medicaid’s coming changes & prospective consumer outcomes
DESCRIPTION
T.H. Pyle PSRT 5402 Advanced PsyR Seminar March 28, 2014. Medicaid’s Coming Changes & Prospective Consumer Outcomes. Topic. What outcomes for NJ consumers from coming changes in Medicaid’s payment for care?. Outcomes. Access Availability Quality Cost Innovation. What is Medicaid?. - PowerPoint PPT PresentationTRANSCRIPT
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Medicaid’s Coming Changes & Prospective Consumer Outcomes
T.H. PylePSRT 5402 Advanced PsyR SeminarMarch 28, 2014
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Topic
What outcomes for NJ consumers
from coming changes inMedicaid’s payment for care?
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Outcomes
AccessAvailabilityQualityCostInnovation
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Big funder of… Health care for poor, disabled Safety-net hospitals, LT care
Federal-state partnership FMAP: 50% to 83% NJ: 50%
What is Medicaid?
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Medicaid as % of…(Foster, 2012)
GDP: 2.8%Health spending: 15%
15%
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Enrollment & Shares, 2010(Centers for Medicare and Medicaid et al., 2012)
~ 60 mm
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Medicaid: Styles
Classic Fee for service
Managed care
Comprehensive set of contractually-defined covered services for an enrolled population in a closed network paid by capitation premiums
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Managed Care: 3 Plan Types
1. Risk-based managed care orgs/plans (MCO)▪ Capitation ▪ Who takes the risk? State or vendor?
2. Primary care case mgt plans (PCCM)▪ Case management fee
3. Non-comprehensive plans▪ In-patient ▪ Ambulatory
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…with “Carve Outs”
Behavioral health
Dental
Medications
Transport
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Medicaid Managed Care: Prevalence(Kaiser Commission on Medicaid and the Insured, 2012)
Medicaid67%
New Jersey 97%
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Affordable Care Act…bringing the biggest change in Medicaid since it began.
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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
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Federal Poverty Level (FPL)
Family of 1: $11,490 x 133% =$15,282
Family of 4: $23,550 x 133% =$31,322
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Eligibility: FPL Limits by Class (US)(Kaiser Commission on Medicaid and the Uninsured)
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Eligibility: FPL Limits by Class (NJ)(Kaiser Commission on Medicaid and the Uninsured)
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Eligibility: FPL Limits (After ACA)(Kaiser Commission on Medicaid and the Uninsured; Tate, 2012))
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ACA: Projected Enrollments(Centers for Medicare and Medicaid, 2012)
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ACA Effect: NJ Enrollments(Cantor et al., 2011)
Medicaid enrollment:Up 22.8% (234,000)
Of total insured:From 13.6% to
16.7%
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ACA Effect: NJ Coverage (Rutgers Center for State Health Policy, 2012)
Change in Coverage in NJ under ACA (ages 0-64)
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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
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NJ’s Comprehensive WaiverGetting it all together
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Medicaid: The State Plan
Required by Section 1902(a) (30)(A)
71 elements Rates Methodology Comment periods
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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”
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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 2011: NJ Public law 2011, Chapter 114
Medicaid Accountable Care Organization demonstration project.
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1915(b): Managed Care (Howell, Palmer & Adams, 2012)
KEEP…
Can be mandated, with choice of plans
Rates must be “actuarially sound”
CHANGE…
AND
“Risk-based” payments and incentives
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Waivers: New Jersey(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)
1. Childless adults2. Family coverage (SCHIP)
3. NJ Care 2000+4. NJ Family Care
5. Global Options (LT care)6. Renewal Waiver7. Community Resources8. Community Care
Alternatives
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Waivers: New Jersey(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)
Comprehensive
including ASOs for behavioral health (adult and child)…
and “fee for service” that it will manage.
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PCP
T
CW
S
IN Px
Out Px
Primary Care
Specialist
Therapist
Case Worker
Hospital
PHP/IOP
LTCF LT Care Facility
Medicaid: Mechanics
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Medicaid: The Old Way
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Managed Care Organization (MCO)
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Managed Care
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Behavioral Health HomeDMHA
S
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Managed Care After the Waiver?
DMHAS
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Managed Care After the Waiver?
DMHAS
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Post Waiver: Unknown No. 1
“Fee for service”?
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Post Waiver: Unknown No. 2
Integration?
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Post Waiver: Unknown No. 3
Rates?
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Challenges
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US 0.72
WY 1.43AK 1.40DE 1.00PA 0.73CA 0.56NY 0.43
NJ 0.3750t
h !
1: Rate Ratio (Zuckerman et al., 2009)
𝑥=𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒𝑟𝑎𝑡𝑒
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Provider Supply = f(Rate Ratio) (Decker, 2012)
𝑥=𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒𝑟𝑎𝑡𝑒
% doctors accepting
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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. The Rate “Bump”(Kaiser Commission on Medicaid and the Uninsured, 2012a)
= 100%
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3. Partial Expansion?(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!
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4. Churn Transitions(Ingram, McMahon & Guerra, 2012)
Wages
Medicaid Exchanges: 35% of all adults below 200% FPL
Exchanges Medicaid: 28 million
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5. Woodwork Effect(Castro, 2013; Alaigh, 2002)
234,000total
eligibles(@ $8000 per)
FMAP = 100%
New eligibles vs. old eligibles not enrolled
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6. Measurements
HEDIS: measure behavioral health? Healthcare Effectiveness Data and
Information Set System metrics, not consumer metrics
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7. Outreach(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
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8. Implementation
South Carolina’s IT Enterprise Strategy Map
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9. Compliance
Reporting
Documentation
Audits
Clawbacks
Penalties
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10. Agency Cash Flow
Reduced fees
Increased costs
New investments EMR Compliance Training
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Outcomes
AccessAvailabilityQualityCostInnovation
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Access
To the System
To Providers
To PsyR services
(To Insurance…)
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Availability
Of basic care
Of specialty care
Of emergency care
Of evidence-based practices
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Quality
Provider What level? What training? What experience? What supervision?
Process Simpler? Smoother?
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Cost
Co-pays
Deductibles
Premiums
(Work incentives?)
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Innovation
Practices
Medications
Technology
Management
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Conclusion?
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Research
FoundationsThink tanksTechnical advisorsPeer journalsGovernments
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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