The State of Medicaid Today & Tomorrow...Source: Source: NABSO State Expenditure Report, 2015–2017...
Transcript of The State of Medicaid Today & Tomorrow...Source: Source: NABSO State Expenditure Report, 2015–2017...
May 2018
The State of Medicaid Today & TomorrowSKYGEN USA SUMMIT 2018
Medicaid Today
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EnrollmentMEDICAID
TODAY
Medicaid enrollment has increased substantially since implementation of the Affordable Care Act (ACA).
Source: CBO 2017, Baseline Projections for Health, Children's Health Insurance Program, Effects of the Affordable Care Act on Health Insurance Coverage, and Medicaid
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2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027
Enro
llees
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Medicaid Enrollment and Growth Breakdown
Adults
Children
Blind and Disabled
Aged
Projected
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Traditional expansion (24 states & DC)
Alternative expansion
Traditional & Alternative Medicaid ExpansionMEDICAID
TODAY
Source: National Academy for State Health Policy “Where States Stand on Medicaid Expansion Decisions”
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0 (5 states)
>0 – 50% (11 states)
51 – 65% (5 states)
66 – 80% (15 states, including DC)
81–100% (16 states, including PR)
U.S. Overall = 68.1%
Comprehensive Medicaid Managed Care PenetrationMEDICAID
TODAY
Source: Centers for Medicare & Medicaid Services Medicaid Managed Care Enrollment and Program Characteristics, Current as of 7/1/2016
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Medicaid Dental OverviewMEDICAID
TODAY
Source: Medicaid and CHIP Payment and Access Commission (MACPAC) Medicaid Coverage of Dental Benefits for Adults
Types of Adult Dental Services Covered for Non-Pregnant, Non-Disabled Adults under Medicaid, 2015
Type of Service Number of States Services Typically Included
Preventive 28Examinations, cleanings, and sometimes fluoride applications or sealants
Restorative 26 Fillings, crowns, endodontic (root canal) therapy
Periodontal 19Periodontal surgery, scaling, root planning (cleaning below the gum line)
Dentures 26 Full and partial dentures
Oral surgery 25 Non-emergency extractions, other oral surgical procedures
Orthodontia 2 Braces, headgear, retainers
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Dental Industry Trends
↗Medicaid proportion of industry reimbursement continues to increase
↗DSOs are spreading across the country and decreasing fragmentation
↗Capitation model is becoming increasingly prevalent
MEDICAID
TODAY
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Dental Industry Trends8
Near-Term 3 – 5 Years 5 – 10 Years
• Several states carve in dental into managed care
• Incorporation of quality metrics for dental
• Stand-alone dental plans seek “equal treatment” of their coverage inside and outside the exchange: required purchase on exchange
• Separate pricing by medical carrier
• More states carve in dental
• Outcome-driven measurements
• Greater data transparency• CMS and State Medicaid
Agencies will have more evidence to consider mandating programs
• Best practice models to emerge
• Greater likelihood of downside risk arrangements that include dental
• Potential emergence of capitated arrangements with built-in PMPM
MEDICAID
TODAY
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Dental under Medicaid Managed CareMEDICAID
TODAY
Coverage of Select Benefits under MCO Contracts, 2015
Children’s Dental
Adult Dental
Carved In Carved Out Carved In Carved Out
AZ, CO, DC, FL, GA, IL, KS, KY, MN, MS, MO, NV, NJ, NM, NY, OH, OR, PA, TN, TX, WV
CA, DE, HI, IA, LA, MD, MA, MI, NE, NH, RI, SC, UT, VA, WA
AZ, CO, DC, FL, IL, KY, MN, MS, MO, NJ, NM, NY, ND, OR, PA
CA, IA, KS, LA, MD, NE, RI, SC, UT, WA
VA, TX and GA: Not covered for adults
SOURCE: Kaiser Family Foundation, Medicaid Reforms to Expand Coverage, Control Costs and Improve Care: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016
Key Influences
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Certainty & Uncertainty KEY
INFLUENCES
Unsustainable Growth in Health
Care Expenditure in the US
Vision and Strategy of President Trump’s
Administration
Medicaid
Long-Term Care
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State Flexibility
1115 Waivers
Eligibility Limitations
Program Design (alternative expansions, benefits)
Political and Ideological Priorities
Reduced Funding (Block Grants)
Rollback of regulatory and consumer protections
Policy & Politics
High Need Populations
LTSS
Prescription drug costs
SUD/Opioid Use
Social Determinants of Health
Legal Challenges
ACA
Eligibility Limitations
Consumer Protections
KEY INFLUENCES
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Political & Ideological Priorities – Federal KEY
INFLUENCES
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Political & Ideological Priorities – Federal KEY
INFLUENCES
Continued Transition to Value-based Models
Price Transparency
Consumer Involvement
New Provider Models
State Flexibility
Fiscal Stewardship
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State Flexibility in Trump EraKEY
INFLUENCES
Premiums (limited)
Some copays above federal limits
DSRIP/DSHP
Waiving retroactive coverage
Cost sharing below 100% FPL
Lock-out period
Partial expansion to 100% FPL with enhanced FMAP
HSA-like models
Healthy behavior incentives
IMD exclusion
Work requirement
Enrollment caps
Enrollment time limits
Closed formularies
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Unsustainable Growth in Health Care ExpenditureKEY
INFLUENCES
19.8%29.0%
21.0%
19.4%
10.4%
10.4%4.0%1.4%3.6%
3.0%9.1%8.1%
32.1% 28.7%
FY 1995 FY 2017
Comparison of State Spending, Fiscal 1995 vs 2017
Medicaid Elementary & Secondary Education
Higher Education Public Assitance
Corrections Transportation
All Other
Source: Source: NABSO State Expenditure Report, 2015–2017 (left); Kaiser Family Foundation, 2016 (right)
26%
21%
46%
3%
4%
Distribution of Medicaid Spending By Service
FFS Acute Care FFS Long-Term Care
Managed Care & Health Plans Payments to Medicare
DHS Payments
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Political & Ideological Priorities - StateKEY
INFLUENCES
Source: MACPAC, 2017, analysis of state expenditure reports from the National Association of State Budget Officers
Distribution of Medicaid, Education, and All Other Spending from State-Funded
State Budgets, SFY 2016
Medicaid’s Share of State Budgets Including and Excluding Federal Funds, SFYs 1990 – 2016
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Political & Ideological Priorities - StateKEY
INFLUENCES
SOURCE: Kaiser Family Foundation (left); Medicaid State Resource Center (right)
Social Determinants of Health
By some estimates, social, economic and physical
determinants of health account for 50% of health
outcomes
In 2017, the CMS Innovation Center chose 32organizations to implement the Accountable
Health Communities model to address health-related social needs of Medicare and Medicaid individuals.
Of 39 states with managed care organizations (MCOs),
19 require MCOs to screen enrollees for social
needs as well as provide referrals.
Opioid Response
40 percent of the 1.9 million nonelderly adults with
opioid addiction are covered by Medicaid.
In 2016, those with Medicaid were 2 times as likely to
receive treatment for their addiction.
Several policy changes are allowing states to improve addiction treatment in response to opioid crisis. • 10 states have received 1115 waivers for IMD
exclusion have been received by 10 states• Limited eligibility expansion• Community based services expansion
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Long-Term Services & SupportsKEY
INFLUENCES
Medicaid covers an estimated 62% of US spending on long-term services and supports (LTSS).
Total Medicaid LTSS expenditures were $158 billion in FY2015
The number of people needing LTSS is expected to increase from 12 million today to 27 million by 2050.
To address rising demand for LTSS, states are transforming their LTSS Medicaid delivery system.
More Medicaid LTSS spending is now in home and community based care than institutional care.
As of December 2017, 20 states have established MLTSS programs up from only 8 states in 2008
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States with Managed Long-Term Services and SupportsKEY
INFLUENCES
Current MLTSS Program
MLTSS under consideration
MLTSS in active development
Duals demonstration program only
Source: NASUAD Survey, CMS data
Medicaid Tomorrow
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Leavitt Partners Medicaid Belief StatementsMEDICAID
TOMORROW
• The new HHS secretary will shape agency priorities at a critical juncture in health care.
• Pressure will remain high to address the cost of Medicaid at both the federal and state levels.
• States will seek and HHS is likely to grant additional state Medicaid flexibility to address cost and ideological policy preferences
• States and the federal government will continue to seek new strategies to address high need populations.
• The growing importance of managed care in Medicaid is resulting in a greater focus on MCO contracts and strategies.
• There is unprecedented opportunity for new product vendors to enter the Medicaid technology space.
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Top of Mind Issues for Medicaid LeadersMEDICAID
TOMORROW
Multiple Reimbursement Models
Focused Population Strategies
Social Determinants of Health
Need for an Enabling Infrastructure
Rapidly Changing Program Priorities/Needs
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Move Toward ValueMEDICAID
TOMORROW
Evolutions in Delivery System Reform
Moving toward Value-based Payment Arrangements
Fee-for-Service
PCCM, PAHP, PIHP, & Risk-based
managed care
Managed long-term services and
supports
Managed care for dual eligible
Value-based and Alternative
Payment Models
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Provider StrategiesMEDICAID
TOMORROW
New delivery models require new approaches to provider management:
✓ Accurate directors to ensure access to care
✓ Measure and track performance for value-based contracts
✓ Identify high quality/low cost providers
✓ Track providers across delivery models
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Pregnant
Women
Foster
Children
Persons
with ID/DD CSHCNs
Persons
with
SMI/SED
Adults w/
Physical
Disabilities
Always mandatory 32 20 11 20 18 19
Always voluntary 2 8 4 3 3 4
Varies 4 8 16 14 16 11
Always excluded 1 3 8 2 2 5
Focused Population StrategiesMEDICAID
TOMORROW
SOURCE: Kaiser Family Foundation, Medicaid Moving Ahead in Uncertain Times Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2017 and 2018
MCO Enrollment of Populations with Special Needs, July 2017 (# of States)
Program Needs & Opportunities
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Advanced Data CapabilitiesNEEDS &
OPPORTUNITIES
✓ Better understand population and care needs
✓ Refine benefit packages & programs
✓ Address non-medical needs
✓ Track and measure outcomes to support risk-based contracting
✓ Reduce waste, fraud, and abuse
The ability to collect, analyze and share data across systems is critical
to states’ ability to better understand and manage the populations they serve.
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Modularity ChallengesNEEDS &
OPPORTUNITIES
✓ Procurement
✓ Legacy Systems
✓ Market Diversity
✓ Interoperability
✓ Lack of Standards
✓ Consumer Experience
✓ State Readiness
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New Contracting StrategiesNEEDS &
OPPORTUNITIES
✓ Shifting Managed Care from Controlling Utilization to Increasing Value
✓ Integrating care across services and systems• Medical care, dental, pharmacy, behavioral health, post-acute and long-term care, social
determinants of health
✓ Risk-based Contracting
✓ Direct Provider Contracting
✓ Multiple IT Module Vendors
Smart on Value
www.leavittpartners.com801-538-5082
Offices in Salt Lake City, Chicago, and Washington, D.C.
@LeavittPartners