1part 2. enrollment benefits usage cost sharing (co-pays) access quality accountability 2part...
TRANSCRIPT
Part 2
Rates
Grants (Block Grants)
Encounter-based
(Medicaid FFS)
Case rates
Capitation rates (MCO)
1
Part 2
Managed Care: Elements
Enrollment Benefits Usage Cost sharing (co-pays) Access Quality Accountability
2
Part 2
…with “Carve Outs”
Dental
Medications
Transport
Behavioral health
3
Part 2 4
ACA’s Medicaid Expansion &NJ’s Comprehensive Waiver
Part 2 5
Affordable Care Act…bringing the biggest change in Medicaid since it began.
Part 2 6
The Bill...
Part 2 7
3 Years Later: 2/3rds Don’t Know!(Gold, 2013)
Part 2 8
ACA: Goals(Tate, 2012)
Increase access
Control costs
Add benefits & protections
Address many smaller issues
Part 2 9
ACA: 3 Legged Strategy
1. Insurance reform Individual mandate
2. Exchanges + subsidies Subsidies for those at 100% -400% of
FPL
3. Medicaid expansion For adults < 138% of FPL
Part 2
Federal Poverty Level (FPL)
Family of 1: $11,670 x 133% =$15,521
Family of 4: $23,850 x 133% =$31,721
2014 Federal Poverty Limit (FPL)
10
Part 2 11
Eligibility: FPL Limits by Class (US)(Kaiser Commission on Medicaid and the Uninsured)
Part 2 12
Eligibility: FPL Limits by Class (NJ)(Kaiser Commission on Medicaid and the Uninsured)
Part 2 13
Eligibility: FPL Limits (After ACA)(Kaiser Commission on Medicaid and the Uninsured; Tate, 2012))
Part 2 14
Out-of-Pocket Premiums…
Part 2 15
ACA: Projected Enrollments(Centers for Medicare and Medicaid, 2012)
“Old Eligibles”:FMAP = 50%
“New Eligibles”:FMAP = 100% 90%
Part 2 16
ACA Effect: NJ Coverage (Rutgers Center for State Health Policy, 2012)
Change in Coverage in NJ under ACA (ages 0-64)
Part 2 17
Premiums: NJ 19%, US 41%, (Roy, 2013)
Part 2 18
Rate Ratios(Zuckerman et al., 2009)
𝑥=𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒𝑟𝑎𝑡𝑒
Part 2 19
US 0.72
WY 1.43AK 1.40DE 1.00PA 0.73CA 0.56NY 0.43
NJ 0.37
Rate Ratios(Zuckerman et al., 2009)
𝑥=𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒𝑟𝑎𝑡𝑒
Part 2 20
US 0.72
WY 1.43AK 1.40DE 1.00PA 0.73CA 0.56NY 0.43
NJ 0.3750t
h !
Rate Ratios(Zuckerman et al., 2009)
𝑥=𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒𝑟𝑎𝑡𝑒
Part 2 21
Provider Supply = f(Rate Ratio)
(Decker, 2012)
𝑥=𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒𝑟𝑎𝑡𝑒
% doctors accepting
Part 2 22
Rate Ratios After ACA
But…
For PCPs only Family practitioners Internists Pediatricians
= 1.00!
Only for 2013, 2014
Also for managed care
Part 2 23
Innovation: Medicaid ACO “Accountable Care Organization”
Part 2 24
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
Part 2 25
NJ’s Comprehensive WaiverGetting it all together
Part 2 26
NJ Medicaid
“Division of Medical Assistance and Health Services”
$11 billion (federal and state)
500 people
Director: Valerie Harr
(“NJ FamilyCare”)
Part 2 27
Medicaid: The State Plan
Required by Section 1902(a) (30)(A)
71 elements Rates Methodology Comment periods
Part 2 28
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”
Part 2 29
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 (ACO) 2011: NJ Public law 2011, Chapter 114
Medicaid Accountable Care Organization demonstration project.
Part 2 30
1915(b): Mandatory Managed Care (Howell, Palmer & Adams, 2012)
KEEP…
Mandated services
Choice of plans
“Actuarially sound” rates
ADD…
…“Risk-based” payments
LOSE…
Part 2 31
Managed Care: NJ’s 4 HMOs
Part 2 32
NJ Waivers: Previously (Centers for Medicare & Medicaid, 2013)
Section 1115 Research and
demonstration
Section 1915(b) Managed Care
(Mandatory)
Section 1915(c) Home and
Community Based
Concurrent 1915(b) & (c)
1. Childless adults2. Family coverage (SCHIP) ACOs
3. NJ Care 2000+4. NJ Family Care BH ASO
5. Global Options (LT care)6. Renewal Waiver7. Community Resources8. Community Care
Alternatives
Part 2 33
NJ Waivers: Additional(Centers for Medicare & Medicaid, 2013)
Section 1115 Research and
demonstration
Section 1915(b) Managed Care
(Mandatory)
Section 1915(c) Home and
Community Based
Concurrent 1915(b) & (c)
1. Childless adults2. Family coverage (SCHIP) Accountable Care (ACO)
3. NJ Care 2000+4. NJ Family Care Behavioral Health
(ASO)
5. Global Options (LT care)6. Renewal Waiver7. Community Resources8. Community Care
Alternatives
Part 2 34
NJ Waivers: Additional(Centers for Medicare & Medicaid, 2013)
Section 1115 Research and
demonstration
Section 1915(b) Managed Care
(Mandatory)
Section 1915(c) Home and
Community Based
Concurrent 1915(b) & (c)
1. Childless adults2. Family coverage (SCHIP) Accountable Care (ACO)
3. NJ Care 2000+4. NJ Family Care Behavioral Health
(ASO)
5. Global Options (LT care)6. Renewal Waiver7. Community Resources8. Community Care
Alternatives
Part 2 35
NJ Waivers: Now (Centers for Medicare & Medicaid, 2013)
Section 1115 Research and
demonstration
Section 1915(b) Managed Care
(Mandatory)
Section 1915(c) Home and
Community Based
Concurrent 1915(b) & (c)
One Comprehensiv
e Waiver
Part 2 36
BH Managed Care ASO
One already exists! In DCF: “CSOC” 40,000 kids
Phase in risk-based over 5 years
Administrative Services Organization
Part 2 37
10 Challenges for Consumers
Part 2 38
1. Coverage: Less for Newbies? (Garfield, Lave, & Donohue, 2010)
Part 2 39
1. Coverage: Less for Newbies? (Garfield, Lave, & Donohue, 2010)
“Benchmark”coverage
under ACA
Part 2 40
1. Coverage: Less for Newbies? (Garfield, Lave, & Donohue, 2010)
“Benchmark”coverage
under ACA
Excludable
for newbiesunder ACA
Part 2 41
2. Providers: Enough?
Part 2 42
US 0.72
WY 1.43AK 1.40DE 1.00PA 0.73CA 0.56NY 0.43
NJ 0.3750t
h !
2. Providers: Rate Ratios(Zuckerman et al., 2009)
𝑥=𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒𝑟𝑎𝑡𝑒
Part 2 43
2. Providers: Supply = f(Rate Ratio) (Decker, 2012)
𝑥=𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒𝑟𝑎𝑡𝑒
% doctors accepting
Part 2 44
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…
2. Providers: “Rate Bump” For…?(Kaiser Commission on Medicaid and the Uninsured, 2012a)
= 100%
Part 2 45
3. Exchanges: FPL Overlap?(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!
Part 2 46
3. Exchanges: FPL Overlap?(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!
Part 2 47
3. Exchanges: FPL Overlap?(Blahous, 2013)
Overlap! Medicaid: < 138% FPL. Exchanges: > 100% FPL.
Partial expansion? All > 100% to exchanges, where no state funding needed?…
NO! HHS: no 100% FMAP if states do partial
Part 2 48
4. Transitions: Coverage Churn?(Ingram, McMahon & Guerra, 2012)
Wages
Medicaid Exchanges: 35% of all adults below 200% FPL
Exchanges Medicaid: 28 million p.a.?
Part 2
5. “Woodwork” Effect?(Castro, 2013; Alaigh, 2002)
234,000total
eligibles
FMAP = 100%
New eligibles vs. old eligibles not enrolled
49
Part 2 50
6. Measures: Of What?
HEDIS: measure behavioral health? Healthcare Effectiveness Data and
Information Set
System metrics, not consumer metrics
Part 2 51
7. Outreach: Can It Succeed?(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
Part 2 52
8. Implementation: Too Complex?
South Carolina’s IT Enterprise Strategy Map
Part 2 53
Deadlines: Too Tight?
ASO: July 1, 2014! “Managed care”, but… Fee for service
“Live”: January 1! Medicaid Expansion ExchangesPOSTPONED!
Part 2 54
9. Compliance: Too Heavy? Reporting
Documentation
Audits
Clawbacks
Penalties
Part 2 55
10. Agency Cash Flow: Enough? Reduced fees
Increased costs
New investments EMR Compliance Training
Part 2 56
And.. The Mega Challenge…
Part 2 57
Entitlement Spending...
Part 2 58
... And Its Consequences
Part 2 59
Outcomes
AccessAvailabilityQualityCostInnovation
Part 2 60
How To Evaluate?...
Enrolled To be enrolled Not enrolled
Access
Availability
Quality
Cost
Innovation
Part 2 61
Access
To the System
To Providers
To PsyR services
(To Insurance…)
Part 2 62
Availability
Of basic care
Of specialty care
Of emergency care
Of evidence-based practices
Part 2 63
Quality
Provider What level? What training? What experience? What supervision?
Process Simpler? Smoother?
Part 2 64
Cost
Co-pays
Deductibles
Premiums
(Work incentives?)
Part 2 65
Innovation
Practices
Medications
Technology
Management
Part 2 66
Conclusion?
Part 2 67
Right Now? One Father’s View...
Enrolled To be enrolled Not enrolled
Access Availability Quality Cost Innovation
Part 2 68
…with the army that you have…
Will the ACA’sMedicaid Changes Improve Outcomes for Schizophrenia? A New Jersey Case Study
Part 2 69
References
Alzer, A., Currie, J., & Moretti, E. (2007). Does Medicaid managed care hurth health? Evidence from Medicaid mothers. The Review of Economics and Statistics, 89(3).
Averill, Patricia M., Ruiz, Pedro, Small, David R., Guynn, Robert W., & Tcheremissine, Oleg. (2003). Outcome assessment of the Medicaid managed care program in Harris County (Houston). Psychiatric Quarterly, 74(2), 103-114.
Bigelow, Douglas A., McFarland, Bentson H., McCamant, Lynn E., Deck, Dennis D., & Gabriel, Roy M. (2004). Effect of Managed Care on Access to Mental Health Services Among Medicaid Enrollees Receiving Substance Treatment. Psychiatric Services, 55(7), 775-779.
Cook, Judith A., Heflinger, Craig Anne, Hoven, Christina W., Kelleher, Kelly J., Mulkern, Virginia, Paulson, Robert I., . . . Kim, Jong-Bae. (2004). A Multi-site Study of Medicaid-funded Managed Care Versus Fee-for-Service Plans' Effects on Mental Health Service Utilization of Children With Severe Emotional Disturbance. The Journal of Behavioral Health Services & Research, 31(4), 384-402.
Coughlin, Teresa A., & Long, Sharon K. (2000). Effects of medicaid managed care on adults. Medical Care, 38(4), 433-446.
Cunningham, Peter J., & Nichols, Len M. (2005). The Effects of Medicaid Reimbursement on the Access to Care of Medicaid Enrollees: A Community Perspective. Medical Care Research and Review, 62(6), 676-696. doi: 10.1177/1077558705281061
Felix, Holly C., Mays, Glen P., Stewart, M. Kathryn, Cottoms, Naomi, & Olson, Mary. (2011). Medicaid Savings Resulted When Community Health Workers Matched Those With Needs To Home And Community Care. Health Affairs, 30(7), 1366-1374. doi: 10.1377/hlthaff.2011.0150
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Gold, Marsha, & Mittler, Jessica. (2000). "Second-generation" Medicaid managed care: Can it deliver? Health Care Financing Review, 22(2), 29-47.
Kaye, H. Stephen, LaPlante, Mitchell P., & Harrington, Charlene. (2009). Do noninstitutional long-term care services reduce Medicaid spending? Health Affairs, 28(1), 262-272. doi: 10.1377/hlthaff.28.1.262
Keenan, Patricia S., Elliott, Marc N., Cleary, Paul D., Zaslavsky, Alan M., & Landon, Bruce E. (2009). Quality assessments by sick and healthy beneficiaries in traditional Medicare and Medicare managed care. Medical Care, 47(8), 882-888.
Liu, Heng-Hsian Nancy. (2012). Policy and practice: An analysis of the implementation of supported employment in Nebraska. Dissertation Abstracts International: Section B: The Sciences and Engineering, 72(7-B), 4324.
McCombs, Jeffrey S., Luo, Michelle, Johnstone, Bryan M., & Shi, Lizheng. (2000). The Use of Conventional Antipsychotic Medications for Patients with Schizophrenia in a Medicaid Population: Therapeutic and Cost Outcomes over 2 Years. Value in Health, 3(3), 222-231.
McFarland, Bentson H., Deck, Dennis D., McCamant, Lynn E., Gabriel, Roy M., & Bigelow, Douglas A. (2005). Outcomes for Medicaid Clients With Substance Abuse Problems Before and After Managed Care. The Journal of Behavioral Health Services & Research, 32(4), 351-367.
Norris, Margaret P., Molinari, Victor, & Rosowsky, Erlene. (1998). Providing mental health care to older adults: Unraveling the maze of Medicare and managed care. Psychotherapy: Theory, Research, Practice, Training, 35(4), 490-497.
Parks, Joseph J. (2007). Implementing practice guidelines: Lessons from public mental health settings. Journal of Clinical Psychiatry, 68(Suppl4), 45-48.
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Parks, Joseph J. (2007). Implementing practice guidelines: Lessons from public mental health settings. Journal of Clinical Psychiatry, 68(Suppl4), 45-48.
Ray, Wayne A., Daugherty, James R., & Meador, Keith G. (2003). Effect of a mental health "carve-out" program on the continuity of antipsychotic therapy. The New England Journal of Medicine, 348(19), 1885-1894.
Wallace, Neal T., Bloom, Joan R., Hu, Teh-Wei, & Libby, Anne M. (2005). Medication treatment patterns for adults with schizophrenia in Medicaid managed care in Colorado. Psychiatric Services, 56(11), 1402-1408.
Wan, Thomas T. (1989). The effect of managed care on health services use by dually eligible elders. Medical Care, 27(11), 983-1001.
Warner, Richard, & Huxley, Peter. (1998). Outcome for people with schizophrenia before and after Medicaid capitation at a community agency in Colorado. Psychiatric Services, 49(6), 802-807.
West, Joyce C., Wilk, Joshua E., Rae, Donald S., Muszynski, Irvin S., Stipec, Maritza Rubio, Alter, Carol L., . . . Regier, Darrel A. (2009). Medicaid prescription drug policies and medication access and continuity: Findings from ten states. Psychiatric Services, 60(5), 601-610