Wednesday, August 24, 2016

Unintended Consequences - 340B

340B, drug rebates, Affordable Care Act, Medicaid
It began with Medicaid.

In 1991, Congress passed the Omnibus Budget Reconciliation Act (OBRA 90). The goal was to enlist the aid of pharmaceutical manufacturers in lowering the cost of pharmaceuticals prescribed to Medicaid patients, and financed by the Federal and state governments. Access to manufacturers’ “best price” was the goal, to help balance the Federal budget.

Manufacturers, commercial entities all, recognized that the “best prices” were the ones on the Federal Supply Schedule (FSS); the prices paid by the Veterans Administration (VA) and the Department of Defense (DOD). There was no legislated exemption for these, so manufacturers raised the FFS prices to list price. These actions severely impacted the DOD and VA budgets, so an amendment was added to exempt FSS prices from OBRA. On June 30, 1992, this amendment expired.

Subsequently, P.P 102-585, the Veteran’s Health Care Act (VHCA) of 1992 was passed. Sections 601 and 603 establish the pricing rules for DOD and VA. Section 602 amended the Public Health Service (PHS) Act by adding a “Subpart VII, Sec. 340B” to Part D of Title III. 340B was born!

Congress created a program to offer uninsured indigent patients better access to prescription drugs by providing these drugs at discounted prices to covered entities (CE) serving large numbers of this uninsured population. Intention….give these patients better access to these drugs.

Over time, for many reasons, the program has grown exponentially. HRSA sub-regulations, the Medicare Modernization Act (MMA), and the Affordable Care Act (ACA) have wrought significant changes in the program participants and their collective behaviors. The program has outgrown its mission.

The patient definition, or its interpretation, has expanded to include all outpatients of the CE, regardless of insurance coverage. The CE list has been broadened, and now includes hospital satellite locations, sole community hospitals, and free-standing cancer centers, to name a few. In 2010, CEs were allowed to begin utilizing multiple contract pharmacies to supply these drugs. Manufacturers concerns, other than the low pricing requirements, involve diversion and double dipping.


340-priced drug, drug rebates, Affordable Care Act (ACA)Diversion happens when a 340B-priced drug is dispensed to anyone not entitled to receive it. That list includes in-patients, and any outpatient that does not fit the HRSA definition. Diversion also happens if the drug is sold or transferred to another entity. Double dipping occurs when a Medicaid claim is filed with the state for a 340B drug, thereby duplicating the Medicaid rebate. Over time, states have improved the identification of 340B claims in the Fee-For-Service (FFS) arena, and have excluded them. However, since the ACA now requires manufactures to pay Medicaid rebates on Medicaid MCO utilization, double dipping is back in focus. The Office of Inspector General (OIG) issued a report in June stating that many state methods for identifying 340B drugs may create a risk of “duplicate discounts and foregone rebate.” Since the ACA now requires manufactures to pay Medicaid rebates on Medicaid MCO utilization, double dipping is back in focus, along with the potential for “forgone” rebates.


Concerns:


• CEs are profiting from the system. In any economic system, if access to low priced commodities is available, organizations will find ways to maximize them. And if the penalties for non-compliance are weak and non-existent, boundaries will be pushed. Consider: A CE can legitimately purchase drugs at 340B prices, and then bill the applicable insurance company. They cannot legally bill Medicaid, but all others are fair game.

• A retail store serving as a contract pharmacy has the potential to profit from the same situation. Oversight of these institutions is the duty of the CE whom it serves. Regular audits of these entities are expected by HRSA, but enforcement is apparently not currently a HRSA priority.

• A CE can acquire a physician oncology practice to gain access to 340B pricing on those drugs.

• Patient care may be impacted clinically by moving or scheduling a procedure on an out-patient facility or status to take advantage of the cheaper medications.

These are just a few of the concerns to be considered. The 340B Program has grown into something beyond what its creators had envisioned. The 21th MDRP Summit by IIR includes a full day workshop on this critical topic. Hear from HRSA, attorneys and colleagues about what is being done to address these concerns. Download the agenda to see a complete topic list here



About the author:

John Bliss is a contributing writer for the Medicaid Drug Rebate Program summit. He has extensive experience in the pharmaceutical industry, including AstraZeneca, Sanofi Aventis, Merck, Pfizer, Daiichi Sankyo, and Bristol-Myers Squibb (BMS). The bulk of John’s career was at BMS. When OBRA90 hit, Government Pricing took over his life. Government pricing, managed care contracting, rebates, and chargebacks continue to extend challenges and provide meaningful employment. John now works as a consultant, primarily subcontracted by other consulting firms, providing value added services to each of them and their clients.



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Wednesday, August 17, 2016

Election 2016: What Each Candidate Could Mean for Pharma

Election 2016
Every four years we are inundated with non-stop coverage of the presidential election, with both sides vying contentiously for control of the White House as well as Congress. Thankfully, each election year also brings us the Summer Olympics, which offer a brief but much-needed respite from the talking heads and partisan bickering. For two short weeks, Americans come together to support the heroes who motivate and inspire us all, before returning to the ones who polarize and divide us. It’s easy for all of us to rally behind Michael Phelps and Simone Biles, sharing in their successes and taking pride in the honor they bring to our country. However, reaching a consensus on Trump and Clinton is a different story.

After the Olympics are over and the kids are back in school, Government Pricing professionals will convene in Chicago once again for IIR’s 21st Annual Summit on the Medicaid Drug Rebate Program (MDRP). We will all come with our own opinions and political convictions, but we will also be wondering how our day-to-day responsibilities will be impacted by the election. Although we at Government Pricing Specialists (GPS) don’t have a crystal ball, we can compare and contrast the candidates’ platforms, and how they could change the face of GP. Here are their positions on a few GP-related issues:

The Patient Protection and Affordable Care Act (ACA)

• Clinton – Per her website, Clinton would “Defend and expand the Affordable Care Act, which covers 20 million people.”

• Trump – Per Trump’s website, “On day one of the Trump Administration, we will ask Congress to immediately deliver a full repeal of Obamacare.”

• Potential GP Impact:  

Under a Clinton presidency, if the ACA stands, the changes codified in the recent MDRP Final Rule would likely remain in effect but the “Cadillac Tax,” the excise tax on high-cost health insurance plans, would likely be repealed. 

Under a Trump presidency, the legitimacy of the Final Rule could be challenged if the ACA is repealed. However, repealing the ACA may be difficult since taking away a benefit is usually unpopular with voters. If the Republicans control both houses of Congress, it is more likely that substantial changes to the ACA would be introduced but if Democrats control the House of Representatives or the Senate, it is unlikely that we will see significant change.

Medicaid

• Clinton – Per Clinton’s website, she would “Fight for health insurance for the lowest-income Americans in every state by incentivizing states to expand Medicaid – and make enrollment through Medicaid and the Affordable Care Act easier.” 

 Trump – Trump has said that the Federal Government should provide block-grants to the states for Medicaid, that it should be entirely controlled by the states which he believes would reduce the fraud, abuse, and waste. 

 Potential GP Impact:

Under Clinton, if Medicaid enrollment increases, Medicaid sales would likely increase, as would the volume of Medicaid rebates. 

Under Trump, if federal funding is reduced, it could actually put pressure on manufacturers to provide more in terms of rebates. However, Trump believes that his plan to get more Americans working would actually reduce the need for Medicaid because more people would have access to health insurance through their employer.

Medicare

• Clinton – Per her website, Clinton would “require drug manufacturers to provide rebates for low-income Medicare enrollees that are equivalent to rebates in the Medicaid program.” She would also “Allow Medicare to negotiate drug and biologic prices… Clinton believes that we should drive the best bargain for Americans, and especially for senior citizens, by allowing Medicare to negotiate drug prices, notably for high-cost drugs with limited competition.” Clinton also supports the idea of allowing people to “buy into” Medicare if they do not meet the eligibility requirements.

• Trump – Although he does not specifically address allowing Medicare to negotiate prices on his website, at a January rally in NH Trump supported allowing Medicare to negotiate drug prices, saying, “Drugs with Medicare, they don’t bid ‘em out… They pay like this wholesale incredible number… They say like $300 billion could be saved if we bid ‘em out. We don’t do it…”

• Potential GP Impact – A proposal to create a rebate program for Medicare, similar to the MDRP, would likely take significant time to pass and be finalized (think of the 6 years we waited for the AMP Final Rule). More likely is an extension of the Medicaid rebate to prescription drugs for “dual eligibles” (participants eligible for Medicaid and Medicare), but even that may take a bit of time. A plan to allow Medicare to negotiate drug prices with manufacturers, which both candidates support, although not the GOP at large, could require manufacturers to manage Medicare contracts similar to how they manage their VA contracts.

This election may be the most interesting one in our lifetimes, at least to date. As healthcare and health insurance become a greater part of our nation’s economy, and our own budgets, these issues will continue to receive a lot of focus. Government Pricing has always been the image of that old saying, “May you live in interesting times,” but this election year has become the poster child for it!

We look forward to the MDRP Summit to hear more on the potential GP implications of the 2016 election, and to hear your questions and comments. If you have not already registered, do so today and use code XP2158MISC to get an additional $100 off of the current registration fee. GPS will be onsite and blogging for the 2nd year in a row, so we look forward to seeing you there!


Sources:
https://trumpcare.com/trumpcare-and-medicaid/
http://www.nytimes.com/2016/04/09/us/politics/donald-trump-health-care.html?_r=0 
https://www.hillaryclinton.com/issues/social-security-and-medicare/ http://www.ontheissues.org/Senate/Hillary_Clinton_Health_Care.htm http://www.nytimes.com/2016/05/11/us/politics/hillary-clinton-health-care-public-option.html 
http://www.ontheissues.org/2016/Donald_Trump_Health_Care.htm


About the Authors: 
Katie Lapins & Dana Zelig Collins, Government Pricing Specialists, LLC, 303.993.6456, K.Lapins@GP-Specialists.com. ; D.Collins@gp-specialists.com





Thursday, July 28, 2016

Value Based Purchasing Session Added to MDRP Agenda

Increasingly, manufacturers have been reaching out to us at Government Pricing Specialists (GPS) to discuss value based purchasing (VBP) arrangements, and how this could impact their Government Pricing (GP) calculations. In response to these inquiries, IIR has added a session on VBP to its agenda for the upcoming conference in Chicago, 21st Annual Summit on the Medicaid Drug Rebate Program (MDRP), which will be led by Stephanie Trunk, Partner at Arent Fox. This session will cover the potential impact of VBP on manufacturer’s GP calculations, with a Q&A to allow attendees to ask questions and voice concerns.


Background:

So what do we mean by value based purchasing arrangements? In this type of agreement, payment is linked to an outcome of a medication instead of another value such as a contract price based on volume or formulary. The better the outcome, the higher the price. Of course, in this type of agreement, there must be clearly defined standards regarding how the outcomes will be defined and measured. Products that are more likely to fall under this type of arrangement are those such as medications for high cholesterol, asthma, hypertension, or treatment of tumors – conditions that can be objectively measured.

In 2010, the Affordable Care Act established CMS’ Hospital VBP program, which rewards hospitals with incentive payments for the quality of care they provide to Medicare beneficiaries. On July 14, 2016, CMS issued Manufacturer Release No. 99 and State Technical Release No. 176, encouraging states “to consider entering into (VBP) arrangements as a means to address, as well as offset, Medicaid’s high cost drug treatments,” and reminding states “that they may extend their Medicaid supplemental rebate agreement to some or all of their managed care prescription claims.” These VBP arrangements are meant to reduce the government’s health spending, but it is unclear what impact they will have on pharmaceutical manufacturers.


Best Price Implications:

On the commercial side, if a manufacturer enters into a VBP agreement and a drug is shown to be less effective than anticipated, there could be an impact to Best Price (BP). Manufacturer Release No. 99 and State Technical Release No. 176 also respond to questions pharmaceutical manufacturers have raised about this possibility. The releases note that “CMS has concluded that the impact on a manufacturer’s best price will differ depending on the structure of the VBP arrangement,” and “recommends that when manufacturers negotiate such arrangements with entities, they consult both the statute and implementing regulations regarding the determination of best price.” CMS specifically references Section 1927(c)(1)(C) of the Social Security Act, 42 CFR 447.505(a), and 42 CFR 447.510 for BP requirements.

The releases also encourage manufacturers to enter into VBP arrangements with state Medicaid programs, noting that supplemental rebates provided as a result of VBP would be excluded from BP.


Additional Guidance:

Although CMS has not offered definitive guidance on VBP’s impact to BP, the agency did say it is available to address questions on specific arrangements, and encourages manufacturers to submit questions to the CMCS Division of Pharmacy at RxDRUGPolicy@cms.hhs.gov. CMS also indicated that additional guidance based on manufacturer feedback could be forthcoming in future releases.

If your company is exploring VBP arrangements, or you just want to network with you peers and to hear more on this and other hot topics, I strongly recommend you attend IIR’s 21st Annual Summit on the Medicaid Drug Rebate Program (MDRP) . This event is one of the best well-attended conferences each year and attracts top speakers from the industry. And if you register using code XP2158MISC, you get an additional $100 off of the current registration fee. GPS will be onsite and blogging for the 2nd year in a row, so we look forward to seeing you there!



About the Authors:
Katie Lapins & Dana Zelig Collins, Government Pricing Specialists, LLC, 303.993.6456, K.Lapins@GP-Specialists.com. ; D.Collins@gp-specialists.com




Wednesday, June 1, 2016

MDRP 2016: Final Agenda Available!


Medicaid Drug Rebate Program
September 20-22, 2016 | Chicago, IL
Download the final agenda: http://bit.ly/1TY7XCQ 

Now in its 21st year, IIR's MDRP Summit (http://bit.ly/1ZdEll3) has continued to be THE authoritative MDRP Event for Everything Government Pricing, Rebates and Regulation. MDRP provides unparalleled access to the government regulators creating the rules, the industry leaders interpreting them, and the pharmaceutical executives implementing them.

Don't miss out on your opportunity to benchmark best practices and gain solutions to overcome new operational challenges brought on by AMP Final Rule, 340B, Medicaid Expansion, Class of Trade, Fair Market Value, FSS, VA, OIG, and other critical government programs.

Why should you attend MDRP?

Learn:
• AMP Final Rule Implementation
• 120+ Speakers
• 6 Keynote Presentations
• 340B Guidance Updates

Benchmark:
• State Dispute Resolution Meetings
• New Executive Leadership Boardroom
• Town Hall between Manufacturers and States

Connect:
• 14+ Federal and State Agencies
• 600+ MDRP Executives
• 20+ States
• 30+ Solution Providers

Access the final agenda: http://bit.ly/1TY7XCQ

$400 savings ends Friday, July 1st! Click here to register: http://bit.ly/1RNJ5rF





Tuesday, May 24, 2016

How to Demonstrate the Efficiency of New Technology to Patients

Technology can be very confusing, especially if it isn't something you wouldn't normally interact with. While most medical technology can seem mundane to doctors, it is elaborate, complex and sometimes scary to patients. This isn't because they are techno-phobic; it is often just because they don't understand.

Introducing new technology to individual patients can be very difficult, especially if you aren't sure how to explain the benefits of using it. Use this quick guide to learn more about how to incorporate technology into your practice and make patients more aware of how things can help them. 

Explaining Change


Technology is improving at a rapid rate and it affects everything that we do. The medical field is no exception, with technology revolutionizing the industry even more. With all of the technology in the medical field, it isn't uncommon for patients to have to undergo new procedures or screenings.

If you need to introduce your patient to a new routine, start by explaining the reason for the change. You don't have to go into too many details. For example, if the screening would better help you understand the vitamin levels in a patient, say so. Explain that the new method is more efficient and tell them how it directly benefits them to use the technology. This will make them more apt to agree to use the new test or device.

Keep in mind that most patients won't understand complex medical jargon. For example, if you are trying to tell them the importance of using a vendor neutral archive, you can't just recite a dictionary explanation. You need to explain that the technology stores images and documents so that other machines can quickly access it. 

Show Examples


While you can't always show specific examples of tests, you can show a diagram that does. Even showing a cartoon drawing of a completed test can give the patient a little clarity. The more detailed the example is, the easier it will be to convey your message. People respond to visuals and can gain a lot of insight just by looking at a picture.

If you are trying to prove that a new method is more efficient than an old one, show the patient results. Even if it is your first time using the technology, you should be able to produce results of previous tests or information from the company showing how much it can help. 

Create a Video


Sometimes, new technology becomes widespread very quickly. To keep from having to explain yourself and the reasons for the change over and over again, try making a video to show your patients. During the video, you can:

• Explain how the technology works
• Why you are choosing this method
• How this method benefits the patient
• Go over statistics and proof that the method works
• Show a visual demonstration of the entire process.


The great thing about using video to demonstrate the effectiveness of medical technology is that it can be viewed at any time. You can send the patient home with a copy or ask them to watch it online before their visit. This helps to save you time and improves the efficiency of your office.

Be Personal and Relate to the Patient


Regardless of what method you use to explain how efficient your medical technology is, you need to be able to relate it to the patient. When patients enter a medical office, they want to know what the fastest and most efficient way to get healed is. If you don't clearly convey that the technology is helping the patient, they might not want to use it.

Demonstrating the efficiency of new technology doesn't have to be difficult. 


About the author: Greg Dastrup is a world traveler and professional writer with a passion for learning new languages. He’s spent most of his career consulting for businesses in North America. You can follow Greg here.





Friday, May 20, 2016

With Some Flexibility, Medicaid’s Future Seems Bright in a Polarized America


By Rene Macapinlac

Medicaid reform is as contentious as the upcoming presidential election. Critics abound questioning the expansion’s impact on state budgets and Medicaid’s effectiveness in delivering quality care.

What will happen to Obamacare soon after Obama leaves office? Will states reject Medicaid expansion? Len M. Nichols, director of the Center for Health Policy Research and Ethics (CHPRE) and a professor of health policy at George Mason University, believes that will not be the case. 

Nichols is confident that states will see expansion for what it is -- good for the budget, and good for the health of their residents. 

Waivers, including section 1332 of the Affordable Care Act (ACA), will play a key role to states that have yet to expand Medicaid. Section 1332 of the ACA allows a state to apply for a waiver to opt out of certain portions of the ACA in order to engage in innovative strategies for providing access to high quality, affordable health insurance. It gives states the latitude to pursue their own kind of health reform.

Although it will not be until January 2017 until the first of these waivers can be filed, states are beginning to see the potential for designing a health care program that will work specifically for their state. They may modify the rules governing covered benefits and subsidies, or make changes to the requirement for maintaining minimum essential coverage.

Some states are also now beginning to implement innovative programs reforming how care is delivered and paid for.  Part of the broader Section 1115 Waiver programs, the Delivery System Reform Incentive Payment (DSRIP) provides states with significant funding that can be used to support hospitals and other providers in changing how they provide care to Medicaid beneficiaries.

Under DSRIP initiatives, funds to providers are tied to meeting performance milestones or metrics.  DSRIP waivers generally focus on infrastructure development and system redesign, and clinical outcome improvements and population-focused improvements. Funding for DSRIP initiatives varies across states, but it can be significant.  

In the days ahead, there will be negotiations between states and the federal government over policy and budget. Some states have become so politically polarized to the point that anything linked to Obamacare has been deemed ineffective by some residents. But there are facts to support the case for Medicaid expansion. 

A recent study found that in states that expanded Medicaid, insurance coverage increased for low-income adults. The study, published by the Annals of Internal Medicine, also found better healthcare usage and diagnosis rates for chronic diseases.

Nichols believes it is not impossible to find a common ground on the issue of Medicaid expansion. It will no doubt take a lot of effort, but it can be done. After all, history has shown us that despite contentious politics, we have always been able to make programs work.

Rene Macapinlac is the Director of Operations at ManagedCareBiz, an online resource for managed care professionals who need to stay up-to-date on industry news, analysis and commentary.




Medicaid Directors and the Brand New Challenges They Face


By Rene Macapinlac

The most recent State Medicaid Operations Survey, conducted by the National Association of Medicaid Directors (NAMD), shows just how the Medicaid program has changed and will continue to change rapidly in the days ahead.


Topping the list of major Medicaid innovations is payment and delivery system reform. Agencies are moving toward performance-based reimbursement models both within traditional fee-for-service care delivery and managed care. Directors face challenges with staffing, data and systems infrastructure, budgets, and procurement processes.

Difficulties in recruiting and retaining staff are pushing directors to internally shift existing staff resources and step up initiatives for acquiring new skill sets.  On top of the challenges with limited staffing and resources, the directors must deal with higher expectations, increased public visibility, and greater accountability.

Medicaid today has become a complex program covering a wide range of services requiring a broad scope of operational functions. These operational functions often involve contractors, making day-to-day management even more complex. Contractor involvement varies by state, with some agencies contracting key functions while others only do back-office functions.

Despite the persistent and increasing job challenges, Medicaid directors remain committed to building new capabilities in order to meet the needs of more than 72 million Americans. They are implementing new or expanded program integrity activities - conducting various audits, enhancing data resources and analytical tools, strengthening program policies and procedures, and coordinating with other entities.

Rene Macapinlac is the Director of Operations at ManagedCareBiz, an online resource for managed care professionals who need to stay up-to-date on industry news, analysis and commentary.




Thursday, May 19, 2016

Using Technological Advancements to Improve Health Care Delivery

By Rene Macapinlac


Through the years, technology has played a vital role in improving the delivery of health. During day one of the Medicaid Managed Care Congress, the subject of technology often came up in discussing efforts to move beyond Medicaid and provide higher quality care.

Telecommunication technology or telehealth has become one of the main tools for health plans and providers to improve care and outcomes. Video conferencing is being used by patients and doctors for real-time consultations and discussions. Electronic devices available for transmitting patient health information to doctors and other health care providers. Pre-recorded videos and digital images of x-rays can now be electronically transmitted between primary care providers and specialists.

Mobile applications are increasingly being used for health services, information and education.

Underserved populations can be reached through targeted text messages to promote healthy practices, and through public alerts to inform them about disease outbreaks.

Technology has also played a vital role in data-gathering and building metrics to better measure patient outcomes and member engagement. It is a key component in the development of state-led payment and service delivery innovations.


Patient-Centered Medical Home (PCMH), the model of care for transforming the delivery of comprehensive primary care is leaning on technology -- email, video chat and mobile apps -- to help patients stay on top of their health and get health care when they need it.


The Children’s Community Health Plan uses claims-based technology to detect women at risk for delivering a child with neonatal abstinence syndrome (NAS). The number of cases of infants with NAS has increased with the rise in substance use disorder. Once algorithms identify at-risk women, they are provided with educational materials and their care providers are notified.


When it comes to diabetes management, Cigna-HealthSpring is using cellular technology (along with nurse visits) to help its members with uncontrolled diabetes. They give these members information on self-management and monitoring.


These are just some of the ways technology is changing the Medicaid managed care industry. Although implementation comes with issues and challenges to be hurdled, there is no question that all of these technological advancements have been improving outcomes and mitigating rising health care costs.


Technological innovations support the provisions of the Affordable Care Act by providing educational materials and opportunities for patients to care for themselves better. Furthermore they provide opportunities for doctors and other providers to intervene with a patient early on when the health condition is still easily treatable.



Rene Macapinlac is the Director of Operations at ManagedCareBiz, an online resource for managed care professionals who need to stay up-to-date on industry news, analysis and commentary.




How Community Advocacy Improves Health and Outcomes

By Rene Macapinlac

Access to primary care is important, but there are other factors outside of the doctor’s office that determine one’s health. To help its member lead healthier lives, health plans should focus on advocacy and community-based programs.

Speaking to attendees of the Medicaid Managed Care Congress in Baltimore, Carol Steckel, senior director of public policy at WellCare, emphasized how identifying community-based solutions help improve health outcomes of their members and ultimately lower overall cost of care.

At WellCare, Steckel said they examine the health and welfare in the populations they serve. Using that data, they are able to identify the gaps in the network of social services. Where needed they link their members to such services as housing assistance, employment services, food banks and education support. They also improve quality of life for residents by providing transportation for seniors and people with disabilities so that they could go to medical appointments, day programs and shop for groceries.

 
Linking members with the community and social services improves health outcomes and ultimately lowers overall cost of care.

Rene Macapinlac is the Director of Operations at ManagedCareBiz, an online resource for managed care professionals who need to stay up-to-date on industry news, analysis and commentary.




Tuesday, May 10, 2016

Medicaid Expansion Boosts Insurance Coverage, Use of Healthcare Services

- By Rene Macapinlac

Critics of Medicaid expansion have voiced out several reasons why states should not expand the program. Aside from concerns that it will burden the state budgets, they question Medicaid’s effectiveness in providing quality care. 

Now there are solid facts to support the case for Medicaid expansion.

A recent study found that in states that expanded Medicaid under the Affordable Care Act, insurance coverage increased for low-income adults. The study, published by the Annals of Internal Medicine, also found better healthcare usage and diagnosis rates for chronic diseases.

Researchers at the University of Michigan and the University of California-Los Angeles analyzed data from the National Health Interview Survey between 2010 and 2014. They compared the changes in outcomes among adults (ages 19 to 64, with family incomes 138 percent below the federal poverty level) in the 26 states that expanded Medicaid in 2014 with outcomes for adults in states that did not enact Medicaid expansion.

Among other factors, the researchers looked into coverage improvements compared to the previous year, doctor visits, hospitalizations and emergency department visits.

Here are some of the study’s key findings:


• In states that expanded Medicaid, insurance coverage increased 7.4 percent and Medicaid coverage increased 10.5 percent compared to non-expansion states.

• States that expanded Medicaid saw an increase in adults reporting an overnight hospital stay (2.4 percent), or visit to a physician (6.6 percent) in 2014, compared to non-expansion states.

• In states the expanded Medicaid, the rate of diabetes diagnoses increased (5.2 percent) as well as cholesterol diagnoses (5.7 percent).


It’s important to note that there were limitations to this study. Researchers only looked at the experiences of low-income adults during the first year of enactment of Medicaid expansion. They were not able to definitively rule out other factors unrelated to Medicaid expansion that may have influenced the results.

Although the study showed low-income adults were more likely to go to a physician or hospital, it was not able to determine improvement in the adults’ health because of the limited available data.

The researchers, however, have no doubt that greater use of health services could pay off in the future. They pointed out in the study that increased detection of chronic health conditions under Medicaid expansion could have important implications for both population health and national spending on health care “if it leads to improved management and control of these conditions." Since states began Medical expansion in 2014, Medicaid enrollment has gone up to more than 70 million people.

Monitoring these trends over time will be critically important for Medicaid managed care professionals as they prepare to adapt to changes, particularly when it comes to the people now gaining Medicaid coverage. Under the Affordable Care Act, states are now using Medicaid managed care plans to cover beneficiaries in rural areas, those with complex and chronic conditions, and many new enrollees. It will be interesting to see in the coming months how access to providers will be affected - as enrollment goes up and the number of uninsured people go down.


About the author:

Rene Macapinlac is the Director of Operations at ManagedCareBiz, an online resource for managed care professionals who need to stay up-to-date on industry news, analysis and commentary.