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Will the ACA’s Medicaid Changes Improve Outcomes for Schizophrenia? A New Jersey Case Study

Will the ACA’s Medicaid Changes Improve Outcomes for Schizophrenia? A New Jersey Case Study. Tom Pyle MBA, MS ( PsyR ), CPRP. Presentation at the Recovery Workforce Summit o f the Psychiatric Rehabilitation Association at Baltimore, MD Tom Pyle MBA, MS ( PsyR ), CPRP June 2014.

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Will the ACA’s Medicaid Changes Improve Outcomes for Schizophrenia? A New Jersey Case Study

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  1. Will the ACA’s Medicaid Changes Improve Outcomes for Schizophrenia? A New Jersey Case Study Tom Pyle MBA, MS (PsyR), CPRP

  2. Presentation at the Recovery Workforce Summit of the Psychiatric Rehabilitation Association at Baltimore, MD Tom Pyle MBA, MS (PsyR), CPRP June 2014 Will the ACA’sMedicaid Changes Improve Outcomes for Schizophrenia?A New Jersey Case Study

  3. 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?

  4. Joisey...

  5. Joisey...

  6. Joisey... • 11th most populous (8.9 million) • Highest density (1030 psm) • Most urban (90% in urban areas) • Strongest state executive • “Blue” State

  7. Joisey... • Taxes • Real estate taxes: Nation’s highest… • Income tax: 1% pays 50%… • Budget gap: $800 million! • Public workers vs. pensioners vs. bond holders • Bonds downgraded: A- • 49th of 50 states…

  8. Joisey... • Budget: $ 33 billion • Pension fund: $47 billion short! • Needs $5 billion p.a.!

  9. Medicaid: An Overview The macro view from 30,000 feet…

  10. Medicaid’s 3 Big Changes… • Reform • “Innovations” (ACOs) • “Benchmark” plans • Expansion • 25% increase • Managed care • BH  ASO • Grant  FFS  Case Capitated

  11. …Amidst ACA’s 6 Mechanisms… • Public program changes (Medicaid) • Private insurance changes • Health insurance exchanges • Cost containment measures • Quality improvement measures • Funding measures (e.g., taxes)

  12. ...From 4 Perspectives... • Beneficiaries • Providers • Agencies • Government

  13. ...3 Subtypes of Beneficiaries... • Beneficiaries • Enrolled • To be enrolled • Not enrolled

  14. Considered by... 5 Big Outcomes Access Availability Quality Cost Innovation

  15. Dealing with... 10 Challenges • Coverage: As much? • Providers: Enough? • Exchanges: Overlap? • Transitions: Churn? • “Woodwork Effect”? • Measures: Of What? • Outreach: Possible? • Implement: Complex? • Deadlines: Too Tight? • Agency $: Enough?

  16. How To Evaluate?... • 

  17. The Whole Story... • Health insurance for all • Individual Mandate • Corporate Requirement • Help for those who need it • Medicaid • Subsidies for premiums and cost-sharing

  18. What is Medicaid?

  19. What is Medicaid? • An entitlement • Big funder of… • Health care for poor, disabled • Safety-net hospitals, LT care • Federal-state partnership • FMAP: 50% to 83%

  20. What is “FMAP”? Federal Medical Assistance Percentage: Federal matching funds to state Medicaidprograms.

  21. What is “FMAP”? ...For NJ Federal Medical Assistance Percentage NJ: 50%

  22. FMAP Map 2014(Snyder & Rudowitz, 2014)

  23. What is “FMAP”? ... Under ACA Federal Medical Assistance Percentage: For “new eligibles”:

  24. What is “FMAP”? ... Under ACA Federal Medical Assistance Percentage: For “new eligibles”: Till 2017: 100%

  25. What is “FMAP”? ... Under ACA Federal Medical Assistance Percentage: For “new eligibles”: Till 2017: 100% By 2020: 90%

  26. Medicaid Expansion, June 2014(Henry J. Kaiser Foundation, 2014)

  27. Medicaid: 4 Constituencies

  28. Health insurance coverage Medicaid: 5 Functions(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 funding • 16% national health funding; 35% safety net hospitals • Funding for state capacity • FMAP • Safety net & system funding • Assistance to Medicare beneficiaries

  29. US: Medicaid: FY 2010 Spend(Centers for Medicare and Medicaid, 2012) $404.1 billion

  30. By Contrast... $404.1 billion $33.0 billion

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

  32. US: Segments Paid by Medicaid (Foster, 2012)

  33. US BH Funding: Medicaid’s Share (Substance Abuse and Mental Health Services Administration, 2013)

  34. US: Medicaid: Acute/LT Care 2009(Kaiser Commission on Medicaid and the Uninsured) 5 x

  35. US: Spending Per Enrollee, 2010(Young, Rudowitz, & Garfield, 2014)

  36. US: Average Spend Per, by Group(Young, Rudowitz, & Garfield, 2014)

  37. US: Average Spend Per, by Group(Young, Rudowitz, & Garfield, 2014)

  38. US: Average Spend Per, by Group(Young, Rudowitz, & Garfield, 2014) $30,834 (CT) $22,595 (DE) $19,951 (NJ) $15,893 (CA) $15,747 (PA)

  39. From the NJ FY 2015 Budget... (State of New Jersey, 2014)

  40. 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

  41. Overview: Role in state budgets • Counter-cyclical to economy • Largest source of federal revenue ( jobs) • Biggest target for state cost controls

  42. 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

  43. Jerseyans with SZ on Medicaid?(NJ DMAHS, 2014) NJ Medicaid, May 2014 NJ population 2010 8,900,000 x 1% ~ 90,000 20%? (~40,000?) 50%? (~45,000?)

  44. Medicaid Overview • 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 Functions • 4 Constituencies

  45. Mechanics of Medicaid

  46. Eligibility (3 kinds)

  47. 1. Eligibility: Category Mandatory (before ACA): • Children • Pregnant women • Parents of certain children • Seniors • Individuals with disabilities • NOT childless non-elderly adults

  48. 2. Financial: By “FPL” The Federal Poverty Level (HHS) 2014: Family of 1: $11,670 Family of 4: $23,850

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

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

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