missouri healthcare: past, present, and future · missouri healthcare: past, present, and future...
TRANSCRIPT
Missouri Healthcare: Past, Present, and Future
October 13th, 2017
Timothy McBride, PhD
Co-Director, Center for Health Economics and Policy
Overview of Presentation•Background/Context for Missouri• Access • historical insurance coverage rates in Missouri
• Missouri’s contribution to the supply of providers
• Costs• Drivers: access issues, inequality, aging population
• Health status in Missouri
•Moving forward• Solutions from other states?
• Achieving improved access, improving population health, within Missouri’s budget
• Finding feasible policy solutions
Background/ Context History of Insurance in Missouri
Missouri Medicaid History
Missouri’s Healthcare Providers Trained
Missourians’ Health
History of Insurance in MissouriMissouri has tended to be above the national average in terms of the percent of the population obtaining health insurance coverage through an employer. This is still true today, although the numbers have declined steadily since 1999-2000.
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Per
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nPercent of Population Covered by Employer-Sponsored Insurance
U.S.
MO
Percent Uninsured in Missouri and U.S., 2008-16
14.6%15.1%
15.5%15.1%
14.8%14.5%
11.7%
9.4%8.6%
12.4%
13.2% 13.2%13.7% 13.6%
13.0%
11.7%
9.8%
8.9%
8%
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18%
2008 2009 2010 2011 2012 2013 2014 2015 2016
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U.S. MO
SOURCE: Bureau of the Census, September2017, https://www.census.gov/library/publications/2017/demo/p60-260.html .
Uninsurance rates in Missouri were lower than in the U.S. until 2014, when the U.S. uninsured rate dropped below Missouri’s rate.
< 138% FPL
138-399% FPL
>= 400% FPL
Distribution of Uninsured Population in Missouri, by Income, 2016
229,084(43%)
238,658(45%)
61,506(12%)
Missouri Medicaid History1959:
MO limited medical
assistance program covering inpatient hospital care with a max reimbursement
of $5 per day
1963: MO added a limited drug and dental
program for adults
1965: Title XIX of the federal
Social Security Act establishes Medicaid
1967: Establishment
of the Missouri Medicaid program
1996: The Personal Responsibility
Work Opportunity
Reconciliation Act creates
TANF to replace AFDC
1998: MO creates
CHIP program, expanding
health coverage to low-income
children with family income
up to 300% FPL
2005: MO reduces
optional Medicaid services provided
to adults, excluding
pregnant women and blind persons
2007: Missouri Health
Improvement Act renames program MO HealthNet to reflect new
goals
Missouri’s Healthcare Providers Trained
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2011-12 2012-13 2013-14 2014-15 2015-16
Number of Doctors Trained in Missouri AnnuallyU of Missouri at Columbia
U of Missouri at Kansas City
St. Louis U
Washington U in St. Louis
A.T.Still U at Kirksville Collegeof Osteopathic Medicine
College of OsteopathicMedicine at Kansas City U
In 2016, there were 448 new MDs and 413 new DOs trained in Missouri.
Meanwhile, 1699 (11%) of current active MDs are above 65, with another 3192 (20%) between the ages of 55 and 64.
Also, 298 (13%) of current active DOs are above 65, and another 541 (24%) are between ages 55 and 64.
Missourians’ Health
According to America’s Health Rankings 2016 Annual Report: In the past year
excessive drinking increased 10% from 16.1% to 17.7% of Missouri adults. obesity increased 7% from 30.2% to 32.4% of Missouri adults. HPV immunization among Missouri males aged 13 to 17 years increased 122%
from 11.3% to 25.1%. In the past eight years
preventable hospitalizations decreased 36% from 88.6 to 56.6 discharges per 1,000 Missouri Medicare enrollees.
In the past two years, diabetes increased 20% from 9.6% to 11.5% of Missouri adults.
Health Spending
National trends
Medicaid cost drivers
Indirect costs
Taking all this in, can we find a balance between the ideas of access for everyone and a healthy state budget not dominated by health care costs?
CDC: “86% of nation’s $2.7 trillion annual health care expenditures are for people with chronic and mental health conditions.”
National Trends in US Health Spending
Note: Total health care spending is defined as the amount spent on health care services across all payers, including patient out-of-pocket payments.
Average utilization is presented; not everyone uses a particular service in a given year, especially inpatient stays and ED visits.
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1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 2020 2025
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U.S. Health Spending as Percent of GDP
Actual Projected
Costs Due to Chronic Conditions•Chronic disease accounts for approximately 86% of nation's aggregate health care spending, an estimated $8,350 per person in U.S. each year (CDC)
•Treatment of chronic disease captures an even larger of public spending:• 96 cents per dollar for Medicare
• 83 cents per dollar for Medicaid.
•Example: Healthcare costs for a person with diabetes are over $13,000/year; for a person without diabetes, $2,500. • For every one point reduction in HbA1c (a measure of blood sugar over time), a 40%
reduction in microvascular complications is reported (blindness, kidney disease, nerve damage) and up to $4,100 can be saved in annual healthcare costs.
The Role of Rising Inequality
Rising income inequality in US and Missouri has contributed to growth in Medicaid enrollment, even when eligibility standards remain the same.
Workers in low wage jobs are less likely to be offered insurance through employer.
All this is a barrier to preventive care and early detection that can potentially lower overall health care spending over time.
Share of Income of the Top 1%
Missouri Income Data
OverallTop 1% of Incomes
Bottom 99% of Incomes
Cumulative Real Growth
1979-2007 31.9% 140.5% 20.3%
2009-2013 0.6% 14.8% -1.8%
Average Incomes
2013 $49,653 $833,823 $41,641
Missouri’s ratio of
20.0 ranks 22nd in the
nation.
The Role of AgingThe number of people aged 65 and over in Missouri is projected to rise 41% over the next 15 years. Elders face higher health costs and are more likely to be on Medicaid, so this will drive up state spending on Medicaid.
922,418 1,047,071 1,189,605 1,301,714
15.2%16.9%
18.8%20.2%
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Missouri Population Projections, 2015-2030
Population 65 and over Percent of Total Population
Missouri Medicaid (MOHealthNET) Enrollment
SOURCE: Missouri DSS, https://dss.mo.gov/mhd/oversight/pdf/170306-SFY-2018-Budget-Update.pdf
Missouri Medicaid (MOHealthNET) Enrollment
SOURCE: Missouri DSS, https://dss.mo.gov/mhd/oversight/pdf/170306-SFY-2018-Budget-Update.pdf
Unpacking Growth in Medicaid SpendingHow much of the change in Medicaid spending is attributable to what sources?
Using the data available to us, we can disentangle these sources of growth, attributing overall spending growth into growth attributable to: Enrollment growth,
Spending per enrollee
Prices/inflation
Utilization per enrollee
What might account for the rise in “utilization”? Some possibilities: Enrollees are sicker/older and need more services
Services are billed more intensively may be a provider response to low reimbursement rates
may be due to lack of code options for less intensive services
Unnecessary services are provided, through duplication, incomplete recordkeeping, etc.
Other possibilities?
Growing Medicaid Spending in MissouriOur analysis of CY 2011-2016 data shows many instances in which increased utilization is the driving force in growth of costs.
(Interactive version available on web resources page.)
2015 Blind and DisabledEnrollment change from last year: 3,888 (2.47%)Sum of expenditures: $3,813,567,140Change from 2014: $211,079,388 (5.86%)- - - - - - - - - - - - - - - - - - -Breakdown of Expenditure Change (% contribution to change)Change due to inflation: $3,813,567 (2%)Change due to enrollment increase: $92,149,094 (44%)Change due to higher utilization: $115,116,727 (55%)
Indirect Costs: Uncompensated CareMissouri Hospital Association reports a 469% increase in uncompensated care cost at its member hospitals over the past 10 years.
So even if we don’t cover those on Medicaid, demographically similar non-Medicaid eligible population may be adding to the trends we have seen.
Indirect Costs: Productivity Losses
Annual Productivity Loss by Number of Health Conditions and Risk Level
% Mean Annual Absent DaysMean Annual Unproductive
Days
Condition Level
No conditions 45% 1.4 3.7
1 condition 29% 1.9 7.9
2+ conditions 27% 3 20.1
Risk Level
Low (0–2 risks) 68% 1.6 5.1
Medium (3–4 risks) 21% 2.4 12.9
High (5+ risks) 10% 3.6 28.9
Additional indirect costs come in the form of productivity losses for workers. Productivity losses linked to absenteeism cost employers $225.8 billion annually in the United States, or $1,685 per employee (CDC)
Also, “chronic diseases, a rapidly-aging workforce and factors like stress, fatigue and depression all affect employers’ revenue.”
Solutions? Missouri Waivers
Solutions from Other States?
Charge for Today
Missouri WaiversThrough Section 2176 of PL97-35 of the Social Security Act, certain statutory limitations have been waived in order to give states, with approval from the HHS, the opportunity for innovation. Currently, Missouri has approval to provide services under the following waivers:
1115 Demonstration Waivers: experimental, pilot, or demonstration projects that promote the objectives of the Medicaid and CHIP programs, giving . The purpose of these demonstrations, which give states additional flexibility to design and improve their programs, is to demonstrate and evaluate policy approaches. MO HealthNet and Department of Mental Health Waivers1115 Women's Health Services ProgramGateway to Better Health WaiverMental Health Crisis Prevention Project
1915(c) Home & Community Based Waivers: under a waiver, certain services that could not otherwise be reimbursed under Title XIX may be provided to a select group of participants, in order to provide an alternative to institutional care. Department of Health & Senior Services WaiversAdult Day Care WaiverAged and Disabled WaiverAIDS WaiverIndependent Living WaiverMedically Fragile Adult Waiver
Department of Mental Health WaiversMO Children with Developmental Disabilities (MOCDD) Waiver Autism WaiverComprehensive WaiverCommunity Support WaiverPartnership for Hope Waiver
Solutions from Other States? WaiversStates have flexibility to alter some of the requirements of Medicaid law
1932(a) State Plan: Managed care delivery system by getting a state plan amendment approved by CMS.
1915(a) Waiver: voluntary managed care program simply by executing a contract with companies that the state has procured using a competitive procurement process. 13 states (and Puerto Rico) use 1915(a) contracts to administer 24 voluntary managed care programs.
1915 (b) Waiver: managed care delivery system using waiver authority under 1915(b). Uses Freedom of Choice, Enrollment Broker, Non-Medicaid Services Waiver, Selective Contracting Waiver
1115 Demonstrations: experimental, pilot, or demonstration projects that promote the objectives of the Medicaid and CHIP programs. Gives states additional flexibility to design and improve their programs, is to demonstrate and evaluate policy approaches such as:
◦ Expanding eligibility to individuals who are not otherwise Medicaid or CHIP eligible
◦ Providing services not typically covered by Medicaid
◦ Using innovative service delivery systems that improve care, increase efficiency, and reduce costs.
Solutions from Other States?Sections 1115 of the Social Security Act gives Secretary of HHS authority to approve experimental, pilot, or demonstration projects that promote the objectives of the Medicaid and CHIP programs. The purpose of these demonstrations, which give states additional flexibility to design and improve their programs, is to demonstrate and evaluate policy approaches such as:
Expanding eligibility to individuals who are not otherwise Medicaid or CHIP eligible;
Providing services not typically covered by Medicaid; or
Using innovative service delivery systems that improve care, increase efficiency, and reduce costs.
There are currently 29 approved and 37 pending waivers across these three goal areas.
Alabama Medicaid Transformation * Arkansas’ Tax Equity and Fiscal Responsibility Act * Colorado Adult Prenatal Coverage and Premium Assistance CHP+ * Florida Managed Medical Assistance (MMA) * Indiana
End Stage Renal Disease (ESRD) * Maryland Health Choice * Healthy Michigan * Flint Michigan Section 1115 Demonstration * Minnesota Prepaid Medical Assistance Project Plus * Healthier Mississippi * Missouri
Gateway to Better Health * Montana Plan First * Nevada Comprehensive Care Waiver * New Hampshire Building Capacity for Transformation * New Hampshire Health Protection Program Premium Assistance *
New Jersey FamilyCare Comprehensive Demonstration * New Mexico Centennial Care * New York Medicaid Redesign Team * Oregon Contraceptive Care * Oregon Health Plan * Pennsylvania Medicaid Coverage
for Former Foster Care Youth from a Different State * Vermont Global Commitment to Health * Virginia FAMIS MOMS and FAMIS Select * The Virginia GAP and ARTS Delivery System Transformation * Washington
Take Charge * Washington Medicaid Transformation Project * West Virginia Creating a Continuum of Care for Medicaid Enrollees with Substance Use Disorders * Wisconsin Senior Care * WY Pregnant By Choice
Solutions from Other States?Some states have turned to waivers for coverage expansionsAt least 9 states have Section 1115 waiver proposals for coverage expansions
undergoing public comment or CMS review
Common elements to most proposals include charging premiums,
cost sharing,
healthy behavior incentives,
work-related provisions.
Some states: time limits and health savings accounts.
Two states propose “partial expansion”.
Key requirement: budget neutrality, cannot reduce coverage (until now).
Solutions from Other States?Other states are trying Delivery System Reform Incentive Payment (DSRIP) Waivers (CA, MA, NH, NJ, NY, RI, TX, WA as of 2017)
Early findings/lessons learned, according to Kaiser Family Foundation (2015), on DSRIP in CA, MA, NY, and TX: DSRIP is changing the way care is delivered by promoting collaboration, supporting innovation, and
focusing on social services.
It is critical, but challenging, to design appropriate measures of the impact of DSRIP
DSRIP’s role in broader delivery system reform and Medicaid managed care remains unclear
The financing structure underpinning DSRIP waivers can dramatically affect how they are used
Charge for TodayThroughout the day, we challenge audience to be mindful of the issues discussed here, in the other talks and discussions, and think about the following question:
How do we balance the competing goals of healthcare access for everyone and ensuring a healthy state budget over time?
Are there innovative ways to pay that emphasize population health?
Are there “easy” policy solutions in the short term that improve efficiency while also improving outcomes?
Can we broaden our perspective beyond the short-term to look at ideas for investing now and obtaining the dividends in the medium- and long-term?
Questions?Center Co-Director Tim McBride at
For data questions related to this presentation,
contact Center Affiliate Abigail Barker at
https://publichealth.wustl.edu/centers/health-economics/