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Spoto & Associates, LLC
Medicaid Redesign
Mike Scribner / Beth Spoto
National Medicaid FindingsAs states search for delivery models which decrease cost and provide more benefit, they are focused on efforts to
control Medicaid spending for the highest-cost populations. In 2011:
Elderly: 8% of the enrollees20% of the cost
Disabled: 15% of the enrollees44% of the cost
Adults: 27% of the enrollees14% of the cost
Children: 50% of the enrollees22% of the cost
Spoto & Associates, LLC
Georgia is one of the lowest in per capita spending
Spoto & Associates, LLC
States Aged Disabled Adults Children Unknown Total
US Average
$12,938 $14,840 $2,668 $2,164 $975 $5,337
Georgia $8,919 $9,573 $4,046 $1,809 $0 $4,074
Florida $8,456 $11,628 $2,841 $1,785 $0 $4,573
Alabama $8,110 $6,702 $1,845 $2,169 $0 $3,928
SC $10,706 $11,277 $2,847 $2,086 $0 $4,652
NC $10,046 $15,004 $3,599 $2,531 $0 $5,706
Navigant Options
Analyzed nine (9) delivery models; Recommend 3:
•Option 1: Georgia Families Plus•Option 2: Georgia Families Plus – Transitioning to “Commercial Style” Managed Care •Option 3: Georgia Families Plus – Transitioning to “Commercial Style” Managed Care Program that requires use of PCMHs and ACOs
Spoto & Associates, LLC
Georgia Families Plus (expansion of current CMO Program)
• Includes all Medicaid populations• Enrollment of Low-Income Medically Needy Adults & potential
Medicaid expansion population.• Includes all State Plan Service, including behavioral health• Value Based Purchasing• Medical Home Use – Encourage use of patient centered medical
home (PCMH) model• Reduced administrative complexities• Wellness Programs
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Recommended Services to Carve In
•Behavioral health•LTC Services•Home and community based waiver services•Dental services•Transportation services•Pharmacy services
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Option # 2 Commercial Style Managed Care
• Expands Option #1 by potentially adding the following:• Use phased approach to enroll patients in
“Commercial Style” plans.• Employs all levers/innovations that are used in
commercial marketplace, such as deductibles and co-pays.
• Utilizes copays, deductibles, HRAs, incentive payments, prizes, etc. to encourage healthy behaviors.
Spoto & Associates, LLC
Spoto & Associates, LLC
Option #3
Georgia Families Plus “Commercial Style” Managed Care Program with use of ACOs and PCMHs.
CMO Feedback• Little support for carving in long term care.
• ABD is a done deal.
• ACO/PCMH concepts valid; Meeting federal definition is not.
• Use of commercial style patient payment is ineffective and only lowers provider payment.
• Use of health rewards has been shown to be effective.
• 3 – 5 CMOs will be approved. All statewide.
Spoto & Associates, LLC
What are CMO’s looking for?
• Willingness to move toward gainsharing mechanisms.
• Quick network development to support RFP response.
• Complete statewide network.
• Ability to address overutilization/high costs.
Spoto & Associates, LLC
Key Strategic Thoughts:
• More leverage prior to RFP award.
• More $’s in gainsharing than in FFS negotiations.
• What’s in it for you to help a prospect?
• Do you need to contract with all CMOs?
• Given current history, be smart about language / administrative items as well.
Spoto & Associates, LLC
Redesign Timeline:I. Assessment
August – December 2011. Completed.
II. Recommendation
January 2012. Posting of the Strategy Report.
January – April 2012. Review and analysis of the Strategy Report.
April - Summer 2012. Finalization of the Redesign Model.
III. Procurement
April – July/August 2012. Procurement planning/workgroups ongoing
September/October 2012. Procurement documents posted. (RFP issued)
1st quarter 2013. Contract award to successful vendors.
IV. Implementation
January 2014. Implementation begins.
Spoto & Associates, LLC
Next Steps?
• Finalization of redesign model.
• Ongoing discussions with CMOs
Spoto & Associates, LLC