Medicaid Managed Care 2012 Fiscal Analysts Seminar August 30, 2012 National Conference of State Legislatures Neva Kaye Managing Director for Health System Performance National Academy for State Health Policy
2 Primary Sources of Data Original i research and literature t review (www.nashp.org) Day long meeting on state strategies to promote integrated delivery systems Seven point-in-time surveys of state Medicaid managed care policies NASHP: 1990, 1994, 1996, 1998, 2000, 2002 CMS: 2010 data
3 Payment Reform Image credit: A. Shih, K. Davis, S. Schoenbaum, A. Gauthier, R. Nuzum, and D. McCarthy, Organizing the U.S. Health Care Delivery System for High Performance, The Commonwealth Fund, August 2008.
4 State Medicaid Seeks Greater Integration of Delivery Systems Fee-for-Service Managed Care Primary Care Case Management (PCCM) Comprehensive Managed Care Organizations (MCOs) Specialty plans, such as Behavioral Health Organizations (BHOs) Emerging Models Medical home and Health home Payment for episodes of care Accountable Care Organization (ACO) & ACO-like
5 Key Trends: 1990-2012 Managed care is the dominant delivery system in Medicaid States enroll people with complex needs into managed care States have saved money and there are indications of improved quality
6 As early as 1990 more than half of all agencies reported using managed care 50 # Stat tes (50+D DC) 40 30 20 10 0 1990 1994 1996 1998 2000 2002 2008 2010 Risk PCCM Either
7 47 States t and DC Used Managed Care in 2010 WA MT ND ME CA OR NV ID UT WY CO SD NE KS MN IA MO WI IL IN MI KY OH WV NY PA VA VT NH CT NJ DE MD DC MA RI NC AZ NM OK AR TN SC MS AL GA TX LA AK FL HI Uses Managed Care
8 Medicaid s Use of Comprehensive MCOs in 2010 WA MT ND ME CA OR NV ID UT WY CO SD NE KS MN IA MO WI IL IN MI KY OH WV PA VA NY VT NH CT NJ DE MD DC MA RI NC AZ NM OK AR TN SC MS AL GA TX LA AK FL HI Use comprehensive MCOs Mental health and/or substance abuse services included in Comprehensive MCO benefits package
9 Medicaid s Use of Specialty Plans in 2010 WA MT ND ME CA OR NV ID UT WY CO SD NE KS MN IA MO WI IL IN MI KY OH WV PA VA NY VT NH CT NJ DE MD DC MA RI NC AZ NM OK AR TN SC MS AL GA TX LA AK FL HI Medicaid Specialty Plans Specialized contracts that include mental health and/or substance abuse services
10 Distribution of Medicaid Managed Care Enrollment: 2010
11 # State es (50+D DC) Since 1994 over half of all states have enrolled some people with complex needs into managed care 50 40 30 20 10 0 Family coverage Aged SSI children SSI adult 1990 1994 1996 1998 2000 2002
12 The Lewin Group Analyzed 24 Studies Savings from 0.5%-20% over fee-for-servicef Indications of potential significant savings through enrolling SSI populationsp Indications savings comes from inpatient hospital Evidence of increased access Study produced in 2004, updated in 2009 Study conducted for America s Health Insurance Plans (AHIP) http://www.ahip.org/content/default.aspx?docid=27090
13 Savings Reported by Selected States 10.7% in Wisconsin in 2002; also reports MCOs outperform fee-for-service on quality measures 7% in Arizona from 1983-1993 4.2% in Ohio in 2006
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15 On the Horizon
16 Continued Drive Toward Greater Integration Di Drivers Unsustainable cost growth in Medicaid Relentless pressure on state budgets Many more Medicaid beneficiaries in 2014 Medicaid managed care to expand: Moving from voluntary to mandatory enrollment More comprehensive set of services New areas of the state New populations Emerging new models
17 Tweaking Standard Managed Care New Mexico: single BHO for all state agencies: Medicaid, Child Welfare, Juvenile Justice.. Wisconsin: Specialized MCO for children with extensive mental health needs at risk of incarceration
Patient Centered Medical Homes Key model features: Multi-stakeholder partnerships Qualification standards aligned with new payments Data & feedback Health Information Technology Practice Education Graphic Source: Ed Wagner. Presentation entitled The Patient-centered Medical Home: Care Coordination. Available at: www.improvingchroniccare.org/downloads/care_coordination.ppt 18
19 Support For Medical and Health Homes Payment, usually per member per month Support for changing how practice delivers care Training, learning collaboratives for practices or practice-based care coordinators Providing resources that support improved g pp p coordination with specialty and community services: Networks, community health teams.
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Section 2703 Health Home Activity WA CA OR NV ID UT MT WY CO ND SD NE KS MN IA MO WI IL IN MI KY OH WV PA VA VT NY NJ DE MD DC ME CT RI NH MA AZ NM OK AR MS TN AL GA SC NC TX LA FL HI Approved = 6 States (8 SPAs) Submitted = 3 States Planning Grant = 14 States and Washington, D.C. As of June 12, 2012
Bridging gto Accountable Care Models Key model features: Central hub linked to community networks High-performing providers Contractual agreements between providers Shared goals & risk Population health management tools Health information technology & exchange Engaged patients 22
Examples of 2 Medicaid d ACOs Colorado Accountable Care Collaborative (ACC) Seven regional care collaborative organizations (RCCOs) charged with achieving cost/quality outcomes Support primary care providers (PCPs) through medical management, care coordination, and more Statewide data and analytics contractor supports RCCOs through high-risk patient identification and more Per member per month (PMPM) payments to PCPs and RCCOs, with possibility for incentive payments ACC as platform for future payment reform efforts For more information: http://www.nashp.org/sites/default/files/webinars/jantz_and_trollan _slides.pdf http://www.colorado.gov/cs/satellite/hcpf/hcpf/1233759745246 23
Examples of 2 Medicaid ACOs Oregon Coordinated Care Organizations (CCOs) Each CCO will receive a fixed global budget for physical/mental/dental care for each Medicaid enrollee CCOs must have the capacity to assume risk CCOs to coordinate care and engage g enrollees/providers in health promotion 11 provisionally certified CCOs approved so far; launch expected by August 2012 Projecting savings of $3.1 billion over five years For more information: http://www.oregon.gov/oha/ohpb/health-reform/ccos.shtml http://washingtonexaminer.com/entertainment/health/2012/05/ore- clears-first-coordinated-care-organizations/672806 24
25 Integrating Care for People Eligible for Medicare and Medicaid (Dual Eligibles) 26 states submitted proposals CMS reviewing proposals; start dates in 2013, 2014 Two models Managed Fee-for-Service: State and CMS form agreement under which state can share in savings Capitated: three way contract between CMS, State, and plan Some states choose multiple models http://www.cms.gov/medicare-medicaid-coordination/medicare-and-medicaid-coordination/medicare- Medicaid-Coordination-Office/FinancialModelstoSupportStatesEffortsinCareCoordination.html
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27 Securing the Value
28 Considerations in Selecting Program Structure What are you willing to invest? How much risk are you willing to take? Where are you (and beneficiaries) getting g least value? More comprehensiveness (services or covered lives) Increases potential for coordination and cost savings Doesn t ensure either! What types of MCOs are ready to go? Waiver or State Plan Amendment (SPA)? What infrastructure do you have in place? What can you modify or repurpose? What do you need to build, borrow, or buy?
29 Ensure sufficient resources to build and oversee a strong program MCO Selection Select MCOs that will deliver value and understand the population Enrollment Offer beneficiaries choice Enroll into the MCO that meets their needs Ensure they understand how to access services Payment Payment amounts high enough to pay for needed care-and low enough to produce savings Use payment to incent change: shared risk/savings, quality incentives MCO oversight Measure and report performance Structure for improving performance at agency and plan levels
30 When Planning for Medicaid Managed Care Clarify goals Cost containment Improved access to high performing medical homes Efficient use of resources, coordinated and integrated care Consider the target population Rural/underserved areas People with disabilities Consider needed d linkages To other systems (long term care, Exchanges) Among different types of MCOs (physical and mental health)
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