Post on 22-Dec-2015
Will the ACA’s Medicaid Changes Improve Outcomes for Schizophrenia? A New Jersey Case Study
Tom Pyle MBA, MS (PsyR), CPRP
2
Will the ACA’sMedicaid Changes
Improve Outcomes for Schizophrenia?
A New Jersey Case Study
Presentation at the Recovery Workforce Summitof the Psychiatric Rehabilitation Association at Baltimore,
MDTom Pyle MBA, MS (PsyR), CPRP June 2014
3
Topic
Fee for service managed care… Integration of PH and BH… Medicaid expansion… Health insurance exchanges… Evidence-based practices.. Community integration… Medical model Recovery model…
The biggest change in 50 years…
How will our loved ones be affected?
Joisey...
Joisey...
6
Joisey...
11th most populous (8.9 million)
Highest density (1030 psm)
Most urban (90% in urban areas)
Strongest state executive
“Blue” State
7
Joisey...
Taxes Real estate taxes: Nation’s highest… Income tax: 1% pays 50%…
Budget gap: $800 million! Public workers vs. pensioners
vs. bond holders
Bonds downgraded: A- 49th of 50 states…
8
Joisey...
Budget: $ 33 billion
Pension fund: $47 billion short! Needs $5 billion p.a.!
FY Budgeted Revised2011 02012 $485 mm 2013 $1.029 bn 2014 $1.582 bn $696 mm2015 $2.249 bn $681 mm2016 $3.000 bn ?2017 $3.857 bn ?2018 $4.800 bn ?
9
Medicaid: An OverviewThe macro view from 30,000 feet…
Medicaid’s 3 Big Changes…
1. Reform “Innovations” (ACOs) “Benchmark” plans
2. Expansion 25% increase
3. Managed care BH ASO Grant FFS Case Capitated
10
11
…Amidst ACA’s 6 Mechanisms…
1. Public program changes (Medicaid)2. Private insurance changes3. Health insurance exchanges
4. Cost containment measures5. Quality improvement measures6. Funding measures (e.g., taxes)
...From 4 Perspectives...
1. Beneficiaries
2. Providers
3. Agencies
4. Government
...3 Subtypes of Beneficiaries...
Beneficiaries
1. Enrolled2. To be enrolled3. Not enrolled
14
Considered by... 5 Big Outcomes
1. Access2. Availabilit
y3. Quality4. Cost5. Innovatio
n
15
Dealing with... 10 Challenges
1. Coverage: As much?2. Providers: Enough?3. Exchanges: Overlap?4. Transitions: Churn?5. “Woodwork Effect”?6. Measures: Of What?7. Outreach: Possible?8. Implement: Complex?9. Deadlines: Too Tight?10.Agency $: Enough?
16
How To Evaluate?...
Enrolled To be enrolled Not enrolled
Access
Availability
Quality
Cost
Innovation
17
The Whole Story...
Health insurance for all Individual Mandate Corporate Requirement
Help for those who need it Medicaid Subsidies for premiums and cost-sharing
18
What is Medicaid?
19
An entitlement
Big funder of… Health care for poor, disabled Safety-net hospitals, LT care
Federal-state partnership FMAP: 50% to 83%
What is Medicaid?
What is “FMAP”?
Federal Medical Assistance Percentage: Federal matching funds to state Medicaid programs.
20
What is “FMAP”? ...For NJ
Federal Medical Assistance Percentage
21
NJ: 50%
FMAP Map 2014(Snyder & Rudowitz, 2014)
What is “FMAP”? ... Under ACA
Federal Medical Assistance Percentage:
For “new eligibles”:
23
What is “FMAP”? ... Under ACA
Federal Medical Assistance Percentage:
For “new eligibles”:
24
Till 2017: 100%
What is “FMAP”? ... Under ACA
Federal Medical Assistance Percentage:
For “new eligibles”:
25
Till 2017: 100%
By 2020: 90%
Medicaid Expansion, June 2014(Henry J. Kaiser Foundation, 2014)
Medicaid: 4 Constituencies
• Eligibility• Enrollment• Coverage• Cost
Consumers
• Rates• Autonomy• Referrals• Administration• Compliance
Providers
• “Rights”• “Access”• Administration• Quality• Cost
Governments
• Administration• Overheads• Compliance• Cash flow
Agencies
27
28
Medicaid: 5 Functions(Kaiser Commission on Medicaid and the Uninsured)
Health insurance coverage 31 mm children; 16 mm adults; 16 mm E&D
Long-term care assistance 1.6 mm institutionals; 2.8 mm community-based
Assistance to Medicare beneficiaries 9.4 mm E&D (20% of Medicare enrollees)
Safety net funding 16% national health funding; 35% safety net
hospitals
Funding for state capacity FMAP
Health insurance coverage
Assistance to
Medicare beneficiar
ies
Long-term care assistanc
e
Safety net & system funding
Funding for state capacity
29
US: Medicaid: FY 2010 Spend(Centers for Medicare and Medicaid, 2012)
$404.1 billion
30
By Contrast...
$404.1 billion $33.0 billion
31
US: Medicaid as % of…(Foster, 2012)
GDP: 2.8%
Health spending: 15%
15%
32
US: Segments Paid by Medicaid (Foster, 2012)
US BH Funding: Medicaid’s Share (Substance Abuse and Mental Health Services Administration, 2013)
34
US: Medicaid: Acute/LT Care 2009(Kaiser Commission on Medicaid and the Uninsured)
5 x
US: Spending Per Enrollee, 2010(Young, Rudowitz, & Garfield, 2014)
US: Average Spend Per, by Group(Young, Rudowitz, & Garfield, 2014)
US: Average Spend Per, by Group(Young, Rudowitz, & Garfield, 2014)
US: Average Spend Per, by Group(Young, Rudowitz, & Garfield, 2014)
$30,834 (CT)
$15,893 (CA)$15,747 (PA)
$22,595 (DE)
$19,951 (NJ)
From the NJ FY 2015 Budget... (State of New Jersey, 2014)
40
Waste, Fraud, Abuse(Kaiser Commission on Medicaid and the Uninsured, 2012)
Overtreatment Failure of care coordination Failure of care process (Tx) Administration complexity Failure of pricing Fraud and abuse
At least 20% of costs
41
Overview: Role in state budgets Counter-cyclical to economy
Largest source of federal revenue ( jobs)
Biggest target for state cost controls
42
Overview: How Control Costs?(Substance Abuse and Mental Health Services Administration, 2013)
Medicaid an entitlement
States can only... Reduce provider payments “Manage” utilization Restrict eligibility
43
Jerseyans with SZ on Medicaid?(NJ DMAHS, 2014)
Aged 84,962Blind 755Disabled 205,419Non ABD Children 742,286NON ABD Adults 452,154
Total 1,485,576
NJ Medicaid, May 2014
20%? (~40,000?)
NJ population 2010
8,900,000 x 1% ~ 90,000
50%? (~45,000?)
Medicaid Overview
3 Big Changes 5 Big Outcomes FMAP: NJ = 50% 2.8% of GDP 15% of all health spending W,F,A = 20% 18% beneficiaries 45% cost 5 Functions 4 Constituencies
44
45
Mechanics of Medicaid
46
Eligibility (3 kinds)
Category
Financial
Resource
47
1. Eligibility: Category
Children Pregnant women Parents of certain children Seniors Individuals with disabilities
NOT childless non-elderly adults
Mandatory (before ACA):
48
2. Financial: By “FPL”
The Federal Poverty Level (HHS)
2014:Family of 1: $11,670Family of 4: $23,850
49
Eligibility: FPL by Class (US)(Kaiser Commission on Medicaid and the Uninsured)
50
Eligibility: FPL by Class (NJ)(Kaiser Commission on Medicaid and the Uninsured)
51
Eligibility: FPL (After ACA)(Kaiser Commission on Medicaid and the Uninsured; Tate, 2012))
52
2. Eligibility: Financial
2014 Federal Poverty Limit (FPL)
53
2. Eligibility: Financial
Family of 1: $11,670 x 133% =$15,521
Family of 4: $23,850 x 133% =$31,721
2014 Federal Poverty Limit (FPL)
Eligibility: Childless Adults 2014(Henry J. Kaiser Foundation, 2014)
55
Eligibility: ACA’s effect(et al., 2013)
56
3. Eligibility: Resource (SSI)
< + (To keep SSI,
net worth < $2000)
57
Eligibility: Overlap!(Blahous, 2013)
Medicaid: < 138% FPL. Exchanges: > 100% FPL.
58
Enrollment
59
US: Medicaid Enrollment?(Centers for Medicare and Medicaid et al., 2012)
Before:
62 mm?(53 mm PYEs)
After:
+ 6 mm more?
60
Medicaid: Dual Eligibles 2009(Kaiser Commission on Medicaid and the Uninsured)
61
Today’s enrollee demographics(Kenen, 2012)
Poor families with children 2/3rd of enrollees 1/3rd of spending
Elderly and disabled 1/3rd of enrollees (70% in nursing homes)
2/3rd of spending
62
“Eligibles” Actually Enrolled?(Sommers & Epstein, 2010)
US average: only ~ 2/3rds !
Enrolled eligibles: Highly variable by state
OK 44% MA 80%
NJ 53%
63
US: Currently Enrolled by Groups(Kaiser Commission on Medicaid and the Uninsured)
NJ: Total Uninsured Since 2000(Castro, 2012)
65
Coverage
66
Medicaid: Focuses on...
Services, not programs
Discrete and individual, not comprehensive
67
Medicaid: Benefits (Centers for Medicare and Medicaid, 2013)
Doctor visits Emergency care Hospital care Prescription drugs Long-term care Vaccinations Hearing Vision Preventative care for children
68
Medicaid: Must Cover...(Substance Abuse and Mental Health Services Administration, 2013)
Inpatient hospital Outpatient hospital EPSDT Nursing facility Home health Physician Rural health clinic Federally qualified health center (FQHC) Laboratory and X-ray Family planning Nurse midwife Certified pediatric and family nurse practitioner Freestanding birth center (when licensed or otherwise recognized
by the state) Transportation to medical care Tobacco cessation and tobacco cessation counseling for pregnant
women and youth under 21 as part of EPSDT
69
Coverage(Garfield, Lave, & Donohue, 2010)
70
Challenge: Less Coverage?(Garfield, Lave, & Donohue, 2010)
“Benchmark”EssentialBenefitscoverage
under ACA
Excludable
for newbiesunder ACA
71
“Rehab Option”: Its Scope(Substance Abuse and Mental Health Services Administration, 2013)
Service Setting Type of Provider Extent of Coverage
72
“Rehab Option”: A Distinction(Substance Abuse and Mental Health Services Administration, 2013)
“Habilitative” services: to develop skills never acquired (as among DD population) Only through home/community-based
waiver
“Rehabilitative” services: to restore lost functioning (as among PD population) Not limited to clinical treatment
73
Medicaid: Costs
Deductibles
Co-pays
(Opportunity costs)
74
Medicaid: Styles
Classic Fee-for-Service
Managed care Contractually-defined services… For an enrolled population… In a closed network… Paid by capitation premiums
75
Managed Care: 3 Types
1. Managed care organization (MCO)▪ Capitation: Per person per month▪ Risk: Who accepts it? State or vendor?
2. Primary care case management (PCCM)▪ Case management fee
3. Pre-paid Health Plans (PHP)▪ In-patient ▪ Ambulatory