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The Weekly Scan

Last Updated: 1:00 PM EST

Medicare & Medicaid

  • On Thursday, the CMS released new state tools and guidance that provide standard monitoring metrics and recommended research methods geared specifically for section 1115 demonstrations that test innovative approaches to Medicaid eligibility and coverage policies. For each approved 1115 demonstration, states must provide CMS with regular reporting on key monitoring metrics upon implementation. States are also required to conduct evaluations by partnering with an independent evaluator. States are required to submit an evaluation design to CMS for approval following approval of the final demonstration. These monitoring and evaluation tools and guidance were designed to support these activities and were developed by CMS through a rigorous process with subject matter experts, a state monitoring advisory group, and contributions from experts in the field of evaluation research. The resources include an implementation plan template, a monitoring report template, and evaluation design guidance. (CMS.gov)

  • A federal judge in the District of Columbia heard oral arguments Thursday morning in a lawsuit challenging Arkansas's work requirement for certain Medicaid expansion beneficiaries. Immediately afterward, U.S. District Judge James E. Boasberg heard arguments in a related suit over Kentucky's efforts to implement a similar policy. At the conclusion of the hearings, Boasberg said he hoped to issue rulings in both cases by the end of the month. "I plan to issue them simultaneously since there is some overlap," the judge said. The March 31 date is significant for both states. In Arkansas, the work rule says beneficiaries lose Medicaid coverage — and are locked out of the program for the rest of the calendar year — if they are out of compliance for three months. That means thousands of Arkansans could be kicked off their insurance on April 1. (Some 18,000 people were kicked off the program last year for noncompliance.) Kentucky, meanwhile, hopes to begin phasing in a new set of rules on April 1 that would culminate in establishing a work requirement later this year. (ArkTimes.com)


  • On Wednesday, Oregon Governor Kate Brown signed House Bill 2010 into law. The bill is the first piece of her priority legislative proposal for sustainable, long-term health care funding to ensure Oregonians have access to affordable health coverage. House Bill 2010 includes a hospital assessment, generating $98 million for the Oregon Health Plan (Oregon's Medicaid program); and a health insurance assessment and managed care tax, generating $334 million for the Oregon Health Plan and the Oregon Reinsurance Program, which helps stabilize insurance rates for individuals who buy coverage through the private market. To provide the rest of the needed funding, Governor Brown has proposed a $2-per-pack increase in the cigarette tax, a tax on e-cigarettes, and the creation of an assessment on employers that do not provide affordable coverage to their workers. (Oregon.gov)

  • HHS Secretary Alex Azar revealed Thursday that his department is in talks with states about instituting block grants in Medicaid without congressional approval. “We have discussions with states where they will come in and suggest ideas,” Azar said at a Senate hearing in response to questions from Sen. Bob Casey Jr. (D-Pa.). “There may be states that have asked about block granting, per capita, restructurings around especially expansion populations ... It's at their instigation.” Imposing block grants in Medicaid has long been a major conservative goal for the health insurance program for the poor. Democrats fiercely oppose the idea, and a similar idea known as per capita caps, because both limit the amount of money going to Medicaid, which Democrats argue would require harmful cuts in the program.

Republicans say the move allows for more state flexibility and is more fiscally sustainable. (TheHill.com)


  • The Department of Justice announced on Monday that Covidien LP has agreed to pay $17,477,947 to resolve allegations that it violated the False Claims Act by providing free or discounted practice development and market development support to physicians located in California and Florida to induce purchases of Covidien’s vein ablation products. The United States alleged that Covidien violated the Anti-Kickback Statute and, correspondingly, the False Claims Act by providing practice development and market development support to health care providers located in California and Florida from Jan. 1, 2011, through Sept. 30, 2014, to induce those providers to purchase ClosureFast radio frequency ablation catheters that were billed to Medicare and to the California and Florida Medicaid programs. ClosureFast catheters are used in procedures that treat venous reflux disease, a disease often marked by the presence of varicose veins. The practice and market development support Covidien provided included customized marketing plans for specific vein practices; scheduling and conducting “lunch and learn” meetings and dinners with other physicians to drive referrals to specific vein practices; and providing substantial assistance to specific vein practices in connection with planning, promoting, and conducting vein screening events to cultivate new patients for those practices. (Justice.gov)

  • The creator of a fraudulent Chicago-area pharmacy has been sentenced to 60 months in federal prison for his role in a $1.6 million health care fraud scheme. As part of his guilty plea, James Calhoun admitted that he defrauded Medicare Part D of $1.6 million through an elaborate scheme in which he created a fictitious pharmacy on paper called “Cal’s Pharmacy” and used it to process hundreds of prescription claims for drugs that were never dispensed. For most of its existence, the pharmacy had no physical location or inventory, he admitted. Calhoun further admitted that he enrolled himself as a beneficiary in a Part D program and, for three years, Calhoun went to doctors’ appointments to try to obtain prescriptions for drugs that he would then pretend to fill at Cal’s Pharmacy, most often for the drug Arixtra, an expensive daily injection. Calhoun also admitted that acting as Cal’s Pharmacy’s owner, a fact that was concealed through the use of a straw owner, he collected all of the Part D reimbursement payments made to Cal’s Pharmacy. In addition to pretending to fill prescriptions for himself, Calhoun admitted that he fabricated prescription claims for three other people. Calhoun also admitted that later on in the scheme, when Medicare started to deny the prescription claims, Calhoun appealed the denial and knowingly created and submitted to Medicare false and fabricated checks as part of his appeal, including to an administrative law judge, claiming they showed his payment for Arixtra prescriptions from Cal’s Pharmacy. (Justice.gov)


  • A new study was published this week in JAMA titled "Patient Outcomes After Hospital Discharge to Home With Home Health Care vs to a Skilled Nursing Facility." A cohort study of Medicare data of more than 17 million hospitalizations using instrumental variable methods to account for confounding by indication showed that compared with discharging patients to skilled nursing facilities, discharging patients to home with home health care was associated with a higher 30-day rate of readmission but a significantly lower Medicare payment for initial postacute care and for the total 60-day episode of care including hospitalization, all postacute care, and subsequent readmissions. There were no significant differences in 30-day mortality rates or improved functional status. (JAMANetwork.com)

Private Sector

  • On Tuesday, Geisinger and Highmark Inc. announced the completion and details of a previously-announced clinical joint venture. The organizations signed a letter of intent to explore the joint venture in May 2017, and in the time since have been working together to plan and design new facilities and services that will improve access to needed primary care, specialty care and appropriate acute inpatient care in north central Pennsylvania. The agreement creates a new, not-for-profit health care organization that includes existing Geisinger locations and developing new facilities to expand access to care for those who need it most in a four-county region covering Clinton, Lycoming, Sullivan and Tioga counties. The new health care organization will include existing Geisinger Clinics and Careworks Urgent Care facilities in the Lock Haven and Williamsport areas to serve as key access points to care in the new health care organization. The joint venture will serve both Highmark and Geisinger Health Plan members - including those in Medicare Advantage Plans - as well as patients with other insurance plans, Rice-Johnson added. (Geisinger.org)

  • Stryker, one of the world's leading medical technology companies, announced Thursday it has completed the acquisition of OrthoSpace, Ltd., a privately held company founded in 2009 and headquartered in Caesarea, Israel, in an all cash transaction for an upfront payment of $110 million and future milestone payments of up to an additional $110 million. OrthoSpace’s product portfolio provides a highly differentiated technology for the treatment of massive irreparable rotator cuff tears. The InSpace product is a biodegradable sub-acromial spacer, which is designed to realign the natural biomechanics of the shoulder. The technology has a long clinical history with over 20,000 patients treated across 30 countries. In the U.S., InSpace is currently under clinical study and not approved for use. “The acquisition of OrthoSpace is highly complementary to our existing portfolio and aligns with Stryker’s focus on investing in sports medicine,” said Andy Pierce, Stryker’s Group President, MedSurg. “We are excited about the momentum OrthoSpace has in key global markets and the additional surgical option this technology provides our customers to address a complex pathology.” (Investors.Stryker.com)

#PrivateSector #Research #Litigation #Legislation #Medicaid #Medicare


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