Medicaid’s Coming Changes & Prospective Consumer Outcomes

T.H. PylePSRT 5402 Advanced PsyR SeminarMarch 28, 2014

Topic

What outcomes for NJ consumers

from coming changes inMedicaid’s payment for care?

Outcomes

AccessAvailabilityQualityCostInnovation

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?

Medicaid as % of…(Foster, 2012)

GDP: 2.8%Health spending: 15%

15%

Enrollment & Shares, 2010(Centers for Medicare and Medicaid et al., 2012)

~ 60 mm

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

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

…with “Carve Outs”

Behavioral health

Dental

Medications

Transport

Medicaid Managed Care: Prevalence(Kaiser Commission on Medicaid and the Insured, 2012)

Medicaid67%

New Jersey 97%

Affordable Care Act…bringing the biggest change in Medicaid since it began.

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

Federal Poverty Level (FPL)

Family of 1: $11,490 x 133% =$15,282

Family of 4: $23,550 x 133% =$31,322

Eligibility: FPL Limits by Class (US)(Kaiser Commission on Medicaid and the Uninsured)

Eligibility: FPL Limits by Class (NJ)(Kaiser Commission on Medicaid and the Uninsured)

Eligibility: FPL Limits (After ACA)(Kaiser Commission on Medicaid and the Uninsured; Tate, 2012))

ACA: Projected Enrollments(Centers for Medicare and Medicaid, 2012)

ACA Effect: NJ Enrollments(Cantor et al., 2011)

Medicaid enrollment:Up 22.8% (234,000)

Of total insured:From 13.6% to

16.7%

ACA Effect: NJ Coverage (Rutgers Center for State Health Policy, 2012)

Change in Coverage in NJ under ACA (ages 0-64)

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

NJ’s Comprehensive WaiverGetting it all together

Medicaid: The State Plan

Required by Section 1902(a) (30)(A)

71 elements Rates Methodology Comment periods

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”

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.

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

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

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.

PCP

T

CW

S

IN Px

Out Px

Primary Care

Specialist

Therapist

Case Worker

Hospital

PHP/IOP

LTCF LT Care Facility

Medicaid: Mechanics

Medicaid: The Old Way

Managed Care Organization (MCO)

Managed Care

Behavioral Health HomeDMHA

S

Managed Care After the Waiver?

DMHAS

Managed Care After the Waiver?

DMHAS

Post Waiver: Unknown No. 1

“Fee for service”?

Post Waiver: Unknown No. 2

Integration?

Post Waiver: Unknown No. 3

Rates?

Challenges

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

Provider Supply = f(Rate Ratio) (Decker, 2012)

𝑥=𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒𝑟𝑎𝑡𝑒

% doctors accepting

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%

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!

4. Churn Transitions(Ingram, McMahon & Guerra, 2012)

Wages

Medicaid Exchanges: 35% of all adults below 200% FPL

Exchanges Medicaid: 28 million

5. Woodwork Effect(Castro, 2013; Alaigh, 2002)

234,000total

eligibles(@ $8000 per)

FMAP = 100%

New eligibles vs. old eligibles not enrolled

6. Measurements

HEDIS: measure behavioral health? Healthcare Effectiveness Data and

Information Set System metrics, not consumer metrics

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

8. Implementation

South Carolina’s IT Enterprise Strategy Map

9. Compliance

Reporting

Documentation

Audits

Clawbacks

Penalties

10. Agency Cash Flow

Reduced fees

Increased costs

New investments EMR Compliance Training

Outcomes

AccessAvailabilityQualityCostInnovation

Access

To the System

To Providers

To PsyR services

(To Insurance…)

Availability

Of basic care

Of specialty care

Of emergency care

Of evidence-based practices

Quality

Provider What level? What training? What experience? What supervision?

Process Simpler? Smoother?

Cost

Co-pays

Deductibles

Premiums

(Work incentives?)

Innovation

Practices

Medications

Technology

Management

Conclusion?

Research

FoundationsThink tanksTechnical advisorsPeer journalsGovernments

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

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.

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