View
797
Download
0
Tags:
Embed Size (px)
DESCRIPTION
Citation preview
Wisconsin’s Experience in Slowing Cost Growth In
Medicaid
Medicaid Managed Care Conference
Curtis Cunningham, Deputy Director
Bureau of Fiscal Management
Wisconsin Department of Health Services
September 28, 2010
Agenda
� Impetus for Rate Reform
� Rate Reform Approach
� Rate Reform Process
� Highlights from Rate Reform Version 1.0
� Rate Reform Version 2.0 and Beyond
� Lessons Learned
Wisconsin Department of Health Services 2
Rate Reform Overview� The Medicaid program was required to find $625 million (all funds) in savings
(2009 Act 28) as a result of the 2009-11 State Budget Deficit.
� Rather than achieving these savings by doing across-the-board cuts, DHS decided to take the opportunity to find real reform opportunities in the Medicaid program.
� DHS’s Rate Reform approach includes:� A comprehensive examination of how MA purchases specific health care services � Identification of areas where true reform can be achieved in Medicaid and the program
can achieve savings� Goal – to utilize the creativity of stakeholders to help identify ways to make Medicaid
more efficient without harming the program. We invited all the provider and advocate groups to participate. Everyone had a seat at the table.
Wisconsin’s Rate Reform Project is Now Our Process for Continuous Quality Improvement and Program Reform.
3Wisconsin Department of Health Services
What Wisconsin could do to meet the legislative mandate to reduce Medicaid spending by $600 million AF
� Across-the-board rate cuts of approximately 5.5% over the biennium; 19% if applied only to non-institutional services
� Sweeping reductions in benefits and services. Samples of submitted ideas included: � Eliminating oral health coverage for BC+ Benchmark plan
� Expanding use of provider assessments
� Ending the expansion of Family Care
� Eliminating SeniorCare
� Dramatically increasing co-payments for expansion populations
4Wisconsin Department of Health Services
� ARRA Restrictions
� Mandatory covered service requirements
� Governor’s Priorities
� Guiding Principles
Context of Rate Reform:
5Wisconsin Department of Health Services
� The American Reinvestment & Recovery Act (ARRA) prohibits the imposition of stricter eligibility standards.
� Wisconsin risks losing $1.2 billion in federal funding.
� ARRA funding is up for a 6-month continuation; however, this funding comes with no guarantees and eventually will end.
ARRA Restrictions
6Wisconsin Department of Health Services
� The Federal Government requires that states cover:� Inpatient hospital services (other than IMD services) � Outpatient care and ambulatory services of RHCs and FQHCs� Laboratory and X-ray services� Nursing facility services (other than an IMD) for individuals 21 or
older� Early and periodic screening, diagnosis and treatment (EPSDT) for
individuals who are eligible under the plan and are under age 21� Family planning services and supplies � Physicians' services and the medical services of dentists� Pregnancy-related services, including treatment of conditions
which may complicate the pregnancy or threaten the safe deliveryof the fetus, until 60 days after delivery
� Nurse midwife and nurse practitioner services in states where they are licensed
� Medicare cost-sharing for dual-eligible beneficiaries
Mandatory Services
7Wisconsin Department of Health Services
� Wisconsin should continue to be a national leader in access to basic, affordable health care coverage
� We need to build on our achievements in providing healthcare coverage
� Budget savings will not be accomplished through stricter eligibility standards or reductions in benefits
� The state will have to trim back reimbursement rates for services such as medical care
Governor’s Priorities
8Wisconsin Department of Health Services
� Identify savings to reach targeted reduction levels� Look for both short-term solutions and long-term
systemic changes� Ensure that no one provider group is singled out for rate
reductions� Ensure access to care for MA patients� Align payments with value rather than volume� Build on previous MA quality improvement efforts
including managed care P4P initiative� Implement care management/coordination strategies� Focus on high-intensity services� Cost containment now about “continuous improvement”
Guiding Principals
9Wisconsin Department of Health Services
� Very public process.� 200 stakeholders participating in multiple meetings.
� On-line survey tool.
� Process generated over 500 ideas.
� Rate Reform Version 1.0 was completed June 2009.
� State is now implementing the plan.
� Process was well received. � Key was everyone was at the table and understood that
something had to be done. Status quo was not an option.
� So well in fact that we hope to continue into the future.
� This is the way we should do business!
Framework for Project
10Wisconsin Department of Health Services
� All-Provider Kick-Off Call (3/23/09)
� Round 1 Advisory Group Meetings (4/2/09-4/17/09)
� Over 200 advisory group participants
� Web survey to 30,000 portal users
� Generated over 500 ideas
� Highest volume of ideas for Pharmacy, LTC & PA-related changes
� Package Development (4/20/09-7/1/10)
� Balanced approach across all providers
� State Budget Impact Need: SFY10-11 savings; target has grown
� Round 2 Advisory Group Meetings (7/15/10-7/22/10)
� Implement Recommendations (begin 8/1/10)
Rate Reform Project Overview
11Wisconsin Department of Health Services
� Ideas analyzed and prioritized based on:
� Short & long term impact
� Current spend & potential savings
� Benefit considerations
� Policy impacts
� Regulatory parameters
� Contract changes
� Reviewed and triaged each idea internally
� Developed list of short-term savings ideas for
2009-11 biennium
Template completed for each idea
Idea Analysis and Development
12Wisconsin Department of Health Services
� Original Target (March 2009): Governor’s SFY 10-11 Budget� $140 million GPR $415 million AF
-------------------------------------------------------------------------------� Revised Target (May 2009): Joint Finance Committee
� $191 million GPR $581 million AF------------------------------------------------------------------------------� Final Target (June 2009): Conference Committee
� $205 million GPR $625 million AF-------------------------------------------------------------------------------Separate Savings Items:
� Hospital assessment� $300 million GPR (over three fiscal years)
� Increase in hospital assessment� $93 million GPR (over three fiscal years)
� New ambulatory surgical center assessment� $21 million GPR (2009-11 biennium)
� Increase in nursing home assessment� $23 million GPR (2009-11 biennium)
Savings Target
13Wisconsin Department of Health Services
� SE Wisconsin Managed Care RFP – New focus on quality.
� Reimburse Physicians based on cost effectiveness.
� Create an incentive for nursing homes to avoid preventable adverse health conditions (e.g. pressure ulcers) or other alternative.
� 100 Day Supply requirement for specified maintenance drugs/earlyrefill limits.
� Reimburse C-Sections at Same Rate As Vaginal Deliveries, Unless C-Section is Medically Necessary.
� Care Management contract for high cost Fee-For-Service members.
� More aggressive approach to MAC pricing/Balanced with additionalpayments for enhanced pharmaceutical care.
� Reform the way Critical Access Hospitals are paid.
� Adopt APC approach for outpatient payments.
Highlights of Specific Proposals
14Wisconsin Department of Health Services
�On track to save $633 million (all funds) as required by the 2009-11 state budget.
� Initially explored 72 items, though some have been eliminated or consolidated.
�32 of the remaining 56 ideas have been implemented to date.
�These 32 ideas are projected to save $277.8 million (all funds) over the biennium.
Rate Reform Version 1.0 has been a success!
15Wisconsin Department of Health Services
� However, Medicaid program grows during difficult economic times.� Demand for Medicaid services exceeds current funding.
� Continually looking for more efficiencies and enhancements to the program.
� Result = Wisconsin Medicaid Rate Reform 2.0.
Continuous Quality Improvement & Rate Reform
16Wisconsin Department of Health Services
RATE REFORM VERSION 2.0
DRAFT PACKAGE
Rate Reform 2.0 Package Summary� Rate Reform 2.0 is much smaller than version 1.0
� We did not hit our target of $100M GPR
� Total Preliminary Savings Estimate:
$39,779,668 (AF)
� Focus is on:
� Program Improvement
� Medicare Alignment
� Focus is not on:
� Items needing legislation changes
� Total Number of Recommended Ideas: 36
18Wisconsin Department of Health Services
Jan.
Ongoing
Jul.Jun.
MayApr.
Mar.Feb.
1/26Kick-Off Meeting
2/19 – 3/9Meetings with 4 Stakeholder
GroupsBrief the
Secretary’s Office
ImplementationsBegin*
7/1Final
Package
Modify Package
Brief the Legislature
DRAFT Final Package to
Stakeholders at Meeting
Brief the Governor’s
Office
*Note: Some initiatives require State Plan language changes. Implementation
start dates will be impacted by these changes.
Rate Reform 2.0 Timeline
19Wisconsin Department of Health Services
DescriptionProjected Biennial
Savings*
Recoup double payments for Medicare cross-overs $858,000
Reduce paper mailings $55,000
Allow WIC Agencies to become Medicaid certified to do blood lead
testing $0
Reform policy for enteral nutrition $200,000
Expand never events beyond Medicare requirements to all ,
Children's hospitals, and Critical Access Hospitals$0
Rev Max: review income maintenance and child care programs in
Milwaukee county$4,825,000
Avoid Medicaid payment for rental equipment in nursing homes that
is eligible for Medicare reimbursement$497,407
APCs for Hospitals (Start collecting 7/10, start paying based on
APCs 1/11 or 7/11)$0
*All Funds
Rate Reform 2.0 DRAFT Package
20Wisconsin Department of Health Services
DescriptionProjected Biennial
Savings*
PA for atypical antipsychotics prescribed by PCPs for children TBD
PA for growth hormone prescribed for children $200,000
Medicare/Medicaid analysis for radiology $4,200,000
Implement 3rd Party Identification and recovery processes to
maximize the recovery of funds from liable parties, including
casualty and subrogation cases.
$1,450,000
Use HMS's national eligibility database to ID commercial insurance
coverage upon applicationTBD
Use Pharmacy and Rx Claim Audits to systematically audit client
retail pharmacy providers.$5,000,000
Contain Costs through Clinical Editing (Bloodhound) TBD
Enhanced Medicare Reimbursement at State Mental Health
InstitutesTBD
Educate pharmacists and doctors on OTC coverage policy TBD
Rate Reform 2.0 DRAFT Package
21
*All Funds
Wisconsin Department of Health Services
DescriptionProjected Biennial
Savings*
Improve data-sharing for children in foster care $370,000
Develop a Health Care Fraud Prevention and Enforcement Action
Team (HEAT) for Home Health ServicesTBD
Paper Claims Payment Reduction $700,000
Enroll Part B entitled into Medicare$12,000,000
Examine whether state should do HMO subrogation or adjust HMO
rates (no COB or TPL)TBD
Establish uniform residential rate-setting methodology in Family
CareTBD
Maximize capture of Medicare, third party reimbursement and
casualty claims in Family Care TBD
Review time studies that impact claiming to various DHS programs,
including FoodShareTBD
Contract with UW for specialty pharmacy TBD
Rate Reform 2.0 DRAFT Package
22
*All Funds
Wisconsin Department of Health Services
DescriptionProjected Biennial
Savings*
Lab Fee settlements for HMOs TBD
Enhance DHCAA's current data exchanges with DWD and DOR for
state wage data and unemployment compensation data.TBD
Modify Enrollment and Benefit booklets sent to Nursing Home
residents to use less paperTBD
Investigate utilizing certain recycled/used DME (e.g., wheelchairs) TBD
Implement improved drug utilization controls $5,000,000
Increase dispensing fee to pharmacists for increasing generic fill
rates $1,000,000
Use a group number to distinguish benefit plans $0
Claim portion of case management cost in Partnership program for
Medicare reimbursement (note: long term goal)$2,000,000
Raise criteria for eligibility for bedhold payment $1,424,261
Rate Reform 2.0 DRAFT Package
23
*All Funds
Wisconsin Department of Health Services
DescriptionProjected Biennial
Savings*
Contract with Medicare Advantage Organizations for services to
dual eligible enrollees (SNPs)TBD
National Health Care Reform: Require physicians to see patients in
person in order to receive Home Care servicesTBD
National Health Care Reform: Allow children in hospice to continue
to receive treatmentTBD
National Health Care Reform: FFS members to have Primary Care
Provider under a Medical Home$8,959,064
Rate Reform 2.0 DRAFT Package
24
*All Funds
Wisconsin Department of Health Services
� Thanks to BadgerCare Plus, Wisconsin leads the nation in health care access.
� Budgets are about values and priorities. Governor Jim Doyle has made health care access a priority during good and challenging budget times.
� Managing the budget effectively must include engaging stakeholders and thinking creatively.
� Legislative changes are difficult to accomplish� Fewer focus groups are easier to manage � Be aware of systems and staff limitations� In open process - be prepared for anything
Lessons Learned
25Wisconsin Department of Health Services
(608) 250-5833http://www.dhs.wisconsin.gov/medicaid/ratereform/
26Wisconsin Department of Health Services