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Presentation for Consumer Providers Association of New Jersey Tom Pyle, Advisor August 2013. Medicaid’s 3 Big Changes: Consequences for Consumers. What’s coming…. What’s coming…. Topic. Fee for service Managed care… Integration of PH and BH… Medicaid expansion…
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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
Topic Fee 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?
Medicaid’s 3 Big Changes • Reform • “Innovations” (ACOs) • “Benchmark” plans • Expansion • 25% increase • Managed care • BH ASO • Grant FFS Case Capitated
Outcomes Access Availability Quality Cost Innovation
What is Medicaid? • Big funder of… • Health care for poor, disabled • Safety-net hospitals, LT care • Federal-state partnership • FMAP: 50% to 83% • NJ: 50%
What is “FMAP”? • Federal Medical Assistance Percentages (FMAP): the percentage rates that determine the matching funds allocated annually to Medicaid.
Medicaid: Expenditures FY 2010 (Centers for Medicare and Medicaid, 2012) Total = $404.1 billion
Medicaid as % of…(Foster, 2012) GDP: 2.8% Health spending: 15% 15%
MH Funding: Only 1 Component (Smith, Kennedy, Knipper & O’Brien, 2005)
Medicaid: Acute/LT Care 2009(Kaiser Commission on Medicaid and the Uninsured)
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
Enrollment & Shares, 2010(Centers for Medicare and Medicaid et al., 2012) ~ 60 mm
Overview: Role in state budgets • Counter-cyclical to economy • Largest source of federal revenue ( jobs) • Biggest target for state cost controls
Overview: Role in federal budget • 3rd largest domestic program • Exempt from automatic budget reductions
Overview: Medicaid role in ACA • Coverage base for the poor (< 133% FPL) • Insurer of 17 mm currently uninsured • Funder of experimental models being tested
Health insurance coverage Medicaid: Components(Kaiser Commission on Medicaid and the Uninsured) • Long-term care assistance • Funding for state capacity • 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 • Safety net & system funding • Assistance to Medicare beneficiaries
1. Category Eligibility • Children • Pregnant women • Parents • Seniors • Individuals with disabilities
2. Financial Eligibility 2013 Federal Poverty Limit (FPL) Family of 1: $11,490 x 133% = $15,282 Family of 4: $23,550 x 133% = $31,322
Eligibility: FPL by Class (US)(Kaiser Commission on Medicaid and the Uninsured)
Eligibility: FPL by Class (NJ)(Kaiser Commission on Medicaid and the Uninsured)
Eligibility: FPL (After ACA)(Kaiser Commission on Medicaid and the Uninsured; Tate, 2012))
Eligibility: Overlap!(Blahous, 2013) • Medicaid: < 138% FPL. • Exchanges: > 100% FPL.
Enrollment FY 2010(Centers for Medicare and Medicaid et al., 2012) 62 mm (53 mm PYEs)
Expenditures by Enrollment 2010(Centers for Medicare and Medicaid et al., 2012)
Medicaid: Dual Eligibles 2009(Kaiser Commission on Medicaid and the Uninsured)
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
Medicaid: Enrollment after ACA(Tate, 2012) • New eligibles • 9 mm old eligibles not yet enrolled 57%
Enrollment demographics(Sommers & Epstein, 2010) • Eligibles: Nearly 1 in 3 not enrolled! • Enrolled eligibles: Highly variable by state OK 44% MA 80%
Enrollment demographics(Sommers & Epstein, 2010) • Eligibles: Nearly 1 in 3 not enrolled! • Enrolled eligibles: Highly variable by state OK 44% MA 80% NJ 53%
Currently Enrolled by Groups(Kaiser Commission on Medicaid and the Uninsured)
Challenge: Less Coverage?(Garfield, Lave, & Donohue, 2010) “Benchmark” Essential Benefits coverage under ACA Excludable for newbies under ACA
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
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
Managed Care: Elements • Enrollment • Benefits • Usage • Cost sharing (co-pays) • Access • Quality • Accountability
Managed Care: 3 Plan Types • Risk-based managed care orgs/plans (MCO) • Capitation • Who takes the risk? State or vendor? • Primary care case mgt plans (PCCM) • Case management fee • Limited plans • In-patient • Ambulatory