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September 24, 2014
Pam ColemanSenior Consultant
Medicaid Managed CareTrends and Opportunities
About Sellers Dorsey
Sellers Dorsey is a national healthcare consulting firm that navigates the ever-changing landscape within the public and private sector. Together with its clients, Sellers Dorsey realizes opportunities that enhance the bottom-line and ultimately improve the lives of people.
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About the presenter
Pam Coleman, Senior Consultant, leads projects focusing on long term services and supports, a rapidly growing area of healthcare. She brings a deep background in managed care techniques in delivering LTSS to a diverse population. Pam frequently presents at national conferences on complex care populations and integrated delivery systems. Most recently Pam served as the Senior Vice President of Government Programs at OptumHealth after dedicating 26 years to the Texas Health and Human Services Commission.
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Today we will:
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Review Medicaid Managed Care growth.1
Today we will:
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Review a “top ten list” of market trends.2
Review Medicaid Managed Care growth.1
Today we will:
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Review a “top ten list” of market trends.2
Highlight select opportunities to leverage emerging trends.3
Review Medicaid Managed Care growth.1
Medicaid Population and Spending - 2012
Total Medicaid Population: 50M Members
Source:
Medicaid Population and Spending - 2012
Total Medicaid Population: 50M Members
Temporary Assistance to Needy Families
(TANF)
36M Members$163B Spend
Source:
Medicaid Population and Spending - 2012
Total Medicaid Population: 50M Members
Temporary Assistance to Needy Families
(TANF)
36M Members$163B Spend
Aged Blind and Disabled
(ABD)
14M Members$265B Spend
Source:
Medicaid Population and Spending - 2012
Total Medicaid Population: 50M Members
Temporary Assistance to Needy Families
(TANF)
36M Members$163B Spend
Aged Blind and Disabled
(ABD)
14M Members$265B Spend
Children
25M Members$80B Spend
$3,246 PMPY
Source:
Medicaid Population and Spending - 2012
Total Medicaid Population: 50M Members
Temporary Assistance to Needy Families
(TANF)
36M Members$163B Spend
Aged Blind and Disabled
(ABD)
14M Members$265B Spend
Children
25M Members$80B Spend
$3,246 PMPY
Adults (pre-expansion)
11M Members$56B Spend
$4,841 PMPY
Source:
Medicaid Population and Spending - 2012
Total Medicaid Population: 50M Members
Temporary Assistance to Needy Families
(TANF)
36M Members$163B Spend
Aged Blind and Disabled
(ABD)
14M Members$265B Spend
Children
25M Members$80B Spend
$3,246 PMPY
Adults (pre-expansion)
11M Members$56B Spend
$4,841 PMPY
Dual Eligibles
9M Members
$160B Spend$19,758PMPY
Source:
Medicaid Population and Spending - 2012
Total Medicaid Population: 50M Members
Temporary Assistance to Needy Families
(TANF)
36M Members$163B Spend
Aged Blind and Disabled
(ABD)
14M Members$265B Spend
Children
25M Members$80B Spend
$3,246 PMPY
Adults (pre-expansion)
11M Members$56B Spend
$4,841 PMPY
Dual Eligibles
9M Members
$160B Spend$19,758PMPY
Non Duals
5M Members$104B Spend
$17, 337 PMPY
Source:
Growth Predictions for Medicaid Managed Care
• Currently two-thirds of Medicaid members are served through managed care
• 20% growth in Medicaid managed care in 20141
• 28 states with Managed LTSS by 20152
• 75 Million Medicaid members in Medicaid managed care by 2020 (compared with 40 Million in 2014) 3
• All but Alaska and Wyoming have all or a portion of their Medicaid population in a managed care system (includes PCCM) 4
1. Avalere - Analysis: Medicaid Plans Expected to Grow 20% This Year Under ACA Expansion – January 2014 2. http://www.ahcancal.org/News/news_releases/Pages/Surge-of-Medicaid-Managed-Care-is-Fraught-with-Problems-Unless-Root-Concerns-are-Addressed.aspx3. HMA projections HMA, based on CMS, Office of the Actuary, September 2013 “4. http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-and-Systems/Downloads/2011-Medicaid-MC-Enrollment-Report.pdf
ABD environment as of November 2013
Managed Care for Seniors and Persons with Disabilities
Existing ABD (29)
Transitioning to ABD (4)
Remaining FFS (17)
Source: Kaiser Family Foundation – August 28, 2014
Current Status of State Medicaid Expansion Decisions
Implementing Expansion (28)
Open Debate (2)
Not Moving Forward Now (17)
Source: Kaiser Family Foundation – August 28, 2014
Medicare Medicaid Integration Program
States Pursuing
Medicare Medicaid Integration Program (Capitated vs FFS)
Capitated
Fee for Service
*Washington pursuing FFS and capitated
Source: Kaiser Family Foundation – August 28, 2014
Medicare Medicaid Integration Program (MOUs)
With MOU
Without MOU
Medicare Medicaid Integration Program (Enrolling)
Currently Enrolling*
Not Enrolling
* Washington enrolling in FFS
Trends in Medicaid Managed Care
Trend 1: Movement to Managed Long Term Services and Supports
• Currently 24 states have implemented MLTSS• MLTSS includes nursing facility and community based services and supports• Goal is to integrated physical, behavioral, and LTSS in a person centered plan of
care• Requirements for service coordination• Assessment of all members to determine unmet needs• Flexibility in services – in lieu of services• Focus on serving members in the most integrated setting and transitioning persons
out of institution
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Trend 2: New Medicaid Populations for Managed Care
• Medicare Medicaid dual eligible population• Adults with disabilities• Children with Special Health Care Needs• Persons with Intellectual and Developmental Disabilities• Foster Care Children• Medicaid Expansion population
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Trend 3: Focus on Quality Improvement and Performance
• Begins with the contract - Value based purchasing concepts• Performance incentives and disincentive• Shared savings models• New quality measures for MLTSS are under development• Evidence-based, best practices to detect both under and overutilization of LTSS• Member and Provider Complaints and Grievances analyses• Member Satisfaction Survey• MLTSS-oriented Performance Improvement Projects
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Trend 4: Person Centered Service Integration
Section 2402(a) of the Affordable Care Act requires the Secretary to ensure all states receiving federal funds develop service systems that are responsive to the needs and choices of beneficiaries receiving home and community-based long-term services (HCBS), maximize independence and self-direction, provide support coordination to assist with a community-supported life, and achieve a more consistent and coordinated approach to the administration of policies and procedures across public programs providing HCBS.
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Trend 5: Carve-Ins Instead of Carve-Outs
• Most Medicaid Directors agree that services should be carved-in when possible• Carve-ins support trend of integration of care• Widespread view that medical issues cannot be addressed without also addressing
behavioral issues, pharma, and community supports• Integration hindered by lack of progress in developing EMRs among providers of
behavioral health services
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Trend 6: Increased Regulatory Requirements
• Increase focus on fraud and abuse• Increase regulations around rate setting methodology• Increased focus on quality ratings and outcomes• Increased focus on Network Adequacy• Increased focus on readiness review processes• Expansion of reporting requirements
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Trend 7: Rate Setting
• Risk adjustment programs that account for both clinical and community support needs
• Rates that are actuarially sound• Medical expenses to include care coordination, health homes, and other similar
activities• Rates that consider new medical technologies • Rates that consider new medications like Sovaldi• MLR requirements should consider MLTSS and pass-throughs
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Trend 8: Focus on High Cost Members and Services
• 5% of Medicaid Managed care membership drives 50% of the expenses• Need for MCOs to target these high cost, high risk members for in-home
interventions• Biggest cost drivers are ED and inpatient services• Focus also on post-acute care and short term interventions
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Trend 9: Information Systems, Technology, and Reporting
• Comprehensive, accessible, and integrated real time electronic health records and care management platforms
• IT hardware for field-based staff (laptops, cell phones, portable printers/faxes, etc.)• Electronic Verification Systems for home-based services• Risk stratification and• Comprehensive performance reporting metrics • Telemedicine, and telepysch
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Trend 10: The Future of Medicaid Managed Care
• The total cost of Medicaid will continue to increase and there are increased pressure to reduce costs
• Managed care saving typically represent 3-4% • Managed care produces short-term savings yet there remains concerns about the
long-term trend toward increased costs• The movement to ACOs, Health Homes and other initiatives will continue but the
results of these models remains unclear• There will continue to be a movement away from FFS to more integrated models
of service delivery
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OPPORTUNITIES:The Future of Medicaid Managed Care
OPPORTUNITIES: The Future of Medicaid Managed Care
• Innovative programs for new managed care populations• Stakeholder engagement and consumer outreach• Care management interventions for high cost, high risk members• Integration of Medicare and Medicaid services• Person-centered care models that integration of physical, behavioral, social and
community services and supports with the member in the pilot seat• Supportive models for moving persons out of institutions with creative ideas
funding housing
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OPPORTUNITIES: The Future of Medicaid Managed Care
• Provider engagement and payment reforms that move away from FFS and offer shared savings or performance incentives/disincentives
• New strategies for detecting and preventing fraud and abuse• IT enhancements that allow for sharing of data between providers, health plans
and the state• Improvements in RFPs and MCO contracts to establish value based performance
and purchasing• States will always be looking for the next best approach for cost containment and
improved outcomes for Medicaid beneficiaries
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