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: National & State Change. The biggest changes in 50 years… How will consumers be affected? - PowerPoint PPT Presentation
Transcript of 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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Topic: National & State Change
The biggest changes in 50 years…
How will consumers be affected?
What should CPANJ advocate?
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...To Ask Lynn Kovich
What 3 Key Questions...
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The Whole Thing, in 20 Words...
THE NATIONAL THING... Health insurance for
all Individual Mandate Corporate Requirement
Help for those who need it Medicaid Subsidies
THE STATE THING...
Comprehensive Waiver Consolidation: 8 1
B H to managed care Contracted FFS Medicaid rate setting
Merger of services MH + SUD
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The Whole Thing, in 20 Words...THE NATIONAL THING... Health insurance for
all Individual Mandate Corporate Requirement
Help for those who need it Medicaid Subsidies
THE STATE THING...
Comprehensive Waiver Consolidation: 8 1
B H to managed care Contracted FFS Medicaid rate setting
Merger of services MH + SUD
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The Whole Thing, in 20 Words...THE NATIONAL THING... Health insurance for
all Individual Mandate Corporate Requirement
Help for those who need it Medicaid Subsidies
THE STATE THING...
Comprehensive Waiver Consolidation: 8 1
B H to managed care Contracted FFS Medicaid rate setting
Merger of services MH + SUD
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The Whole Thing, in 20 Words...THE NATIONAL THING... Health insurance for
all Individual Mandate Corporate Requirement
Help for those who need it Medicaid Exchanges Subsidies
THE STATE THING...
Comprehensive Waiver Consolidation: 8 1
B H to managed care Contracted FFS Medicaid rate setting
Merger of services MH + SUD
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The Whole Thing, in 20 Words...THE NATIONAL THING... Health insurance for
all Individual Mandate Corporate Requirement
Help for those who need it Medicaid Exchanges Subsidies
THE STATE THING...
Comprehensive Waiver Consolidation: 8 1
B H to managed care Contracted FFS Medicaid rate setting
Merger of services MH + SUD
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The Whole Thing, in 20 Words...THE NATIONAL THING... Health insurance for
all Individual Mandate Corporate Requirement
Help for those who need it Medicaid Exchanges Subsidies
THE STATE THING...
Comprehensive Waiver Consolidation: 8 1
B H to managed care Contracted FFS Medicaid rate setting
Merger of services MH + SUD
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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...and 1 Big Challenge
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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?
What is “FMAP”?
Federal Medical Assistance 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%
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%
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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Segments % paid by Medicaid (Foster, 2012)
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)
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
At least 20% of costs...(~ $80 billion?...)
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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...(~ $80 billion?...)
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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 funding
Funding 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 funding
Funding 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 funding
Funding 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 funding
Funding 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 funding
Funding 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
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. Category Eligibility: Required
Children Pregnant women Parents of certain children Seniors Individuals with disabilities
NOT childless non-elderly adults
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2. Financial Eligibility
2013 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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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 FY 2010(Centers for Medicare and Medicaid et al., 2012)
~ 62 mm
~ 20%
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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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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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Coverage
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Medicaid: Focuses on...
Services, not programs
Discrete and individual, not comprehensive
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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: Previous (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
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
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
Crisis residential/stabilizationClinically managed 24 hr careClinically managed med. Intense careAdult mental health residentialChildren’s mental health residentialYouth subtance abuse residentialTherapeutic foster care
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
Substance abuse intensive outpxSubstance abuse ambulatory detoxPartial hospitalAssertive Community TreatmentIntensive home-base treatmentMulti-systemic therapyIntensive Case Management
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
Individual evidence-based therapiesGroup therapyFamily therapyMultifamily therapyConsultation to caregivers (e.g., IFSS)
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
Outpx medical servicesAcute primary careGeneral health screens, tests, etc.Comprehensive care managementCare coordination and health promotionIndividual and family supportReferral to 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
Medication managementPharmacotherapy (incl. MAT)Laboratory 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
AssessmentSpecialized evaluationsService planning (incl. crisis planning)Consumer/Family Education (e.g. IMR)Outreach
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
Screening and referral to txBrief motivational interviewsParent trainingFacilitated referralsRelapse preventionWellness recovery supportWarm Line
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
Parent/caregiver supportSkills building (social, ADLs, cognitive)Case managementBehavior managementSupported EmploymentPermanent Supported HousingTherapeutic mentoring, life coachingDay habilitation
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
Personal careHomemakerRespiteSupported EducationTransportationAssisted livingRecreational 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
Peer supportRecovery support coachingRecovery support center servicesSupports for self-directed careContinuing care for substance use disorders
Where are the peer provider positions?
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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: Elements
Enrollment Benefits Usage Cost sharing (co-pays) Access Quality Accountability
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…with “Carve Outs”
Dental
Medications
Transport
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…with “Carve Outs”
Dental
Medications
Transport
Behavioral health
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Rates
Grants (Block
Grants)
Encounter-based (Medicaid FFS)
Case rates
Capitation rates (MCO)
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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
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Affordable Care Act
THE NATIONAL THING...
…bringing the biggest change in Medicaid since it began.
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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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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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Subsidies: Amounts by FPL
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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Expansion: Projected Enrollments(Centers for Medicare and Medicaid, 2012)
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Expansion 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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Innovation: Medicaid ACO
“Accountable Care Organization”
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NJ’s Comprehensive WaiverGetting it all together
THE STATE THING...
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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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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 Concentrated care...
Accountable Care Organizations (ACO) Coordinated, cost-effective care...
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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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NJ’s Managed Care Companies
For physical health...
For behavioral health...
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NJ’s Managed Care Companies
For physical health...
For behavioral health...
TBD
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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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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) ACOs
3. NJ Care 2000+4. NJ Family Care BH 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 B H Managed Care
(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 B H Managed Care
(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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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”
136
Managed Care
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Managed Care After the Waiver?
DMHAS
Physical “Health Home”
“Behavioral
Health Home”
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Managed Care After the Waiver?
DMHAS
Physical “Health Home”
“Behavioral
Health Home”
142
Post Waiver: Unknown No. 1
“Fee for service”?
“Behavioral
Health Home”
Physical “Health Home”
143
Post Waiver: Unknown No. 2
Physical “Health Home”
“Behavioral
Health Home”
Integration?
144
Post Waiver: Unknown No. 3
Rates?
Physical “Health Home”
“Behavioral
Health Home”
145
10 Challenges for Consumers
146
1. Coverage: Less for Newbies? (Garfield, Lave, & Donohue, 2010)
147
1. Coverage: Less for Newbies? (Garfield, Lave, & Donohue, 2010)
“Benchmark”coverage
under ACA
148
1. Coverage: Less for Newbies? (Garfield, Lave, & Donohue, 2010)
“Benchmark”coverage
under ACA
Excludable
for newbiesunder ACA
149
1. Coverage: Less for Newbies? (Garfield, Lave, & Donohue, 2010)
“Benchmark”coverage
under ACA
Excludable
for newbiesunder ACA
Advocacy Question:
Shouldn’t newly eligible Medicaid-covered consumers receive the same
benefits as current Medicaid-covered
consumers?
150
2. Providers: Enough?
151
2. Providers: Rate Ratios(Zuckerman et al., 2009)
𝑥=𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒𝑟𝑎𝑡𝑒
152
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
153
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
154
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
155
2. Providers: Supply = f(Rate Ratio) (Decker, 2012)
𝑥=𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒𝑟𝑎𝑡𝑒
% doctors accepting
156
2. Providers: Supply = f(Rate Ratio) (Decker, 2012)
𝑥=𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒𝑟𝑎𝑡𝑒
% doctors accepting
157
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%
158
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%
159
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%
160
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%
Advocacy Question:
Shouldn’t NJ set Medicaid rates sufficient to...
...attract more providers, especially specialists
(at least to 70% accepting new patients)?
...assure a living wage to community behavioral health sector workers,
especially peer providers?
161
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!
162
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!
163
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
164
4. Transitions: Coverage Churn?(Ingram, McMahon & Guerra, 2012)
Wages
Medicaid Exchanges: 35% of all adults below 200% FPL More for those with
SMI
Exchanges Medicaid: 28 million
165
4. Transitions: Coverage Churn?(Ingram, McMahon & Guerra, 2012)
Wages
Medicaid Exchanges: 35% of all adults below 200% FPL More for those with
SMI
Exchanges Medicaid: 28 million
Advocacy Questions:
How will consumers who get “churned”
be assured smooth and seamless coverage?
Who will help them? In what way?
What impact will “churning”have on consumer employment?
5. “Woodwork” Effect?(Castro, 2013; Alaigh, 2002)
234,000total
eligibles
(@ $8000 per)
FMAP = 100%
New eligibles vs. old eligibles not enrolled
166
5. “Woodwork” Effect?(Castro, 2013; Alaigh, 2002)
234,000total
eligibles
(@ $8000 per)
FMAP = 100%
New eligibles vs. old eligibles not enrolled
167
Advocacy Question:
Will unexpected costs (e.g. only 50% FMAP for old eligibles)
cause the State to cut its share of Medicaid funding?
168
6. Measures: Of What?
HEDIS: measure behavioral health? Healthcare Effectiveness Data and
Information Set
169
6. Measures: Of What?
HEDIS: measure behavioral health? Healthcare Effectiveness Data and
Information Set
BUT:
System metrics, not consumer metrics
170
6. Measures: Of What?
HEDIS: measure behavioral health? Healthcare Effectiveness Data and
Information Set
BUT:
System metrics, not consumer metrics
Advocacy Questions:
What specific consumer outcomesdoes the State propose to measure ?
Who will decide? When?
171
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
172
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
173
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
174
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
Advocacy Questions:
How specifically willuninsured consumers be reached?
How will private health and financial information be protected?
What role will consumer providers play?
What training will be required?
175
8. Implementation: Too Complex?
South Carolina’s IT Enterprise Strategy Map
176
8. Implementation: Too Complex?
South Carolina’s IT Enterprise Strategy MapAdvocacy Questions:
What assurance is NJ seeking that the Federal systems will be ready on time?
What privacy protections will be in place?
How will identity theft be prevented?
What state oversight (e.g., by DOBI)will be exercised?
177
Deadlines: Too Tight?
ASO: July 1! “Managed care”, but… Fee for service
“Go Live”: January 1! Medicaid Expansion Exchanges
178
Deadlines: Too Tight?
ASO: July 1! “Managed care”, but… Fee for service
“Go Live”: January 1! Medicaid Expansion ExchangesPOSTPONED!
179
Deadlines: Too Tight?
ASO: July 1! “Managed care”, but… Fee for service
“Go Live”: January 1! Medicaid Expansion ExchangesPOSTPONED!
Advocacy Questions:
Why is NJ setting Medicaid ratesbefore the ASO is established?
Why is NJ not permitting the ASOthis management flexibility so better
to help the agencies transition?
180
9. Compliance: Too Heavy?
Reporting
Documentation
Audits
Clawbacks
Penalties
181
9. Compliance: Too Heavy?
Reporting
Documentation
Audits
Clawbacks
Penalties
Advocacy Questions:
What is NJ specifically doing to help agencies
address conflicting auditing requirements?
What transition period will agencies have
to manage their compliance transitions
without onerous penalties?
182
10. Agency Cash Flow: Enough?
Reduced fees
Increased costs
New investments EMR Compliance Training
183
10. Agency Cash Flow: Enough?
Reduced fees
Increased costs
New investments EMR Compliance Training
Advocacy Question:
Why financial support (e.g., working capital)
will NJ provide to help non-profit agencies
manage the heavy investment requirements
of both the ACA and B H Managed Care?
184
1 Big Challenge for America
185
Entitlement Spending...
186
The Ultimate Advocacy Question
187
Outcomes
AccessAvailabilityQualityCostInnovation
188
Access
To the System
To Providers
To PsyR services
(To Insurance…)
189
Availability
Of basic care
Of specialty care
Of emergency care
Of evidence-based practices
190
Quality
Provider What level? What training? What experience? What supervision?
Process Simpler? Smoother?
191
Cost
Co-pays
Deductibles
Premiums
(Work incentives?)
192
Innovation
Practices
Medications
Technology
Management
193
Will Outcomes Improve?
194
Winners and Losers... 1 2 3 4 5 6
Mechanisms Medicaid Private Insurance
Insurance Exchanges
Cost Containment
Quality Improvement
Taxes
Eligibility Change FMAP Increase rates Coverages Caps Cancellations Elements Features More groups
Higher FPLs
FMAP to 100%, then 90% (instead of 50%) for new eligibles
Medicaid rates = 100% Medicare rates (instead of 72%)
10 basics
No lifetime caps No rescission Premium subsidies
Cost subsidies
Benefits Fewer uninsured
More costs paid by Federal gov’t
More incentive for PCP participation
More coverage More coverage for big problems
Durable coverage
“Affordable” premiums, lower costs.
Costs More waiting
Faster visits
More APNs
...but not for “old eligibles”
...but not for specialists, only for 2 years.
Applied to others
Applied to others
Applied to others
Very expense for Fed gov’t. Very complex. Very systems intensive. Pri-vacy issues.
Improve? Access Availability Quality Cost Innovation Winners? Clients (old and new “elig-ibles”, and existing bene-ficiaries)
New:
Old:
Existing:
New:
Old:
Existing:
New:
Old:
Existing:
New:
Old:
Existing:
New:
Old:
Existing:
New:
Old:
Existing:
New:
Old:
Existing:
New:
Old:
Existing:
New:
Old:
Existing:
New:
Old:
Existing:
Providers Agencies Government State:
Federal:
State:
Federal:
State:
Federal:
State:
Federal:
State:
Federal:
State:
Federal:
State:
Federal:
State:
Federal:
State:
Federal:
State:
Federal: Insurers
195
Conclusion?
196
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
197
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.
198
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)
![”Zero defects” and Zero Zero defects” and ”Zero nonconformities ... The critical defect is the defect which can have serious consequences on consumers [2, 58]](https://static.fdocuments.in/doc/165x107/5ab8a97e7f8b9a28468d1bdf/zero-defects-and-zero-zero-defects-and-zero-nonconformities-the.jpg)
