Standards Perspectives: Healthcare regulations and policies are very complex and ever-evolving. It’s important for managers of health plans and state Medicaid agencies to understand what new legislation means and how it affects their programs. Standards Perspectives brings you the latest details on new policies and standards so you can quickly and clearly learn what’s important to make the right decisions.
The transition of political power at the Chief Executive position leads to the appointment and confirmation of new leadership of government agencies, including health and human services. The following individuals will help shape and implement federal health policy and legislation during the next few years.
Tom Price, MD – Health and Human Services Secretary
Tom Price practiced medicine for 20 years as an orthopaedic surgeon and medical director. He served four terms in the Georgia State Assembly, finally serving as the Senate Majority Leader. He served in the U.S. House of Representatives for Georgia’s 6th Congressional District between 2005 and 2017. He was confirmed as the HHS Secretary on February 10, 2017.
According to the HHS website, Dr. Price is “…[c]ommitted to advancing positive solutions under principled leadership [and] remains a fierce advocate for a patient-centered healthcare system that adheres to six key principles: affordability, accessibility, quality, choices, innovation and responsiveness.”
HHS has 11 operating divisions, including eight agencies in the U.S. Public Health Service and three human services agencies. Among these are:
- Centers for Disease Control and Prevention (CDC)
- Centers for Medicare & Medicaid Services (CMS)
- Food and Drug Administration (FDA)
- Indian Health Service (IHS)
- National Institutes of Health (NIH)
- Office for Civil Rights (OCR)
- Office of Inspector General (OIG)
- Office of the National Coordinator for Health Information Technology (ONC)
Seema Verma – Centers for Medicare and Medicaid Services Administrator
Seema Verma is a public healthcare policy expert who has worked for two decades in the public and private sectors. In Indiana, Ohio and Kentucky, she developed Medicaid expansion reform programs using the Medicaid waiver process. She was a lead architect in developing “Healthy Indiana Plan 2.0,” an alternative Medicaid expansion that uses the Section 1115 waiver.
The Section 1115A waiver authority establishes the Center for Medicare and Medicaid Innovation (CMMI) to test, evaluate and expand different service delivery and payment methodologies to foster patient-centered care, improve quality and slow cost growth in Medicare, Medicaid and CHIP.
Donald Rucker – Office of the National Coordinator for Health Information Technology (ONC) Chief
Over his career, Donald Rucker has been an emergency room doctor, internal medicine physician, clinical informatics expert, inventor, designer, researcher and innovator. Over the past four years, he was a professor at Ohio State University, where he taught Clinical Emergency Medicine and Biomedical Informatics. He was also the 2003 recipient of the HIMSS Nicholas Davies Award for his work at Cincinnati Children’s Hospital.
While most significant changes require congressional approval, there is also a wide range of guidance that agencies can issue. The new administration has already released guidance encouraging states to increase the use of waivers in their Medicaid programs to take more state control.
A letter from Tom Price and Seema Verma to the nation’s governors emphasized that states must administer their own Medicaid programs in an effort to meet the needs of vulnerable populations in the most cost-effective manner. It also indicates that CMS will strive to make the State Plan Amendment approval process more transparent, efficient and less burdensome.
The letter also encourages work programs tied to Medicaid:
The best way to improve the long-term health of low-income Americans is to empower them with skills and employment. It is our intent to use existing Section 1115 demonstration authority to review and approve meritorious innovations that build on the human dignity that comes with training, employment and independence.
On March 13, Secretary Price reinforced these goals with a letter to the governors of all 50 states, encouraging them to come up with ideas that would qualify for exemptions called 1332 waivers. As stated in the letter, “HHS is committed to supporting states that are offering innovative patient-centered proposals, which can mean lower premiums, greater choices and more stable insurance markets.”
CMS reminded states that they must have an approved Advanced Planning Document prior to beginning any development work on an enhancement using additional federal funds.
What this Means for Medicaid
The agencies under the jurisdiction of the individuals outlined above will likely take a different approach than that of the previous administration. This includes the federal government ceding some authority to the states. In the Medicaid and Exchange programs, this likely means approving greater state flexibility through waivers. Experimentation such as that in the Indiana HIP program is likely to proliferate.
As published in the Price/Verma letter, “States may also consider creating greater alignment between Medicaid’s design and benefit structure with common features of commercial health insurance. These state-led reforms could include, as allowed by law:
- Alternative benefit plan designs and cost-sharing models, including consumer-directed health care with Health Savings Account-like features, for individuals at all income levels;
- Facilitating enrollment in affordable employer-sponsored health insurance options;
- Reasonable, enforceable premium or contribution requirements, with appropriate protections for high-risk populations;
- Initiatives designed to break down the barriers that prevent families from being together on the same plan;
- Waivers of non-emergency transportation benefit requirements;
- Expanded options to design emergency room copayments to encourage the use of primary and other non-emergency providers for non-emergency medical care; and
- Waivers of enrollment and eligibility procedures that do not promote continuous coverage, such as presumptive eligibility and retroactive coverage.”
In addition, some states are likely to tie Medicaid eligibility to work requirements and experiment with healthy behavior incentives (or penalties for non-compliance), value-based payments and delivery system reform. The country is likely to see states acting as test centers for methodologies intended to improve health outcomes at a sustainable cost.
You can read more Conduent insights about healthcare regulations in previous editions of Standards Perspectives.