And, just like that, the governor of Kansas decided tele-health and Kansas Board of Medical Arts attacks on non face-to-face medical diagnosis must give way to the exigencies of the Corona Virus.
It was down to the wire, but Kansas has received CMS approval (for the most part) of its Section 1115 Medicaid waiver application, allowing it to proceed with its experiment with state-specific Medicaid reform beginning tomorrow, January 1, 2013. The waiver is time limited, but waiver renewals and extensions are pretty common, so think of this as the first cycle of Kansas Medicaid reform efforts.
Since Kansas has announced its intention to not expand Medicaid under the ACA, its attempts to reign in Medicaid spending on its existing Medicaid eligible population should be interesting. As KanCare's August, 2012 waiver application pointed out, Kansas has experienced Medicaid cost increases exceeding seven percent each year of the past decade.
The hard questions are: why has this occurred? And what is found in the KanCare proposal that will help to turn the tide on Medicaid health care inflation?
The plan is to push as many Medicaid enrollees in Kansas to managed care as quickly as possible, in the hopes of improving utilization review and care integration. Though CMS, in its recent section 1115 demonstration project waiver letter, put the brakes on this slightly by delaying the movement of certain Mediciad sub-populations into managed care and by refusing to waive the 45 day appeal process for Medicaid managed care vendor patient assignment decisions, we will see a big move into the Medicaid managed care products of the three selected vendors: Amerigroup of Kansas; Sunflower State Health Plan, and United Healthcare Community Plan.
All of this will happen while the general pool of Medicaid eligibles in Kansas likely expands considerably under the seamless enrollment mechanisms between the Federal Health Exchange for Kansans and the Medicaid eligibility portal for Kansans. Even without a state specific exchange, the plan is for Kansans to experience simplified enrollment under the ACA, a part of the ACA unchanged by NFIB v. Sebelius.
These are interesting times to be a Medicaid administrator in a non-Medicaid expansion state. As Medicaid take up rates change, in line with the streamlining of eligibility, Medicaid will likely expand considerably even in non-expansion states. And those new enrollees, in Kansas, will be in managed care.
This may be reinventing Medicaid as we know it for Kansas, but it is a fairly well trod path to Medicaid reform in other states. Medicaid Managed Care has been around for some time. What is unusual about KanCare is the extension of Medicaid Managed Care, eventually, to the disabled, to low income seniors, and to those in skilled nursing facilities. These folks are the expensive folks in the Medicaid budget.
So the real challenge for Kansas, as it is for every state, is to stop health care cost inflation for this group. Not surprisingly, this will be the challenging part of the assignment for a number of reasons — the most significant of which are that Kansas is, outside of a very few metropolitan areas, a sparsely populated state. Sparsely populated places are notoriously difficult to serve in health and senior services for two reasons: geographic distance can challenge economies of scale pretty quickly and managed care entities have, historically, found it difficult to serve rural areas in a cost effective manner.
How will Kansas do this? It is an experiment, so let's watch it unfold. In the meantime, Kansas has already indicated its ultimate goal: a global waiver that will administer an outcomes based Medicaid and CHIP program under a per-capita block grant.
On August 12, 2012, I blogged on how the Missouri Supreme Court struck down its noneconomic damages cap as an unconstitutional interference with the right to trial by jury. You can read it here:
Now the Kansas Supreme Court has upheld its cap as consistent with a valid public interest objective. You can read Miller v. Johnson here: http://www.kscourts.org/Cases-and-Opinions/opinions/SupCt/2012/20121005/99818.pdf
Interestingly, the Kansas Supreme Court expressed some skepticism about "the conflicting evidence regarding the existence and causes of the medical malpractice insurance and liability insurance 'crises' and whether there is any necessity for, or efficacy of, a cap on noneconomic damages." The Court then cites to Kansas precedent establishing that legislative choice may be based on rational speculation unsupported by evidence or empirical data.
I, myself, am still looking for some Kansas or Missouri data — specifically a retrospective study on the relationship between medical malpractice insurance rates over time in relationship to noneconomic damages caps.
Last week, the Insurance Department of the State of Kansas held a three-hour hearing to collect public input on what should constitute the state's essential health benefits benchmark plan under the ACA. No, Gov. Brownback did not attend. But some of the staff of Insurance Commission Sandy Praeger was present as were a number of interested parties. I did not attend but was struck by the number of providers who submitted written testimony or asked to speak.
What's at stake? A great deal, apparently.
Under the ACA, the states may choose to participate in the creation of the models or templates for minimum essential benefits to be offered through their state exchanges or the federal government will perform this function for them. Each state has until September 30th to indicate what their benchmark plan recommendations are, though there are rumors of some give on that date.
A number of states have been busy benchmarking existing coverage in their states and developing recommendations on minimum essential benefits. This is because they believe health insurance markets are best understood on a local level and health insurance infrastructure is best crafted on a local level.
If you're interested in seeing the work being done on this in other states, you could look here (scroll down to the spreadsheet, about half way down the page):
States have some leeway in designing their core benefits plans, though they must meet certain federal guidelines and benchmark off of certain popular basic insurance plans found in the state. For Kansas, this would likely mean looking at a basic health insurance plan significantly richer than its current Medicaid benefit. That may be the rub.