Highlight on Montana: Shocking disparities prompt Governor to create Office of American Indian Health

On June 16, 2015, the Governor of Montana, Steve Bullock (D) announced that he had signed an Executive Order to create an Office of American Indian Health within the Montana Department of Health and Human Services. This office, according to Bullock, will “focus on identifying specific factors contributing to health disparities,” between Native Americans and other residents of the state. The Governor’s office noted that the average life span for American Indians in Montana is 20 years shorter than for non-Indian Montanans.

More stats

The perhaps shocking statistic on Montanan American Indians’ lifespans cited by the Governor’s office was one of the results uncovered by a 2013 state health department report, which stated that Native Americans were more likely to suffer from certain diseases and chronic illnesses, including cardiovascular disease, cancer, and respiratory illness. Moreover, the report noted that these groups also tended to have less access to health care in the state. The Bismarck Tribune summarized the relevant data this way, with reference to the expanded eligibility for Medicaid due to implementation of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) in the state: “Although Native Americans comprise less than 10 percent of Montana’s population, it’s estimated that they account for 20,000—nearly 30 percent—of the 70,000 Montanans who will be newly eligible for Medicaid under the state law enacted this spring to cover very low-income citizens.”

The new role

Although the new office will only consist of one full-time employee, the role will allow for improved collaboration with other state agencies, tribal leaders, and federal Indian health centers in order to “ensure that the state’s native and non-native residents have the same access to essential health services,” according to Montana Public Radio. In Bullock’s words, the new employee will be tasked with identifying the reasons behind the disparities, coordinating the development of strategies, and overseeing an action plan to attack the disparities and improve access for Montanan American Indians. The Governor’s order also outlines other duties of the newly-created position, including: (1) coordinating efforts within the health department to address the disparities; (2) establishing continuous consultations with local leaders and experts, including federal government agency representatives; (3) coordinating efforts with other state agencies; (4) identifying and developing a list of state programs that may be useful in addressing the disparities; and (5) providing updates on the progress of actions taken in this area. The details, including the projected costs of the creation of this office and the date the office will be filled, remain unknown.

Medicaid and the ACA in Montana

The implementation of the ACA not only highlights the identified disparities but also could play a large role in the strategies adopted by the new office to address these disparities. Earlier this year, the Montana legislature voted to expand Medicaid in the state. This expansion still awaits federal approval but Governor Bullock has begun to prepare the state for the transition to expansion.

A report released by the Montana Budget and Policy Center explained that Medicaid expansion in Montana would result in coverage for 70,000 residents. Moreover, the report warned that the failure to adopt expanded Medicaid in the past has resulted in the state losing “as much as 1.96 million of federal funds every day.”

The benefits that the ACA may bring to the Native American population in the country in general have been highlighted in a report issued by Kaiser Health News (KHN). In addition to noting the benefits of the expansion of Medicaid, (which the report noted could make a huge impact on the Native American community since nearly half of the population is eligible for Medicaid services) KHN also explained that the ACA implemented new provisions, through the amendment of the Indian Health Care Improvement Act, that provided for easier ways for Indian health centers to accept payment from different types of payers and expanded the types of services these facilities may offer.

With the effect that ACA could have on Native American residents in Montana as it is further embraced by the state, the newly-created Office of American Indian Health will have plenty of avenues to explore.



Kusserow on Compliance: OIG work planning driven by CMS program mandates

The HHS Office of Inspector General (OIG) Mid-Year Update to the OIG Work Plan for fiscal year (FY) 2015 described ongoing OIG audits, evaluations, and certain legal and investigative initiatives, as well as removed items that have been completed, postponed, or canceled. The report explained that the OIG work planning is a dynamic process and adjustments are made throughout the year to meet priorities and to anticipate and respond to emerging issues within the constraints of available resources. Priorities are set as a result of assessing relative risks confronting the more than 100 HHS programs and in identifying areas most in need of attention. The agency then allocates its available resources accordingly. A number of factors are considered in generating specific task work for any given period including:

  • Legal, regulatory, and other mandates;
  • Requests by Congress, HHS management, or the Office of Management and Budget;
  • Top management and performance challenges facing HHS;
  • Work generated by partner organizations;
  • Management’s actions in response to recommendations from previous reviews; and
  • Timeliness of issues.

It should be noted however that the entire process is distorted by funding requirements, which direct more than three quarters of their resources be devoted to the Medicare and Medicaid program. As such, the OIG Work Plan devotes most of its resources to reducing Medicare Parts A and B and ensuring quality, including quality in nursing home, hospice care, and home- and community-based care. As a result, the overarching OIG planning efforts reflected in the current fiscal year and beyond involve the following:

Quality of care: Planned work will examine settings in which the OIG has identified gaps in program safeguards intended to ensure medical necessity, patient safety, and quality of care. It will also continue its focus on access to care, including beneficiary access to durable medical equipment prosthetics, orthotics, and supplies (DMEPOS) in the context of new programs involving competitive bidding.

Appropriate payments: Planning is ongoing to expand OIG’s portfolio examining inefficient payment policies or practices, including comparison among government programs to identify instances when Medicare paid significantly different amounts for the same or similar services or when less efficient payment methodologies were used. Planning is ongoing for work addressing Medicare costs incurred because of deficiencies in services or defective medical devices, as well as noncompliance or other vulnerabilities in care settings with high payment error rates.

Oversight of payment and delivery reform: Planning is underway to expand OIG’s work addressing changes to Medicare programs designed to improve efficiency and quality of care and to promote program integrity and transparency. OIG will consider work examining the transition from volume- to value-based payments and the soundness and effectiveness of the payment structures, care coordination, and administration of these new payment models. Work expected to begin in 2015 and beyond includes examinations of data and metrics to document and measure quality and performance.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2015 Strategic Management Services, LLC. Published with permission.

Strong Start for Mothers and Newborns experiences growing pains in year one

The Strong Start for Mothers and Newborns initiative has experienced “growing pains” in its development, according to a study by the Urban Institute, Health Management Associates, American Institutes for Research, and Briljent. The study evaluates the implementation and impacts of the Strong Start initiative on health care delivery, outcomes, and cost, based on qualitative case studies, participant-level process evaluation, and impact analysis, as well as numerous program monitoring measures. The purpose of the report is to present early findings of the evaluation, summarize the status of the evaluation’s research efforts, and present a plan for the next year of work.


The Strong Start initiative is funded under Section 3021 of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) with the goal of improving maternal and infant outcomes for pregnancies covered by Medicaid and the Children’s Health Insurance Program (CHIP). It funds three enhanced prenatal care models: (1) maternity care homes; (2) group prenatal care; and (3) birth centers. The initiative currently supports 27 awardees and 213 provider sites across 30 states, the District of Columbia, and Puerto Rico, serving a target of 80,000 women.

Awardees and sites

Of the 27 Strong Start awardees, 13 are implementing the maternity care home model, 12 are implementing group prenatal care, one is implementing birth center care, and two are implementing more than one model. Of the 213 provider sites, 133 are implementing maternity home care, 42 are implementing group prenatal care, and 38 are offering birth center care. All of these awardees maintain a goal of reducing preterm birth and decrease the rate of low birth rate. Other common goals include decreasing the cost of care, increasing Medicaid and CHIP outreach to inform them of Strong Start, and increasing rates of breastfeeding.

Early observations

Though enrollment in Strong Start was lower than expected during the program’s first year, with slow development of intake and enrollment processes and barriers such as time commitments and transportation identified as possible causes, enrollment is steadily increasing. The study also determined that participants have high levels of emotional and psychosocial needs.Strong Start providers work diligently to address those needs but are constrained by resource limitations and Medicaid- and CHIP-related barriers.

While it is too early to make generalizations about the effects of Strong Start, current data suggests that women served by the program have lower than average Cesarean section rates, higher rates of breastfeeding, and lower rates of preterm deliveries than the country as a whole. Participants also expressed overwhelming satisfaction with their prenatal care, though satisfaction with delivery experiences is somewhat lower

Progress of the study

Much of year one was spent developing foundational documents to set the stage for data gathering. The launch of data collection occurred in the second half of the project year. Year two of evaluation calls for continued data collection and could possibly see the collection and compilation of the first wave of data to be used in the study’s impact analysis.

Michigan hospitals conspired to hide information from consumers

Four hospital systems in south-central Michigan had an unlawful marketing territory agreement that deprived consumers and physicians of important information about competing providers for years, according to the Department of Justice (DOJ), which filed a lawsuit against the hospital systems in the Eastern District of Michigan. “These hospitals conspired to deprive consumers and physicians of important health information and education,” said Assistant Attorney General Bill Baer of the DOJ’s Antitrust Division. “Instead of putting patients first, these hospitals secretly agreed not to compete.”

Unlawful agreement

Hospitals compete to attract patients by advertising, including the use of direct mailings to patients, outreach to physicians and employers, conducting health fairs, and offering free health screenings. According to the DOJ’s complaint, four hospitals—each the only hospital in its respective county—entered into agreements to limit the marketing of competing health care services. As a result, patients and physicians were deprived of information needed to make informed health care decisions, and some were prevented from receiving free medical services like health screenings and physician seminars that, in the absence of the unlawful agreements, they would have received.

The hospitals sued by the DOJ are:

  • Hillsdale Community Health Center (Hillsdale)—a Michigan corporation headquartered in Hillsdale, Michigan, with a general acute care hospital located in Hillsdale County, Michigan. Hillsdale has 47 beds and a medical staff of over 90 physicians.
  • Community Health Center of Branch County, Michigan (Branch)—a Michigan corporation headquartered in Coldwater, Michigan, with a general acute care hospital located in Branch County, Michigan. Branch has 87 beds and a medical staff of over 100 physicians.
  • ProMedica Health System Inc. (ProMedica)—an Ohio corporation headquartered in Toledo, Ohio, with locations in northwest Ohio and southern Michigan, including Bixby and Herrick Hospitals in Lenawee County, Michigan. Bixby is a general acute care hospital with 88 beds and a medical staff of over 120 physicians. Herrick is a general acute care hospital with 25 beds and a medical staff of over 75 physicians.
  • A. Foote Memorial Hospital, doing business as Allegiance Health (Allegiance)—a Michigan corporation headquartered in Jackson, Michigan, with a general acute care hospital located in Jackson County, Michigan. Allegiance has 480 beds and a medical staff of over 400 physicians.

The complaint alleges that Hillsdale curtailed competition for years by entering into agreements with Allegiance, Branch, and ProMedica to limit the marketing of competing health care services.


Three of the hospital systems—Hillsdale, Branch, and ProMedica—agreed to settle the charges, while the DOJ will continue to litigate against Allegiance. The proposed settlement would prohibit the three systems from entering into agreements with other health care providers, including hospitals and physicians, to limit marketing or to divide any geographic market or territory. It also prohibits communications among the hospital systems about their marketing activities and requires them to implement compliance measures tailored to prevent the recurrence of these types of anticompetitive practices in the future.

The proposed settlement will be published in the Federal Register. Written comments may be submitted within 60 days of its publication.