Part 2

Rates

Grants (Block Grants)

Encounter-based

(Medicaid FFS)

Case rates

Capitation rates (MCO)

1

Part 2

Managed Care: Elements

Enrollment Benefits Usage Cost sharing (co-pays) Access Quality Accountability

2

Part 2

…with “Carve Outs”

Dental

Medications

Transport

Behavioral health

3

Part 2 4

ACA’s Medicaid Expansion &NJ’s Comprehensive Waiver

Part 2 5

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

Part 2 6

The Bill...

Part 2 7

3 Years Later: 2/3rds Don’t Know!(Gold, 2013)

Part 2 8

ACA: Goals(Tate, 2012)

Increase access

Control costs

Add benefits & protections

Address many smaller issues

Part 2 9

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

Part 2

Federal Poverty Level (FPL)

Family of 1: $11,670 x 133% =$15,521

Family of 4: $23,850 x 133% =$31,721

2014 Federal Poverty Limit (FPL)

10

Part 2 11

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

Part 2 12

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

Part 2 13

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

Part 2 14

Out-of-Pocket Premiums…

Part 2 15

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

“Old Eligibles”:FMAP = 50%

“New Eligibles”:FMAP = 100% 90%

Part 2 16

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

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

Part 2 17

Premiums: NJ 19%, US 41%, (Roy, 2013)

Part 2 18

Rate Ratios(Zuckerman et al., 2009)

𝑥=𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒𝑟𝑎𝑡𝑒

Part 2 19

US 0.72

WY 1.43AK 1.40DE 1.00PA 0.73CA 0.56NY 0.43

NJ 0.37

Rate Ratios(Zuckerman et al., 2009)

𝑥=𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒𝑟𝑎𝑡𝑒

Part 2 20

US 0.72

WY 1.43AK 1.40DE 1.00PA 0.73CA 0.56NY 0.43

NJ 0.3750t

h !

Rate Ratios(Zuckerman et al., 2009)

𝑥=𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒𝑟𝑎𝑡𝑒

Part 2 21

Provider Supply = f(Rate Ratio)

(Decker, 2012)

𝑥=𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒𝑟𝑎𝑡𝑒

% doctors accepting

Part 2 22

Rate Ratios After ACA

But…

For PCPs only Family practitioners Internists Pediatricians

= 1.00!

Only for 2013, 2014

Also for managed care

Part 2 23

Innovation: Medicaid ACO “Accountable Care Organization”

Part 2 24

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

Part 2 25

NJ’s Comprehensive WaiverGetting it all together

Part 2 26

NJ Medicaid

“Division of Medical Assistance and Health Services”

$11 billion (federal and state)

500 people

Director: Valerie Harr

(“NJ FamilyCare”)

Part 2 27

Medicaid: The State Plan

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

71 elements Rates Methodology Comment periods

Part 2 28

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”

Part 2 29

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 (ACO) 2011: NJ Public law 2011, Chapter 114

Medicaid Accountable Care Organization demonstration project.

Part 2 30

1915(b): Mandatory Managed Care (Howell, Palmer & Adams, 2012)

KEEP…

Mandated services

Choice of plans

“Actuarially sound” rates

ADD…

…“Risk-based” payments

LOSE…

Part 2 31

Managed Care: NJ’s 4 HMOs

Part 2 32

NJ Waivers: Previously (Centers for Medicare & Medicaid, 2013)

Section 1115 Research and

demonstration

Section 1915(b) Managed Care

(Mandatory)

Section 1915(c) Home and

Community Based

Concurrent 1915(b) & (c)

1. Childless adults2. Family coverage (SCHIP) ACOs

3. NJ Care 2000+4. NJ Family Care BH ASO

5. Global Options (LT care)6. Renewal Waiver7. Community Resources8. Community Care

Alternatives

Part 2 33

NJ Waivers: Additional(Centers for Medicare & Medicaid, 2013)

Section 1115 Research and

demonstration

Section 1915(b) Managed Care

(Mandatory)

Section 1915(c) Home and

Community Based

Concurrent 1915(b) & (c)

1. Childless adults2. Family coverage (SCHIP) Accountable Care (ACO)

3. NJ Care 2000+4. NJ Family Care Behavioral Health

(ASO)

5. Global Options (LT care)6. Renewal Waiver7. Community Resources8. Community Care

Alternatives

Part 2 34

NJ Waivers: Additional(Centers for Medicare & Medicaid, 2013)

Section 1115 Research and

demonstration

Section 1915(b) Managed Care

(Mandatory)

Section 1915(c) Home and

Community Based

Concurrent 1915(b) & (c)

1. Childless adults2. Family coverage (SCHIP) Accountable Care (ACO)

3. NJ Care 2000+4. NJ Family Care Behavioral Health

(ASO)

5. Global Options (LT care)6. Renewal Waiver7. Community Resources8. Community Care

Alternatives

Part 2 35

NJ Waivers: Now (Centers for Medicare & Medicaid, 2013)

Section 1115 Research and

demonstration

Section 1915(b) Managed Care

(Mandatory)

Section 1915(c) Home and

Community Based

Concurrent 1915(b) & (c)

One Comprehensiv

e Waiver

Part 2 36

BH Managed Care ASO

One already exists! In DCF: “CSOC” 40,000 kids

Phase in risk-based over 5 years

Administrative Services Organization

Part 2 37

10 Challenges for Consumers

Part 2 38

1. Coverage: Less for Newbies? (Garfield, Lave, & Donohue, 2010)

Part 2 39

1. Coverage: Less for Newbies? (Garfield, Lave, & Donohue, 2010)

“Benchmark”coverage

under ACA

Part 2 40

1. Coverage: Less for Newbies? (Garfield, Lave, & Donohue, 2010)

“Benchmark”coverage

under ACA

Excludable

for newbiesunder ACA

Part 2 41

2. Providers: Enough?

Part 2 42

US 0.72

WY 1.43AK 1.40DE 1.00PA 0.73CA 0.56NY 0.43

NJ 0.3750t

h !

2. Providers: Rate Ratios(Zuckerman et al., 2009)

𝑥=𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒𝑟𝑎𝑡𝑒

Part 2 43

2. Providers: Supply = f(Rate Ratio) (Decker, 2012)

𝑥=𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒𝑟𝑎𝑡𝑒

% doctors accepting

Part 2 44

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. Providers: “Rate Bump” For…?(Kaiser Commission on Medicaid and the Uninsured, 2012a)

= 100%

Part 2 45

3. Exchanges: FPL Overlap?(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!

Part 2 46

3. Exchanges: FPL Overlap?(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!

Part 2 47

3. Exchanges: FPL Overlap?(Blahous, 2013)

Overlap! Medicaid: < 138% FPL. Exchanges: > 100% FPL.

Partial expansion? All > 100% to exchanges, where no state funding needed?…

NO! HHS: no 100% FMAP if states do partial

Part 2 48

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

Wages

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

Exchanges Medicaid: 28 million p.a.?

Part 2

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

234,000total

eligibles

FMAP = 100%

New eligibles vs. old eligibles not enrolled

49

Part 2 50

6. Measures: Of What?

HEDIS: measure behavioral health? Healthcare Effectiveness Data and

Information Set

System metrics, not consumer metrics

Part 2 51

7. Outreach: Can It Succeed?(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

Part 2 52

8. Implementation: Too Complex?

South Carolina’s IT Enterprise Strategy Map

Part 2 53

Deadlines: Too Tight?

ASO: July 1, 2014! “Managed care”, but… Fee for service

“Live”: January 1! Medicaid Expansion ExchangesPOSTPONED!

Part 2 54

9. Compliance: Too Heavy? Reporting

Documentation

Audits

Clawbacks

Penalties

Part 2 55

10. Agency Cash Flow: Enough? Reduced fees

Increased costs

New investments EMR Compliance Training

Part 2 56

And.. The Mega Challenge…

Part 2 57

Entitlement Spending...

Part 2 58

... And Its Consequences

Part 2 59

Outcomes

AccessAvailabilityQualityCostInnovation

Part 2 60

How To Evaluate?...

  Enrolled To be enrolled Not enrolled

Access 

     

Availability 

     

Quality 

     

Cost 

     

Innovation 

     

    

Part 2 61

Access

To the System

To Providers

To PsyR services

(To Insurance…)

Part 2 62

Availability

Of basic care

Of specialty care

Of emergency care

Of evidence-based practices

Part 2 63

Quality

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

Process Simpler? Smoother?

Part 2 64

Cost

Co-pays

Deductibles

Premiums

(Work incentives?)

Part 2 65

Innovation

Practices

Medications

Technology

Management

Part 2 66

Conclusion?

Part 2 67

Right Now? One Father’s View...

  Enrolled To be enrolled Not enrolled

Access  Availability  Quality     Cost       Innovation     

    

Part 2 68

…with the army that you have…

Will the ACA’sMedicaid Changes Improve Outcomes for Schizophrenia? A New Jersey Case Study

Part 2 69

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

Part 2 70

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.

Part 2 71

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