Ochsner Health System Issues Public Comment on Centers for Medicare & Medicaid Services Proposed Rule

WASHINGTON, March 17 -- William "Billy" Lennarz, system chair of pediatrics and associate medical director of the Ochsner Health System, New Orleans, Louisiana, has issued a public comment on the Centers for Medicare and Medicaid Services proposed rule entitled "Coordinating Care from Out-of-State Providers for Medicaid Eligible Children with Medically Complex Conditions CMS-2324-NC". The comment was written and posted on March 13, 2020:

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On behalf of Ochsner Health (Ochsner), headquartered in New Orleans, with sites of care throughout Louisiana and Mississippi, I am writing to express our appreciation to you for the opportunity to submit comments on "Coordinating Care From Out-of-State Providers for Medicaid-Eligible Children With Medically Complex Conditions." We commend you, the Centers for Medicare and Medicaid Services (CMS), and the leadership of the U.S. Department of Health and Human Services (HHS) for your work together to advance the care coordination and quality of care for Medicaid-eligible children with medically complex conditions. As a regional center of excellence providing comprehensive primary and specialty care to children with special health care needs, we feel strongly that Medicaid-eligible children be able to see the provider of their choice -- in their state of residence and/or outside their state of residence with Medicaid covering medically-necessary care and services, irrespective of provider location.

We are proud to serve children and their families from Louisiana and Mississippi, as well as dozens of states from across the country. When we care for patients -- particularly those who travel from other states to our sites of care -- we work closely with their referring physicians and seek to ensure seamless care transitions, promote care coordination, and work intentionally to help patients return home to their communities as quickly and safely as possible. In our experience, clear, consistent, and regular communication between our team and referring providers is essential to care coordination and patient-centered care. We maintain a longstanding commitment to delivering patient-centered care, particularly to those most medically-vulnerable, such as children with medically complex conditions.

Overview of Ochsner Health System

Ochsner, Louisiana's largest not-for-profit health system, is one of the nation's leading integrated health systems and one of the largest independent academic health systems in the United States Specifically, in an innovative approach with the Ochsner Health Network (OHN), Ochsner partners with other health systems to offer 41 owned, managed, and affiliated hospitals and specialty hospitals -- a model that allows many communities to maintain local ownership and control of their hospitals, while bringing to bear the benefit of the Ochsner clinical, operational and administrative teams.

Each year Ochsner, with more than 100 total sites of care, including its health centers and urgent care clinics, and its hospital and physician partners serve approximately 1 million patients who come from every state in the nation and more than 70 countries. Ochsner offers clinical expertise in more than 90 medical specialties and subspecialties, and includes approximately 3,600 affiliated physicians, with nearly1,500 employed Ochsner physicians practicing in more than 90 specialties and subspecialties, and another 26,00 employees In 2019, Ochsner earned two "Best Hospital" Specialty Category Rankings in U.S. News & World Report. Ochsner is also one of the nation's largest independent academic medical centers with nearly 300 full-time residents and fellows participating in 30 ACGME accredited programs and eight additional specialty programs; a global medical school in partnership with The University of Queensland School of Medicine based in Brisbane, Australia; and programs of biomedical research. Further, Ochsner has developed a public private partnership with Louisiana State University Health Sciences Center -- Shreveport to jointly manage major teaching and safety net hospitals in Shreveport and Monroe, including approximately 530 full-time residents and fellows participating in 39 ACGME accredited programs

We maintain a strong commitment to helping lead the nation's shift toward successful implementation of value-based payment models. From a payment and delivery system reform perspective, Ochsner has developed -- and is highly committed to -- the type of integrated health care system many policymakers envision. More specifically, Ochsner offers a comprehensive range of services, coordinated systems of patient care, a sophisticated electronic health record, and the geographic reach, scale and clinical capability necessary to manage and improve the health of a large and diverse patient population.

Medicaid Health Homes Ochsner supports Congressional interest in advancing patient-centered care; Congress, as part of such an effort authorized Medicaid health homes under the Patient Protection and Affordable Care Act of 2010, which allowed "states to elect a Medicaid state plan option to provide a comprehensive system of care coordination for Medicaid beneficiaries with chronic conditions"/1 Ochsner understands the goal of health homes to be the integration and coordination of "all primary, acute, behavioral health, and long-term services and supports to treat the whole person."/2

Further, we appreciate that Congress in its enactment of the new optional Medicaid health home benefit in the Medicaid Services Investment and Accountability Act of 2019 (MSIA, or P.L. 116-16) sought to facilitate the provision of health home services to Medicaid-eligible children with medically complex conditions who choose to enroll in a health home and that such services include medically necessary care from out-of-state providers.

Access to Specialty Care for Medicaid-Eligible Children with Medically Complex Needs

Ochsner commends Congress for recognizing that Medicaid-eligible children with medically complex needs should have access to health home services and be able to have prompt and timely access to out-of-state providers as their medical and health care needs dictate We welcome the ability of additional infants, children, and adolescents from other states to have access to the high-quality, primary and specialty care we offer in Louisiana and Mississippi We feel strongly that patients and their caregivers have facilitated access to the care they need at the site of care and from the provider they choose.

Per the request for public feedback, we wish to note that there can be administrative, reimbursement, and other barriers that "prevent children with medically complex conditions from receiving care ... from out-of-state providers in a timely fashion " We have serious concerns that some states are proposing in their state plan amendments to eliminate reimbursement for certain procedures and services performed out-of-state, with limited exceptions, which ostensibly results in the children in that state being required to receive care for that procedure or service in-state, even if the provider of choice is elsewhere. While a state may have a provider who can perform the procedure or deliver the service, a provider in another state may be a center of excellence, or have better outcomes, maintain a more appropriate care setting (e.g., tailored to children on the autism spectrum) or offer an alternative approach, which is better for that particular child; in all of these cases, the patient deserves access to such an out-of-state provider.

A state's reimbursement restriction on out-of-state procedures and services also thwarts in-state providers from referring patients to out-of-state providers if they know the care will not be reimbursed. This prevents "caregivers from accessing or navigating care from out-of-state providers in a timely fashion."/3

Patients have the right to know about the best provider for their condition and should not have any barriers to receiving such referrals to out-of-state providers and should they choose to seek care from such providers, they should have unencumbered access to covered, medically-necessary care.

These state plan amendment changes eliminate patient and family choice and severely limit access to care. We further are concerned that the restriction of certain procedures and services is being done under the guise of care coordination and the "health home" but its intention is to restrict patient choice and retain care in the home state, which is not patient-centered and counter to Congressional intent. As such, we strongly urge you to review such state plan amendments and ensure that they comport with the requirements, intention, and goals of the MSIA.

Summary

We thank you for your consideration of our feedback and recommendations and stand ready to be of assistance as you review comments and seek to issue guidance to state Medicaid directors on the coordination of care from out-of-state providers for children with medically complex conditions. If you have any question or if we can be a resource to you, please contact Will Crump at [email protected] or (662) 719-4969.

Sincerely,

William (Billy) Lennarz, MD, MMMOIIII FAAEM

System Chair of Pediatrics and Associate Medical Director, Ochsner Health System

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Footnotes:

1/ HHS CMS 42 CFR Chapter IV, CMS-2324-NC, R1N 0938-ZB7, Coordinating Care From Out-of-State Providers with Medicaid-Eligible Children with Medically Complex Conditions, Federal Register Vol 85, No 13, Page 3330, Tuesday, January 21, 2020

2/ Ibid

3/ Ibid Page 3333

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The proposed rule can be viewed at: https://www.regulations.gov/document?D=CMS-2020-0006-0001

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