MACPAC Holds Public Meeting
National Council on Medicaid Homecare – a NAHC Affiliate - Attended the Meeting and Reports on the Most Relevant Topics
October 8, 2013 10:13 AM
The Medicaid and CHIP Payment Access Commission (MACPAC) held a public meeting on September 19 and 20, 2013 in Washington, DC. National Council on Medicaid Home Care (the Council) policy director, Michelle Martin, attended the relevant portions of the meeting.
MACPAC issues reports to Congress in March and June of each year. The September meeting was the Commission’s first meeting since issuing its June 2013 report to Congress. The meeting was to review the plan for the 2014 Report Cycle and to give the analysts working on the various topics some guidance on the particular issues the Commissioners would like to see reviewed in the next report. Two of the topics that were presented and may be included in the March 2014 report are of interest to the Council: Analyses of Medicaid Waiver Authorities: Emerging Themes, and Medicaid Long Term Services and Supports.
The discussion on Medicaid waiver authorities was brief but informative. Ben Finder, senior analyst for MACPAC, reviewed the work that MACPAC has done on waivers so far and explained the important issues. The waiver approval and renewal process, including the process timeline, waiver consolidation, and a path to permanency, as well as the budget neutrality requirement for waivers and the reporting and evaluation requirements have all been reoccurring themes in the Commission’s work. Within each of these areas, Mr. Finder posed a series of questions to the Commissioners, designed to elicit feedback that would guide the coming work on waivers.
The Commissioners agreed that the themes identified by Mr. Finder are important and require further review. The requirement for budget neutrality in waivers was discussed during the question and answer session, with one Commissioner pointing to conflicting reports—one saying that it is impossible to determine cost neutrality through the use of waivers and another saying that home and community based service (HCBS) waivers are cost effective. The question that arose from these conflicting assertions is: is HCBS really cost effective? The idea that HCBS costs less seems to be widely accepted but without any real proof. Because of this lack of proof, the Council is working on a study that analyzes the availability of data to demonstrate the value of home care with the ultimate goal of obtaining data that does, in fact, prove the cost effectiveness of home care.
A second point that was discussed further by the Commissioners is the idea of a “path to permanency.” In previous hearings, some state representatives have explained how cumbersome the waiver application or renewal process can be, even if the waiver has existed for many years and is not changing in the renewal. Making waivers permanent by way of a state plan amendment seems like an obvious solution. However, the Commissioners agreed that they must tread lightly on this topic as there is a reason that states are opting to continue with HCBS waivers instead of implementing the HCBS option under 1915(i). The most likely reason is the ability to cap spending through the use of waivers that would not be available if a waiver program became part of a state’s Medicaid plan. The issue of the time and effort required to apply for waivers has been discussed at length but the Commissioners recognize the need to proceed cautiously and avoid the possibility of creating major budget difficulties by requiring waivers to become part of the state plan after some number of years.
The second Commission topic of interest to the Council was Medicaid Long-term Services and Supports, which was presented by Angela Lello and Molly McGinn-Shapiro, both senior analysts for MACPAC. The purpose of the presentation was to provide the Commissioners with foundational information on Medicaid LTSS. The information provided included the definition of LTSS, the populations that receive LTSS, eligibility pathways, mandatory LTSS benefits versus optional benefits, utilization information, and a description of the amount of Medicaid dollars spent on various LTSS programs. The presenters offered a set of key policy questions for the Commissioners’ consideration in three areas:
LTSS Payment and Access
Variation in Medicaid LTSS
In conclusion, the presenters admitted that there is a long list of policy questions to consider as well as a considerable amount of information about Medicaid LTSS for the Commission to review as they move forward. Recognizing the size and complexity of the Medicaid LTSS issue, the presenters have created a background paper (which is, unfortunately, not available to the public) to help to guide the Commissioners through the session and to help inform the Commissioners’ opinions on which policy areas should be prioritized for the coming report cycle. The Commissioners offered comments on what policy questions can be taken on by MACPAC this year, where MACPAC can make a contribution, what questions/issues would be most relevant and timely and what policy questions can be saved for future work. The three issues the Commissioners felt would be most important in Medicaid LTSS are:
Determining the big picture, or goal of Medicaid home care
I.e. Why people need home care and how to determine if the goal is being met;
Standardization in terms of eligibility, need assessment, etc.; and
Managed long term services and supports.
Several areas of focus suggested by the Commissioners are of great interest to the Council and its policy goals. Given the recent move by the Department of Labor to modify the companionship exemption and exclude home care workers from the exemption, the Commissioners felt that the home care workforce would be deserving of attention in the coming months. The movement of many home care programs from state-based Medicaid to Medicaid managed care is also an intended focal point, with some Commissioners expressing concern over the drastic variation between states, definitions of services and the units the services are paid in. Other areas suggested by the Commissioners, that are directly in line with the Council’s policy priorities, include considering the goals of the home care intervention and metrics to measure attaining those goals that is separate from quality, a method to determine cost effectiveness, standardization in Medicaid home care so that each state does not drastically change the rules for beneficiaries, and the perceived prevalence of fraud and abuse in Medicaid home care. One Commissioner, who is a physician, shared that he has had negative experiences with providers being inappropriately aggressive about insisting that a patient required a high level of care. The experience has caused that Commissioner to feel that home care is a “great area” for fraud and abuse.
Because the September public hearing was meant to be a sort of planning session, which areas will be prioritized by the Commission is not yet known. It is possible that the MLTSS section will be discarded for this report cycle. However, Council policy director Michelle Martin has been in contact with the senior analyst managing the Medicaid LTSS section of the reporting process who feels that discarding that section entirely is not likely given the interest the Commissioners expressed during the hearing. The Council has offered to provide any information or assistance that may be of benefit to MACPAC staff as they move forward with the 2014 Report Cycle. The coming work of MACPAC will be closely monitored by Council staff. We will keep Council members apprised of the Commission’s work and focus on Medicaid Long Term Services and Supports.