CMS offers new model for states to redesign health care delivery, equitable access to care
The Centers for Medicare & Medicaid Services (CMS) this week announced a new model to test a state’s ability to improve the overall health care management of its state population. The voluntary States Advancing All-Payer Health Equity Approaches and Development Model (AHEAD Model) aims to better address chronic disease, behavioral health, and other medical conditions. CMS said that under the AHEAD Model, participating states will be better equipped to promote health equity, increase access to primary care services, set health care expenditures on a more sustainable trajectory, and lower health care costs for patients. Participants in the model will be accountable for quality and population health outcomes, while reducing all-payer avoidable care spending to spur statewide and regional health care transformation. CMS will partner with states that volunteer to join the model. In doing so, CMS will strive to strengthen primary care, improve care coordination for people with Medicare and Medicaid, and increase screening and referrals to community housing and transportation to address social drivers of care. CMS said it will issue awards to up to eight states. Each state that participates in the model will have a chance to receive up to $12 million from CMS to support state implementation.
Humana sues CMS over final RADV rule and potential Medicare payment clawbacks
Humana last week filed a lawsuit in the U.S. District Court in the Northern District of Texas against CMS over its final rule that made significant changes to risk adjustment data validation audits, the agency’s primary audit and oversight tool for Medicare Advantage program payments. Humana claims in the lawsuit that the overhaul of the program violates the Administrative Procedure Act and aims to block the agency from using the new methodology to recover payments CMS made to Humana since 2018. In the lawsuit, Humana claimed that “CMS abused its discretion by concluding that retroactive application of the Final Rule is necessary to comply with statutory requirements.”
OIG: Most nursing homes unprepared for public health emergencies, natural disasters
A new report from the Office of Inspector General (OIG) finds that 77 percent of nursing homes reported challenges with preparedness activities intended to ensure they can meet resident care needs during an emergency. The most frequently cited concerns were ensuring proper staffing during emergencies and transporting residents during evacuations. The findings are based on a random sample of 199 nursing homes in geographic areas that have a high risk for natural hazards. The watchdog received responses from 168 nursing homes. An estimated 62 percent of nursing homes reported at least one challenge regarding staffing and an estimated 50 percent noted at least one challenge regarding transportation. Other challenges reported by some nursing homes related to securing beds for evacuated residents and planning for infection control and quarantine during emergencies. The nursing homes that reported challenges had lower community resilience compared to other nursing homes, which OIG said indicated that the availability of community resources may be a factor in nursing homes’ experience with preparedness activities. In addition, one in five nursing homes reported difficulties coordinating preparedness activities with multiple community partners.
Doctor convicted in $9.5M health care fraud conspiracy to accept kickbacks
A federal jury in Nashville has convicted Benjamin T. Toh, M.D., of Chicago, for his role in a more than $9.5 million health care fraud conspiracy, announced United States Attorney Henry C. Leventis for the Middle District of Tennessee. The defendant was indicted by a federal grand jury in December 2022. He was convicted of conspiracy to violate the federal Anti-Kickback Statute after a two-week trial.
Toh was enrolled as a Medicare provider and licensed to practice medicine in multiple states and worked with purported telemedicine companies to obtain access to Medicare and Medicaid patients around the country. From March 2019 through September 2019, he and others caused the submission of more than $9.5 million in fraudulent claims to Medicare and Medicaid for cancer genetic tests. The defendant ordered thousands of these tests despite never actually meeting the patients in person or via telemedicine and never reviewing test results.
In exchange for providing signed orders for genetic testing, the defendant was paid kickbacks by co-conspirator telemedicine companies. These companies were, in turn, paid by co-conspirator marketing companies that targeted Medicare and Medicaid patients through door-to-door marketing, at senior fairs, at nursing homes, and at other locations, and convinced patients to provide their genetic material via a mouth swab kit.
The marketers then provided the swab kits to a lab in Spring Hill, Tennessee, for laboratory cancer genetic testing and in exchange for kickbacks paid to them by the lab. The lab billed Medicare and Medicaid for the tests.
Based on the count of conviction, Toh faces up to five years in prison and a $250,000 fine. He will be sentenced on January 9, 2024. The jury was unable to reach a verdict on a second conspiracy charge.
Report: 68.5M adults in the United States don’t have dental insurance
Approximately 68.5 million adults in the United States do not have dental insurance, according to new data released today by CareQuest Institute for Oral Health®. This data, which comes from the third annual State of Oral Health Equity in America survey, also reveals that the number of adults without dental coverage could rise significantly by the end of 2023 due to additional household members losing coverage and the Medicaid redetermination process. Indeed, the report finds an estimated 14 million adults in the US stand to lose their Medicaid dental insurance coverage with the public health emergency expiration. This results in as many as 91.4 million individuals without dental insurance by the end of this calendar year.
The survey was administered in January and February 2023, with a final sample size of 5,240 adults ages 18 and older by the National Opinion Research Center at the University of Chicago as part of the AmeriSpeak panel.
“With the millions of uninsured adults across the country, we are facing a nationwide oral health crisis that forces many people to forgo critical dental care and disproportionately affects low-income individuals and racial and ethnic minorities,” said Myechia Minter-Jordan, M.D., MBA, president and CEO of CareQuest Institute for Oral Health. “To help combat this, we are calling on health care professionals, administrators, policymakers, and advocates to join us in our efforts to increase broad dental coverage in both Medicaid and Medicare.”
CareQuest Institute supports enhancements to government programs like Medicaid and Medicare by including extensive dental benefits for all enrollees. Currently, state Medicaid programs are not required to provide dental coverage to adults. This results in varied coverage state-to-state—from extensive benefits essential to maintaining optimal health to very limited or emergency-only benefits. Similarly, the Medicare program does not provide comprehensive dental benefits to all eligible older adults and people living with disabilities.
While the data show a three percent increase in the proportion of adults with dental insurance from 2021 to 2023, the increase is likely related to an increase in Medicare Advantage plan enrollment during the same period, according to the study announcement. Medicare Advantage plans offer some dental benefits to attract enrollees who have a choice of plans. However, dental benefits offered through Medicare Advantage plans vary widely and are quite limited, often resulting in high out-of-pocket costs for individuals with severe dental needs.
Among the key findings from the report:
- The portion of the population without dental insurance (27 percent) is almost three times as high as those without health insurance (9.3 percent).
- Adults living in rural areas (34 percent) were more likely to lack dental insurance compared to adults living in suburban (24 percent) or urban (29 percent) areas.
- Hispanic individuals were two times more likely to have lost dental insurance in the last year compared with white non-Hispanic individuals.
- Approximately one-third of both Medicare and Medicaid participants do not have dental coverage.
- Adults with lower incomes were significantly more likely than those with higher incomes to report cost as a barrier to seeing a dentist in the last two years.