An Interesting But Costly Idea – Medicare X

By Ryan Kelly –

A delegation from Mississippi, including Michael Nester, Tommy Bartlett, Joanie Perkins, Tasha Brown, Alvin Hoover, Paul Gardner and myself, are in Washington D.C. this week to discuss rural health policy and legislation with fellow rural professionals and elected officials and staff.

We had the pleasure of hearing from Senator Tim Kaine (D-VA) and his experience and work to help with rural health improvement.  No doubt, Sen. Kaine has been a rural health champion and has supported good work at improving and supporting many vital programs.

He mentioned a “big idea” program today that I have heard before but not to the depth that he provided.  This program, dubbed Medicare X, would be a public insurance offering from Medicare but offered on the healthcare exchange for non-Medicare beneficiaries.  So essentially, anyone would be eligible to “buy in” to this policy  if they desired to do so.

In brief summary, Medicare X would provide all Medicare benefits plus meet all of the minimum essential benefits provided on the exchange via the requirements of the Affordable Care Act.

I have stated before the concern that we have with the minimum essential benefits of the ACA and the “metal plans” offered through the exchange – which has led to a crisis of “under insurance” in Mississippi.  What I see with Medicare X is a related issue.  Although the coverage of such a policy would be fantastic, I would be very concerned about the affordability of such a policy.

Currently, Mississippi Medicare beneficiaries cost Medicare $11,021 per year in cost, according to the Kaiser Foundation.  This is about the national average.  If we round up a bit for the assumed increase with adding the minimum essential benefits, and if nothing changes for the average cost per beneficiary, then we could naturally assume that the monthly premium for such a policy to be approximately $1,000 per month per beneficiary.

I’m not sure about you, but I don’t know many people that would pay $1,000 per month per person for Medicare X.

To Sen. Kaine’s benefit, it’s an effort to shore-up states like Mississippi where there is only one option on the health insurance exchange.  I admire the effort and understand that there could be a number of factors that, if implemented, could reduce the cost per person.  My recommendation would be to take the minimum essential benefits off of the table, and stagger the cost ratio based on a variety of health-related factors (age, sex, fitness level, etc).  This would help to provide better coverage at a more affordable price and encourage people to live healthier.

There are a number of “big ideas” on the table, alongside ideas including complete Medicare expansion, block granting Medicaid to states, and recreating new insurance plans with greater flexibility.  I think we need to understand the reality of what people need vs. what Washington wants before we make a decision on what direction to go.

MRHA Supports the All of Us Research Program

About the All of Us Research ProgramScreen Shot 2019-08-29 at 9.54.02 AM

The All of Us Research Program began national enrollment, inviting people ages 18 and older, regardless of health status, to join this momentous effort to advance individualized prevention, treatment and care for people of all backgrounds. Part of the National Institutes of Health, All of Us is expected to be the largest and most diverse longitudinal health research program ever developed.

Participants are asked to share different types of health and lifestyle information, including through online surveys and electronic health records, which will continue to be collected over the course of the program. Those who join will have access to study information and data about themselves, with choices about how much or little they want to receive.

Data that are collected will be broadly accessible to researchers of all kinds, including citizen scientists, to support thousands of studies across a wide range of different health topics. By doing so, they are hoping to discover how to more precisely prevent and treat other health conditions. Knowledge gained from this research could help researchers improve health for generations to come.

Why All of Us is Important for Patients

Health care is often “one size fits all” and is not able to fully consider differences in individuals’ lifestyles, environments, or biological makeup. This is because we have limited data from past research studies about how those elements interact. The average patient is often prescribed drugs and treatments as if they are all the same. Learning more about the differences between individuals can help researchers develop tailored treatments and care for all people.

How All of Us Benefits Health Care Providers

Today there are too few conditions with evidence and options for individualized care. Too often, patients from underserved communities have not been included in clinical research, and our ability to care for diverse populations is diminished as a result. More data, discoveries, and tools can help providers to give their patients customized care more easily, especially for those communities that are disproportionately impacted by health issues.

Why Diversity Matters

Historically, many segments of the U.S. population have been left behind in medical research, including people of color, sexual/gender minorities, those with lower socioeconomic and educational status, rural communities, and other groups. The result is significant health disparities. The All of Us Research Program seeks to help fill in the gaps of information about those communities that previously have not been well represented.

How to Join the All of Us Research Program

The program is seeking one million or more people from all walks of life to participate in this historic endeavor. Those interested in joining the program can do so by visiting, Enrollment is open to all eligible adults who live in the United States.

Medicaid EASE Initiative aims to improve access to needed services for Medicaid beneficiaries – Physician visit limit to increase from 12 to 16 on Jan. 1, 2019

Effective Jan. 1, 2019, the Mississippi Division of Medicaid (DOM) is increasing the number of physician visits it covers for Medicaid beneficiaries, the first of a series of changes the agency plans to roll out in the coming year.

The move is part of the new Medicaid EASE Initiative — Enhancing Access to Services and Engagement — a bundle of programmatic changes aimed at bolstering Medicaid beneficiaries’ access to needed services in the most appropriate setting.

With the first phase of the EASE Initiative, DOM will increase the physician visit limit for beneficiaries from 12 to 16 visits per year. This increase supplements limit flexibility already in place for different populations of Medicaid beneficiaries. Beneficiaries in nursing homes, for instance, can receive up to 36 physician visits annually. Individuals who participate in the MississippiCAN program will continue to be eligible for enhanced services offered by the managed care company with which they are enrolled, which include unlimited physician visits. DOM will also continue to offer unlimited medically necessary physician visits for children up to age 21.

DOM plans to announce additional EASE Initiative reforms in the coming months. These projects are still in development and include increases to the monthly prescription drug limit and home health visit limit, behavioral health and substance use disorder reforms, and an effort to reduce potentially preventable hospital readmissions. DOM will share more information about these projects as they are developed.

Behavioral Health Workforce Projections and Estimates of New Entrants

HRSA’s National Center for Health Workforce Analysis recently conducted analyses on the adult and pediatric mental health and substance abuse disorder workforce.

They have generated national-level projection estimates for the health workforce for the following behavioral health occupations between 2016 and 2030.  Click on the following links to view these estimates.

Medicaid Releases Updated Guidelines on NPs Ordering DME

The Mississippi Division of Medicaid recently updated their guidelines after a series of conversations and internal discussions for Nurse Practitioners ordering Durable Medical Equipment (DME).  This guideline change is in response to recent CMS reviews of Mississippi’s policies, which were outdated as of the passage of the Affordable Care Act.  CMS required that Mississippi comply with ACA guidelines, which prevented NPs from ordering DME without physician approval.

Click here to view Medicaid’s updated guidelines, complete with scenarios to better understand how to comply.

UMMC Expands Care in the Delta

By Ryan Kelly –

I had an opportunity recently to visit the new UMMC Community Care Clinic in Belzoni, MS.  Dr. Tonya Moore, a huge driver in the creation of this clinic, provided a guided tour for me through the facility.

The facility was previously used to house the MSU Extension Center in Humphreys County (which has now been moved next door), and the building was completely renovated using largely USDA grant funds to provide what certainly appears to be a completely new look and feel.  The clinic has beautiful furniture, bright, clean colors, and excellent equipment highlighted by a top-of-the-line x-ray machine.

Naturally, this clinic is connected back to the main campus using state-of-the-art telehealth connectivity.  Tele-urgent services allow the clinic staff to triage patients and connect for additional consultation with Category B and C calls – those being calls that are more urgent in nature.  Such could include a gun shot wound or chest pain of unknown origin.  The tele-urgent call will allow a physician from the main campus to diagnose and help treat the patient until an ambulance arrives.

This clinic opened on July 16, 2018 and maintains a daily census of 10-20 patients.  The clinic is led by Jorri Davis, FNP-C and a small team of experienced providers/staff.  Notable about the clinic’s staff is that they are all from the Mississippi Delta.  This certainly shows a direct connection to the efforts to better train and employ local providers in our rural communities, and it ties-in well to the Governor’s recent Healthcare Economic Development Summit which showed the financial impact of a quality healthcare facility to a community.

One surprising feature of the clinic is not just the urgent care side, but that it also houses a large educational classroom and fitness center.  The classroom will be available for both UMMC-led training as well as health-related classes for local citizens.  The fitness center will be staffed by a personal trainer and will be soon open to the community for a small monthly fee.

I firmly believe that rural Mississippi is gaining strength from efforts like this.  With the establishment of new clinics like this and the constant improvements in both quality care and infrastructure of our existing clinics and hospitals, Mississippi’s rural health status is improving!

Be on the Lookout for this Potential Payment Glitch with Add-On Medicaid Services

By Ryan Kelly –

The Mississippi Division of Medicaid informed us last Friday that there may be a small, technical glitch in their system related to add-on services being billed to Medicaid.  They are working on a resolution to this glitch and are prepared to pay any unpaid claims that have already been submitted.  Please check your statements and reconcile them to your billable encounters to ensure that all payments have been made correctly.

If you see anything that may be missing respective to these add-on services, please contact Joe Jackson at

New Medicaid Regulations on NPs Prescribing DME

View an update from this article by the MS Division of Medicaid by clicking here.

Nurse practitioners throughout Mississippi recently received letters from the Mississippi Division of Medicaid stating that they are no longer able to prescribe durable medical equipment (DME) due to a change in the CMS regulations for DME under hospice regulations.  This was a shock to many, and it prompted many meetings throughout the state to figure out the “whats” and “why” behind this.

As we have investigated and been part of the discussions around this, we have learned much.  Here is a brief summary.

The origin of this language appears to stem back to the passage of the Affordable Care Act in 2008.  Language from the ACA changed CMS guidelines to require that only physicians are eligible to order DME – a change from what was previously allowed.  At that time, Mississippi had just recently submitted and received approval for our new Medicaid technical language.

This language had stayed in effect until this year, 2018, where Mississippi Medicaid filed its new State Plan Amendment (SPA) 17-0001 in response to the passage of the 2018 Medicaid technical bill.  This new language this year was approved by CMS with one caveat, that the DME portion of home health is changed to meet their standing guidelines as stated by the ACA in accordance with 42 CFR 440.70.

Representatives from the Mississippi Division of Medicaid had lengthy conversations with CMS to determine the cause of this change, and to fight for the state’s providers.  It turns out that CMS actually asked Mississippi Medicaid to not only enforce the new policy effective immediately, but to actually back-bill providers for a period of time for improperly ordering DME, despite the fact that it was done according to Mississippi-approved policies.  Mississippi Medicaid fought hard for Mississippi providers, and it prompted CMS to compromise on not requiring the retroactive refunded payments, but rather kicked out the effective date to September 1, 2018.  At and after this date, only physicians will be eligible to order DME.

As I mentioned, there have been numerous conversations around this and many considerations of how to fix it.  We are likely looking at a short-term fix and a long-term fix, but more investigate is underway with other states that have already dealt with the issue and found resolution.  In order to not disrupt the work that is being done, I will hold back from detailing the solutions that are being discussed at this time.  I can say that the goal, though, is to find a way that is legal and medically compliant to allow NPs to continue to order DME.

We are monitoring the situation closely and have a “seat at the table” with discussions.

Hopefully there will be headway soon before this takes full effect on September 1, 2018 so that we do not hamper the good work that is being done to treat patients in Mississippi that have a need for basic DME.

Please contact Ryan Kelly at 601.898.3001 for questions or additional information.


Lowering Drug Costs

By Ryan Kelly –

I think we can all agree that prescription drug prices are often too high.  Of course, there are several key reasons why this is the case: 1) research, 2) litigation defense and payout, 3) shareholder profits, among several others.

So, how will we work to lower these drug prices?

First, it involves leadership.  Recently President Trump delivered a speech in which is called for a lowering of drug prices, whether voluntary or forced.  Being the free-market person that President Trump is, it’s likely that the “behind the scenes work” would involve incentives to companies for lowering the cost.  For patients, though, this could be very positive.

A second effort underway currently is with prescription discount cards.  One that the MRHA uses as a partner is Mississippi Drug Card.  This card is loaded with pre-negotiated pricing that helps patients to lower their burden.  These prices are often competitive to those offered with insurance on many prescription types.  Another unique card is offered by individual pharmaceutical companies.  These cards, or vouchers, will entitle beneficiaries to receive steep discounts on drugs at the counter.  One such from Astra Zeneca, for instance, can be used with 340(b) pricing on diabetes medications like Farxiga, Xigduo XR, and Qtern to allow a patient to receive medication at no cost.  But, these cards cannot be used alongside government-funded insurance plans (Medicare, Medicaid, and Tricare).

We look forward to seeing more efforts on how to reduce the cost burden of prescription drugs for our members.  At the moment, it looks like the tide is starting to turn.


CR Bills Passes – Provides Vital Funding for Healthcare Services

By Ryan Kelly –

Delegates from the Mississippi Rural Health Association traveled to Washington last week (week of February 5th) to attend the NRHA Policy Institute as well as visit with elected officials in the House and Senate.  Delegates included Michael Nester, H.C. Watkins; Zach Allen, Children’s International; Joanie Perkins, North Sunflower; and Paul Gardner, MS Hospital Association.

We are pleased to say that our needs were many but our ask was simple – support the Continuing Resolution bill, which provided needed funding and regulatory relief asked in our 2018 Legislative Packet.

And, we are more pleased to say that the CR bill passed the House and the Senate.  Our concerns were heard through our visits with Sens. Cochran and Wicker and Reps. Harper, Palazzo, Kelly and Thompson.

Sen. Wicker may have said it best when he paused in our conversation, reflected, and said “it’s a lot of money, but there’s a lot of need, and if we’re going to continue to be a first world country, then we need to fund what is needed to do just that.”  We appreciate the candor of all of our legislators and the hard decision that it is to balance a budget, provide tax relief and regulatory relief, and fund the programs that we all need.  It’s not an easy job.

The C.R. Bill accomplished the following

2 year extension of federal qualified health centers (community health centers)

Averts FY18 and FY19 Medicaid Disproportionate Share Hospital reductions

Provides a 2 year extension of public health programs:

  • National Health Service Corps
  • Teaching health Center Graduate Medical Education
  • Family-to-Family Health Information Centers
  • Sexual risk avoidance education programs
  • Personal responsibility education program
  • Special Diabetes Program for Type 1 Diabetes and the Special Diabetes Program for Indians

Provides Permanent Medicare Changes

  • Repeal Medicare payment cap for therapy services
  • Removal of the rental cap for durable medical equipment under Medicare with respect to speech generating devices

2 year extension of Medicare policies

  • Funding for quality measure endorsement, input, and selection
  • Medicare-Dependent hospital and Low-Volume hospital programs
  • Geographic Practice Cost Indices (GPCI) floor for physician payments

5 year extension of Medicare policies with reforms

  • Home health rural add-on payment
  • Ground ambulance add-ons

Telehealth provisions including:

  • Expanding access to home dialysis therapy
  • Increasing convenience for Medicare Advantage enrollees through telehealth
  • Providing accountable care organizations (ACOs) the ability to expand the use of telehealth
  • Expanding the use of telehealth for individuals with stroke