CMS in 2015 and early 2016 imposed 25 enforcement actions ...

... on Medicare Advantage and Part D sponsors that included five intermediate sanctions and 20 civil money penalties totaling $10.3 million, with an average of $516,163 per CMP

Hillary Clinton is not even president and ...

... there is already a sharp line being drawn by the health insurance lobby against talk in Democratic circles of her proposal to make a public insurance option available through the public exchanges. Stung by the exit of so many large carriers from the exchanges, most notably Aetna Inc.'s departure from most of its marketplaces for 2017 after the company said it would do the opposite, Senate Democrats have recently circulated a non-binding resolution to amend the ACA and create a public option. What form this public option would take is a mystery, as it is in Clinton's campaign platform.

The Senate resolution spearheaded by Sen. Jeff Merkley (D-Ore.) has 33 co-signers and declares support "to build on the ACA by ensuring that, in addition to the coverage options provided by private insurers, every American has access to a public health insurance option which, when established, will strengthen competition, improve affordability for families by reducing premiums and increasing choices, and save American taxpayers billions of dollars."

Media reports said that after the Merkley push became public, industry lobbyists worked association members to call lawmakers and object to the plan, even if a public option has zero chance of being enacted with the current Congress led by Republican majorities in the House and Senate.

CMS releases new data to increase transparency on Medicare hospice payments

CMS News

FOR IMMEDIATE RELEASE
October 6, 2016

Contact: CMS Media Relations
(202) 690-6145 | CMS Media Inquiries
 

CMS releases new data to increase transparency on Medicare hospice payments and the Third Release of the Market Saturation and Utilization Data Tool

Data serves as comprehensive resource for information on payments and utilization

 

As part of our efforts to improve care delivery, payments to providers, and the sharing and utilization of information, the Centers for Medicare & Medicaid Services (CMS) today released a privacy-protected public data set, the Hospice Utilization and Payment Public Use File (Hospice PUF), which provides information on services provided to Medicare beneficiaries by hospice providers. CMS also released an update to the Market Saturation and Utilization Data Tool, formerly called the Moratoria Provider Services and Utilization Data Tool. For the first time, this tool will include information on hospice services.

“The Hospice data and Market Saturation and Utilization Data Tool made available today support our goals of increasing access to Medicare data and improving the flow of information,” said CMS Chief Data Officer Niall Brennan.  “CMS believes that greater data transparency leads to a more effectively functioning health care system, which leads to better care and smarter spending.”

The Hospice PUF contains information on utilization, payments, submitted charges, diagnoses, and hospice beneficiary demographics organized by provider and state. The Hospice PUF covers calendar year 2014 and includes information on 4,025 hospice providers, over 1.3 million hospice beneficiaries, and over $15 billion in Medicare payments. With this data, it is now possible to analyze geographic variation in the delivery of hospice care, as well as variation across individual hospice providers.  The Hospice PUF also includes a number of metrics on hospice beneficiary demographics and diagnoses to facilitate analyses of differences in the patient population across providers.

The third release of the Market Saturation and Utilization Data Tool includes interactive maps and supporting data sets that show national-, state-, and county-level provider services and utilization data for three reference periods and the following health service areas: Home Health, Ambulance (Emergency, Non-Emergency, Emergency & Non-Emergency), Independent Diagnostic Testing Facilities (Part A and Part B), Skilled Nursing Facilities, and Hospice.

The Market Saturation and Utilization Data Tool can be used by CMS to monitor market saturation as a means to prevent fraud, waste, and abuse.  The data can also be used to reveal the degree to which use of a service is related to the number of providers servicing a geographic region. Provider services and utilization data by geographic regions are easily compared using an interactive map. There are a number of research uses for these data, but one objective of making these data public is to assist health care providers in making informed decisions about their service locations and the beneficiary populations they serve.

The release of the Hospice PUF and the Market Saturation and Utilization Data Tool continues CMS’ commitment to greater data transparency.  The Hospice PUF also adds to the suite of provider-level transparency data sets that CMS has released over the past several years, including hospital-, physician-, and prescriber-level utilization and payment data files.

To view a fact sheet on the Hospice PUF, visit:

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-10-06.html

To access the Hospice PUF, visit: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Hospice.html

To view the Market Saturation and Utilization Data Tool visit: https://data.cms.gov/market-saturation

Medicare Learning Network News

The MLN Connects Provider eNews contains important news, announcements, and updates for health care professionals. Thursday, October 6, 2016

 

News & Announcements CMS Finalizes Improvements in Care, Safety, and Consumer Protections for Long-Term Care Facility Residents CMS Awards $347 Million to Continue Progress toward a Safer Health Care System HH Quality of Patient Care Star Ratings and HH Compare Preview Reports Available New Electronic Appeals System: MOD E-File Available New EHR Contract Guide and Health IT Playbook EHR Incentive Programs: Learn About Important Changes EHR Incentive Programs: 2016 CQM Requirements October is National Breast Cancer Awareness Month Provider Compliance Automatic External Defibrillators: Inadequate Medical Record Documentation Claims, Pricers & Codes Billing for Influenza: New CPT Code 90674 Upcoming Events IMPACT Act: Data Elements and Measure Development Call — October 13 Physician Compare Public Reporting Information Sessions — October 18 and 19 2015 Supplemental QRUR Physician Feedback Program Call — October 20 Long-Term Care Facilities: Reform of Requirements Call — October 27 How to Report Across 2016 Medicare Quality Programs Call — November 1 Medicare Learning Network® Publications & Multimedia Medicare Part B Drug Average Sales Price Reporting by Manufacturers – Blending National Drug Codes MLN Matters® Article — New Medicare Parts A & B Appeals Process Booklet — Revised Resources for Medicare Beneficiaries Booklet — Revised View the full edition as a: PDF | Webpage Like the eNews? Have suggestions? Please let us know! The Medicare Learning Network®, MLN Connects®, and MLN Matters® are registered trademarks of the U.S. Department of Health and Human Services (HHS).

Medicare Advantage Value-Based Insurance Design Model

FACT SHEET

 FOR IMMEDIATE RELEASE
October 3, 2016

Contact: CMS Media Relations
(202) 690-6145 | CMS Media Inquiries

 

Medicare Advantage Value-Based Insurance Design Model

The Centers for Medicare & Medicaid Services (CMS) Center for Medicare and Medicaid Innovation is announcing refinements to the design of the second year of the Medicare Advantage Value-Based Insurance Design (MA-VBID) model.  The MA-VBID model is an opportunity for Medicare Advantage plans (MA plans), including Medicare Advantage plans offering Part D benefits (MA-PD plans), to offer clinically nuanced benefit packages aimed at improving quality of care while also reducing costs.

In the second year of the model, beginning January 1, 2018, CMS will: open the model test to new applicants; conduct the model test in three new states - Alabama, Michigan, and Texas; add rheumatoid arthritis and dementia to the clinical categories for which participants may offer benefits; make adjustments to existing clinical categories; and change the minimum enrollment size for some MA and MA-PD plan participants. 

Value-Based Insurance Design (VBID) generally refers to health insurers’ efforts to structure enrollee cost sharing and other health plan design elements to encourage enrollees to use high-value clinical services – those that have the greatest potential to positively impact enrollee health.  VBID approaches are increasingly used in the commercial market, and evidence suggests that the inclusion of clinically-nuanced VBID elements in health insurance benefit design may be an effective tool to improve the quality of care while reducing its cost for Medicare Advantage enrollees with chronic diseases.  As part of the “better care, smarter spending, healthier people” approach to improving health care delivery, CMS will test VBID in Medicare Advantage and measure whether structuring patient cost sharing and other health plan design elements encourages enrollees to use health care services in a way that improved their health and reduces costs.

The MA-VBID model will begin January 1, 2017 and run for five years.  CMS expects to release a Request for Applications for the second year of the model test in the fall of 2016, and will accept proposals from MA and MA-PD plans to offer VBID benefits in 2018.

In its first year, CMS will test the model in seven states: Arizona, Indiana, Iowa, Massachusetts, Oregon, Pennsylvania, and Tennessee.  Beginning January 1, 2018, CMS will also test the model in Alabama, Michigan, and Texas.  These states have been selected in order to be generally representative of the national Medicare Advantage market, including urban and rural areas, areas with both high and low average Medicare expenditures, areas with high and low prevalence of Low-Income Subsidies, and areas with varying levels of penetration of and competition within Medicare Advantage.  Test states have also been selected based on the availability of appropriate paired comparison areas for the purposes of evaluation.  Eligible MA plans in these states, upon CMS approval, may offer varied plan benefit designs for enrollees who fall into certain clinical categories identified and defined by CMS.  Benefit design changes made through this model may reduce cost sharing and/or offer additional services to targeted enrollees; however, targeted enrollees can never receive fewer benefits or be charged higher cost sharing than other MA enrollees in their plan as a result of the model.

Background

The existing Medicare Advantage “uniformity” requirement generally requires that an MA plan’s benefits and cost sharing be the same for all plan enrollees.  Because of this, clinically-nuanced VBID approaches have generally not been incorporated into MA or MA-PD plans.

The model will test the hypothesis that giving MA plans flexibility to offer supplemental benefits or reduced cost sharing to targeted groups of enrollees with CMS-specified chronic conditions in order to encourage the use of services that are of highest value to them, will lead to higher-quality and more cost-efficient care.  The increase in high-quality, cost-efficient care is expected to improve beneficiary health, reduce utilization of avoidable high-cost care, and reduce overall costs for plans, beneficiaries, and the Medicare program.  The model is also intended to improve outcomes and reduce costs by encouraging targeted enrollees to obtain care from high-value providers and by providing new supplemental benefits specifically tailored to targeted enrollees’ clinical needs.

The MA-VBID model is authorized under Section 1115A of the Social Security Act (added by section 3021 of the Affordable Care Act) (42 U.S.C. § 1315a), which authorizes the Center for Medicare and Medicaid Innovation to test innovative health care payment and service delivery models that have the potential to reduce Medicare, Medicaid, and Children’s Health Insurance Program expenditures while preserving or enhancing the quality of beneficiaries’ care.  CMS will test this model in the Medicare program through a limited waiver of the Medicare Advantage and Part D uniformity requirements. 

Description

The MA-VBID model supports improved health outcomes and health care cost savings or cost neutrality through the use of structured patient cost sharing and other health plan design elements that encourage enrollees to use high-value clinical services.  The MA-VBID model will provide flexibility for MA and MA-PD plans accepted into the model to develop clinically-nuanced benefit designs for enrollee populations that fall within certain clinical categories.

The conditions are:

• Diabetes
• Chronic Obstructive Pulmonary Disease (COPD)
• Congestive Heart Failure (CHF)
• Patient with Past Stroke
• Hypertension
• Coronary Artery Disease
• Mood disorders
• Rheumatoid Arthritis (starting in 2018)
• Dementia (starting in 2018)                                                                           

In addition to developing interventions targeted at all enrollees in one or more of the above categories, participating MA plans will have the flexibility to identify specific combinations of the listed chronic conditions for one or more “multiple co-morbidities” groups and establish tailored VBID interventions for each group.  Participating MA plans are required to provide VBID benefits to all VBID-eligible enrollees in the selected group.  Participating MA plans selecting the Mood Disorders group will also have additional flexibility to focus on specific conditions within that group. 

For each of the selected enrollee groups, participating plans may select one or more plan design modifications from a menu of four general approaches.  Within each approach, plans have flexibility on how (and to what extent) to implement that approach.  Plans may vary their proposed interventions from one target population to another, and from one participating plan to another.  CMS will also consider proposals for related variants of these interventions offered to targeted groups of enrollees, such as supplemental benefits conditional on participation in a disease management program.

The four approaches are:

1.Reduced Cost Sharing for High-Value Services

Plans can choose to reduce or eliminate cost sharing for items or services, including covered Part D drugs, that they have identified as high-value for a given target population.  Participating plans have flexibility to choose which items or services are eligible for cost-sharing reductions; however, these services must be clearly identified and defined in advance, and cost-sharing reductions must be available to all enrollees within the target population.

Examples of interventions within this category include eliminating co-pays for eye exams for diabetics and eliminating co-pays for angiotensin converting enzyme inhibitors for enrollees who have previously experienced an acute myocardial infarction.

2. Reduced Cost Sharing for High-Value Providers

Plans can choose to reduce or eliminate cost sharing when providers that the plan has identified as high-value treat targeted enrollees.  Plans may identify high-value providers based on their quality and  not solely based on cost, across all Medicare provider types, including physicians/practices, hospitals, skilled-nursing facilities, home health agencies, ambulatory surgical centers, etc.

Examples of interventions within this category include reducing cost sharing for diabetics who see a physician who has historically achieved strong results in controlling patients’ HbA1c levels and eliminating cost sharing for heart disease patients who elect to receive non-emergency surgeries at high-performing cardiac centers.

3. Reduced Cost Sharing for Enrollees Participating in Disease Management or Related Programs 

Participating plans can reduce cost sharing for an item or service, including covered Part D drugs, for enrollees who choose to participate in a plan-sponsored disease management or similar program.  This could include an enhanced disease management program, offered by the plan as a supplemental benefit, or it could refer to specific activities that are offered or recommended as part of a plan’s basic care coordination activities.  Plans using this approach can condition enrollee eligibility for cost-sharing reductions on meeting certain participation milestones.  For instance, a plan may require that enrollees meet with a case manager at regular intervals in order to qualify.  However, plans cannot make cost-sharing reductions conditional on achieving any specific clinical goals (e.g., a plan cannot condition cost-sharing reductions on enrollees achieving certain thresholds in HbA1c levels or body-mass index).

Examples of interventions within this category include elimination of primary care co-pays for diabetes patients who meet regularly with a case manager and reduction of drug co-pays for patients with heart disease who regularly monitor and report their blood pressure.

4. Coverage of Additional Supplemental Benefits

Under this approach, participating plans can make coverage for specific supplemental benefits available only to targeted populations.  Such benefits may include any service currently permitted under existing Medicare Advantage rules for supplemental benefits.

Examples of interventions within this category include physician consultations via real-time interactive audio and video technologies for diabetics, or supplemental tobacco cessation assistance for enrollees with COPD.

Value-Based Insurance Design Participants for 2017

Medicare Advantage Organization	State
BCBS of Massachusetts	Massachusetts
Fallon Community Health Plan	Massachusetts
Tufts Associated Health Plan	Massachusetts
Geisinger Health Plan	Pennsylvania
Aetna	Pennsylvania
Independence Blue Cross	Pennsylvania
Highmark	Pennsylvania
UPMC Health Plan	Pennsylvania
Indiana University Health Plan	Indiana

 

Eligible Applicants and Application Process for 2018

The MA-VBID model test is open to all qualifying MA and MA-PD plans in the test states that submit acceptable programmatic proposals to CMS.  Only certain MA and MA-PD plan types are eligible and certain restrictions apply to multi-state plans. 

CMS will generally restrict the model test to plans with a minimum enrollment in the test states of 2,000 enrollees. However, beginning in 2018, a MA organization participating in the model test with at least one plan with enrollment over 2,000 enrollees may have additional Plan Benefit Packages (PBPs) participate with a minimum enrollee requirement of 500 enrollees; an additional plan benefit package using this lower enrollment requirement may be from that MA organization or other organizations with the same parent organization.  CMS may also grant an exception upon request. 

Additionally, plans must meet minimum quality thresholds, including: being rated by CMS at three stars or higher, not consistently low-performing, not an outlier in the CMS past performance analysis, not under sanction, and able to pass a program integrity screening.

The plan must have been offered in at least three annual coordinated election (open enrollment) periods prior to the open enrollment period for the year for which the plan is applying to participate. There is no cap on the total number of participating plans.

CMS will accept applications for the second year of the MA-VBID model via a Request for Applications (RFA), to be released shortly.  Once released, application materials will be available at: http://innovation.cms.gov/initiatives/VBID.

More information

More information about the MA-VBID model test can be found in the model’s announcements and other documents, available at http://innovation.cms.gov/initiatives/VBID. The announcement includes instructions for providing CMS with feedback on this model test’s design. 

For more information on the Center for Medicare and Medicaid Innovation’s division of Health Plan Innovation, please visit: http://innovation.cms.gov/initatives/HPI. 

Participants Selected for Part D Enhanced Medication Therapy Management Model

FACT SHEET 

FOR IMMEDIATE RELEASE
October 3, 2016

 Contact: CMS Media Relations
(202) 690-6145 | CMS Media Inquiries

Participants Selected for Part D Enhanced Medication Therapy Management Model

Today, the Centers for Medicare & Medicaid Services (CMS) Center for Medicare and Medicaid Innovation (Innovation Center) is announcing the participants in the Part D Enhanced Medication Therapy Management (MTM) model. This Enhanced MTM model offers an opportunity and financial incentives for basic stand-alone Part D Prescription Drug Plans (PDPs) in selected regions to offer innovative MTM programs in lieu of the standard CMS MTM model, aimed at improving the quality of care while also reducing costs. As part of the “better care, smarter spending, healthier people” approach to improving health delivery, CMS will test changes to the Part D program that aim to achieve better alignment of PDP sponsor and government financial interests, while also creating incentives for robust investment and innovation in MTM targeting and interventions. The objectives for this model are for stand-alone PDP sponsors to identify and implement innovative strategies to optimize medication use, improve care coordination, and strengthen system linkages.

The Enhanced MTM model test will begin January 1, 2017 with a five-year performance period.   CMS will test the model across 5 Part D regions:  Region 7 (Virginia), Region 11 (Florida), Region 21 (Louisiana), Region 25 (Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota, Wyoming), and Region 28 (Arizona).   Regions were evaluated based on variation in market competition, the range of geographic, population, and market characteristics, and the range of Parts A and B spending variance.  This set of regions was selected so as to allow for a sufficiently powered model test with comparison regions and to (in aggregate) be broadly representative of national market characteristics.  

Six Part D sponsors that operate a total of 22 Plan Benefit Packages and provide benefits to an estimated 1.6 million beneficiaries in eligible Part D Regions will participate in the first year of the model. Upon approval from CMS, the selected basic stand-alone PDPs in these regions can vary the intensity and types of MTM interventions they provide based on beneficiary risk level and seek out a range of strategies to individualize beneficiary and prescriber outreach and engagement.  The selected PDPs can accomplish these goals by leveraging the core competencies of their own organizations, their network pharmacy providers, and prescribers to accurately identify and effectively intervene with beneficiaries whose issues with medication management have caused, or are likely to cause, adverse outcomes and/or significant non-drug program utilization and costs. 

The Enhanced MTM Model is authorized under section 1115A of the Social Security Act (added by section 3021 of the Affordable Care Act) (42 U.S.C. 1315a), which authorizes the Center for Medicare and Medicaid Innovation to test innovative health care payment and service delivery models that have the potential to lower Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) expenditures while maintaining or enhancing the quality of beneficiaries’ care.  CMS will test this model in the Medicare program through a limited waiver of certain Part D requirements, including current CMS MTM program requirements, for participants in the test regions during the performance period.  

Background   
The Medicare Modernization Act (MMA), which created the Part D program, required that every Part D plan offer an MTM program as a quality improvement feature. MTM generally refers to activities intended to optimize therapeutic outcomes by ensuring that patients are taking their medications safely and as prescribed, addressing any barriers to their doing so, and bringing any medication issues to the attention of the treating physician.

MTM programs can generate cost savings and result in improved outcomes for patients in a variety of ways. Evidence has shown MTM can improve medication adherence, which is associated with medical cost savings even when accounting for changes in drug expenditures.  MTM can also help to ensure that medications are taken properly and adverse drug events are avoided, particularly when new or high-risk medications are initiated, resulting in improved care for beneficiaries and significant savings from reduced hospitalizations and emergency department use.  Improved accuracy of medication administration can both improve outcomes and reduce waste, especially for high-cost drugs where therapeutic goals may not be achieved and expensive regimens may have to be repeated if medications are not taken correctly.  MTM programs can also improve the appropriateness of prescribing, ensuring that beneficiaries are receiving evidence-based therapies appropriate for their condition, potentially reducing complications and unnecessary medical costs in order to improve beneficiary outcomes.  Finally, MTM can help to identify and eliminate duplicative therapies, as well as identify opportunities to switch to similar, lower-cost medications, both of which can reduce prescription drug costs.

Evidence suggests that the MTM services currently offered by Part D plans fall short of their potential to improve quality and reduce unnecessary medical expenditures, most likely due to misaligned financial incentives and regulatory constraints. Competitive market dynamics and Part D program requirements and metrics may incentivize investment in these activities only at a level necessary to meet the minimum compliance standards.  Currently, Part D statutory and regulatory MTM provisions require uniform service offerings to enrollees who meet the plan’s program criteria, based on numbers of medications and chronic conditions and expected annual prescription drug costs. The result is that Part D MTM programs may not include the level or resources nor the type of activities that could have the greatest positive effect on beneficiary outcomes.

Description The Enhanced MTM model features a combination of regulatory flexibilities and payment incentives for basic stand-alone PDPs. Key elements of this model include:

• Significant regulatory flexibilities, including:
• The ability to offer different MTM services to individual enrollees based on their level of medication-related risk, with interventions tailored to those enrollees’ specific barriers to improvement;
• The ability to offer a more expansive set of MTM-related items and services, as well as cost sharing reductions to financially needy beneficiaries;  
• The flexibility to experiment with alternative communication strategies to improve beneficiary, pharmacist, and medical provider coordination and engagement;

• A plan-specific prospective payment to support more extensive MTM interventions that will be outside of a plan’s annual Part D bid and will therefore not impact plan premiums;
• The opportunity to qualify for a performance payment in the form of an increased beneficiary premium subsidy (in a future year) for plans that successfully achieve a 2 percent reduction in expected beneficiary fee-for-service expenditures (net of model prospective payments);
• The ability to request beneficiary-level Parts A and B claims data from CMS to assist with identification and care coordination of individuals at risk of medication-related problems; and,
• A new MTM encounter data collection effort leveraging existing work by industry experts to develop MTM-specific code sets, which will support the vision of the Office of National Coordinator for Health Information Technology (ONC) for prescription drug data interoperability.

Enhanced MTM services are likely to be complementary to, rather than duplicative of, those of ACOs and other integrated care models.  Participating PDPs are expected to test new approaches for integrating pharmacists into physician medication management workflows.

Beneficiary Benefits and Protections PDPs in this model can only offer MTM-related items or services, or lower cost sharing for financial need to targeted beneficiaries, and cannot restrict benefits or raise cost sharing to discourage use of medically necessary prescription drugs as a model intervention.  Participating PDPs will be expected to continue to meet current standards required by the Medicare program.  Eligible beneficiaries who do not want the Enhanced MTM items or services may opt out of any offered assistance at any time.

Monitoring and Evaluation CMS will closely monitor model implementation to ensure that model interventions are consistent with model rules and plan proposals, that additional model funding is being used for the appropriate purpose, and that the model is not leading to any adverse beneficiary outcomes.  New MTM encounter data will be utilized to both monitor ongoing compliance with approved intervention plans and assess whether the plan interventions are correlated with outcomes such as mortality, emergency department utilization, hospital readmissions, or beneficiary satisfaction measures.

The evaluation will include the collection and analysis of qualitative and quantitative data in order to understand the context of the programs and to capture the nuances occurring at the sites.  For the quantitative analyses, a longitudinal case-control study design will be used. Three years of pre-model data will be compared with three to five years of performance data collected at quarterly and annual increments during the model. Similar Part D plans that are not selected to participate in the model will be included in the comparison group. These comparison group plans will be selected to match the participating Part D plans along a variety of measurable dimensions, including but not limited to patient- and market-specific characteristics.

Enhanced MTM Model Participants for 2017

PDP Sponsor	Contract #	Part D Region
Blue Cross and Blue Shield of Florida, Inc.	S5904	Florida
Blue Cross and Blue Shield Northern Plains Alliance	S5743	Great Plains Region*
CVS Health	S5601	Arizona, Florida, Louisiana, Virginia, Great Plains Region*
Humana Insurance Company	S5884	Arizona, Florida, Louisiana, Virginia, Great Plains Region*
UnitedHealthcare	S5921	Arizona, Florida, Louisiana, Virginia, Great Plains Region*
WellCare Prescription Insurance Co.	S4802	Arizona, Florida, Louisiana, Virginia, Great Plains Region*

*Great Plains Region is comprised of Iowa, Minnesota, North Dakota, South Dakota, Nebraska, Wyoming, and Montana
Estimated Enrollment across all participating plans for 2017: 1.6 million beneficiaries

More information about the Enhanced MTM model test can be found in the model’s announcement, available at http://innovation.cms.gov/initiatives/enhancedmtm/.  

a sharp line being drawn by the health insurance lobby against talk in Democratic circles

Hillary Clinton is not even president and there is already a sharp line being drawn by the health insurance lobby against talk in Democratic circles of her proposal to make a public insurance option available through the public exchanges. Stung by the exit of so many large carriers from the exchanges, most notably Aetna Inc.'s departure from most of its marketplaces for 2017 after the company said it would do the opposite, Senate Democrats have recently circulated a non-binding resolution to amend the ACA and create a public option. What form this public option would take is a mystery, as it is in Clinton's campaign platform.

The Senate resolution spearheaded by Sen. Jeff Merkley (D-Ore.) has 33 co-signers and declares support "to build on the ACA by ensuring that, in addition to the coverage options provided by private insurers, every American has access to a public health insurance option which, when established, will strengthen competition, improve affordability for families by reducing premiums and increasing choices, and save American taxpayers billions of dollars." Media reports said that after the Merkley push became public, industry lobbyists worked as

sociation members to call lawmakers and object to the plan, even if a public option has zero chance of being enacted with the current Congress led by Republican majorities in the House and Senate.