Medicaid Managed Care

Medicaid Managed Care Wednesday, April 23, 2014

Disclaimer: Nothing that we are sharing is intended as legally binding or prescrip7ve advice. This presenta7on is a synthesis of publically available informa7on and best prac7ces.

Medicaid Managed Care

•  Allow states to pay a capitated rate per enrollee

•  Shi6 the risk to the managed care organiza:ons

•  Ul:mately decrease costs and improve care to those that would not otherwise seek care

Medicaid Managed Care

•  In the past, Medicaid has been a fee for service. Managed Care programs have become more common over the past 15 years.

•  Under the managed care plans, the pa:ent receives most or all of their services from organiza:ons that have contracts with the state

•  Almost 50 million people receive care via a managed care system either voluntarily or mandatory basis

Two Classifica:ons of Medicaid Managed Care Plans

•  Commercial managed care plans – non-‐medicaid popula:on (Medicaid plans where less than 75 percent are medicaid Enrollees; these usually fall under a marke:ng )

•  Medicaid dominant HMO's which primarily serve Medicaid enrollees (75-‐100 percent enrollees are Medicaid beneficiaries)

Three types of Medicaid Managed Care En::es

•  Managed Care Organiza:on MCO -‐ companies agree to provide most Medicaid benefits in exchange for a monthly fee from the state

•  Limited Benefit Plans -‐ limited in that they only provide one or two Medicaid benefits (like mental or dental)

•  Primary Care Case Managers -‐ individual or groups of providers act as primary care providers to help coordinate referrals and other medical services

MCO Medicaid Managed Care En::es

•  By 2010, these MCOs provided coverage for 53% of all Medicaid beneficiaries in 35 of the 50 states, plus DC and Puerto Rico

•  The idea is for the state to pay appropriately higher rates for enrollees who, based on their demographic or other observable characteris:cs, are likely to have higher costs, and likewise lower rates for those likely to have lower costs according to the actuarial data collected

PCCM Medicaid Managed Care En::es in the US

Ob/Gyn Nurse Prac??oner

FQHC Physician Group/Clinic

Physician Specialist

Physician Assistant

Nurse Midwife

Other

27 Yes 23 Yes 24 Yes 22 Yes 18 Yes 14 Yes 12 Yes 14 Yes

h[p://kff.org/medicaid/state-‐indicator/primary-‐care-‐providers-‐in-‐pccm-‐programs/

Rates based on Demographic Data

Rate adjustments based on Demographic Data

•  “age 18-‐45, female, non-‐disabled, TANF-‐eligible •  “age 45-‐65, male, disabled”

•  “infants” (age 0-‐1) and “children” (age 1-‐17). •  “pregnant women”

•  “residents of different parts of the state based on regional varia:on in costs”

h[p://www.forbes.com/sites/aroy/2012/10/18/benefits-‐and-‐challenges-‐of-‐medicaid-‐managed-‐care/

Rates based on Demographic Data with Risk Based Data

•  Risk Adjustment based on Chronic Disease

•  Diagnoses for specific pa:ents deduced from their past claims such as –  Diabetes –  Heart disease –  Hypertension –  other condi:ons that affect costs in a somewhat predictable way

h[p://www.forbes.com/sites/aroy/2012/10/18/benefits-‐and-‐challenges-‐of-‐medicaid-‐managed-‐care/

State Op:ons in choosing Medicaid Managed Care En::es

•  Authori:es allow states to par:cipate at the county or parish level rather than the whole state

•  Comparability of Services lets the states provide different benefits to people enrolled at different levels

•  Freedom of choice allows states choose between managed care plans or primary care plans

•  Ul:mately, States pay a company to do this for the state government so states would not absorb as much of the costs

Medicaid.gov


States are required to have a quality program, provide appeal and grievance rights.

States can implement managed care delivery through one of 3 federal authori:es:

•  State plan authority

•  Waiver authority sec:on 1915 a and b

•  Waiver authority sec:on 1115

Medicaid.gov


h[p://kff.org/medicaid/report/why-‐does-‐medicaid-‐spending-‐vary-‐across-‐states/

•  Nearly all states operate comprehensive Medicaid managed care programs. Across all 50 states and DC, only three states reported that they did not have Medicaid managed care as of October 2010.

•  Overall, 36 of the 48 states with comprehensive managed care programs reported contrac:ng with MCO’s and 31 reported opera:ng a PCCM program.






h[p://www.cms.gov/Research-‐Sta:s:cs-‐Data-‐and-‐Systems/Computer-‐Data-‐and-‐Systems/MedicaidDataSourcesGenInfo/Downloads/2010December31f.pdf


h[p://www.cms.gov/Research-‐Sta:s:cs-‐Data-‐and-‐Systems/Computer-‐Data-‐and-‐Systems/MedicaidDataSourcesGenInfo/Downloads/2010December31f.pdf


•  California –  Managed care serves about 6.6M Medi-‐Cal beneficiaries in 58

coun:es. This is about 70% of the total Medi-‐Cal popula:on –  Many flavors and varies across many regions –  Mostly fee for service with the choice of a few commercial plans

h[p://www.dhcs.ca.gov/provgovpart/Documents/MMCDModelFactSheet.pdf

•  Florida –  Fees vary from county to county –  In 2011, the Florida Legislature created a new program called

Statewide Medicaid Managed Care (SMMC). –  There are two different parts that make up the SMMC program:

•  The Managed Medical Assistance (MMA) Program •  The Long-‐term Care (LTC) Program h[ps://www.flmedicaidmanagedcare.com/MMA/ProgramInforma:on.aspx

Dual Eligible Beneficiaries


•  Poorest and Sickest •  In FFY 2009, dual eligible beneficiaries represented only 15 percent of

Medicaid enrollment but accounted for 38 percent of Medicaid spending •  The cost of caring and the lack of coordina:on between Medicare and

Medicaid pa:ents •  In April 2011, CMS awarded design contracts to 15 states to develop

service delivery and payment models to integrate care for dual eligible beneficiaries

•  This ini:a:ve was expanded in July 2011, when CMS released a le[er outlining its proposed capitated and managed fee-‐for-‐service models to integrate Medicare and Medicaid benefits and align financing

•  Twenty-‐five states, including the 15 that received design contracts, have submi[ed proposals to CMS to test one or both of the proposed model

•  Used to be able to go wherever they wanted, but now under the dual program the pa:ent is being swayed to choose someone in the network



h[p://www.cms.gov/Research-‐Sta:s:cs-‐Data-‐and-‐Systems/Computer-‐Data-‐and-‐Systems/MedicaidDataSourcesGenInfo/Downloads/Dec10DualEligiblesf.pdf

Providers Taking on Medicaid Pa:ents

•  Increase in commercial has driven likelihood that physicians would accept medicaid pa:ents

•  However, the medicaid dominant prac:ces that already accepted medicaid were not affected by the increase in Managed Medicaid


•  More Younger, Male, and foreign medical graduates were more likely to accept medicaid managed care beneficiaries

•  However, there was a decreased acceptance rate by board cer:fied physicians. This makes cri:cs ques:on the quality of care

•  Physicians in large groups, university clinics, and employed by hospitals were more likely to accept medicaid pa:ents under managed care plans


•  There were fewer medicaid managed care pa:ents accepted in markets where there were federally qualified health centers

•  Generally speaking, the medicaid fees increased in areas where an MCO was implemented that already had medicaid services

•  Some providers are opera:ng within the confines of a Medicaid Managed Care Agreement, that is branded by the payer (Humana, Aetna, BCBS) and they may not even realize it

Impacts

•  Pa:ents would have been pushed over to managed care plans or told, “you can keep you your doctor for 20 years” in the past, but the restric:ons to the provider network will now decrease the op:ons

•  Would have said switch now, but states are leaning toward s:ck with your provider but switch later

Final Discussion Points •  Medicaid dominant markets resulted in an increase in ED u:liza:on and

decreased outpa:ent, acute care, and surgery

•  Physicians are not encouraged to implement MCOs but the medicaid pa:ent popula:on does increase already in the network

•  Most states use a take it or leave it approach

•  Aside from seong adjustment factors based on beneficiary characteris:cs, most states set “take-‐it-‐or-‐leave-‐it” rate schedules for each cohort, and others nego:ate individually with each prospec:ve MCO

•  States may need to increase reimbursement, decrease admin costs of those in the networks, and revise contracts to include incen:ves to reduce costs for low-‐income pa:ents

References

•  h[p://www.cms.gov/Research-‐Sta:s:cs-‐Data-‐and-‐Systems/Computer-‐Data-‐and-‐Systems/MedicaidDataSourcesGenInfo/index.html

•  h[p://www.cms.gov/CCIIO/Resources/Fact-‐Sheets-‐and-‐FAQs/Downloads/medicaid-‐mco-‐enrollee-‐outreach-‐faq-‐2-‐21-‐14.pdf

•  h[p://www.cms.gov/Research-‐Sta:s:cs-‐Data-‐and-‐Systems/Computer-‐Data-‐and-‐Systems/MedicaidDataSourcesGenInfo/Downloads/Dec10-‐1115f.pdf

•  h[p://www.cms.gov/Research-‐Sta:s:cs-‐Data-‐and-‐Systems/Computer-‐Data-‐and-‐Systems/MedicaidDataSourcesGenInfo/Downloads/Dec10DualEligiblesf.pdf

•  h[p://www.cms.gov/Research-‐Sta:s:cs-‐Data-‐and-‐Systems/Computer-‐Data-‐and-‐Systems/MedicaidDataSourcesGenInfo/Downloads/2010December31f.pdf

•  h[ps://www.flmedicaidmanagedcare.com/MMA/ProgramInforma:on.aspx •  h[p://www.dhcs.ca.gov/provgovpart/Documents/MMCDModelFactSheet.pdf •  h[p://www.forbes.com/sites/aroy/2012/10/18/benefits-‐and-‐challenges-‐of-‐medicaid-‐managed-‐

care/ •  h[p://kff.org/medicaid/report/why-‐does-‐medicaid-‐spending-‐vary-‐across-‐states/ •  Academyhealth.org •  The primary data sources for Medicaid sta:s:cal data are the Medicaid Sta:s:cal Informa:on

System (MSIS), the Medicaid Analy:c eXtract (MAX) files, and the CMS-‐64 reports. The following is a general explana:on of these reports and the types of program and financial data collected from the states.

Ques:ons?

Healthcare

Medicaid Managed Care