Medicaid’s 3 Big Changes: Consequences for Consumers

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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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Presentation for Consumer Providers Association of New Jersey Tom Pyle, Advisor August 2013. Medicaid’s 3 Big Changes: Consequences for Consumers. What’s coming…. What’s coming…. Topic. Fee for service  Managed care… Integration of PH and BH… Medicaid expansion… - PowerPoint PPT Presentation

Transcript of Medicaid’s 3 Big Changes: Consequences for Consumers

Page 1: Medicaid’s 3 Big Changes: Consequences for Consumers

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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?

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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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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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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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...From the Perspective of...

1. Beneficiaries

2. Providers

3. Agencies

4. Government

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Considered by... 5 Big Outcomes

1. Access2. Availabilit

y3. Quality4. Cost5. Innovatio

n

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Considered by... 5 Big Outcomes

1. Access2. Availabilit

y3. Quality4. Cost5. Innovatio

n

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Considered by... 5 Big Outcomes

1. Access2. Availabilit

y3. Quality4. Cost5. Innovatio

n

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Considered by... 5 Big Outcomes

1. Access2. Availabilit

y3. Quality4. Cost5. Innovatio

n

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Considered by... 5 Big Outcomes

1. Access2. Availabilit

y3. Quality4. Cost5. Innovatio

n

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Dealing with... 10 Challenges

1. Coverage: As much?2. Providers: Enough?3. Exchanges: Overlap?4. Transitions: Churn?5. “Woodwork Effect”?6. Measures: Of What?7. Outreach: Possible?8. IT: Too Complex?9. Deadlines: Too Tight?10.Agency $: Enough?

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Dealing with... 10 Challenges

1. Coverage: As much?2. Providers: Enough?3. Exchanges: Overlap?4. Transitions: Churn?5. “Woodwork Effect”?6. Measures: Of What?7. Outreach: Possible?8. Implement: Complex?9. Deadlines: Too Tight?10.Agency $: Enough?

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The Whole Story, in 10 Words...

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The Whole Story, in 10 Words... Health insurance for all

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The Whole Story, in 10 Words... Health insurance for all

Help for those who need it

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The Whole Story, in 10 Words... Health insurance for all

Individual Mandate Corporate Requirement

Help for those who need it

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The Whole Story: 10 Words... Health insurance for all

Individual Mandate Corporate Requirement

Help for those who need it Medicaid Subsidies for premiums and cost-sharing

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The Whole Story: 6 Mechanisms1. Public Program Changes (Medicaid)2. Private Insurance Changes3. Health Insurance Exchanges

4. Cost containment measures5. Quality improvement measures6. Funding measures, e.g., taxes!

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The Whole Story: 6 Mechanisms1. Public Program Changes (Medicaid)2. Private Insurance Changes3. Health Insurance Exchanges

4. Cost containment measures5. Quality improvement measures6. Funding measures, e.g., taxes!

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An entitlement

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

Federal-state partnership FMAP: 50% to 83%

What is Medicaid?

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An entitlement

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

Federal-state partnership FMAP: 50% to 83%

What is Medicaid?

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An entitlement

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

Federal-state partnership FMAP: 50% to 83%

What is Medicaid?

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An entitlement

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

Federal-state partnership FMAP: 50% to 83%

What is Medicaid?

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What is “FMAP”?

Federal Medical Assistance Percentage: The percentage of Federal matching funds to state Medicaid.

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What is “FMAP”? ...For NJ

Federal Medical Assistance Percentage

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NJ: 50%

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What is “FMAP”? ... Under ACA

Federal Medical Assistance Percentage:

For “new eligibles”:

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What is “FMAP”? ... Under ACA

Federal Medical Assistance Percentage:

For “new eligibles”:

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Till 2017: 100%

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What is “FMAP”? ... Under ACA

Federal Medical Assistance Percentage:

For “new eligibles”:

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Till 2017: 100%

By 2020: 90%

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Medicaid: SMI Jersyans affected?(Substance Abuse and Mental Health Services Administration, 2013a)

10% (~42,000?)

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

$404.1 billion

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By Contrast...

$404.1 billion $33.0 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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BH Funding: Medicaid’s Share (Substance Abuse and Mental Health Services Administration, 2013)

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

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

5 x

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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

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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: How Control Costs?(Substance Abuse and Mental Health Services Administration, 2013)

Medicaid an entitlement

States can only...

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Overview: How Control Costs?(Substance Abuse and Mental Health Services Administration, 2013)

Medicaid an entitlement

States can only... Reduce provider payments

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Overview: How Control Costs?(Substance Abuse and Mental Health Services Administration, 2013)

Medicaid an entitlement

States can only... Reduce provider payments “Manage” utilization

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Overview: How Control Costs?(Substance Abuse and Mental Health Services Administration, 2013)

Medicaid an entitlement

States can only... Reduce provider payments “Manage” utilization Restrict eligibility

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Medicaid: 5 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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Medicaid: 5 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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Medicaid: 5 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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Medicaid: 5 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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Medicaid: 5 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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Medicaid: 4 Constituencies

• 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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Medicaid: 4 Constituencies

• 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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Medicaid: 4 Constituencies

• 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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Medicaid: 4 Constituencies

• 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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Review

3 Big Changes 5 Big Outcomes FMAP: NJ = 50% 2.8% of GDP 15% of all health spending W,F,A = 20% 18% beneficiaries 45% cost 5 Components 4 Constituencies

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Eligibility (3 kinds)

Category

Financial

Resource

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1. Eligibility: Mandatory

Children Pregnant women Parents of certain children Seniors Individuals with disabilities

NOT childless non-elderly adults

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2. Financial Eligibility2013 Federal Poverty

Limit (FPL)

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

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3. Resource Eligibility (SSI)

< +

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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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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)

http://www.nejm.org/na101/home/literatum/publisher/mms/journals/content/nejm/2010/nejm_2010.363.issue-22/nejmp1010866/production/images/large/nejmp1010866_f1.jpeg
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Currently Enrolled by Groups(Kaiser Commission on Medicaid and the Uninsured)

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NJ: Total Uninsured Since 2000(Castro, 2012)

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ACA Effects: NJ Beneficiaries(Castro, 2012)

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ACA Effects: Federal Funding NJ(Castro, 2012)

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Coverage

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Medicaid: Focuses on...

Services, not programs

Discrete and individual, not comprehensive

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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: Must Cover...(Substance Abuse and Mental Health Services Administration, 2013)

Inpatient hospital Outpatient hospital EPSDT Nursing facility Home health Physician Rural health clinic Federally qualified health center (FQHC) Laboratory and X-ray Family planning Nurse midwife Certified pediatric and family nurse practitioner Freestanding birth center (when licensed or otherwise recognized by

the state) Transportation to medical care Tobacco cessation and tobacco cessation counseling for pregnant

women and youth under 21 as part of EPSDT

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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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Rehab Option: Its Scope(Substance Abuse and Mental Health Services Administration, 2013)

Service Setting Type of Provider Extent of Coverage

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“Rehab Option”: A Distinction(Substance Abuse and Mental Health Services Administration, 2013)

“Habilitative” services: to develop skills never acquired (as among DD population) Only through home and community-based

waiver

“Rehabilitative” services: to restore lost functioning (as among PD population) Not limited to clinical treatment

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Services Range

As per SAMHSA’s...

“Good and Modern Addictions and Mental Health Service System”

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Services Range

Acute IntensiveOut-of-home Residential

Intensive SupportOutpatient Services

Healthcare Home/Physicial HealthMedication Services

Engagement ServicesPrevention

Community Support (Rehab)Other Support (Habilitative)

Recovery Support

Increasing Intensity of Medical and Behavioral Health Specialty

Increasing Intensity of Social and Community Services

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Services Range

Acute IntensiveOut-of-home Residential

Intensive SupportOutpatient Services

Healthcare Home/Physicial HealthMedication Services

Engagement ServicesPrevention

Community Support (Rehab)Other Support (Habilitative)

Recovery Support

Increasing Intensity of Medical and Behavioral Health Specialty

Increasing Intensity of Social and Community Services

Where are the peer provider positions?

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Services Range

Acute IntensiveOut-of-home Residential

Intensive SupportOutpatient Services

Healthcare Home/Physical HealthMedication Services

Engagement ServicesPrevention

Community Support (Rehab)Other Support (Habilitative)

Recovery Support

Increasing Intensity of Medical and Behavioral Health Specialty

Increasing Intensity of Social and Community Services

Mobile crisisMedically monitored intensive inpxPeer-based crisisUrgent care23 hr. crisis stabilization24/7 crisis hotline

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Services Range

Acute IntensiveOut-of-home Residential

Intensive SupportOutpatient Services

Healthcare Home/Physical HealthMedication Services

Engagement ServicesPrevention

Community Support (Rehab)Other Support (Habilitative)

Recovery Support

Increasing Intensity of Medical and Behavioral Health Specialty

Increasing Intensity of Social and Community Services

Crisis residential/stabilizationClinically managed 24 hr careClinically managed med. Intense careAdult mental health residentialChildren’s mental health residentialYouth subtance abuse residentialTherapeutic foster care

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Services Range

Acute IntensiveOut-of-home Residential

Intensive SupportOutpatient Services

Healthcare Home/Physical HealthMedication Services

Engagement ServicesPrevention

Community Support (Rehab)Other Support (Habilitative)

Recovery Support

Increasing Intensity of Medical and Behavioral Health Specialty

Increasing Intensity of Social and Community Services

Substance abuse intensive outpxSubstance abuse ambulatory detoxPartial hospitalAssertive Community TreatmentIntensive home-base treatmentMulti-systemic therapyIntensive Case Management

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Services Range

Acute IntensiveOut-of-home Residential

Intensive SupportOutpatient Services

Healthcare Home/Physical HealthMedication Services

Engagement ServicesPrevention

Community Support (Rehab)Other Support (Habilitative)

Recovery Support

Increasing Intensity of Medical and Behavioral Health Specialty

Increasing Intensity of Social and Community Services

Individual evidence-based therapiesGroup therapyFamily therapyMultifamily therapyConsultation to caregivers (e.g., IFSS)

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Services Range

Acute IntensiveOut-of-home Residential

Intensive SupportOutpatient Services

Healthcare Home/Physical HealthMedication Services

Engagement ServicesPrevention

Community Support (Rehab)Other Support (Habilitative)

Recovery Support

Increasing Intensity of Medical and Behavioral Health Specialty

Increasing Intensity of Social and Community Services

Outpx medical servicesAcute primary careGeneral health screens, tests, etc.Comprehensive care managementCare coordination and health promotionIndividual and family supportReferral to community services

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Services Range

Acute IntensiveOut-of-home Residential

Intensive SupportOutpatient Services

Healthcare Home/Physical HealthMedication Services

Engagement ServicesPrevention

Community Support (Rehab)Other Support (Habilitative)

Recovery Support

Increasing Intensity of Medical and Behavioral Health Specialty

Increasing Intensity of Social and Community Services

Medication managementPharmacotherapy (incl. MAT)Laboratory services

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Services Range

Acute IntensiveOut-of-home Residential

Intensive SupportOutpatient Services

Healthcare Home/Physical HealthMedication Services

Engagement ServicesPrevention

Community Support (Rehab)Other Support (Habilitative)

Recovery Support

Increasing Intensity of Medical and Behavioral Health Specialty

Increasing Intensity of Social and Community Services

AssessmentSpecialized evaluationsService planning (incl. crisis planning)Consumer/Family Education (e.g. IMR)Outreach

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Services Range

Acute IntensiveOut-of-home Residential

Intensive SupportOutpatient Services

Healthcare Home/Physical HealthMedication Services

Engagement ServicesPrevention

Community Support (Rehab)Other Support (Habilitative)

Recovery Support

Increasing Intensity of Medical and Behavioral Health Specialty

Increasing Intensity of Social and Community Services

Screening and referral to txBrief motivational interviewsParent trainingFacilitated referralsRelapse preventionWellness recovery supportWarm Line

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Services Range

Acute IntensiveOut-of-home Residential

Intensive SupportOutpatient Services

Healthcare Home/Physical HealthMedication Services

Engagement ServicesPrevention

Community Support (Rehab)Other Support (Habilitative)

Recovery Support

Increasing Intensity of Medical and Behavioral Health Specialty

Increasing Intensity of Social and Community Services

Parent/caregiver supportSkills building (social, ADLs, cognitive)Case managementBehavior managementSupported EmploymentPermanent Supported HousingTherapeutic mentoring, life coachingDay habilitation

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Services Range

Acute IntensiveOut-of-home Residential

Intensive SupportOutpatient Services

Healthcare Home/Physical HealthMedication Services

Engagement ServicesPrevention

Community Support (Rehab)Other Support (Habilitative)

Recovery Support

Increasing Intensity of Medical and Behavioral Health Specialty

Increasing Intensity of Social and Community Services

Personal careHomemakerRespiteSupported EducationTransportationAssisted livingRecreational services

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Services Range

Acute IntensiveOut-of-home Residential

Intensive SupportOutpatient Services

Healthcare Home/Physical HealthMedication Services

Engagement ServicesPrevention

Community Support (Rehab)Other Support (Habilitative)

Recovery Support

Increasing Intensity of Medical and Behavioral Health Specialty

Increasing Intensity of Social and Community Services

Peer supportRecovery support coachingRecovery support center servicesSupports for self-directed careContinuing care for substance use disorders

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Medicaid: Styles

Classic Fee for service

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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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Managed Care: 3 Types

1. Managed care organization (MCO)▪ Capitation: Per person per month▪ Risk: Who accepts it? State or vendor?

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

3. Pre-paid Health Plans (PHP)▪ In-patient ▪ Ambulatory

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Managed Care: 3 Types

1. Managed care organization (MCO)▪ Capitation: Per person per month▪ Risk: Who accepts it? State or vendor?

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

3. Pre-paid Health Plans (PHP)▪ In-patient ▪ Ambulatory

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Rates

Grants (Block

Grants)

Encounter-based

(Medicaid FFS)

Case ratesCapitation

rates (MCO)

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Managed Care: Elements

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

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…with “Carve Outs”

Dental

Medications

Transport

http://www.google.com/url?sa=i&rct=j&q=carve+out+image&source=images&cd=&cad=rja&docid=v7zELFz8H1I5PM&tbnid=HO8AJZayR-LMmM:&ved=0CAUQjRw&url=http://myretirementchronicles.blogspot.com/2009/11/you-say-you-have-leftover-pumpkins-that.html&ei=hcNQUfmIFvCO0QHejIHIBA&bvm=bv.44158598,d.dmg&psig=AFQjCNH-8a0xbL9hREZFCuj01YANesbdrA&ust=1364333731426447
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…with “Carve Outs”

Dental

Medications

Transport

Behavioral health

http://www.google.com/url?sa=i&rct=j&q=carve+out+image&source=images&cd=&cad=rja&docid=v7zELFz8H1I5PM&tbnid=HO8AJZayR-LMmM:&ved=0CAUQjRw&url=http://myretirementchronicles.blogspot.com/2009/11/you-say-you-have-leftover-pumpkins-that.html&ei=hcNQUfmIFvCO0QHejIHIBA&bvm=bv.44158598,d.dmg&psig=AFQjCNH-8a0xbL9hREZFCuj01YANesbdrA&ust=1364333731426447
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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?

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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

http://www.google.com/url?sa=i&rct=j&q=changes+image&source=images&cd=&cad=rja&docid=IbIny_kizy4xdM&tbnid=GPrI-tsyk-CZ0M:&ved=0CAUQjRw&url=http://soshable.com/changes-coming-at-soshable/&ei=otNQUZPVO-Xx0gHbroGADw&bvm=bv.44158598,d.dmg&psig=AFQjCNHopSwq8R8i62LcAj-1TgHYp0iVeQ&ust=1364337940433117
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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

http://www.youtube.com/watch?feature=player_embedded&v=KoE1R-xH5To
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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3 Years Later: 2/3rds Don’t Know!(Gold, 2013)

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ACA: Goals(Tate, 2012)

Increase access

Control costs

Add benefits & protections

Address many smaller issues

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ACA: 3 Legged Strategy

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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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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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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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HIEs: :Premium Subsidies

Income % of FPLPremium Cap as

a Share of Income

Income $ (family of 4)

Max Annual Out-of-Pocket Premium

Premium SavingsAdditional Cost-Sharing Subsidy

133% 3% of income $31,900 $992 $10,345 $5,040 150% 4% of income $33,075 $1,323 $9,918 $5,040 200% 6.3% of income $44,100 $2,778 $8,366 $4,000 250% 8.05% of income $55,125 $4,438 $6,597 $1,930 300% 9.5% of income $66,150 $6,284 $4,628 $1,480 350% 9.5% of income $77,175 $7,332 $3,512 $1,480 400% 9.5% of income $88,200 $8,379 $2,395 $1,480

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HIEs: Premium Subsidies

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

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

“Old Eligibles”:FMAP = 50%

“New Eligibles”:FMAP = 100% 90%

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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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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”

http://www.google.com/url?sa=i&source=images&cd=&cad=rja&docid=CSi-85usLlIDJM&tbnid=vA4imybYMYKIzM:&ved=0CAgQjRwwAA&url=http://www.easthanovermma.com/flexibility-club-east-hanover-mma-west-orange-nj/impressive-flexibility/&ei=0Wg-UczWO-f30gHgmIH4BQ&psig=AFQjCNHLjGs3njgHjzx4QhsNf_PNwLRm1A&ust=1363130962055439
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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): Mandatory 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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Managed Care: NJ’s 4 HMOs

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NJ Waivers: Previously (Centers for Medicare & Medicaid, 2013)

Section 1115 Research and

demonstration

Section 1915(b) Managed Care

(Mandatory)

Section 1915(c) Home and

Community Based

Concurrent 1915(b) & (c)

1. Childless adults2. Family coverage (SCHIP) ACOs3. NJ Care 2000+4. NJ Family Care BH ASO5. Global Options (LT care)6. Renewal Waiver7. Community Resources8. Community Care

Alternatives

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NJ Waivers: Additional(Centers for Medicare & Medicaid, 2013)

Section 1115 Research and

demonstration

Section 1915(b) Managed Care

(Mandatory)

Section 1915(c) Home and

Community Based

Concurrent 1915(b) & (c)

1. Childless adults2. Family coverage (SCHIP) Accountable Care (ACO)3. NJ Care 2000+4. NJ Family Care Behavioral Health

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

Alternatives

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NJ Waivers: Additional(Centers for Medicare & Medicaid, 2013)

Section 1115 Research and

demonstration

Section 1915(b) Managed Care

(Mandatory)

Section 1915(c) Home and

Community Based

Concurrent 1915(b) & (c)

1. Childless adults2. Family coverage (SCHIP) Accountable Care (ACO)3. NJ Care 2000+4. NJ Family Care Behavioral Health

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

Alternatives

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NJ Waivers: Now (Centers for Medicare & Medicaid, 2013)

Section 1115 Research and

demonstration

Section 1915(b) Managed Care

(Mandatory)

Section 1915(c) Home and

Community Based

Concurrent 1915(b) & (c)

One Comprehensiv

e Waiver

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BH Managed Care ASO

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

Phase in to risk-based over 5 years

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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Behavioral Health HomeDMHA

S

http://www.bridgewayrehab.com/index.shtml
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Behavioral Health HomeDMHA

S

“Behavioral

Health Home”

http://www.bridgewayrehab.com/index.shtml
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Managed Care After the Waiver?

DMHAS

Physical “Health Home” “Behaviora

lHealth Home”

http://www.bridgewayrehab.com/index.shtml
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Managed Care After the Waiver?

DMHAS

Physical “Health Home” “Behaviora

lHealth Home”

http://www.bridgewayrehab.com/index.shtml
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Managed Care After the Waiver?

DMHAS

http://www.bridgewayrehab.com/index.shtml
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Post Waiver: Unknown No. 1

“Fee for service”?

“Behavioral

Health Home”

Physical “Health Home”

http://www.bridgewayrehab.com/index.shtml
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Post Waiver: Unknown No. 2

Physical “Health Home” “Behaviora

lHealth Home”

Integration?

http://www.bridgewayrehab.com/index.shtml
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Post Waiver: Unknown No. 3

Rates?

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170

10 Challenges for Consumers

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

𝑥=𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒𝑟𝑎𝑡𝑒

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176

US 0.72

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

NJ 0.37

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

𝑥=𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒𝑟𝑎𝑡𝑒

Page 177: Medicaid’s 3 Big Changes: Consequences for Consumers

177

US 0.72

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

NJ 0.37

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

𝑥=𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒𝑟𝑎𝑡𝑒

Page 178: Medicaid’s 3 Big Changes: Consequences for Consumers

178

US 0.72

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

NJ 0.3750t

h !

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

𝑥=𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒𝑟𝑎𝑡𝑒

Page 179: Medicaid’s 3 Big Changes: Consequences for Consumers

179

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

𝑥=𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒𝑟𝑎𝑡𝑒

% doctors accepting

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180

2. 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…

2. 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…

2. 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…

2. 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…

2. 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

Page 189: Medicaid’s 3 Big Changes: Consequences for Consumers

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

234,000total

eligibles(@ $8000 per)

FMAP = 100%

New eligibles vs. old eligibles not enrolled

189

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6. Measures: Of What?

HEDIS: measure behavioral health? Healthcare Effectiveness Data and

Information Set

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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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193

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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195

8. Implementation: Too Complex?

South Carolina’s IT Enterprise Strategy Map

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196

Deadlines: Too Tight?

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

“Go Live”: January 1! Medicaid Expansion Exchanges

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197

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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1 Big Challenge for America

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201

Entitlement Spending...

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202

... And Its Consequences

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=zklEufa37kyTCM&tbnid=je489a0ZoBS9FM:&ved=0CAUQjRw&url=http://www.wfs.org/blogs/thomas-frey/when-countries-go-bankrupt&ei=z4IYUt2kM8nJsAS4uoGoBQ&bvm=bv.51156542,d.dmg&psig=AFQjCNFH-hnqZMbHP9WQsjIRfGubeYwG1Q&ust=1377424456443546
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Outcomes

AccessAvailabilityQualityCostInnovation

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Access

To the System

To Providers

To PsyR services

(To Insurance…)

Page 205: Medicaid’s 3 Big Changes: Consequences for Consumers

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Availability

Of basic care

Of specialty care

Of emergency care

Of evidence-based practices

Page 206: Medicaid’s 3 Big Changes: Consequences for Consumers

206

Quality

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

Process Simpler? Smoother?

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207

Cost

Co-pays

Deductibles

Premiums

(Work incentives?)

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Innovation

Practices

Medications

Technology

Management

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209

Conclusion?

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210

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

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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.

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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

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Privacy

Navigators Training reduced from 30 t0 20 hours 20% of funding for navigators from

diversion from disease prevention. (Attorney Gen’l Bondi, FL)


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