HHS marks Prescription Opioid and Heroin Epidemic Awareness week with $44.5M grant

The Health Resources and Services Administration (HRSA) and the Substance Abuse and Mental Health Services Administration (SAMHSA) will award more than $44.5 million in awards to training programs aimed at increasing the number of mental health providers and substance abuse counselors in the United States.  The funding includes 144 new and continuing grants through the Behavioral Health Workforce Education and Training (BHWET) program.

Behavioral Health Workforce Education and Training Program

 The BHWET program supports clinical internships and field placement programs for professional and paraprofessional behavioral health disciplines and occupations. The initiative serves children, adolescents, and transitional-age youth at risk for developing or who have a recognized behavioral health disorder by adding to the behavioral health workforce. Recipients of grants under this program are expected to expand the behavioral health workforce by participating in internships and field placements focusing on working with these at-risk individuals. Activities under the grant emphasize prevention and clinical intervention and treatment for those at risk of developing mental and substance abuse disorders and the involvement of families in preventing and treating behavioral health conditions.

Of the $44.5 million grant, more than $7.9 million will support a total of 34 new grantees, and the other $36.6 million will fund the program’s 110 existing grantees.

Prescription Opioid and Heroin Epidemic Awareness Week

President Barack Obama designated the week of September 18 – 23, 2016, Prescription Opioid and Heroin Epidemic Awareness Week. During this time, federal agencies focused on the work being done across government entities and announced new efforts to address the epidemic of prescription opioid and heroin abuse. In his announcement, Obama stated that he continues to “call on the Congress to provide $1.1 billion to expand access to treatment services for opioid use disorder.” The investments would build on the steps already taken to expand overdose prevention strategies and increase access to the overdose reversal drug naloxone.

AMA warns of drastically reduced competition if mergers allowed

More competition is needed in the health insurance markets, a premise supporting the efforts to block the merger of four of the nation’s biggest health insurance companies, according to an analysis by the American Medical Association (AMA). Anthem’s acquisition of Cigna and the merger of Aetna and Humana would essentially eliminate competition in 24 states. The Department of Justice filed suit in July to challenge the two mergers (see DOJ lawsuit steps in between Aetna-Humana and Anthem-Cigna mergers, Health Law Daily, July 21, 2016).

Competition in health insurance markets

The AMA assessed the anticompetitive impact of the potential mergers in “Competition in Health Insurance: A Comprehensive Study of U.S. Markets,” which is based on 2014 data captured from commercial enrollment in fully and self-insured health maintenance organizations (HMOs), preferred provider organizations (PPOs), and point-of-services (POS) plans. The analysis found a significant absence of health insurer competition in 71 percent of the metropolitan areas studied. In 40 percent of the metropolitan areas studied, a single health insurer had at least a 50 percent share of the commercial health insurance market. In 14 states, a single insurer had at least a 50 percent share of the commercial health insurance market.

Specifically, the Anthem-Cigna merger stands to quash competition in 121 metropolitan areas throughout 14 states. Nine of the states are attempting to block the merger, but Indiana, Kentucky, Nevada, Ohio, and Wisconsin have not yet taken a position. The Aetna-Humana merger would shut down competition in 57 metropolitan areas in 15 states. Only four states have acted to block the merger, but Arizona, Indiana, Kansas, Kentucky, Louisiana, Mississippi, Tennessee, Texas, Utah, West Virginia, and Wisconsin have not yet taken a position.

“The AMA analyses show that Anthem-Cigna and Aetna-Humana mergers would significantly compromise market competition in the health insurance industry and threaten health care access, quality and affordability,” said Andrew W. Gurman, M.D., president of the AMA. “With existing competition in health insurance markets already at alarmingly low levels, federal and state antitrust officials have powerful reasons to block harmful mergers and foster a more competitive marketplace that will operate in patients’ best interests.”

Highlight on Idaho: Premiums are higher, but state retains five insurers on exchange

Health insurance rates are increasing by 24 percent in Idaho for 2017, according to the state’s Department of Insurance (DOI). The increases affect both individual and small group health plans and follows the trends seen across the country.

Rising premiums

On Idaho’s health insurance exchange, where 95,000 state residents are enrolled and 90 percent are eligible for a premium tax credit under the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), consumers may chose form five carriers and 196 medical plans, depending on the part of the state. The DOI reported increases in all plans. Weston Trexler, DOI product review bureau chief, told KTVB that the growing premiums are driven by claims.

“Anytime that an insurance company is paying out more claims than premium collected, they’re operating at a loss,” Trexler said. “Claims in this new marketplace have been higher than the carriers originally expected.” Trexler also noted that costs for services and rugs go up every year, and health insurance premiums must change to account for the increase.

Rate review

The DOI stated that carriers filed initial requests for rate review in May but were allowed to submit revised requests based on federal risk adjustment payment requirements released in July. From there, the DOI took public comment and determined whether the requested rate increases were reasonable based on claims experience, premiums, network provider agreements, administrative, and other costs. Most carriers agreed to reduce their revised requests after they had been reviewed, and the DOI could not find the rate increases unreasonable.

“While other states have seen dramatic reduction in carriers participating on their health insurance exchanges, the good news for Idaho is that we continue to have robust choice with five carriers and 186 medical plans in Idaho with at least four companies in every county,” said DOI Director Dean Cameron. “More choice leads to more competition, which should lead to lower premiums.

HHS uses CIAs to teach fraudulent providers a lesson

The United States reached a $28.5 million settlement with a private for-profit corporation that operates 35 skilled nursing facilities (SNF), most located in California following allegations that the corporation engaged in a scheme to submit false claims to Medicare and TRICARE for medically unnecessary rehabilitation therapy services. Under the settlement, the corporation entered into a corporate integrity agreement (CIA) with the HHS Office of Inspector General (OIG). In an unrelated case, the OIG imposed a $3 million penalty—the largest penalty for CIA violations to date—on another provider that failed to correct improper billing practices during the term of its CIA.

Settlement and CIA for false claims scheme

North American Health Care Inc. (NAHC), its chairman of the board, and its senior vice president of reimbursement analysis will pay $30 million to resolve allegations that they violated the False Claims Act (31 U.S.C. §§3729–3733) by causing the submission of false claims to Medicare and TRICARE for medically unnecessary rehabilitation therapy services provided to skilled nursing facility (SNF) residents. The government alleges that the senior vice president of reimbursement analysis contributed to the conduct by creating the improper billing scheme and that the chairman reinforced the scheme at NAHC facilities. As part of the settlement, NAHC entered into a five-year CIA with the OIG requiring an independent review organization to annually review therapy services billed to Medicare.

Violation of CIA

Kindred Health Care, Inc., paid a penalty of more than $3 million to the federal government for failing to comply with a CIA, marking the largest penalty for CIA violations to date. Kindred entered into a CIA with the OIG after it was discovered that Kindred billed Medicare for hospice care provided to patients who were not eligible for the services. In audits mandated by the CIA, internal auditors found that Kindred failed to correct improper billing practices in the fourth year of its five-year agreement. The OIG caught wind of the noncompliance during several unannounced visits.

“This penalty should send a signal to providers that failure to implement these requirements will have serious consequences,” said Inspector General Daniel R. Levinson. “We will continue to closely monitor Kindred’s compliance with the CIA.”