医疗补助国家定向支付：CBO模型的更新（英）

Presentation to the Panel of Health Advisers Cyrus Ekland, Claire Hou, Aaron Pervin, and Rajan TopiwalaBudgetAnalysis andHealthAnalysis Divisions For more information about the panel, seewww.cbo.gov/about/panels-advisers, and for the meeting agenda, seewww.cbo.gov/sites/default/files/agendas/PHA_Agenda_2025.pdf. Road Map ▪Background on State-Directed Payments▪The 2025 Reconciliation Act Made Significant Changes to Future SDPs▪Basis of CBO’s Estimate of the Effects of the SDP Policy▪Key Questions▪References Cited Background onState-Directed Payments What Are State-Directed Payments? ▪State-directed payments (SDPs) are payments that states direct to specific providers throughMedicaid managed care organizations. –SDPs are similar to fee-for-service supplemental payments (for example, disproportionateshare or upper payment limit payments). ▪States finance most SDPs through provider taxes and intergovernmental transfers.1–Both are permissible forms of Medicaid financing under statute and shift the financing burdenfrom states to the federal government and providers.1,2 ▪In 2024, the Centers for Medicare & Medicaid Services (CMS) allowed states to pay providers upto average commercial rates (ACRs) by using SDP authority (2024 Managed Care Rule).3 –In a review of SDP applications approved by the end of 2020, the Medicaid and CHIP Paymentand Access Commission showed that, in practice, CMS had been allowing states to payproviders above-Medicare rates.4 –In 2022, ACRs for hospital services were 254 percent of Medicare rates, on average.5 How Large Are State-Directed Payments? ▪SDPs grew significantly in recent years and represent a large share of Medicaid spending:–$26 billion in fiscal year 2020 to $102 billion in fiscal year 20244–8 percent of managed care spending in fiscal year 2020 to 21 percent in fiscal year 2024 ▪Although SDPs go mainly to hospitals and nursing facilities, some payments are targeted toother types of providers, such as behavioral health facilities.6 The 2025 Reconciliation Act MadeSignificant Changes to Future SDPs The 2025 Reconciliation Act Lowered the Limit for SDPs ▪The 2025 reconciliation act (P.L. 119-21) lowered the limit for SDPs from ACRs toMedicare rates for hospitals, nursing facilities, and academic medical center (AMC)–affiliated physicians. –For states that have expanded Medicaid coverage to low-income adults throughthe Affordable Care Act, new SDPs are limited to 100 percent of Medicare rates.For states that have not, the limit is 110 percent.–For existing SDP arrangements, payment rates stay at current rates until 2028 andthen will be cut by 10 percentage points per year until they reach the limit. ▪CMS retains the authority to approve SDPs at any rate and change payment limits forother types of services (such as primary care services and behavioral health services). CBO’s Estimate of How the SDP Policy AffectsFederal Spending on Medicaid ▪The law further limited provider taxes, a major source of financing for SDPs. –P.L. 119-21 phased down the safe-harbor threshold for provider taxes from 6 percent to3.5 percent for expansion states and disallowed increases in provider tax rates amongnonexpansion states. ▪Provider taxes shift the burden of Medicaid financing away from states, increasing the effectivefederal match.2 ▪CBO estimates that the law’s SDP provision will reduce federal direct spending for Medicaid by$149 billion over the 2025–2034 period.7 Basis of CBO’s Estimate of theEffects of the SDP Policy CBO’s Medicaid Managed Care Baseline ▪CBO evaluated the law’s SDP policy by estimating how the legislation would affect spending inrelation to CBO’s January 2025 Medicaid managed care baseline.8 –In its baseline, CBO projects that SDP spending would grow by an average of11 percent per year from fiscal years 2025 to 2028. –By fiscal year 2028, that growth rate slows to match the overall growth rate of managed carespending (about 4 percent annually), once all provisions in the 2024 Managed Care Rule gointo effect. oBy 2028, CMS will no longer allow separate payment terms and will implement newguardrails regarding SDP state financing. Analysis of SDP Applications ▪Data sources for SDPs –The agency used SDP applicationsavailable on CMS’s website to compile state-level dataon spending by provider type and payment levels, typically as a percentage of commercial orMedicare rates.9–SDP applications are unstandardized and often lack detail on categories of service orprovider types. –CBO used data from RAND to convert each state’s commercial payment levels to theirMedicare-equivalent rates for each provider type.5 CBO’s Basis for the Estimate ▪CBO estimated the SDP provision within the law by freezing payment levels for hospitals,nursing facilities, and AMC-affiliated physicians that are above the payment limit withrespect to Medicare from fiscal years 2025 to 2028. –Starting in fiscal year 2028, SDP payment rates above the payment limit are reducedby