a cornerstone of new york’s health insurance system
DESCRIPTION
Medicaid Managed Care for Persons with Severe Mental Illness in New York: Challenges and Implications Michael Birnbaum Director of Policy, Medicaid Institute United Hospital Fund June 5, 2008. - PowerPoint PPT PresentationTRANSCRIPT
Medicaid Managed Care for Persons with
Severe Mental Illness in New York:
Challenges and Implications
Michael Birnbaum
Director of Policy, Medicaid Institute
United Hospital Fund
June 5, 2008
2
The Medicaid Institute at the United Hospital Fund provides information and analysis explaining New York’s Medicaid program, with the goal of helping all stakeholders redesign, restructure, and rebuild the program.
“The Institute’s mission is to shape sound health policy and practice so that Medicaid can meet its most important challenges: covering more low-income New Yorkers, better managing patient care, reforming payment systems, providing effective long-term care, and improving program administration.”
James R. Tallon, Jr. PresidentUnited Hospital Fund
3
A cornerstone of New York’s health insurance system
Medicaid provides insurance to 4.1 million low-income New Yorkers.
1.6 million children
1.5 million (non-elderly, non-disabled) adults
Over 1 million elderly or disabled beneficiaries
Medicaid funding sustains nearly one-third of New York’s health care economy.
Medicaid accounted for $44.7 billion in payments to health care providers and plans in New York in 2006.
Note: Medicaid enrollment is from June 2007; categories do not sum to total due to rounding. Source: United Hospital Fund analysis of NYS DoH enrollment reports; CMS NHE and 64 data.
4
0
500,000
1,000,000
1,500,000
2,000,000
2,500,000
3,000,000
Original MMC Family Health Plus
Source: United Hospital Fund analysis of NYS Department of Health enrollment reports: March 1997 – March 2007.
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Managed care enrollment: 1997 - 2007
5
Managed care penetration
Source: United Hospital Fund analysis of NYS Department of Health enrollment reports: April 2007.
77%
15%
85%
23%
0%
25%
50%
75%
100%
Children and Adults Elderly and Disabled
Managed care enrollees All others
6
Managed care: 60% of enrollment and 14% of spending
Note: Medicaid spending is from FFY 2006. Enrollment is from December 2006.Source: UHF analysis of New York State Department of Health enrollment reports andCMS 64.
60%
14%
40%
86%
0%
25%
50%
75%
100%
Medicaid enrollment Medicaid spending
Managed care FFS, residential care, all other services
7
Disabled and Elderly (SSI) Medicaid beneficiariesin New York City
SED mandate10,000
Initial mandate125,000
Enrolled voluntarily
50,000
SPMI mandate25,000 Excluded
350,000
RemainingExempt40,000
N = 600,000
(2006)
(Prior to 2006 )
(2007)
(2007)
8
Medicaid Institute analysis of beneficiaries with SPMI
Analysis of beneficiaries’ spending, service use, and diagnostic patterns using the Medicaid paid claims file. Data provided by New York State Department of Health
Research and statistical programming by Center for Health and Public Service Research, New York University
SSI adults (18-64) with SPMI in FFS Medicaid as of December 2004 and facing mandatory managed care. Cohort identified using DOH algorithm, based on utilization
thresholds for mental health services.
Slightly different population than those meeting a clinical definition of SPMI.
9
Those with the most severe mental health conditions
SSI adults with SPMI most often have :
Major depression
Bipolar disorder
Schizophrenia
Other psychosis
Some combination of the above
10
19%25% 26%
18%
30% 31%
42% 40%50% 51%
20%21%
0%
20%
40%
60%
80%
100%
All Lower cost High cost Ultra-highcost
Asthma Diabetes Cardiovascular condition
Rates of select chronic conditions: SSI adults with SPMI
Note: Data are from 1999 through 2004. Cardiovascular conditions include coronary heart disease, congestive heart failure, and hypertension. Source: Birnbaum M. and L. Powell. Medicaid Managed Care for Persons with Severe Mental Illness: Challenges and Implications. Medicaid Institute at United Hospital Fund, 2007.
Bottom 80% Next 15%Top 5%
11
19% 20% 18% 17%
28%23%
48%54%
0%
20%
40%
60%
80%
100%
All Lower cost High cost Ultra-highcost
Cancer Substance abuse condition
Prevalence of other significant health conditions: SSI adults with SPMI
Note: Data are from 1999 through 2004. Substance abuse conditions include alcoholism and drug addictions. Source: Birnbaum M. and L. Powell. Medicaid Managed Care for Persons with Severe Mental Illness: Challenges and Implications. Medicaid Institute at United Hospital Fund, 2007.
12
Primary care visits in a one-year period: SSI adults with SPMI
14% 20%
38% 36%37%
49% 49% 51% 43%
13%13%
38%
0%
25%
50%
75%
100%
All Lower cost High cost Ultra-highcost
None 1 to 5 6+
Note: Data are for CY 2004. Shares may not sum to 100 percent due to rounding.Source: Birnbaum M. and L. Powell. Medicaid Managed Care for Persons with Severe Mental Illness: Challenges and Implications. Medicaid Institute at United Hospital Fund, 2007.
13
Outpatient mental health visits in a one-year period: SSI adults with SPMI
9%16% 18%
27%26% 30% 14%
15%
54% 53%63%
49%
3% 5%2%17%
0%
25%
50%
75%
100%
All Lower cost High cost Ultra-highcost
None 1 to 12 13 to 24 25+
Note: Data are for CY 2004. Shares may not sum to 100 percent due to rounding.Source: Birnbaum M. and L. Powell. Medicaid Managed Care for Persons with Severe Mental Illness: Challenges and Implications. Medicaid Institute at United Hospital Fund, 2007.
14
Outpatient prescription drugs: SSI adults with SPMI
98% 97% 93%
7%3% 3%2%
97%
0%
25%
50%
75%
100%
All Lower cost High cost Ultra-highcost
None Some
Note: Data are for CY 2004. Shares may not sum to 100 percent due to rounding.Source: Birnbaum M. and L. Powell. Medicaid Managed Care for Persons with Severe Mental Illness: Challenges and Implications. Medicaid Institute at United Hospital Fund, 2007.
15
Hospital admissions in a one-year period: SSI adults with SPMI
71%
10%
15%13%
24%
16%
14% 5%
42%
74%
34%
82%
0%
25%
50%
75%
100%
All Lower cost High cost Ultra-highcost
None One Two or more
Note: Data are for CY 2004. Shares may not sum to 100 percent due to rounding.Source: Birnbaum M. and L. Powell. Medicaid Managed Care for Persons with Severe Mental Illness: Challenges and Implications. Medicaid Institute at United Hospital Fund, 2007.
16
Hospital admissions in a one-year period – a closer look: SSI adults with SPMI
34%
42%
33%
16%
27%
7%
30%
10%0%
25%
50%
75%
100%
High cost Ultra-high cost
None One or two Three or four Five or more
Note: Data are for CY 2004. Shares may not sum to 100 percent due to rounding.Source: Birnbaum M. and L. Powell. Medicaid Managed Care for Persons with Severe Mental Illness: Challenges and Implications. Medicaid Institute at United Hospital Fund, 2007.
17
Less concentrated Medicaid spending
There are very few low-cost SSI adults with SPMI.
The 80-20 rule does not apply.
The lowest-cost 80 percent accounts for 46
percent of the cohort’s total spending.
18
$24,643
$88,277
$14,395
$49,979
$115,183
$3,810$0
$30,000
$60,000
$90,000
$120,000
Low cost High cost Ultra-high cost
Initial mandate (non-SPMI)
SPMI
Note: Costs are for CY 2004 and are not annualized for full-year enrollment. Source: Birnbaum M. and L. Powell. Medicaid Managed Care for Persons with Severe Mental Illness: Challenges and Implications. Medicaid Institute at United Hospital Fund, 2007. Birnbaum M. and J. Billings. New York’s SSI Beneficiaries: the Move to Managed Care. Medicaid Institute at the United Hospital Fund, 2006.
Comparison of per capita Medicaid spending:SSI adults
(Bottom 80%) (Next 15%) (Top 5%)
19
For lower-cost SSI adults with SPMI—the bottom 80 percent—two-thirds of Medicaid costs are already driven by services that would be a cornerstone of any intervention aimed at curbing spending. Outpatient mental health services Outpatient prescription drugs
Inpatient hospital account for only a small share (13%) of their Medicaid costs—leaving a very small target for spending that is “potentially avoidable.”
Where can the Medicaid savings come from?
20
Patient profile: lower-cost beneficiary
Ms. F
Total Medicaid costs2004 $21,8282003 $22,9022002 $33,196
2004 service useHospital admissions -
Outpatient MH visits 169Outpatient MH costs $12,898
21
Mr. A
Total Medicaid costs2004 $146,6192003 $173,6332002 $124,433
2004 service useHospital admissions 21 Of which MH 21Hospitals visited 12Inpatient days 246Inpatient costs $144,695
Outpatient MH visits 3Outpatient MH costs $646
Patient profile: ultra-high cost beneficiary
22
Services delivered through FFS for MMC enrollees:
Outpatient mental health
Inpatient mental health Includes stays in general hospitals with MH diagnosis
Outpatient substance abuse
Inpatient substance abuse
Outpatient prescription drugs
Key services are carved out of New York’s managed care benefit for SSI enrollees, including those with SPMI.
Note: One substance abuse service, detoxification, is carved-in for SSIs.
23
Note: shaded cells are carve-outs All Lower High Ultra-high
Hospital inpatient 8,346$ 1,816$ 19,955$ 77,970$ physical health 1,890$ 641$ 4,574$ 13,818$
mental health 5,831$ 1,037$ 13,419$ 59,753$ substance abuse 625$ 138$ 1,963$ 4,399$
Outpatient mental health 5,898$ 4,378$ 11,041$ 14,778$ Outpatient substance abuse 355$ 270$ 767$ 483$
Prescription drugs 5,489$ 4,975$ 7,895$ 6,488$ All other 4,686$ 2,955$ 10,320$ 15,464$
Total spending 24,773$ 14,395$ 49,979$ 115,183$
HI as % of total spending 34% 13% 40% 68%Behavioral health as % of HI 77% 65% 77% 82%
Key sectors carved out of MMC 18,197$ 10,798$ 35,084$ 85,901$ Carve-outs as % of total spending 73% 75% 70% 75%
Average per capita spending by service area:
SSI adults with SPMI
Note: Costs are for CY 2004. Source: Birnbaum M. and L. Powell. Medicaid Managed Care for Persons with Severe Mental Illness: Challenges and Implications. Medicaid Institute at United Hospital Fund, 2007.
24
Current policy limits MMC plans’ ability to coordinate care and may undermine incentives to reduce hospitalizations.
Most spending remains outside managed care
State cannot assess MMC plan performance
Achieving cost savings and providing high-quality coordinated care will require a strategy beyond the two existing options:
MMC with significant carve-outs
Fee for service
Challenges and opportunities