KFF - Health Policy Analysis, Polling and Journalism ......provisions that aim to improve quality...
Transcript of KFF - Health Policy Analysis, Polling and Journalism ......provisions that aim to improve quality...
States Focus on Quality and
Outcomes Amid Waiver Changes
Findings from the Annual Kaiser 50-State Medicaid Budget Survey
Robin Rudowitz
Associate Director, Kaiser Program on Medicaid and the Uninsured
The Henry J. Kaiser Family Foundation
Barbara Coulter Edwards
Senior Fellow
Health Management Associates
Washington, DC
October 25, 2018
Figure 1
• Survey of Medicaid directors in all 50 states and DC
• Conducted in June-September 2018
• Study findings and other research in 2 reports:
– Medicaid Enrollment & Spending Growth: FY 2018 & 2019 provides an
analysis of national trends in Medicaid enrollment and spending;
– States Focus on Quality and Outcomes Amid Waiver Changes, jointly
released with NAMD, provides a detailed look at the policy and programmatic
changes in Medicaid programs across all states.
Today we are releasing 2 reports that draw on findings
from our 18th annual survey of Medicaid directors.
SOURCE: Kaiser Family Foundation survey of Medicaid officials in 50 states and DC conducted by Health Management
Associates, October 2018.
Figure 2
4.7%
6.8%
8.7%
10.4%
12.7%
8.5%
7.7%
6.4%
1.3%
3.8%
5.8%7.6%
6.6%
9.7%
-4.0%
3.2%
6.8%
10.5%
3.5%
4.1% 4.2%
5.3%
-1.9%
0.4%
3.2%
7.5%
9.3%
5.6%
4.3%
3.2%
0.2%-0.5%
3.1%
7.8%7.2%
4.8% 2.3%
1.5%
5.3%
13.2%
3.9%
2.8%
-0.6%
0.9%
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Proj2019
Total Medicaid Spending Medicaid Enrollment
Annual Percentage Changes, FY 1998 – FY 2019
NOTE: Spending growth percentages refer to state fiscal year (FY). SOURCE: FY 2018-2019 spending data and FY 2019 enrollment data are derived from the KFF survey of Medicaid officials in 50 states and DC conducted by Health Management Associates, October 2018; historic data from various sources including: Medicaid Enrollment June 2013 Data Snapshot, KCMU, January 2014. FY 2014-2018 are based on KFF analysis of CMS, Medicaid & CHIP Monthly Applications, Eligibility Determinations, and Enrollment Reports and from KFF Analysis of CMS Form 64 Data.
Medicaid enrollment growth is flat and spending growth is
relatively steady in FY 2018 and FY 2019.
Figure 3
8.4%9.9%
12.9%
5.5% 4.9%
10.1%
3.0% 4.0%5.7%
-10.9%
-4.9%
16.1%
20.1%
10.0%
2.6% 3.8% 2.4% 3.6%
4.9%
3.5%
8.7%10.4%
12.7%
8.5% 7.7%
6.4%
1.3%
3.8%
5.8%7.6%
6.6%
9.7%
-4.0%
3.2%
6.8%
10.5%
3.5% 4.1%
4.2%
5.3%
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Proj2019
State Medicaid Spending Growth Total Medicaid Spending Growth
NOTE: FY 2019 projections based on enacted budgets. FMAP: Federal Medical Assistance Percentage.
SOURCE: Historic Medicaid spending growth rates derived from KFF analysis of CMS Form 64 Data. FY 2018-2019 data reflect changes in spending derived
from the KFF survey of Medicaid officials in 50 states and DC conducted by Health Management Associates, October 2018.
Growth in total and state Medicaid spending is generally
parallel, except when statutory changes impact FMAP.
ARRA Enhanced FMAP (2009 – 2011)
Enhanced FMAP / Federal Fiscal Relief (2003-2005)
100% ACA Enhanced Match (CY 2014 – 2016); 95% CY 2017; 94% CY 2018; 93% CY 2019
Expiration of ARRA FMAP
Figure 4
Enrollment Growth
-Stable economy
-Processing delayed eligibility
re-determinations
-New eligibility systems
Spending Growth
-Targeted provider rate increases
-Changing enrollment case-
mix
-Rising Rx and LTC costs
For FY 2019, states project that a number of factors will
contribute to enrollment and spending trends.
SOURCE: Kaiser Family Foundation survey of Medicaid officials in 50 states and DC conducted by Health Management Associates, October 2018.
Figure 5
Key Policy Areas
Eligibility
Delivery Systems / Managed
Care
Provider Rates & Taxes
Pharmacy / Opioid
Strategies
Benefits
Long-Term Services
and Supports
States Focus on Quality and Outcomes Amid Waiver
Changes: Key Policy Areas
SOURCE: Kaiser Family Foundation survey of Medicaid officials in 50 states and DC conducted by Health Management Associates, October 2018.
Figure 6
A number of states are pursuing Section 1115
waivers that include eligibility changes.
Enhancements
- 10 states in FY 2018 and 7 states in FY 2019
- Aside from ACA Medicaid expansion in ME and VA, most enhancements are narrow in scope
- Primarily through SPAs
What to Watch
- 3 states could adopt ACA expansion through ballot initiatives (ID, NE, UT)
- Additional states pursuing eligibility changes through waivers planned for FY 2020 or later years
- 7 states have plans for new or increased premiums in FY 2019 (6 are through waivers)
NOTE: *Policies that have or are likely to result in enrollment declines are counted as restrictions. Waiver provisions in pending waivers that states plan to
implement in FY 2019 or after are not counted here.
SOURCE: Kaiser Family Foundation survey of Medicaid officials in 50 states and DC conducted by Health Management Associates, October 2018.
New Requirements / Restrictions
- 6 in FY 2018 and 11 in FY 2019
- Most common are work requirements, waive retroactive eligibility, and lock-out periods
- Primarily through Section 1115 waivers
Figure 7
32
5
7
3 3
3
3335
23
31
20
All BeneficiaryGroups
39 states
Children39 states*
ACA ExpansionAdults
27 states*
All Other Adults39 states*
Elderly andDisabled39 states*
Excluded <25% 25-49% 50-74% 75+%
1
121
1 1
NOTES: Limited to 39 states with MCOs in place on July 1, 2018. Of the 32 states that had implemented the ACA Medicaid expansion as of July 1, 2018, 27 had MCOs in operation. North Dakota’s rate for “All Beneficiary Groups” was estimated from a state Quarterly Budget Insight report. Illinois reported the MCO penetration rate for “All Beneficiary Groups” but did not report penetration rates for the individual eligibility categories; therefore, state counts in individual eligibility category bars above do not sum to totals below the bars.
SOURCE: KFF survey of Medicaid officials in 50 states and DC conducted by HMA, October 2018.
In 33 states of 39 states with MCOs, at least 75% of
all Medicaid beneficiaries are in an MCO.
211
Figure 8
5
13
23
27
FY 2016 FY 2017 FY 2018 FY 2019(planned)
Require MCOs to Hit a
Target % for APM
States are increasingly implementing MCO contract
provisions that aim to improve quality and outcomes.
NOTES: States with MCOs indicated if selected quality initiatives were in place in FY 2018, new or expanded in FY 2019.
SOURCE: KFF survey of Medicaid officials in 50 states and DC conducted by HMA, October 2018.
State MCO Contract Provisions Related to
Screening for Enrollee Social Needs
In place
FY 2018
Expected in
place FY 2019
Require
MCOs16 states 19 states
Encourage
MCOs 10 states 16 states
Figure 9
35
43
1719
Any MCO Quality Initiative (Total of 39 States)
Any Delivery System Initiatives
In Place in FY 2018 New/Expanded in FY 2019
NOTES: Expansions of existing initiatives include rollouts of existing initiatives to new areas or groups, and other increases in enrollment or
providers.
SOURCE: KFF survey of Medicaid officials in 50 states and DC conducted by HMA, October 2018.
Most states with MCOs are implementing MCO quality
initiatives, and more broadly most states are also
implementing other delivery system reform initiatives.
Figure 10
NOTES: Provider payment restrictions include rate cuts for any provider or freezes for nursing facilities or hospitals. FY 2019 rates had not been
determined for MCOs in Maryland or for Dentists in Ohio at the time of the survey.
SOURCE: KFF survey of Medicaid officials in 50 states and DC conducted by HMA, October 2018.
States were most likely to increase payment rates
for MCOs and LTSS.
23
34 32 2821
12 149
24
4031 31
2418 16 12
InpatientHospitals
NursingFacilities
HCBS MCOs OutpatientHospitals
PrimaryCare
Physicians
SpecialistPhysicians
Dentists
FY 2018 Adopted FY 2019
28
17
27 5 4 3 4
27
11
0 2 1 0 02
States with Rate Increases
States with Rate Restrictions
Figure 11
Nearly all states are expanding community-based LTSS
in FY 2018 and FY 2019.
46
48
FY 2018 FY 2019
LTSS Direct Care Workforce
- Wage increases: 15 states in FY 2018, 24 states in FY 2019
- Workforce development strategies: 12 states in place in FY 2018, 10 states adding/enhancing in FY 2019
Housing Services
- 30 states identified specific housing-related services they plan to continue after MFP funding expires
- About half of MFP-funded states anticipate discontinuing services or admin activities
Total States with HCBS
Expansions
SOURCE: KFF survey of Medicaid officials in 50 states and DC conducted by HMA, October 2018.
Figure 12
Benefit
Restrictions
FY 2018: 4 states
FY 2019: 6 states
Most common:
dental
Benefit Enhancements
FY 2018: 19 states
FY 2019: 24 states
Most common:
MH / SUD services, dental, and telehealth
Mental health and substance use disorder treatment
(MH/SUD) were the most commonly reported benefit
enhancements.
SOURCE: KFF survey of Medicaid officials in 50 states and DC conducted by HMA, October 2018.
Figure 13
Uniform clinical protocols
Uniform PDLs
Risk sharing
States are implementing pharmacy cost-containment
initiatives and strategies to address the opioid epidemic.
Adopting pharmacy benefit management strategies (e.g., quantity limits, use of prior authorization)
Coverage of methadone, in addition to other MAT drugs covered in all states
Some challenges related to access to MAT
Opioid Policies
SOURCE: KFF Survey of Medicaid Officials in 50 states and DC conducted by Health Management Associates, October 2018.
MCO Pharmacy Policies(35 of 39 MCO states carve-in Rx)
Pharmacy Cost-
Containment Actions
Many states reported:Many states reported:Many states reported:
Initiatives to generate greater rebate revenue
Utilization controls
Ingredient cost reductions
Medication therapy management, case management, or adherence programs
Figure 14
IMD Services
Permit use of federal Medicaid funds for IMD services for adults up
to 30 days
Oct. 2019 – Sept. 2023
MAT Drug Coverage
Require coverage of all FDA-approved MAT drugs
Oct. 2020 – Sept. 2025
Corrections
Require suspension of Medicaid eligibility for people under 21 or
former foster care youth up to 26 while incarcerated, require
restoration of coverage upon release
Provider Capacity
Authorize new demonstrations to help states increase Medicaid SUD
provider capacity
Provisions in the SUPPORT Act will help states provide
SUD coverage and services.
SOURCE: MaryBeth Musumeci and Jennifer Tolbert, Federal Legislation to Address the Opioid Crisis: Medicaid Provisions in the SUPPORT Act
(Washington, DC: Kaiser Family Foundation, October 2018), https://www.kff.org/medicaid/issue-brief/federal-legislation-to-address-the-opioid-
crisis-medicaid-provisions-in-the-support-act/.
Figure 15
• Improving quality and focusing on health outcomes through managed care, value-
based purchasing initiatives, and other delivery system reforms
• Implementing or pursuing new Section 1115 waivers:
– Common focus-areas include behavioral health services/the IMD exclusion and
work/community engagement
– Waivers often necessitate system changes, contracting with new support vendors,
outreach and engagement, and other administrative tasks
• Continuing to tackle the opioid epidemic
• Managing program costs (particularly costs tied to new specialty drugs)
• Adapting to new policy directions in some states post November elections
Key priorities and challenges in FY 2019 and beyond
include the following:
SOURCE: KFF Survey of Medicaid Officials in 50 states and DC conducted by Health Management Associates, October 2018.