Post on 25-Feb-2016
description
Medicaid’s Coming Changes & Prospective Consumer Outcomes
T.H. PylePSRT 5402 Advanced PsyR SeminarMarch 28, 2014
Topic
What outcomes for NJ consumers
from coming changes inMedicaid’s payment for care?
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?
Medicaid as % of…(Foster, 2012)
GDP: 2.8%Health spending: 15%
15%
Enrollment & Shares, 2010(Centers for Medicare and Medicaid et al., 2012)
~ 60 mm
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
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. Non-comprehensive plans▪ In-patient ▪ Ambulatory
…with “Carve Outs”
Behavioral health
Dental
Medications
Transport
Medicaid Managed Care: Prevalence(Kaiser Commission on Medicaid and the Insured, 2012)
Medicaid67%
New Jersey 97%
Affordable Care Act…bringing the biggest change in Medicaid since it began.
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
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 Enrollments(Cantor et al., 2011)
Medicaid enrollment:Up 22.8% (234,000)
Of total insured:From 13.6% to
16.7%
ACA Effect: NJ Coverage (Rutgers Center for State Health Policy, 2012)
Change in Coverage in NJ under ACA (ages 0-64)
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
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 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…
AND
“Risk-based” payments and incentives
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
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.
PCP
T
CW
S
IN Px
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)
Managed Care
Behavioral Health HomeDMHA
S
Managed Care After the Waiver?
DMHAS
Managed Care After the Waiver?
DMHAS
Post Waiver: Unknown No. 1
“Fee for service”?
Post Waiver: Unknown No. 2
Integration?
Post Waiver: Unknown No. 3
Rates?
Challenges
US 0.72
WY 1.43AK 1.40DE 1.00PA 0.73CA 0.56NY 0.43
NJ 0.3750t
h !
1: Rate Ratio (Zuckerman et al., 2009)
𝑥=𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒𝑟𝑎𝑡𝑒
Provider Supply = f(Rate Ratio) (Decker, 2012)
𝑥=𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒𝑟𝑎𝑡𝑒
% doctors accepting
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…
2. The Rate “Bump”(Kaiser Commission on Medicaid and the Uninsured, 2012a)
= 100%
3. Partial Expansion?(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!
4. Churn Transitions(Ingram, McMahon & Guerra, 2012)
Wages
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. Measurements
HEDIS: measure behavioral health? Healthcare Effectiveness Data and
Information Set System metrics, not consumer metrics
7. Outreach(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
South Carolina’s IT Enterprise Strategy Map
9. Compliance
Reporting
Documentation
Audits
Clawbacks
Penalties
10. Agency Cash Flow
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?
Cost
Co-pays
Deductibles
Premiums
(Work incentives?)
Innovation
Practices
Medications
Technology
Management
Conclusion?
Research
FoundationsThink tanksTechnical advisorsPeer journalsGovernments
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.
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