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Health Care Reform IT’S COMPLEX!

Health Care Reform IT’S COMPLEX!. Jeffery Thompson, MD MPH Chief Medical Officer Washington State Medicaid. Medicaid Expenditures by Service, 2007. DSH Payments 5.0%. Inpatient 15.0%. Home Health and Personal Care 15.0%. Physician/ Lab/ X-ray 3.7%. Mental Health 1.5%.

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Health Care Reform IT’S COMPLEX!

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  1. Health Care ReformIT’S COMPLEX! Jeffery Thompson, MD MPH Chief Medical Officer Washington State Medicaid

  2. Medicaid Expenditures by Service, 2007 DSH Payments 5.0% Inpatient 15.0% Home Health and Personal Care 15.0% Physician/ Lab/ X-ray 3.7% Mental Health 1.5% Outpatient/Clinic 7.4% Long-Term Care 35.1% ICF/MR 3.9% Acute Care 59.9% Drugs 4.7% Nursing Facilities 14.8% Other Acute 6.7% • Why are costs going up: • PRIVATE SECTOR CUTS • MEDICAL COSTS • ELDERLY • DISABILITIES Payments to Medicare 3.5% Payments to MCOs 19.0% Total = $319.7 billion (WA State Medicaid ~$4 billion) NOTE: Total may not add to 100% due to rounding. Excludes administrative spending, adjustments and payments to the territories. SOURCE: Urban Institute estimates based on data from CMS (Form 64), prepared for the Kaiser Commission on Medicaid and the Uninsured.

  3. Median Medicaid/SCHIP Income Eligibility Thresholds, 2009 • WA State Programs • Categorically Needy (70%) • Categorically Medical (spend down 70%) • SCHIP/Apple Care (300%) • General Assistance Unemployable (38%) • Basic Health Plan (200%) • Aid to Drug and Alcohol (38%) • Long Term Care (75%) • Family Planning (75%) • Maternal Support (185%) • Foster Care (wards of the state) Federal Poverty Line (For a family of four is $21,200 per year in 2008) NOTE: Medicaid income eligibility for most elderly and individuals with disabilities is based on the income threshold of Supplemental Security Income (SSI). SOURCE: Based on a national survey conducted by the Center on Budget and Policy Priorities for KCMU, 2009.

  4. Medicaid and Health Care Reform • Cost Estimates. The Congressional Budget Office (CBO) estimates that the House bill will increase Medicaid/CHIP coverage by 15 million at a cost of $425 billion (2010 to 2019) and an estimated increase in state spending of $34 billion. • Medicaid Coverage and Financing. Expands Medicaid to everyone under 133% of FPL with increased Federal funds for this population; • Children’s and Adult Health Insurance Program. Current eligibility levels, procedures and methodologies are frozen until 12/31/2013 for adults and 9/30/2019 for children (including CHIP) • Benefits and Access. Expands Medicaid to any individual under 26 who aged out of Child Welfare; Creates State-plan option for family planning services • Establishes the CLASS Act: a national long term care insurance program funded by payroll deductions, Creates new options for community care and FMAP increases • Duals and Long-Term Care. The House bill provides payment of Part B deductibles and cost sharing under Medicaid for Medicare beneficiaries under age 65 with incomes below 150% of poverty, subject to regular Medicaid matching rate. • Mandatory Providers Increases. Provider rates Medicaid pays for primary care services (100% Federal funds).

  5. State Options for Coordination of Care • Eligible individuals with chronic conditions’ means an individual who— • is eligible for medical assistance under the State plan or under a waiver of such plan: has at least 2 chronic conditions; 1 chronic condition and is at risk of having a second chronic condition; or 1 serious and persistent mental health condition. • The term ‘health home services’ means comprehensive and timely high-quality services • comprehensive care managed care coordination and health promotion; • comprehensive transitional care, including appropriate follow-up, from inpatient to other settings; • patient and family support (including author­ized representatives); • referral to community and social support serv­ices, if relevant; and • use of health information technology to link services, as feasible and appropriate. • This will cause us to rethink how care is delivered and accessed

  6. How do you spend less and get better care? • Benefit Reform • Pay for what works (EBM, HTA) • Reduce utilization of what doesn’t • Better Informed Decision (PDA) • Payment Reform • Pay for Outcomes not services • (ACO, Integration) • Radiology and Advantaged Imaging • “Generics First” • Integrate Primary Care and • Mental Health/Substance Abuse • Pay for team based care • Administrative Simplification • Reward those that do it better with less • overhead

  7. In 2007, ~ 265,000 eligible youth ages 0 – 18 19,228 (6.5) prescribed a psychotropic Average Number Agents 1.6 (range 1 – 8) Quality Thresholds # % users AAP used in a child less than 5 151 (3%) 2 or more Antipsychotic Agents 807 (17 %) Doses exceeding 2 times recommendations 31 ( 0.6%) 5 or more Psychotropics 567 (3%) Gap In Antipsychotic RX > 20 days 1512 ( 38 %) Let me conclude on a good note: WA is a good state and with King Counties Help it is becoming a Great StateWashington State: What happens when we work together?

  8. Children >= 5 MHD 0.6% 0.3% 0% Working Together the Variation is Less?% of Eligible with 5 or More Mental Health Drugs in Children Comparing 2004 and 2008 What can we learn from King County? • 2008 • 2004

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