Medicaid’s 3 Big Changes: Consequences for Consumers

transcript

Presentation forConsumer Providers Association of New Jersey

Tom Pyle, AdvisorAugust 2013

What’s coming…

TopicFee for service Managed care…

Integration of PH and BH…Medicaid expansion…

Health insurance exchanges…Evidence-based practices..Community integration…

Medical model Recovery model…

The biggest change in 50 years…

How will our loved ones be affected?

Medicaid’s 3 Big Changes

1. Reform “Innovations” (ACOs) “Benchmark” plans

2. Expansion 25% increase

3. Managed care BH ASO Grant FFS Case Capitated

Outcomes

AccessAvailabilityQualityCostInnovation

Big funder of… Health care for poor, disabled Safety-net hospitals, LT care

Federal-state partnership FMAP: 50% to 83% NJ: 50%

What is Medicaid?

What is “FMAP”?

Federal Medical Assistance Percentages (FMAP): the percentage rates that determine the matching funds allocated annually to Medicaid.

Medicaid: Expenditures FY 2010 (Centers for Medicare and Medicaid, 2012)

Total = $404.1 billion

Medicaid as % of…(Foster, 2012)

GDP: 2.8%Health spending: 15%

MH Funding: Only 1 Component (Smith, Kennedy, Knipper & O’Brien, 2005)

Segments % paid by Medicaid (Foster, 2012)

Medicaid: Acute/LT Care 2009(Kaiser Commission on Medicaid and the Uninsured)

Waste, Fraud, Abuse(Kaiser Commission on Medicaid and the Uninsured, 2012)

Overtreatment Failure of care coordination Failure of care process (Tx) Administration complexity Failure of pricing Fraud and abuse

At least 20% of costs

Enrollment & Shares, 2010(Centers for Medicare and Medicaid et al., 2012)

~ 60 mm

Overview: Role in state budgets Counter-cyclical to economy

Largest source of federal revenue ( jobs)

Biggest target for state cost controls

Overview: Role in federal budget 3rd largest domestic program

Exempt from automatic budget reductions

Overview: Medicaid role in ACA Coverage base for the poor (< 133%

Insurer of 17 mm currently uninsured

Funder of experimental models being tested

Medicaid: Components(Kaiser Commission on Medicaid and the Uninsured)

Health insurance coverage 31 mm children; 16 mm adults; 16 mm E&D

Long-term care assistance 1.6 mm institutionals; 2.8 mm community-based

Assistance to Medicare beneficiaries 9.4 mm E&D (20% of Medicare enrollees)

Safety net & system funding 16% national health funding; 35% safety net

hospitals

Funding for state capacity FMAP

Health insurance coverage

Assistance to

Medicare beneficiar

Long-term care assistanc

Safety net & system fundingFunding for state capacity

Thinking about Medicaid…

• Eligibility• Enrollment• Coverage• Cost

Consumers

• Rates• Autonomy• Referrals• Administration• Compliance

Providers

• “Rights”• “Access”• Administration• Quality• Cost

Governments

• Administration• Overheads• Compliance• Cash flow

Agencies

Eligibility (3 kinds)

Category

Financial

Resource

1. Category Eligibility

Children Pregnant women Parents Seniors Individuals with disabilities

2. Financial Eligibility

Family of 1: $11,490 x 133% =$15,282

Family of 4: $23,550 x 133% =$31,322

2013 Federal Poverty Limit (FPL)

Eligibility: FPL by Class (US)(Kaiser Commission on Medicaid and the Uninsured)

Eligibility: FPL by Class (NJ)(Kaiser Commission on Medicaid and the Uninsured)

Eligibility: FPL (After ACA)(Kaiser Commission on Medicaid and the Uninsured; Tate, 2012))

3. Resource Eligibility (SSI)

Eligibility: ACA’s effect(et al., 2013)

Eligibility: Overlap!(Blahous, 2013)

Medicaid: < 138% FPL. Exchanges: > 100% FPL.

Enrollment (et al., 2013)

Enrollment FY 2010(Centers for Medicare and Medicaid et al., 2012)

62 mm(53 mm PYEs)

Expenditures by Enrollment 2010(Centers for Medicare and Medicaid et al., 2012)

Medicaid: Dual Eligibles 2009(Kaiser Commission on Medicaid and the Uninsured)

Today’s enrollee demographics(Kenen, 2012)

Poor families with children 2/3rd of enrollees 1/3rd of spending

Elderly and disabled 1/3rd of enrollees▪ (including 70% of those in nursing

homes) 2/3rd of spending

Medicaid: Enrollment after ACA(Tate, 2012)

New eligibles

9 mm old eligibles not yet enrolled 57%

Enrollment demographics(Sommers & Epstein, 2010)

Eligibles: Nearly 1 in 3 not enrolled!

Enrolled eligibles: Highly variable by state

OK 44% MA 80%

Enrollment demographics(Sommers & Epstein, 2010)

Eligibles: Nearly 1 in 3 not enrolled!

Enrolled eligibles: Highly variable by state

OK 44% MA 80%

NJ 53%

Current vs. Future Eligibles (Sommers & Epstein, 2010)

Currently Enrolled by Groups(Kaiser Commission on Medicaid and the Uninsured)

NJ: Total Uninsured Since 2000(Castro, 2012)

ACA Effects: NJ Beneficiaries(Castro, 2012)

ACA Effects: Federal Funding NJ(Castro, 2012)

Coverage

Coverage(Garfield, Lave, & Donohue, 2010)

Challenge: Less Coverage?(Garfield, Lave, & Donohue, 2010)

“Benchmark”EssentialBenefitscoverage

under ACA

Excludable

for newbiesunder ACA

Medicaid: Benefits (Centers for Medicare and Medicaid, 2013)

Doctor visits Emergency care Hospital care Prescription drugs Long-term care Vaccinations Hearing Vision Preventative care for children

Medicaid: Styles

Classic Fee for service

Managed care

Comprehensive set of contractually-defined covered services for an enrolled population in a closed network paid by capitation premiums

Grants (Block Grants)

Encounter-based (Medicaid FFS)

Case rates

Capitation rates (MCO)

Managed Care: Elements

Enrollment Benefits Usage Cost sharing (co-pays) Access Quality Accountability

Managed Care: 3 Plan Types

1. Risk-based managed care orgs/plans (MCO)▪ Capitation ▪ Who takes the risk? State or vendor?

2. Primary care case mgt plans (PCCM)▪ Case management fee

3. Limited plans▪ In-patient ▪ Ambulatory

…with “Carve Outs”

Behavioral health

Dental

Medications

Transport

“Carve Outs” for…

Behavioral health

3. “Limited” benefit plan

Inpatient MH (US): 4.3 mm Inpatient MH and SA (US): 3.1 mm

NB: Fee for service, not capitated

Medicaid Managed Care: Prevalence(Kaiser Commission on Medicaid and the Insured, 2012)

Medicaid67%

New Jersey 97%

Managed Care: Policy Issues Eligibility What class? By what means? Enrollment Voluntary or mandatory? Education What? How? Choice Self-select or auto-assign? Access/availability Sufficient network?

Continuity Many visits or “one-and-done”? Coordination PH & BH; PCPs and

specialists Rates What level? Costs Risk or non-risk? State or

Federal? Monitoring Access? Quality? Cost?

Satisfaction?

ACA’s Medicaid ExpansionNJ’s Comprehensive Waiver

Affordable Care Act…bringing the biggest change in Medicaid since it began.

Famous Last Words

http://www.youtube.com/watch?feature=player_embedded&v=KoE1R-xH5To

3 years later: still not understood (Gold, 2013)

ACA: Goals(Tate, 2012)

Improve access Control costs Add benefits and protections Address many smaller issues

ACA: 3 Legged Strategy

1. Insurance reform Individual mandate

2. Exchanges + subsidies Subsidies for those at 100% -400% of

3. Medicaid expansion For adults < 138% of FPL

Federal Poverty Level (FPL)

Family of 1: $11,490 x 133% =$15,282

Family of 4: $23,550 x 133% =$31,322

Eligibility: FPL Limits by Class (US)(Kaiser Commission on Medicaid and the Uninsured)

Eligibility: FPL Limits by Class (NJ)(Kaiser Commission on Medicaid and the Uninsured)

Eligibility: FPL Limits (After ACA)(Kaiser Commission on Medicaid and the Uninsured; Tate, 2012))

ACA: Projected Enrollments(Centers for Medicare and Medicaid, 2012)

ACA Effect: NJ Coverage (Rutgers Center for State Health Policy, 2012)

Change in Coverage in NJ under ACA (ages 0-64)

For PCPs only Family practitioners Internists Pediatricians

100% Only for 2013,

Also for managed care

US 0.72

WY 1.43AK 1.40DE 1.00PA 0.73CA 0.56NY 0.43

NJ 0.37

Rate Ratio (Zuckerman et al., 2009)

“Rate Bump”: Also for Duals (Kaiser Commission on Medicaid and the Uninsured, 2012)

Previously… 80% by Medicare, BUT no 20% by

Medicaid Doctors only get 80%

Now… Medicaid will pay 20% copay

100% Federal Match…

Only on the increase over 2009 rates…

Later: 90%.

Innovation: Medicaid ACO “Accountable Care Organization”

NJ Medicaid ACO

Brenner explains his ACO

How? Get “Waivers”

Why? Eligibility changes Service benefit

additions Payment criteria

changes

Waivers for…? Medicaid ACOs▪ Define scope▪ Define new roles▪ Build capacity▪ Include high-cost

groups▪ Multi-payer alliances

Payment models Measurements

NJ’s Comprehensive WaiverGetting it all together

NJ Medicaid

“Division of Medical Assistance and Health Services”

$11 billion (federal and state)

500 people

Director: Valerie Harr

NJ Medicaid: Enrollment

NJ Medicaid: FY 2006-2010

Medicaid: The State Plan

Required by Section 1902(a) (30)(A)

71 elements Rates Methodology Comment periods

Waivers by Type(Centers for Medicare & Medicaid, 2013)

Section 1115 Research and

demonstration

Section 1915(b) Managed Care

Section 1915(c) Home and

Community Based

Concurrent 1915(b) & (c)

…for more “flexibility”

1115: NJ “demonstrations” (new) Health homes

2010: NJ Public Law 2012, Chapter 74 3 year Medicaid Medical Home demonstration project Section 2703 of ACA

Accountable Care Organizations (ACO) 2011: NJ Public law 2011, Chapter 114

Medicaid Accountable Care Organization demonstration project.

1915(b): Managed Care (Howell, Palmer & Adams, 2012)

KEEP…

Can be mandated, with choice of plans

Rates must be “actuarially sound”

CHANGE…

“Risk-based” payments and incentives

NJ: The 4 Current HMOs (adults)… Amerigroup

Healthfirst NJ

Horizon NJ Health

UnitedHealthCare Community Plan

Waivers: New Jersey(Centers for Medicare & Medicaid, 2013)

demonstration

Community Based

1. Childless adults2. Family coverage (SCHIP)

3. NJ Care 2000+4. NJ Family Care

5. Global Options (LT care)6. Renewal Waiver7. Community Resources8. Community Care

Alternatives

Waivers: New Jersey(Centers for Medicare & Medicaid, 2013)

demonstration

Community Based

Comprehensive

including ASOs for behavioral health (adult and child)…

and “fee for service” that it will manage.

ASO (not ACO…) for BH

One already exists! In DCF “CSOC” 40,000 kids

Will phase in risk-based capitation over 5 years

ASO: Administrative Services Organization

Out Px

Primary Care

Specialist

Therapist

Case Worker

Hospital

PHP/IOP

LTCF LT Care Facility

Medicaid: Mechanics

Medicaid: The Old Way

Managed Care Organization (MCO)

Physical “Health Home”

Managed Care

Behavioral Health HomeDMHA

“Behavioral

Health Home”

Managed Care After the Waiver?

Physical “Health Home” “Behaviora

lHealth Home”

Managed Care After the Waiver?

Post Waiver: Unknown No. 1

“Fee for service”?

“Behavioral

Health Home”

Physical “Health Home”

Physical “Health Home” “Behaviora

lHealth Home”

Integration?

Rates?

10 Challenges

1. Coverage: Less for Newbies? (Garfield, Lave, & Donohue, 2010)

“Benchmark”coverage

under ACA

1. Coverage: Less for Newbies? (Garfield, Lave, & Donohue, 2010)

“Benchmark”coverage

under ACA

Excludable

for newbiesunder ACA

2. Providers: Enough?

Providers: Rate Ratios(Zuckerman et al., 2009)

𝑥=𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒𝑟𝑎𝑡𝑒

US 0.72

WY 1.43AK 1.40DE 1.00PA 0.73CA 0.56NY 0.43

NJ 0.37

US 0.72

WY 1.43AK 1.40DE 1.00PA 0.73CA 0.56NY 0.43

NJ 0.37

US 0.72

WY 1.43AK 1.40DE 1.00PA 0.73CA 0.56NY 0.43

NJ 0.3750t

Providers: Supply = f(Rate Ratio) (Decker, 2012)

% doctors accepting

Providers: Supply = f(Rate Ratio) (Decker, 2012)

% doctors accepting

100%! …for PCPs and those they supervise… …even in managed care… …even for dual eligibles.

Result: 10-24% increase in accepting PCPs?

Not for specialists (e.g., psychiatrists)

Only for 2013 and 2014 Extend? Measurement will be key…

Providers: “Rate Bump” For…?(Kaiser Commission on Medicaid and the Uninsured, 2012a)

= 100%

3. Exchanges: FPL Overlap?(Blahous, 2013)

Overlap! Medicaid: < 138% FPL. Exchanges: > 100% FPL.

Partial expansion? All > 100% to exchanges, where no state funding needed…

HHS: 100% FMAP if states do partial? NO!

NO! HHS: 100% FMAP if states do partial

4. Transitions: Coverage Churn?(Ingram, McMahon & Guerra, 2012)

Medicaid Exchanges: 35% of all adults below 200% FPL

Exchanges Medicaid: 28 million

5. “Woodwork” Effect?(Castro, 2013; Alaigh, 2002)

234,000total

eligibles(@ $8000 per)

FMAP = 100%

New eligibles vs. old eligibles not enrolled

6. Measures: Of What?

HEDIS: measure behavioral health? Healthcare Effectiveness Data and

Information Set System metrics, not consumer metrics

7. Outreach: Can It Succeed?(Sommers & Epstein, 2010)

Publicity hurdles 150 different languages in NJ Cultural differences

Application hurdles Multipage application Documentation of income and residency

Tracking hurdles ACA does not apply to incomes < IRS tax filing

threshold ($9,350 for singles, $18,700 for joint) = 50% of eligible uninsureds

8. Implementation: Too Complex?

South Carolina’s IT Enterprise Strategy Map

Deadlines: Too Tight?

ASO: July 1! “Managed care”, but… Fee for service

“Go Live”: January 1! Medicaid Expansion Exchanges

Deadlines: Too Tight?

ASO: July 1! “Managed care”, but… Fee for service

“Go Live”: January 1! Medicaid Expansion ExchangesPOSTPONED!

9. Compliance: Too Heavy? Reporting

Documentation

Audits

Clawbacks

Penalties

10. Agency Cash Flow: Enough? Reduced fees

Increased costs

New investments EMR Compliance Training

Outcomes

AccessAvailabilityQualityCostInnovation

Access

To the System

To Providers

To PsyR services

(To Insurance…)

Availability

Of basic care

Of specialty care

Of emergency care

Of evidence-based practices

Quality

Provider What level? What training? What experience? What supervision?

Process Simpler? Smoother?

Co-pays

Deductibles

Premiums

(Work incentives?)

Innovation

Practices

Medications

Technology

Management

Conclusion?

References

Alzer, A., Currie, J., & Moretti, E. (2007). Does Medicaid managed care hurth health? Evidence from Medicaid mothers. The Review of Economics and Statistics, 89(3).

Averill, Patricia M., Ruiz, Pedro, Small, David R., Guynn, Robert W., & Tcheremissine, Oleg. (2003). Outcome assessment of the Medicaid managed care program in Harris County (Houston). Psychiatric Quarterly, 74(2), 103-114.

Bigelow, Douglas A., McFarland, Bentson H., McCamant, Lynn E., Deck, Dennis D., & Gabriel, Roy M. (2004). Effect of Managed Care on Access to Mental Health Services Among Medicaid Enrollees Receiving Substance Treatment. Psychiatric Services, 55(7), 775-779.

Cook, Judith A., Heflinger, Craig Anne, Hoven, Christina W., Kelleher, Kelly J., Mulkern, Virginia, Paulson, Robert I., . . . Kim, Jong-Bae. (2004). A Multi-site Study of Medicaid-funded Managed Care Versus Fee-for-Service Plans' Effects on Mental Health Service Utilization of Children With Severe Emotional Disturbance. The Journal of Behavioral Health Services & Research, 31(4), 384-402.

Coughlin, Teresa A., & Long, Sharon K. (2000). Effects of medicaid managed care on adults. Medical Care, 38(4), 433-446.

Cunningham, Peter J., & Nichols, Len M. (2005). The Effects of Medicaid Reimbursement on the Access to Care of Medicaid Enrollees: A Community Perspective. Medical Care Research and Review, 62(6), 676-696. doi: 10.1177/1077558705281061

Felix, Holly C., Mays, Glen P., Stewart, M. Kathryn, Cottoms, Naomi, & Olson, Mary. (2011). Medicaid Savings Resulted When Community Health Workers Matched Those With Needs To Home And Community Care. Health Affairs, 30(7), 1366-1374. doi: 10.1377/hlthaff.2011.0150

Gold, Marsha, & Mittler, Jessica. (2000). "Second-generation" Medicaid managed care: Can it deliver? Health Care Financing Review, 22(2), 29-47.

Kaye, H. Stephen, LaPlante, Mitchell P., & Harrington, Charlene. (2009). Do noninstitutional long-term care services reduce Medicaid spending? Health Affairs, 28(1), 262-272. doi: 10.1377/hlthaff.28.1.262

Keenan, Patricia S., Elliott, Marc N., Cleary, Paul D., Zaslavsky, Alan M., & Landon, Bruce E. (2009). Quality assessments by sick and healthy beneficiaries in traditional Medicare and Medicare managed care. Medical Care, 47(8), 882-888.

Liu, Heng-Hsian Nancy. (2012). Policy and practice: An analysis of the implementation of supported employment in Nebraska. Dissertation Abstracts International: Section B: The Sciences and Engineering, 72(7-B), 4324.

McCombs, Jeffrey S., Luo, Michelle, Johnstone, Bryan M., & Shi, Lizheng. (2000). The Use of Conventional Antipsychotic Medications for Patients with Schizophrenia in a Medicaid Population: Therapeutic and Cost Outcomes over 2 Years. Value in Health, 3(3), 222-231.

McFarland, Bentson H., Deck, Dennis D., McCamant, Lynn E., Gabriel, Roy M., & Bigelow, Douglas A. (2005). Outcomes for Medicaid Clients With Substance Abuse Problems Before and After Managed Care. The Journal of Behavioral Health Services & Research, 32(4), 351-367.

Norris, Margaret P., Molinari, Victor, & Rosowsky, Erlene. (1998). Providing mental health care to older adults: Unraveling the maze of Medicare and managed care. Psychotherapy: Theory, Research, Practice, Training, 35(4), 490-497.

Parks, Joseph J. (2007). Implementing practice guidelines: Lessons from public mental health settings. Journal of Clinical Psychiatry, 68(Suppl4), 45-48.

Ray, Wayne A., Daugherty, James R., & Meador, Keith G. (2003). Effect of a mental health "carve-out" program on the continuity of antipsychotic therapy. The New England Journal of Medicine, 348(19), 1885-1894.

Wallace, Neal T., Bloom, Joan R., Hu, Teh-Wei, & Libby, Anne M. (2005). Medication treatment patterns for adults with schizophrenia in Medicaid managed care in Colorado. Psychiatric Services, 56(11), 1402-1408.

Wan, Thomas T. (1989). The effect of managed care on health services use by dually eligible elders. Medical Care, 27(11), 983-1001.

Warner, Richard, & Huxley, Peter. (1998). Outcome for people with schizophrenia before and after Medicaid capitation at a community agency in Colorado. Psychiatric Services, 49(6), 802-807.

West, Joyce C., Wilk, Joshua E., Rae, Donald S., Muszynski, Irvin S., Stipec, Maritza Rubio, Alter, Carol L., . . . Regier, Darrel A. (2009). Medicaid prescription drug policies and medication access and continuity: Findings from ten states. Psychiatric Services, 60(5), 601-610

Medicaid’s 3 Big Changes: Consequences for Consumers

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