Clear Roadblocks to Medicare Programs, Leader of House Panel Urges

Stay ahead of developments in federal and state health care law, regulation and transactions with timely, expert news and analysis.

By Mindy Yochelson

Small, focused Medicare managed care programs can face regulatory impediments that stifle their growth, the head of a House subcommittee said June 7.

Participants in Medicare Advantage special needs plans (SNPs) and the Program of All-Inclusive Care for the Elderly (PACE), two integrated programs for beneficiaries with significant health needs, have run up against regulatory and administrative burdens, Rep. Pat Tiberi (R-Ohio), who chairs the House Ways and Means Health Subcommittee, said. Congress should explore on a bipartisan basis changes to these programs and others within Medicare Advantage as the 65-and-over population grows, he told a subcommittee hearing on promoting coordinated care.

The hearing was part of an effort to look at different programs within the Medicare system and examine opportunities to improve quality and lower costs, a committee spokeswoman said.

Bipartisan Cooperation?

However, Rep. Sander Levin (D-Mich.), the subcommittee’s ranking Democrat, expressed skepticism about whether bipartisan cooperation on helping beneficiaries with complex needs would continue in light of House passage of legislation that would cut Medicaid funding as part of efforts to repeal the Affordable Care Act.

“These cuts would have a major impact on the people who are the subject of this hearing,” the Michigan Democrat said. “Cutting Medicaid will hurt those 11 million Medicare beneficiaries who are dually eligible for both programs and who depend on Medicaid to provide services and cover expenses that Medicare doesn’t.”

Dual Eligibles

Medicaid is important to this population, with a fifth of of Medicare beneficiaries dually eligible for Medicaid, Gretchen Jacobson, associate director, Kaiser Family Foundation’s Program on Medicare Policy, told the hearing.

About a third of dual eligibles are in Medicare Advantage plans. Half of these are in MA plans specifically targeted at dual eligibles, known as special needs plans (D-SNPs).

Jacobson and David Grabowski, professor of health-care policy at Harvard Medical School, cautioned about pushing forward with program expansion without further probing.

Little is known about what additional services or benefits SNP enrollees are receiving and to what extent quality of care and outcomes differ from other MA plans, Jacobson said.

Are They Special?

“It is vitally important that we understand whether there’s anything `special’ about special needs plans to justify their unique status,” Grabowski said.

The typical D-SNP is not accountable for Medicaid outcomes, he said. This type of arrangement is not true financial and clinical integration.

The PACE program also integrates Medicaid and Medicare and is intended to keep frail beneficiaries out of nursing homes through a package of community-based medical and social services. While it shows potential in decreasing hospital use and in other ways, the individual PACE programs are small, and questions have been raised about whether they can be replicated on a larger scale, Jacobson said. Also, data on quality of the programs isn’t available publicly, she said.

The MA Value-Based Insurance Design Model, the third program discussed, allow plans to structure benefits just for those with certain medical conditions. The program requires a waiver because Medicare must offer the same benefits to all. The program is being tested in some states.

VBID could be new model to manage the care of beneficiaries but questions need to be answered first, she Jacobson said. “For instance, what enhanced benefits are plans offering through” the VBID program? she asked.

Regulatory Burden

Cheryl Wilson, chief executive officer of St. Paul’s Senior Services in San Diego, spoke on behalf of the National PACE Association. A major obstacle to PACE program expansion is not only the time and money it takes to get a program up and running but onerous program regulations, she said. The Centers for Medicare & Medicaid Services “puts up so many barriers,” Wilson told the subcommittee.

The CMS in August 2016 proposed regulations intended to ease requirements for participating organizations, but they haven’t been finalized. PACE is waiting for the agency to “pull the trigger” on new program rules, she said.

To contact the reporter on this story: Mindy Yochelson in Washington at MYochelson@bna.comTo contact the editor responsible for this story: Kendra Casey Plank at

Copyright © 2017 The Bureau of National Affairs, Inc. All Rights Reserved.

Request Health Care on Bloomberg Law