medicaid reform proposal stakeholder meeting august 24, 2004

MEDICAID REFORM PROPOSAL

Stakeholder MeetingAugust 24, 2004

Georgia Department of Community Health

2

Medicaid Growth is Unsustainable!

• In FY2005, Medicaid will require 43% of all new state revenue

• By FY2008, Medicaid will require over 50% of all new state revenue.

• By FY2011, Medicaid will require 60% of all new state revenue.

$0.0

$200.0

$400.0

$600.0

$800.0

$1,000.0

$1,200.0

in m

illi

on

s

FY05 FY06 FY07 FY08 FY09 FY10 FY11

New State Revenues New Medicaid Need


New Revenue (Discretionary)

60% 56% 55% 52% 47% 46% 40%

New Revenue (Medicaid)

43% 44% 45% 48% 53% 54% 60%


3

Percent of All New Revenue Required by the Medicaid

Program

35%

40%

45%

50%

55%

60%

65%


New Revenue Available for Other State InvestmentsNew Revenue Required by Medicaid


4

Utilization Management is a Necessity

$1

$101

$201

$301

$401

$501

$601

$701


(in M

illio

ns)

Medicaid utilization drives more than 35% of total growth year over year

Utilization Growth

Enrollment & Price Growth

From FY05 to FY10 utilization is expected to increase in the following major categories of service:

Inpatient Admissions = 23%

Physician Visits = 42%

Prescriptions = 30%

Outpatient Hospital Visits = 34%


5

Quality Indicators HealthCheck Comparative

Data

50.0%

55.0%

60.0%

65.0%

70.0%

75.0%

Participation Screenings0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

20.0%

Lead

National Data Georgia Data

Georgia and National data is current except where noted below.

National Participation & Screenings are FFY 98

National Lead Screening is FFY 0268.0%

70.0%

72.0%

74.0%

76.0%

78.0%

80.0%

Immunizations


6

Quality Indicators ER Utilization Per 1,000

0

100

200

300

400

500

600

700

800

900

1000

Georgia Better Health Care FY2001 APHSA Medicaid MC Plans HEDIS Benchmark FY2001

State Health Benefit Plan FY2003 Medstat Employer (Commercial) Client Data FY2003


7

Why Medicaid Reform? To focus on system-wide improvements

in performance and quality To consolidate fragmented systems of

care To control unsustainable trend rate in

Medicaid expenditures To adopt a “management of care”

approach to achieve the greatest value for the most efficient use of resources


8

Goals of Reform Improve health care status of member

population Establish contractual accountability for

access to and quality of healthcare Lower cost through more effective

utilization management Budget predictability and administrative

simplicity


9

Vision

To create a statewide, full-risk organized system of care for

Medicaid and PeachCare members that incorporates Georgia-specific

initiatives as well as “best practices” for the provision and

purchasing of healthcare.


10

Strategy

A successful model for the “management of care” for Georgia Medicaid involves:

An organized system of care Responsibility for case oversight A network of contractually accountable

providers to ensure both quality and cost containment

Medically based guidelines for appropriate treatment leading to healthy outcomes


11

Population-based Strategy

Enrollment by Subprogram

79%1,048,697

21%275,105

CMOPopulations

All Other

Expense by Subprogram

61%$3.5 Billion

39%$2.2 Billion

DCH will apply different strategies for reform based upon the unique needs of our populations.

Part I will include Low-income Medicaid adults and children PeachCare for Kids, Right from the Start Medicaid and Refugees Part II will include the Elderly and Disabled, Medically Fragile Children and Foster Children


12

The Plan – Part I Regionalized approach – 6 geographic regions Competitive procurement for up to 2 care

management organizations (CMOs) in each region

CMOs will: Be licensed by Georgia Department Of Insurance

as risk-bearing entities Be subject to net worth and solvency standards Have demonstrated ability to provide all covered

healthcare services and an adequate provider network


13

Proposed CMO Regions & Eligible Member Counts – Avg. Member/Month – FY 2004

DADE

CHATTOOGA

WALKER

CHEROKEE

HARALSON

GORDON

DOUGLAS

RABUN

JACKSON

MURRAYGILMER

FORSYTH

CATOOSA FANNIN

LUMPKIN

BARTOW

PICKENS

FLOYD

PAULDING

COBBPOLK

UNIONTOWNS

FRANKLIN

WHITE

STEPHENS

DAWSONHALL

OGLETHORPE

BANKS

COWETA

MADISON

GWINNETT

CLAYTON

CLARKE

HART

FULTON

HEARD

DEKALB

FAYETTE

LAMAR

HENRY

NEWTON

SPALDING

CARROLL

TROUP

HANCOCK

PIKE

MORGAN

JEFFERSON

BARROW

WALTONOCONEE

ELBERT

GREENE

WILKES

JASPERBUTTS

UPSON

LINCOLN

WARREN

PUTNAM

COLUMBIA

BURKE

WASHINGTON

BALDWINJONES

MONROE

WILKINSONBIBB

CRAWFORD TWIGGS

BLECKLEY

EMANUELJOHNSON

JENKINSSCREVEN

BULLOCH

DODGE

HOUSTON

PEACH

TALBOTHARRIS

MUSCOGEE

CHATTAHOOCHEEMARION

STEWART SUMTER

SCHLEYDOOLY

PULASKI

WILCOXTELFAIR

WHEELER

BEN HILLLEETERRELL

RANDOLPH

QUITMAN

WORTHDOUGHERTYCALHOUNCLAY

CRISP

TURNER

TIFT

COFFEE

JEFF DAVIS

TREUTLEN

TOOMBS

APPLING

TATTNALL

WAYNEBACON

COLQUITTMITCHELL

EARLY BAKER

SEMINOLE

DECATUR GRADY THOMAS BROOKS

COOK

LOWNDES

ECHOLS

LANIER

ATKINSON

WARE

PIERCE

BRANTLEY

CHARLTON CAMDEN

GLYNN

LONG

LIBERTY

BRYAN

MCINTOSH

EFFINGHAM

CHATHAM

CANDLER

EVANS

IRWIN

BERRIEN

MILLER

RICHMOND

TAYLOR

CLINCH

TALIAFERROMCDUFFIE

MACONMONTGOMERY

WEBSTER

GLASCOCK

ROCKDALE

MERIWETHER

HABERSHAM

WHITFIELD

LAURENS

Atlanta

North

East

Central

Southeast

Southwest

155,940

499,334

79,851

148,995

114,624131,336

Rev. 12/20/04


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The Plan – Part IAdditional preferred attributes for considerationof CMOs:

Incorporate technological advances (i.e. electronic prescribing and telemedicine)

Focus on the education and empowerment of the Medicaid member

Introduce elements of consumerism to Medicaid members to drive better healthcare choices (i.e. financial incentives and quality information)

Incorporate disease and case management functions as part of their medical management strategy

Georgia provider-owned/sponsored organizations


15

The Plan – Part I

Required enrollment for: Low-income Medicaid adults and children PeachCare for Kids Right from the Start Medicaid Refugees

CMO enrollment mandatory, but: Enrollees will have 30 days to select one of at least two

CMOs Enrollees will have 90 days to change CMO without cause;

thereafter, will remain in selected CMO until one-year anniversary


16

The Plan – Part ICMOs will be responsible for providing allcovered Medicaid services, which include:

Physician visits, laboratory and diagnostic testing, and inpatient and outpatient hospitalization

Mental health and substance abuse treatment Pregnancy-related services Prescription drugs Dental and vision care services (to eligible populations) Screening and preventive services (to eligible

populations) Durable Medical Equipment


17

The Plan – Part I

CMOs will not be responsible for: ICFMR- Intermediate Care Facility/Mentally

Retarded HCBS- Home and Community-based

Services under a 1915 (c) waiver Other long-term services


18

Healthcare Delivery and Access Standards

DCH will protect the patient/provider relationship by contractually requiring

CMOs: To have sufficient numbers of providers of

both primary and specialty care To include sufficient numbers of safety-net

providers and rural and critical access hospitals

To have a culturally appropriate mix of providers


19

Rights of Members

DCH will contractually require CMOs to provide

to members: Bi-lingual written materials and oral

interpretation services Clear information on grievance and appeal

rights Multiple means to access CMO member

services


20

Rights of Providers

DCH will contractually require CMOs to provide

healthcare providers with: Prompt payment and adherence to State

reimbursement policies Expedited grievance and appeal processes Multiple means to access CMO provider

resources


21

Quality Management

DCH will require CMOs to have an internalprogram that monitors and assures DCH-mandated:

Levels of service quality and efficiency Outcomes and health status targets

Contractual obligations will prevent the CMOs from sub-optimal provision of healthcare


22

Quality ManagementDCH will require CMO reporting on:

Well child visits and childhood immunizations Rates of breast cancer and cervical cancer

screening Rates of diabetic eye exams and HgbA1c testing Early initiation of prenatal care and incidence of

C-Sections Appropriateness of emergency room utilization Incidence of avoidable procedures Other possible quality indicators


23

Reform Strategy – Part IIWho is not included in the CMOs:

Elderly and Disabled Medically Fragile Children Foster Children

And what is our strategy for them?…An overview of Part II


24

Care Management for Elderly and Disabled – Part

IIAn initial strategy of statewide diseasemanagement programs focusing on:

Congestive Heart Failure Diabetes Chronic Obstructive Pulmonary Disease

Programs to reach and manage both Medicaid and SHBP members

Programs could be implemented as early as July 1, 2005


25

Care Management for Elderly and Disabled – Part

II A longer-term, more comprehensive strategy in development

for 275,105 Medicaid members in Elderly and Disabled sub-programs

Will be consistent with new policy direction of DHR Will be coordinated with the Governor’s Office and DHR Will combine vigorous assessment and case management with

traditional fee-for-service reimbursement to providers Vouchers for self-directed care could be made available for

those eligible and able to manage Health outcomes improved and utilization reduced through

oversight and management by a statewide ASO vendor Vendor incentivized to attain outcomes and cost goals Program could be moved to full risk over time


26

Timeframe Development of System of Organized Care Model - September 1 – October

30 Statewide consensus building Development of SPA & RFP/Contract

Administrative Functions Submit SPA & RFP/Contract to CMS for review (CMS approval

mandatory and can take 90+ days) Release RFP (target is 1st week of January 2005, pending CMS approval) Evaluation of RFP responses Contract decisions made Contracts negotiated and signed Readiness evaluation

Implementation – January 1, 2006 Implement CMOs in two/three regions, with remaining two/three

regions phased in during the next 6 – 12 months


27

Conclusion

Current trend for the Medicaid program is unsustainable

A more efficient and effective system for appropriate utilization management is necessary

This plan will create a more organized and accountable system of care

Quality outcomes must be a primary goal


28

Questions & Comments

medicaid reform proposal stakeholder meeting august 24, 2004

Documents

georgia medicaid

medicaid program slide

new revenue medicaid

medicaid expenditures

necessity medicaid utilization

georgiaspecific initiatives

lowincome medicaid adults

new state revenue