Upload
colin-wilkerson
View
214
Download
0
Tags:
Embed Size (px)
Citation preview
Better Health, Better Care, and Cost Savings Through Improvement
Greg [email protected]
The Center for Community SolutionsMarch 24, 2011
Medicaid is Ohio’s Largest Health Payer
• Provides health coverage for low-income children, parents, seniors, and people with disabilities
• Covers 2.2 million Ohioans (1 in 5) including 2 in 5 births1
• Spends $18+ billion annually all agencies, all funds (SFY 2011) 1
• Accounts for 4.0% of Ohio’s total economy and is growing2
• Funds are federal (63.69%) and state (36.31%)3
SOURCES: (1) Ohio Department of Job and Family Services, (2) SFY 2011 estimate based on $18.0 billion in Medicaid spending per ODJFS and $498 billion Ohio gross domestic product per the State of Ohio Office of Budget and Management, and (3) Federal Register Vol. 76 No. 22 page 5811.
Source: Ohio Colleges of Medicine Government Resource Center, “Quantifying the Impact of the Recent Recession on Ohioans: preliminary findings from the 2010 Ohio Family Health Survey” (February 16, 2011)
Ohioans Covered by Employer-Sponsored Health Insurance, Medicaid, or Uninsured
2009 2010 2011-10%
0%
10%
20%
30%
40%
50%
60%
70%
66.3% 63.9%57.4%
15.0% 17.0% 18.8%
8.5% 9.8% 11.4%
Employer-Sponsored Insurance
Medicaid
Uninsured
0%
100%
200%
300%
400%
500%
Children PregnantWomen
Parents ChildlessAdults
DisabledWorkers
Disabled Elderly
Federal Health Care Reform:
Government Coverage Expansions
Medicaid Expansion
Medicaid Expansion
Fede
ral P
over
ty L
evel
Medicaid Expansion
Health Benefit Exchange
Medicaid
Private Insurance
Source: X
138%
400%$89,400 for a family of 4
$30,843 for a family of 4
Ohio’s Health System Performance
Health Outcomes – 42nd overall1
– 42nd in preventing infant mortality (only 8 states have higher mortality)– 37th in preventing childhood obesity– 44th in breast cancer deaths and 38th in colorectal cancer deaths
Prevention, Primary Care, and Care Coordination1
– 37th in preventing avoidable deaths before age 75– 44th in avoiding Medicare hospital admissions for preventable conditions– 40th in avoiding Medicare hospital readmissions
Affordability of Health Services2
– 37th most affordable (Ohio spends more per person than all but 13 states)– 38th most affordable for hospital care and 45th for nursing homes– 44th most affordable Medicaid for seniors
Sources: (1) Commonwealth Fund 2009 State Scorecard on Health System Performance, (2) Kaiser Family Foundation State Health Facts (updated March 2011)
A few high-cost cases account for most Medicaid spending
Enrollment Spending0%
20%
40%
60%
80%
100%
96%
49%
1%
23%
28%4% of the Medicaid
population consumes 51% of total spending
1% of the Medicaid population consumes 23% of total Medicaid spending
3%
Source: Ohio Department of Job and Family Services; SFY 2010 for all Medicaid populations and all medical (not administrative) costs
Fragmentation vs. Coordination
Multiple separate providers
Provider-centered care
Reimbursement rewards volume
Lack of comparison data
Outdated information technology
No accountability
Institutional bias
Separate government systems
Complicated categorical eligibility
Rapid cost growth
Accountable medical home
Patient-centered care
Reimbursement rewards value
Price and quality transparency
Electronic information exchange
Performance measures
Continuum of care
Medicare/Medicaid/Exchanges
Streamlined income eligibility
Sustainable growth over time
SOURCE: Adapted from Melanie Bella, State Innovative Programs for Dual Eligibles, NASMD (November 2009)
Source: The New Yorker (Jan 24, 2011).
“The critical flaw in our health care system … is that it was never designed for the kind of patients who incur the highest costs. Medicine’s primary mechanism of service is the doctor visit and the emergency room visit. It’s like arriving at a major construction project with nothing but a screwdriver and a crane.”
Source: American Hospital Association Annual Survey (March 2010) and population data from Annual Population Estimates, US Census Bureau: http://www.census.gov/popest/states/NST-ann-est.html.
Medical Hot Spot:Emergency Department Utilization: Ohio vs. US
1999 2000 2001 2002 2003 2004 2005 2006 2007 20080
100
200
300
400
500
600
365 366 372 382 382 383 387 396 401 404436 452 450 449 468 472 488 509 516 523United States Ohio
Hospital Emergency Room Visits per 1,000 Population
29%
Source: Ohio Department of Job and Family Services for SFY 2010. Note that medical costs include those incurred by MCPs and paid by FFS, excluding institutionalized consumers and their costs. Consumers may have been in both FFS and MC delivery systems within SFY 2010. This analysis includes consumers costs in both systems.
Medicaid Hot Spot:Medicaid Enrollees Who Get Care Primarily from Hospitals*
Non-Institutionalized Medicaid Population
Enrollment SpendingAverage
CostNumber % Amount %
Children 29,552 1.3% $510 million 5% $17,300
Adults 12,530 0.5% $841 million 8% $67,100
Total 42,082 1.8% $1.35 billion 13% $32,100
* Indicating a lack of primary care and/or care coordination
Medicaid Hot Spot:Hospital Admissions for People with Severe Mental Illness
Avoidable hospitalizations per 1000 persons for ambulatory care sensitive conditions (avoidable with proper treatment)
Source: Ohio Colleges of Medicine Government Resource Center and Health Management Associates, Ohio Medicaid Claims Analysis (February 2011)
Diabetes COPD Congestive Heart Failure
Asthma0
1
2
3
4
5
6
7
8
3.53 3.693.24
2.33
7.01 6.75
4.184.86
Non-SMISevere Mental Illness (SMI)
Source: Office of Health Transformation Consolidated Medicaid Budget, All Funds, All Agencies; actual SFY 2008-2010 and estimated SFY 2011-2013; “All Other” includes Federal Funds and Non-General Revenue Funds (non-GRF)
Ohio Medicaid Spending Trend9 percent average annual growth, 2008-2011
2008 2009 2010 2011 2012 2013$0
$5
$10
$15
$20
$25
$4.4 $4.0$3.0 $3.8
$5.3 $5.7
$9.1$11.2 $12.9
$14.3$14.0
$15.1
State General Revenue Fund All Other
$15.2+12%
$13.5
$15.8+4%
$18.0+14%
$19.3+7%
$20.8+8%
Billion
+ 42.8%
The current Ohio HHS Medicaid organization
Governor
Medicaid Single State Agency
HealthAgingADASMHDD
Medicaid as a % of Agency Budget
JFS Medicaid
73%Dev Disabilities
91%Mental Health
61%Alcohol and Drug
28%Aging
83%Health
3%
Agency Medicaid as a % of Total Ohio Medicaid
84% ($13.3 billion)
8% ($1.3 billion)
4% ($590 million)
0.3% ($63 million)
3% ($534 million)
0.1% ($17 million)
56 CombinedCounty Boards
130 County Offices
88 County Boards
12 Area Agencies on
Aging
JFS
Source: Legislative Service Commission, “Total Medicaid Spending by Agency” (State Fiscal Year 2010).
130 Local Health
Departments
John R. Kasich,
Governor
Dr. Ted Wymyslo
(Health)
Bonnie Kantor (Aging)
OrmanHall
(ODADAS)
Tracy Plouck (ODMH)
John Martin (DODD)
Leadership Team
• Elise Spriggs, Government Affairs• Eric Poklar, Communications• Monica Juenger, Stakeholder Relations
Policy Teams
Consultant Team
“OHT shall contract with state and/or private agencies for services in order to facilitate the implementation and operation of the OHT’s responsibilities.”
Stakeholder Partners
Prioritize stakeholder communication
Michael Colbert
(JFS)
John McCarthy (Medicaid)
Greg Moody, Director
“All Cabinet Agencies, Boards and Commissions shall comply with requests or directives issued by OHT, subject to supervision of their respective directors.”
Source: Ohio Governor John R. Kasich, Executive Order 2011-02K (January 13, 2011)
Plan for the long-term efficient administration of the Ohio Medicaid Program and act to improve overall health system performance. In the next six months:
1. Advance the Administration’s Medicaid modernization and cost-containment priorities in the operating budget;
2. Initiate and guide insurance market exchange planning;
3. Engage private sector partners to set clear expectations for overall health system performance; and
4. Recommend a permanent Ohio health and human services organizational structure and oversee transition.
Source: Ohio Governor John R. Kasich, Executive Order 2011-02K (January 13, 2011)
Executive Order
The Vision for Better Care Coordination• Create a person-centered care management approach – not a
provider, program, or payer approach• Services are integrated for all physical, behavioral, long-term
care, and social needs• Services are provided in the setting of choice• Easy to navigate for consumers and providers• Transition seamlessly among settings as needs change• Link payment to person-centered performance outcomes
Source: Ohio Department of Job and Family Services. Institutionalized consumers excluded. Based on SFY 2010 total medical cost either by ODJFS or Medicaid managed care plans. Top managed conditions = Diabetes, CAD, CHF, Hypertension, COPD, Asthma, Obesity, Migraine, HIV, BH, & Sub. Abuse.
Medicaid Hot Spot:Enrollment Spending by Top Managed Chronic Conditions
Enrollm
ent (2.3 m
illion)
Spending (
$10.3 billion)
0%
20%
40%
60%
80%
100%
66%30%
23%
31%
11%39%
Consumers with TWO OR MORE of the top managed
chronic conditions
Consumers with ONE of the top
managed chronic conditions
Consumers without one of the
top managed chronic conditions
Ohio Health Transformation Priorities• Improve Care Coordination • Integrate Behavioral and Physical Health• Rebalance Long-Term Care• Modernize Reimbursement
www.healthtransformation.ohio.gov
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 20110
5,000
10,000
15,000
20,000
25,000
30,000
2,637 2,683 2,8074,495
5,550 5,601 5,663
2,143 2,106 2,064 2,023 2,012 2,004 1,992
Waivers (Home and Community-based Care)DC (Developmental Center)
Num
ber of Individuals
GRF = $335M
A Case Study in Transformation:Ohio Department of Developmental Disabilities
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 20110
5,000
10,000
15,000
20,000
25,000
30,000
2,637 2,683 2,8074,495
5,550 5,601 5,6637,081
9,14510,744
12,902
15,76316,359
18,128
20,753
23,64724,528
2,143 2,106 2,064 2,023 2,012 2,004 1,992 1,942 1,854 1,778 1,663 1,605 1,603 1,517 1,423 1,335 1,251
Waivers (Home and Community-based Care)DC (Developmental Center)
Num
ber of Individuals
GRF = $335M
GRF = $331M
A Case Study in Transformation:Ohio Department of Developmental Disabilities
Source: Ohio Department of Job and Family Services. Includes claims incurred from July 2009 through June 2010 and paid through October 2010; cost differences between institutional and waiver/community alternatives do not necessarily represent program savings because population groups being compared may differ in health care needs.
Ohio Medicaid Spending per Member per Month by Setting
Managed Care
Fee-for-Service
Other in Fee-for-Service
Other in Managed Care
PASSPORT
Assisted Living
Choices
Transitions Aging
Home Care
Nursing Facility
Level One
Transitions
Individual Options
Private Intermediate Care Facility
State Developmental Center
0 2000 4000 6000 8000 10000 12000 14000
Institutional Services Waiver Services All Other Medicaid
People with developmental disabilities
People with other disabilities or over age 65
Other children and parents
$1,695$1,356
$530
$298$254
$4,463
$1,869$2,058
$4,067$4,584
$8,473$5,568
$4,819$1,418
$12,937
Source: Ohio Department of Job and Family Services; based on average monthly recipients for SFYs 2006-2010.
Ohio Medicaid Residents of Institutions Compared to Recipients of Home and Community Based Waivers
2006 2007 2008 2009 201040,000
45,000
50,000
55,000
60,000
65,000
70,000
60,12858,609 57,597 56,891 56,503
46,965
52,745
56,011
59,979
65,907
Home and Community Based (Aging, JFS, and DD waiver recipients)
Facility-Based(NF, ICF/DD, Developmental Center residents)
Source: 2004 Health Expenditure Data, Health Expenditures by State of Residence, Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, released September 2007; available at http://www.cms.hhs.gov/NationalHealthExpendData/downloads/res-us.pdf
Medical Hot Spot:Per Capita Health Spending: Ohio vs. US
Measurement US Ohio Percentage Difference
Affordability Rank (Out of 50 States)
Total Health Spending $5,283 $5,725 + 8% 37
Hospital Care $1,931 $2,166 + 12% 38
Physician and Clinical Services $1,341 $1,337 - 0.3% 27
Nursing Home Care $392 $596 + 52% 45
Home Health Care $145 $133 - 8.3% 35
Source: 2007 The Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on data from Medicaid Statistical Information System (MSIS) and CMS-64 reports from the Centers for Medicare and Medicaid Services (CMS), 2010.
Medicaid Hot Spot:Per Enrollee Medicaid Spending: Ohio vs. US
Measurement US Ohio Percentage Difference
Affordability Rank (Out of 50 States)
All Enrollees $5,163 $5,781 + 12.0% 36
Children $2,135 $1,672 - 21.7% 7
Adults $2,541 $2,844 + 13.5% 18
Elderly $12,499 $18,087 + 44.7% 44
Disabled $14,481 $15,674 + 8.2% 33
Ross7.8%
Athens6.6%
Miami9.6% Belmont
10.0%
Preble9.5%
Fulton9.2%
Hancock9.9%
Monroe8.5%
Shelby8.0%
Warren9.8%
Holmes8.0%
Morgan7.2%
Madison7.0%
Fayette9.2%
Pickaway7.2%
Geauga6.6%
Harrison9.2%
Scioto12.3%
Union11.9%
Pike12.0%
Meigs11.7%
Portage10.8%
Fairfield12.3%
Highland10.5%
Muskingum10.4%
Summit10.4%
Washington10.5%
Ashland11.9%
Jackson10.5%
Clermont11.7%
Delaware11.2%
Columbiana12.0%
Montgomery11.5%
Lake11.8%
Licking15.7%
Wood14.6%
Stark14.5%
Adams13.6%
Huron14.6%
Lorain13.6%
Gallia13.7%
Butler15.1%
Trumbull14.5%
Logan12.5%
Seneca14.4%
Franklin12.6%
Mercer15.9%
Allen15.6%
Carroll13.8%
Marion13.0%
Medina16.1%
Richland13.5%
Greene13.4%
Lucas15.4%
Hocking13.3%
Lawrence13.5%
Hamilton12.7%
Wyandot14.5%
Cuyahoga14.1%
Crawford14.7%
Mahoning14.8%
Sandusky14.0%
Darke18.5%
Knox21.2%
Wayne16.6%
Brown20.0%
Hardin21.3%
Ashtabula21.0%
Perry17.8%
Noble22.3%
Clark16.5%
Putnam21.2%
Clinton19.4%
Morrow21.1%
Guernsey20.4%
Coshocton17.2%
Tuscarawas16.3%
Defiance19.4%
Auglaize18.6%
Van Wert17.8%
Erie16.4%
Jefferson17.1%
Henry23.2%
Vinton25.4%
Williams25.6%
Paulding29.4%
Champaign31.8%
Ottawa35.1%
Nursing Facility SurplusPercentage of total bed days vacant
6.6% - 10.4%
10.5% - 12.5%
12.6% - 16.3%
16.4% - 23.0%
23.1% - 35.1%
Unused Nursing Home CapacityIn 70 counties more than 10% of beds are empty
Rebalance Long Term CareEnable seniors and people with disabilities to live with dignity in the settings they prefer
RECOMMENDATIONS:• Create a Single Point of Care Coordination• Consolidate and Streamline Waiver Programs• Reward Person-Centered Outcomes in Nursing Homes• Expect Greater Efficiency from NF and Waiver Providers• Decrease payments to “hold” empty beds• Reduce the nursing home franchise fee• Saves $427 million all funds over the biennium
Research suggests that person-centered care is associated with improved
organizational performance including higher resident and staff satisfaction,
better workforce performance and higher occupancy rates.
Source: 2010 Annual Quality Report, Alliance for Quality Nursing Home Care and American Health Care Association
Ohio Health Transformation Priorities• Improve Care Coordination • Integrate Behavioral and Physical Health• Rebalance Long-Term Care• Modernize Reimbursement
www.healthtransformation.ohio.gov
Balance the BudgetContain Medicaid program costs in the short term and ensure financial stability over time
RESULTS:• A sustainable system• $1.4 billion in net savings over the biennium• Align priorities for consumers (better health outcomes) and
taxpayers (better value)• Challenge the system to improve performance (better care
and cost savings through improvement)
Source: Ohio Department of Job and Family Services and the Governors Office of Health Transformation. Managed care expenditures are distributed to providers according to information from Milliman. Hospitals include inpatient and outpatient expenditures as well as HCAP Home and community services include waivers as well as home health and private duty nursing.
Total Ohio Medicaid Expenditures, SFY 2010
Hospital; 28%
Nursing Facility; 17%
Intermediate Care Facilities for the De-velopmentally Disabled and Develop-
mental Centers; 5%
Home and Community Services; 14%
Physicians; 8%
Drugs, 9%
Managed Care Administra-tion; 3%
Medicare Buy In and Part D; 3%
Other; 12%
Source: Office of Health Transformation (March 15, 2011)
Medicaid Budget:
Savings and Investments
Provide Accountable Care for ChildrenPromote Health HomesImplement Federal Reform MandatesCreate a Single Point of CoordinationIntegrate Behavioral/Physical Health BenefitsElevate Behavioral Health Financing to the StateCreate a Unified Long Term Care SystemLink Nursing Home Payments to QualityReduce Admin for Federal Agencies on AgingNursing and Home Health Payment ReformAlign Programs for People with DDReduce PASSPORT rates and service utilizationReform Managed Care Plan PaymentsManage Behavioral Health Service UtilizationReform Nursing Facility PaymentsModernize Hospital Payments
-$500 -$400 -$300 -$200 -$100 $0 $100
$87$47
$35$0$0$0
$0$0
-$24-$35
-$62-$137
-$159-$243
-$427-$478
in millions
Source: Office of Health Transformation (March 15, 2011)
Medicaid Budget:
Impact on Rates by Provider
Physician
ICF-DD
Managed Care Plans
Inpatient Hospital PMPM
Aide Services per 4 hours
PASSPORT Provider Rates
Nursing Services per 4 hours
Outpatient Hospital PMPM
Nursing Facilities
-8% -6% -4% -2% 0% 2% 4% 6% 8%
8.8%
0.6%
-1.0%
-1.8%
-2.5%
-3.0%
-4.9%
-6.7%
-7.3%
Estimated change in rate
What this budget does NOT do• Does not cut eligibility• Does not cut optional services, including dental• Does not make arbitrary across-the-board cuts• Does not resort to smoke and mirrors• Does not count hypothetical savings
Thank you.
Greg Moody, DirectorGovernor's Office of Health Transformation
77 South High Street, 30th Floor Columbus, Ohio 43215
Phone: 614-752-2784
Email: [email protected]