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Medicaid’s Coming Changes & Prospective Consumer Outcomes

T.H. Pyle PSRT 5402 Advanced PsyR Seminar March 28, 2014. Medicaid’s Coming Changes & Prospective Consumer Outcomes. Topic. What outcomes for NJ consumers from coming changes in Medicaid’s payment for care?. Outcomes. Access Availability Quality Cost Innovation. What is Medicaid?.

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Medicaid’s Coming Changes & Prospective Consumer Outcomes

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  1. T.H. Pyle PSRT 5402 Advanced PsyR Seminar March 28, 2014 Medicaid’s Coming Changes & Prospective Consumer Outcomes

  2. Topic What outcomes for NJ consumers from coming changes in Medicaid’s payment for care?

  3. Outcomes Access Availability Quality Cost Innovation

  4. 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%

  5. Medicaid as % of…(Foster, 2012) GDP: 2.8% Health spending: 15% 15%

  6. Enrollment & Shares, 2010(Centers for Medicare and Medicaid et al., 2012) ~ 60 mm

  7. 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

  8. 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 • Non-comprehensive plans • In-patient • Ambulatory

  9. …with “Carve Outs” • Behavioral health • Dental • Medications • Transport

  10. Medicaid Managed Care: Prevalence(Kaiser Commission on Medicaid and the Insured, 2012) • Medicaid 67% • New Jersey 97%

  11. Affordable Care Act …bringing the biggest change in Medicaid since it began.

  12. ACA: 3 Legged Strategy • Insurance reform • Individual mandate • Exchanges + subsidies • Subsidies for those at 100% -400% of FPL • Medicaid expansion • For adults < 138% of FPL

  13. Federal Poverty Level (FPL) Family of 1: $11,490 x 133% = $15,282 Family of 4: $23,550 x 133% = $31,322

  14. Eligibility: FPL Limits by Class (US)(Kaiser Commission on Medicaid and the Uninsured)

  15. Eligibility: FPL Limits by Class (NJ)(Kaiser Commission on Medicaid and the Uninsured)

  16. Eligibility: FPL Limits (After ACA)(Kaiser Commission on Medicaid and the Uninsured; Tate, 2012))

  17. ACA: Projected Enrollments(Centers for Medicare and Medicaid, 2012)

  18. ACA Effect: NJ Enrollments(Cantor et al., 2011) Medicaid enrollment: Up 22.8% (234,000) Of total insured: From 13.6% to 16.7%

  19. ACA Effect: NJ Coverage (Rutgers Center for State Health Policy, 2012) Change in Coverage in NJ under ACA (ages 0-64)

  20. 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

  21. NJ’s Comprehensive Waiver Getting it all together

  22. Medicaid: The State Plan • Required by Section 1902(a) (30)(A) • 71 elements • Rates • Methodology • Comment periods

  23. 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”

  24. 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 • 2011: NJ Public law 2011, Chapter 114  Medicaid Accountable Care Organization demonstration project.

  25. 1915(b): Managed Care (Howell, Palmer & Adams, 2012) Keep… Change… • Can be mandated, with choice of plans • Rates must be “actuarially sound” AND • “Risk-based” payments and incentives

  26. Waivers: New Jersey(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) • Childless adults • Family coverage (SCHIP) • NJ Care 2000+ • NJ Family Care • Global Options (LT care) • Renewal Waiver • Community Resources • Community Care Alternatives

  27. Waivers: New Jersey(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) • Comprehensive including ASOs for behavioral health (adult and child)… and “fee for service” that it will manage.

  28. Medicaid: Mechanics Hospital Primary Care IN Px PCP Specialist S PHP/IOP Out Px Therapist T LT Care Facility LTCF Case Worker CW

  29. Medicaid: The Old Way

  30. Managed Care Organization (MCO)

  31. Managed Care

  32. Behavioral Health Home DMHAS

  33. Managed Care After the Waiver? DMHAS

  34. Managed Care After the Waiver? DMHAS

  35. Post Waiver: Unknown No. 1 “Fee for service”?

  36. Post Waiver: Unknown No. 2 Integration?

  37. Post Waiver: Unknown No. 3 Rates?

  38. Challenges

  39. 1: Rate Ratio (Zuckerman et al., 2009) US 0.72 WY 1.43 AK 1.40 DE 1.00 PA 0.73 CA 0.56 NY 0.43 NJ 0.37 50th!

  40. Provider Supply = f(Rate Ratio) (Decker, 2012) % doctors accepting

  41. 2. The Rate “Bump”(Kaiser Commission on Medicaid and the Uninsured, 2012a) • 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… = 100%

  42. 3. Partial Expansion?(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!

  43. 4. Churn Transitions(Ingram, McMahon & Guerra, 2012) • Medicaid  Exchanges: 35% of all adults below 200% FPL • Exchanges  Medicaid: 28 million Wages

  44. 5. Woodwork Effect(Castro, 2013; Alaigh, 2002) New eligibles vs. old eligibles not enrolled FMAP = 100% 234,000 total eligibles (@ $8000 per)

  45. 6. Measurements • HEDIS: measure behavioral health? • Healthcare Effectiveness Data and Information Set • System metrics, not consumer metrics

  46. 7. Outreach(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

  47. 8. Implementation South Carolina’s IT Enterprise Strategy Map

  48. 9. Compliance • Reporting • Documentation • Audits • Clawbacks • Penalties

  49. 10. Agency Cash Flow • Reduced fees • Increased costs • New investments • EMR • Compliance • Training

  50. Outcomes Access Availability Quality Cost Innovation

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