medicaid’s 3 big changes: consequences for consumers
DESCRIPTION
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 PresentationTRANSCRIPT
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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”:
30
Till 2017: 100%
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What is “FMAP”? ... Under ACA
Federal Medical Assistance Percentage:
For “new eligibles”:
31
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)
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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
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…with “Carve Outs”
Dental
Medications
Transport
Behavioral health
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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
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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
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118
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”
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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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Managed Care After the Waiver?
DMHAS
Physical “Health Home” “Behaviora
lHealth Home”
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Managed Care After the Waiver?
DMHAS
Physical “Health Home” “Behaviora
lHealth Home”
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Post Waiver: Unknown No. 1
“Fee for service”?
“Behavioral
Health Home”
Physical “Health Home”
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Post Waiver: Unknown No. 2
Physical “Health Home” “Behaviora
lHealth Home”
Integration?
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Post Waiver: Unknown No. 3
Rates?
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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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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
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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
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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
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2. Providers: Supply = f(Rate Ratio) (Decker, 2012)
𝑥=𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒𝑟𝑎𝑡𝑒
% doctors accepting
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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
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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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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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8. Implementation: Too Complex?
South Carolina’s IT Enterprise Strategy Map
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Deadlines: Too Tight?
ASO: July 1! “Managed care”, but… Fee for service
“Go Live”: January 1! Medicaid Expansion Exchanges
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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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Entitlement Spending...
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Outcomes
AccessAvailabilityQualityCostInnovation
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Access
To the System
To Providers
To PsyR services
(To Insurance…)
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Availability
Of basic care
Of specialty care
Of emergency care
Of evidence-based practices
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Quality
Provider What level? What training? What experience? What supervision?
Process Simpler? Smoother?
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Cost
Co-pays
Deductibles
Premiums
(Work incentives?)
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Innovation
Practices
Medications
Technology
Management
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Conclusion?
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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.
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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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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.
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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)