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Medicaid’s 3 Big Changes: Consequences for Consumers Presentation for Consumer Providers Association of New Jersey Tom Pyle, Advisor August 2013 1
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Medicaid’s 3 Big Changes: Consequences for Consumers
Presentation forConsumer Providers Association of New Jersey
Tom Pyle, AdvisorAugust 2013
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What’s coming…
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What’s coming…
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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
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Outcomes
AccessAvailabilityQualityCostInnovation
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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.
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Medicaid: Expenditures FY 2010 (Centers for Medicare and Medicaid, 2012)
Total = $404.1 billion
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Medicaid as % of…(Foster, 2012)
GDP: 2.8%Health spending: 15%
15%
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MH Funding: Only 1 Component (Smith, Kennedy, Knipper & O’Brien, 2005)
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Segments % paid by Medicaid (Foster, 2012)
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Medicaid: Acute/LT Care 2009(Kaiser Commission on Medicaid and the Uninsured)
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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
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Enrollment & Shares, 2010(Centers for Medicare and Medicaid et al., 2012)
~ 60 mm
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Overview: Role in state budgets Counter-cyclical to economy
Largest source of federal revenue ( jobs)
Biggest target for state cost controls
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Overview: Role in federal budget 3rd largest domestic program
Exempt from automatic budget reductions
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Overview: Medicaid role in ACA Coverage base for the poor (< 133%
FPL)
Insurer of 17 mm currently uninsured
Funder of experimental models being tested
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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
ies
Long-term care assistanc
e
Safety net & system fundingFunding for state capacity
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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
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Eligibility (3 kinds)
Category
Financial
Resource
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1. Category Eligibility
Children Pregnant women Parents Seniors Individuals with disabilities
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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)
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Eligibility: FPL by Class (US)(Kaiser Commission on Medicaid and the Uninsured)
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Eligibility: FPL by Class (NJ)(Kaiser Commission on Medicaid and the Uninsured)
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Eligibility: FPL (After ACA)(Kaiser Commission on Medicaid and the Uninsured; Tate, 2012))
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3. Resource Eligibility (SSI)
< +
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Eligibility: ACA’s effect(et al., 2013)
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Eligibility: Overlap!(Blahous, 2013)
Medicaid: < 138% FPL. Exchanges: > 100% FPL.
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Enrollment (et al., 2013)
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Enrollment FY 2010(Centers for Medicare and Medicaid et al., 2012)
62 mm(53 mm PYEs)
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Expenditures by Enrollment 2010(Centers for Medicare and Medicaid et al., 2012)
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Medicaid: Dual Eligibles 2009(Kaiser Commission on Medicaid and the Uninsured)
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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
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Medicaid: Enrollment after ACA(Tate, 2012)
New eligibles
9 mm old eligibles not yet enrolled 57%
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Enrollment demographics(Sommers & Epstein, 2010)
Eligibles: Nearly 1 in 3 not enrolled!
Enrolled eligibles: Highly variable by state
OK 44% MA 80%
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Enrollment demographics(Sommers & Epstein, 2010)
Eligibles: Nearly 1 in 3 not enrolled!
Enrolled eligibles: Highly variable by state
OK 44% MA 80%
NJ 53%
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Current vs. Future Eligibles (Sommers & Epstein, 2010)
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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)
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Coverage
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Coverage(Garfield, Lave, & Donohue, 2010)
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Challenge: Less Coverage?(Garfield, Lave, & Donohue, 2010)
“Benchmark”EssentialBenefitscoverage
under ACA
Excludable
for newbiesunder ACA
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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
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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
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Rates
Grants (Block Grants)
Encounter-based (Medicaid FFS)
Case rates
Capitation rates (MCO)
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Managed Care: Elements
Enrollment Benefits Usage Cost sharing (co-pays) Access Quality Accountability
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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
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…with “Carve Outs”
Behavioral health
Dental
Medications
Transport
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“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
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Medicaid Managed Care: Prevalence(Kaiser Commission on Medicaid and the Insured, 2012)
Medicaid67%
New Jersey 97%
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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?
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ACA’s Medicaid ExpansionNJ’s Comprehensive Waiver
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Affordable Care Act…bringing the biggest change in Medicaid since it began.
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Famous Last Words
http://www.youtube.com/watch?feature=player_embedded&v=KoE1R-xH5To
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3 years later: still not understood (Gold, 2013)
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ACA: Goals(Tate, 2012)
Improve access Control costs Add benefits and protections Address many smaller issues
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ACA: 3 Legged Strategy
1. Insurance reform Individual mandate
2. Exchanges + subsidies Subsidies for those at 100% -400% of
FPL
3. Medicaid expansion For adults < 138% of FPL
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Federal Poverty Level (FPL)
Family of 1: $11,490 x 133% =$15,282
Family of 4: $23,550 x 133% =$31,322
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Eligibility: FPL Limits by Class (US)(Kaiser Commission on Medicaid and the Uninsured)
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Eligibility: FPL Limits by Class (NJ)(Kaiser Commission on Medicaid and the Uninsured)
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Eligibility: FPL Limits (After ACA)(Kaiser Commission on Medicaid and the Uninsured; Tate, 2012))
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ACA: Projected Enrollments(Centers for Medicare and Medicaid, 2012)
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ACA Effect: NJ Coverage (Rutgers Center for State Health Policy, 2012)
Change in Coverage in NJ under ACA (ages 0-64)
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Rates
For PCPs only Family practitioners Internists Pediatricians
100% Only for 2013,
2014
Also for managed care
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US 0.72
WY 1.43AK 1.40DE 1.00PA 0.73CA 0.56NY 0.43
NJ 0.37
50t
h !
Rate Ratio (Zuckerman et al., 2009)
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“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
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100% Federal Match…
Only on the increase over 2009 rates…
Later: 90%.
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Innovation: Medicaid ACO “Accountable Care Organization”
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NJ Medicaid ACO
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Brenner explains his ACO
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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
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NJ’s Comprehensive WaiverGetting it all together
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NJ Medicaid
“Division of Medical Assistance and Health Services”
$11 billion (federal and state)
500 people
Director: Valerie Harr
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NJ Medicaid: Enrollment
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NJ Medicaid: Enrollment
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NJ Medicaid: FY 2006-2010
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Medicaid: The State Plan
Required by Section 1902(a) (30)(A)
71 elements Rates Methodology Comment periods
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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”
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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.
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1915(b): Managed Care (Howell, Palmer & Adams, 2012)
KEEP…
Can be mandated, with choice of plans
Rates must be “actuarially sound”
CHANGE…
AND
“Risk-based” payments and incentives
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NJ: The 4 Current HMOs (adults)… Amerigroup
Healthfirst NJ
Horizon NJ Health
UnitedHealthCare Community Plan
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Waivers: New Jersey(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)
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
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Waivers: New Jersey(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)
Comprehensive
including ASOs for behavioral health (adult and child)…
and “fee for service” that it will manage.
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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
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PCP
T
CW
S
IN Px
Out Px
Primary Care
Specialist
Therapist
Case Worker
Hospital
PHP/IOP
LTCF LT Care Facility
Medicaid: Mechanics
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Medicaid: The Old Way
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Managed Care Organization (MCO)
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Managed Care Organization (MCO)
Physical “Health Home”
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Managed Care
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Managed Care After the Waiver?
DMHAS
Physical “Health Home” “Behaviora
lHealth Home”
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Post Waiver: Unknown No. 1
“Fee for service”?
“Behavioral
Health Home”
Physical “Health Home”
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Post Waiver: Unknown No. 2
Physical “Health Home” “Behaviora
lHealth Home”
Integration?
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Post Waiver: Unknown No. 3
Rates?
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10 Challenges
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1. Coverage: Less for Newbies? (Garfield, Lave, & Donohue, 2010)
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1. Coverage: Less for Newbies? (Garfield, Lave, & Donohue, 2010)
“Benchmark”coverage
under ACA
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1. Coverage: Less for Newbies? (Garfield, Lave, & Donohue, 2010)
“Benchmark”coverage
under ACA
Excludable
for newbiesunder ACA
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2. Providers: Enough?
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Providers: Rate Ratios(Zuckerman et al., 2009)
𝑥=𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒𝑟𝑎𝑡𝑒
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US 0.72
WY 1.43AK 1.40DE 1.00PA 0.73CA 0.56NY 0.43
NJ 0.37
Providers: Rate Ratios(Zuckerman et al., 2009)
𝑥=𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒𝑟𝑎𝑡𝑒
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US 0.72
WY 1.43AK 1.40DE 1.00PA 0.73CA 0.56NY 0.43
NJ 0.37
Providers: Rate Ratios(Zuckerman et al., 2009)
𝑥=𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒𝑟𝑎𝑡𝑒
108
US 0.72
WY 1.43AK 1.40DE 1.00PA 0.73CA 0.56NY 0.43
NJ 0.3750t
h !
Providers: Rate Ratios(Zuckerman et al., 2009)
𝑥=𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒𝑟𝑎𝑡𝑒
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Providers: Supply = f(Rate Ratio) (Decker, 2012)
𝑥=𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒𝑟𝑎𝑡𝑒
% doctors accepting
110
Providers: Supply = f(Rate Ratio) (Decker, 2012)
𝑥=𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒𝑟𝑎𝑡𝑒
% doctors accepting
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100%! …for PCPs and those they supervise… …even in managed care… …even for dual eligibles.
Result: 10-24% increase in accepting PCPs?
BUT:
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%
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100%! …for PCPs and those they supervise… …even in managed care… …even for dual eligibles.
Result: 10-24% increase in accepting PCPs?
BUT:
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%
113
100%! …for PCPs and those they supervise… …even in managed care… …even for dual eligibles.
Result: 10-24% increase in accepting PCPs?
BUT:
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%
114
100%! …for PCPs and those they supervise… …even in managed care… …even for dual eligibles.
Result: 10-24% increase in accepting PCPs?
BUT:
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%
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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!
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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!
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3. Exchanges: FPL Overlap?(Blahous, 2013)
Overlap! Medicaid: < 138% FPL. Exchanges: > 100% FPL.
Partial expansion? All > 100% to exchanges, where no state funding needed…
NO! HHS: 100% FMAP if states do partial
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4. Transitions: Coverage Churn?(Ingram, McMahon & Guerra, 2012)
Wages
Medicaid Exchanges: 35% of all adults below 200% FPL
Exchanges Medicaid: 28 million
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5. “Woodwork” Effect?(Castro, 2013; Alaigh, 2002)
234,000total
eligibles(@ $8000 per)
FMAP = 100%
New eligibles vs. old eligibles not enrolled
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6. Measures: Of What?
HEDIS: measure behavioral health? Healthcare Effectiveness Data and
Information Set System metrics, not consumer metrics
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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
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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
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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
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8. Implementation: Too Complex?
South Carolina’s IT Enterprise Strategy Map
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Deadlines: Too Tight?
ASO: July 1! “Managed care”, but… Fee for service
“Go Live”: January 1! Medicaid Expansion Exchanges
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Deadlines: Too Tight?
ASO: July 1! “Managed care”, but… Fee for service
“Go Live”: January 1! Medicaid Expansion ExchangesPOSTPONED!
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9. Compliance: Too Heavy? Reporting
Documentation
Audits
Clawbacks
Penalties
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10. Agency Cash Flow: Enough? Reduced fees
Increased costs
New investments EMR Compliance Training
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Outcomes
AccessAvailabilityQualityCostInnovation
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Access
To the System
To Providers
To PsyR services
(To Insurance…)
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Availability
Of basic care
Of specialty care
Of emergency care
Of evidence-based practices
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Quality
Provider What level? What training? What experience? What supervision?
Process Simpler? Smoother?
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Cost
Co-pays
Deductibles
Premiums
(Work incentives?)
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Innovation
Practices
Medications
Technology
Management
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Conclusion?
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References
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