Benefit Design and Delivery System Change in South Carolina Medicaid

1. Benefit Design and Delivery System Change in South Carolina Medicaid Bryan Amick, PharmD, MS, MBA Jim Bradford, MD

2. Why Should We Care about Medicaid?

3. EFFORT ALIGNMENT We Share Provider Networks We Share the Healthcare Delivery System We Share our Social Environment Sometimes, We Share Members We can be most successful when we leverage resources across payers.

4. AGENDA Medicaid Overview Payment Reform Efforts • Transparency • Value-Oriented Payments • Quality Requirements Benefit Redesign • Value-Based Design Philosophy • Limited Benefit Groups • Obesity Benefit Other Initiatives • Health Connections Prime • Healthy Outcomes Plan

5. Medicaid Overview

6. MEDICAID OVERVIEW Enrollment: 1,066,413 Recent Increases: • Express Lane Eligibility for Children • Impacts of Healthcare Reform • 1.1% increase in actual number of applications (9.2% increase when adjusted for improved economic conditions) • Online Application Annual Budget: $6.5 Billion SC Medicaid

7. MEDICAID OVERVIEW 2/3 Enrolled in Managed Care Plan • Select Health 314,000 • Molina 120,000 • Absolute Total Care 98,000 • BlueChoice 71,000 • WellCare 68,000 • Advicare 25,000 Delivery Platforms- Managed Care

8. MEDICAID OVERVIEW 1/3 Remain in State-Run Benefit Group • Limited Benefit Populations • 135,000 Dual Eligible • 90,000 Family Planning Group • Full Benefit • Waiver Populations • SNF Residents • “Churn” Population Delivery Platforms- “Fee for Service”

9. Payment Reform

10. PAYMENT REFORM Big Opportunities for the Commercial World….Less Direct for Medicaid Requires patient financial incentives to work well. Patient financial incentives don’t exist in Medicaid. Information without incentives might yield adverse consequences. Price Transparency

11. PAYMENT REFORM For Medicaid, focus has been on global data transparency to: Inform Network Strategy Identify Steerage Opportunities Establish Reimbursement Rates Highlight Unwarranted Variation Price Transparency in Medicaid

12. PAYMENT REFORM Additional Data: More Provider Types Procedure Level Costs Quality Data Value Pricing Concepts Working with PEBA/SHP and ORS for a broader perspective. Price Transparency- Future Phases

13. PAYMENT REFORM Price Transparency - www.schealthdata.org

14. PAYMENT REFORM Movement Away from Fee-for-Service Largely Operated through Managed Care Plans • New Contractual Requirements • Goal of 20% within then Next 3 Years • Using CPR Guidance to Define Value-Oriented Reimbursement Value Oriented Payments

15. PAYMENT REFORM Incorporation into FFS Benefit Bundled/Episodic Payments • Shared Risk/Savings • Site-Neutral Payment/Standard Fee Schedule These methods work best in an environment of price and quality transparency. Value Oriented Payments

16. PAYMENT REFORM MCO Level: Some of MCO Payment Dependent on Quality Measures (HEDIS) • Alignment with Quality Foci of Commercial Plans • Data-Driven Approach to Find Opportunities Provider Level: More Accountability for Low Quality Care • More Aggressive Non-Payment Policy • Readmissions • Health Acquired Conditions Quality Requirements for Payment

17. BENEFIT DESIGN

18. BENEFIT DESIGN Many components of the Medicaid benefit design (covered services, patient cost share) are set in federal regulation… But we’re still looking for opportunities.

19. BENEFIT DESIGN Rethinking the Medicaid Pharmacy Benefit: Elimination of Prescription Limits Cost Share Considerations Adopting value-based design requires a great deal more clinical nuance and patient level differentiation than most of us are used to. Value-Based Design

20. BENEFIT DESIGN The Family Planning Eligibility Group covers individuals up to 185% of FPL who do not qualify for full Medicaid benefits. TODAY Focus on contraception and STI treatment TOMORROW Additional of biennial physical examination and screenings/labs recommended by the USPSTF Goal: To promote the utilization of preventative healthcare to improve health outcomes of families in South Carolina. Family Planning Eligibility Group

21. BENEFIT DESIGN Physicians and licensed dietitians reimbursement DHEC will continue to promote their current statewide programs • Farm to School, Eat Smart, Move More, Worksite Wellness SCDHHS working with SCMA on establishing obesity CME courses Obesity Benefit

22. Other Initiatives

23. PRIME Goal: To aggregate the components of the Medicaid/Medicare benefits at the payer level. CICOs will provide Medicare and Medicaid services, either directly or through subcontracts. Dual Demonstration

24. PRIME

25. PRIME Prime population inclusion criteria: • Individuals >= 65 • Full-benefit dual eligible • Individuals receiving Home and Community Based Services (HCBS) CLTC waivers (i.e., HIV, Vent, and Community Choices) Excluded populations (at time of enrollment): • Residing in a nursing facility; • Enrolled in hospice; • Receiving End-Stage Renal Disease (ESRD) services; • Enrolled in a Program of All-Inclusive Care for the Elderly (PACE); or • Enrolled in Department of Disabilities and Special Needs (DDSN) operated waiver serving adults (ID/RD, HASCI, and Community Supports). Total full-benefit dual eligible population: 135,000 Prime eligible population: 53,600 Healthy Connections Prime is voluntary; beneficiaries can opt-out as well as change plans at any time.