Policy. New York’s recent law uses what’s known as a “baseball-style” arbitration process, through which the arbiter must decide whether final payment should be the insurer’s initial allowed amount or the provider’s charges. Researchers’ main concern is the state’s guidance that arbiters should consider the 80th percentile of billed charges when determining the final payment amount, and the data reveal that arbitration decisions have averages 8 percent higher than the 80th percentile of charges. Therefore, researchers believe that high out-of-network reimbursement attainable through arbitration has likely increased emergency and ancillary physician leverage in negotiations with commercial insurers, leading to providers dropping out of networks to obtain higher payment, thereby extracting higher in-network payment rates, or some combination, which would increase premiums.

The Oklahoma Health Care Authority announced the statewide expansion of a pilot program to improve the health of Medicaid members with chronic conditions by optimizing their medication. A secure data platform analyzes social, medical and behavioral data to identify health needs, barriers to care and dangerous gaps in care. The platform then uses artificial intelligence to generate personalized treatment plans according to clinical best practices, which it sends to patients’ providers. Plan implementation is monitored to ensure that patients remain on track.

Hot spot maps identify key areas in New York City where Medicaid intervention and social determinants of health ( programming have the potential to help improve the health of individuals, according to a report from the United Hospital Fund. Several current initiatives offer promising strategies to tackle social determinants that could benefit from the use of these hot spot maps, including New York Medicaid’s reform initiative, the Delivery System Reform Incentive payment (DSRIP) program, the Healthy Homes value-based payment pilot and others.

Twenty Mississippi hospitals have filed a civil lawsuit against the companies that manufacture and distribute opioids and drugstore chains such as Walmart, Walgreens and CVS pharmacies that sell opioid-based drugs, according to the SunHerald. Mississippi is one of the top five states for opioid distribution per capita, according to the lawsuit, with 92.9 prescriptions written for every 100 people in 2017, compared to the national average of 58.7 per 100. The lawsuit claims that companies “knowingly and intentionally” concealed facts from the medical community and spent millions on “a misinformation campaign.” 

Healthcare Rising Arizona – an advocacy organization backed by a California-based labor union – filed a 2020 ballot initiative that aims to improve Arizonans’ health and hospital care, according to Chamber Business News. The initiative will address four main areas: patient billing, by requiring providers to offer refunds if patients are overcharged; infection control, by holding private hospitals to national safety standards; new wage mandates for hospital workers, with annual wage increases for four years; and pre-existing conditions. Healthcare Rising Arizona says the initiative is designed to reduce deaths and lower costs, allowing hospitals to focus on improving patient care. Healthcare organizations argue that it would increase patient costs; mandate an increase in health care workers’ salaries regardless of performance; and claim responsibility for improvements already being made by the federal government, the state and local healthcare providers.

Sunflower, a subsidiary of Centene, will be required to issue more than $25 million in health insurance rebates to nearly 19,000 Kansans who purchased Ambetter individual health plans, reports KCUR. The rebates are required by the Affordable Care Act (ACA), which specifies that insurers must spend a certain proportion of what they collect in premiums — usually 80 percent — on their members’ healthcare. The rest can go toward the company’s own costs and profits. Sunflower’s hefty refund puts Kansas’ average rebate at more than $1,000, or seven times the national average. The state’s insurance department, which regulates premiums, has asked Sunflower for information about how it landed so far above the ACA threshold.

In 2018, Massachusetts met the Total Health Care Expenditures benchmark set by the Health Policy Commission, growing by 3.1 percent to $8,827 per resident, according to analysis by the Center for Health Information and Analysis. The report also notes that the public insurance program, MassHealth, launched its accountable care organization (ACO) program in 2018 and shifted more than 60 percent of its members to an ACO in that year. Alternative payment model (APM) adoption declined slightly among commercial health plans in 2018, especially within smaller plans.