Medicaid Managed Care2012 Fiscal Analysts Seminary

August 30, 2012

National Conference of State Legislatures

Neva KayeManaging Director for Health System PerformanceManaging Director for Health System PerformanceNational Academy for State Health Policy

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i fPrimary Sources of Data

O i i l h d lit t i• Original research and literature review (www.nashp.org)

• Day long meeting on state strategies to promote integrated delivery systems

• Seven point-in-time surveys of state Medicaid managed care policiesmanaged care policies▫ NASHP: 1990, 1994, 1996, 1998, 2000, 2002▫ CMS: 2010 data

P R f

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Payment Reform

Image credit: A. Shih, K. Davis, S. Schoenbaum, A. Gauthier, R. Nuzum, and D. McCarthy, “Organizing the U.S. Health Care Delivery System for High Performance,” The Commonwealth Fund, August 2008.

State Medicaid Seeks Greater

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State Medicaid Seeks Greater Integration of Delivery Systems

F f S i• Fee-for-Service

• Managed CareManaged Care▫ Primary Care Case Management (PCCM)▫ Comprehensive Managed Care Organizations (MCOs)

Specialty plans such as Behavioral Health▫ Specialty plans, such as Behavioral Health Organizations (BHOs)

• Emerging Models▫ Medical home and Health home▫ Payment for episodes of carePayment for episodes of care▫ Accountable Care Organization (ACO) & ACO-like

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dKey Trends: 1990-2012

M d i th d i t d li t• Managed care is the dominant delivery system in Medicaid

• States enroll people with complex needs into managed care

• States have saved money and there are indications of improved qualityindications of improved quality

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A l th h lf f ll As early as 1990 more than half of all agencies reported using managed care

50

40

50

DC

)

20

30

tes

(50+

D

10

20

# St

at

01990 1994 1996 1998 2000 2002 2008 2010

Risk PCCM Either

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St t d DC U d M d C i 47 States and DC Used Managed Care in 2010

ME

WA

NH MA

ME

CTRI

VT

NY

PA

MI

MN

WI

ND

SD

MT

WY

IDOR

NJ

CT

DE

DC

MD

NC

PA

VAWV

KY

IN OH

MO

IL

IA

KS

NE

UT

CO

NV

CA

GA

SC

TN

MSAL

AROK

TX

AZ

NM

AK FL

LATX

HI

Uses Managed Care

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Medicaid’s Use of Comprehensive MCOs in

ME

WA

Medicaid s Use of Comprehensive MCOs in 2010

NH MA

ME

CTRI

VT

NYMI

MN

WI

ND

SD

MT

WY

IDOR

NJ

CT

DE

DC

MD

NC

PA

VAWV

KY

IN OH

MO

IL

IA

KS

NE

UT

CO

NV

CA

NC

GA

SC

TN

MSAL

AROKAZ

NM

AK FL

LATX

HI Use comprehensive MCOsMental health and/or substance abuse services included in Comprehensive MCO benefits package

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Medicaid’s Use of Specialty Plans in 2010

WA

Medicaid s Use of Specialty Plans in 2010

NH MA

ME

RI

VT

NYMI

MN

WI

ND

SD

MT

WY

IDOR

NJ

CT

DE

DC

MD

C

PA

VAWV

KY

IN OH

MO

IL

IA

KS

NE

UT

CO

NV

CA

NC

GA

SC

TN

MSAL

AROKAZ

NM

AK FL

LATX

HI

Specialized contracts that include mental health and/or substance abuse services

Medicaid Specialty Plans

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Distribution of Medicaid Managed Care Distribution of Medicaid Managed Care Enrollment: 2010

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Since 1994 over half of all states have Since 1994 over half of all states have enrolled some people with complex needs

into managed careinto managed care

40

50

DC

)

20

30

40

es (5

0+D

0

10

# St

ate

Familycoverage

Aged SSI children SSI adult

1990 1994 1996 1998 2000 2002

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The Lewin Group Analyzed 24 Studies

S i f 0 % 20% f f i• Savings from 0.5%-20% over fee-for-service• Indications of potential significant savings

through enrolling SSI populationsg g p p• Indications savings comes from inpatient

hospital• Evidence of increased access• Evidence of increased access• Study produced in 2004, updated in 2009• Study conducted for America’s Health

I Pl (AHIP)Insurance Plans (AHIP)

http://www.ahip.org/content/default.aspx?docid=27090

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Savings Reported by Selected States

• 10.7% in Wisconsin in 2002; also reports MCOs outperform fee-for-service on quality measures

• 7% in Arizona from 1983-1993

• 4.2% in Ohio in 2006

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Q estions?Questions?

O h i

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On the Horizon

Continued Drive Toward Greater

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Continued Drive Toward Greater Integration

D i• Drivers▫ Unsustainable cost growth in Medicaid▫ Relentless pressure on state budgetsp g▫ Many more Medicaid beneficiaries in 2014

• Medicaid managed care to expand:• Medicaid managed care to expand:▫ Moving from voluntary to mandatory enrollment▫ More comprehensive set of services▫ New areas of the state▫ New populations

• Emerging new models

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Tweaking ‘Standard’ Managed Care

• New Mexico: single BHO for all state agencies: Medicaid, Child Welfare, Juvenile Justice…..

• Wisconsin: Specialized MCO for children with extensive mental health needs at risk ofextensive mental health needs at risk of incarceration

Patient Centered Medical Homes

Key model features:Multi-stakeholderMulti stakeholder partnershipsQualification standards li d ithaligned with new

paymentsData & feedbackHealth Information TechnologyP ti Ed tiPractice Education

G S “

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Graphic Source: Ed Wagner. Presentation entitled “The Patient-centered Medical Home: Care Coordination.” Available at: www.improvingchroniccare.org/downloads/care_coordination.ppt

Support For Medical and Health

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Support For Medical and Health Homes

• Payment, usually per member per month

S t f h i h ti d li• Support for changing how practice delivers care▫ Training, learning collaboratives for practices or

practice-based care coordinatorspractice based care coordinators

• Providing resources that support improved g pp pcoordination with specialty and community services: Networks, community health teams….

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Section 2703 Health Home Activity

NH

MEVT

MN

NDMT

IDOR

WA

NHMA

NJCT

RI

DE

NY

PA

IN OH

MI

IL

IA

MN

WI

NE

SDWY

UT

ID

NV

DCMD

NC

VAWV

SC

KY

TN

MO

AROK

KSCO

AZ

NM

CA

FL

GAMS AL

LATX

HI

Approved = 6 States (8 SPAs)Submitted = 3 StatesSubmitted = 3 StatesPlanning Grant = 14 States and Washington, D.C.

As of June 12, 2012

Bridging to Accountable Care Modelsg g

Key model features:Central hub linked toCentral hub linked to community networksHigh-performing providersContractual agreements between providersShared goals & risk gPopulation health management toolsHealth information technologyHealth information technology & exchangeEngaged patients

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Examples of 2 Medicaid ACOsa p es o ed ca d COs• Colorado Accountable Care Collaborative (ACC)▫ Seven regional care collaborative organizations (RCCOs)—Seven regional care collaborative organizations (RCCOs)

charged with achieving cost/quality outcomesSupport primary care providers (PCPs) through medical management, care coordination, and more

▫ Statewide data and analytics contractor supports RCCOs▫ Statewide data and analytics contractor—supports RCCOs through high-risk patient identification and more

▫ Per member per month (PMPM) payments to PCPs and RCCOs, with possibility for incentive payments, p y p y

▫ ACC as platform for future payment reform efforts▫ For more information:

http://www.nashp.org/sites/default/files/webinars/Jantz_and_Trollanslides pdf_slides.pdf

http://www.colorado.gov/cs/Satellite/HCPF/HCPF/1233759745246

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Examples of 2 Medicaid ACOsExamples of 2 Medicaid ACOs• Oregon Coordinated Care Organizations (CCOs)▫ Each CCO will receive a fixed global budget for▫ Each CCO will receive a fixed global budget for

physical/mental/dental care for each Medicaid enrolleeCCOs must have the capacity to assume risk

▫ CCOs to coordinate care and engage enrollees/providers in g g phealth promotion

▫ 11 “provisionally certified” CCOs approved so far; launch expected by August 2012Projecting sa ings of $3 1 billion o er fi e ears▫ Projecting savings of $3.1 billion over five years

▫ For more information:http://www.oregon.gov/OHA/OHPB/health-reform/ccos.shtmlhttp://washingtonexaminer.com/entertainment/health/2012/05/ore-http://washingtonexaminer.com/entertainment/health/2012/05/oreclears-first-coordinated-care-organizations/672806

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Integrating Care for People Eligible for Integrating Care for People Eligible for Medicare and Medicaid (Dual Eligibles)

• 26 states submitted proposals

• CMS reviewing proposals; start dates in 2013 2014CMS reviewing proposals; start dates in 2013, 2014

• Two models▫ Managed Fee for Service: State and CMS form▫ Managed Fee-for-Service: State and CMS form

agreement under which state can share in savings▫ Capitated: three way contract between CMS, State,

and planand plan▫ Some states choose multiple models

http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-p gMedicaid-Coordination-Office/FinancialModelstoSupportStatesEffortsinCareCoordination.html

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Q estions?Questions?

S i th V l

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Securing the Value

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Considerations in Selecting Program Considerations in Selecting Program Structure

• What are you willing to invest? How much risk are you• What are you willing to invest? How much risk are you willing to take?

• Where are you (and beneficiaries) getting least value?y ( ) g g

• More comprehensiveness (services or covered lives)▫ Increases potential for coordination and cost savings▫ Doesn’t ensure either!▫ Doesn t ensure either!

• What types of MCOs are ‘ready to go’?

• Waiver or State Plan Amendment (SPA)?

• What infrastructure do you have in place? What can you modify or repurpose? What do you need to build borrow ormodify or repurpose? What do you need to build, borrow, or buy?

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Ensure sufficient resources to build and Ensure sufficient resources to build and oversee a strong program• MCO SelectionMCO Selection▫ Select MCOs that will deliver value and understand the

population • Enrollment▫ Offer beneficiaries choice▫ Enroll into the MCO that meets their needs▫ Ensure they understand how to access services

• Payment• Payment▫ Payment amounts high enough to pay for needed care-and low

enough to produce savings▫ Use payment to incent change: shared risk/savings, quality

i tiincentives• MCO oversight▫ Measure and report performance▫ Structure for improving performance at agency and plan levelsStructure for improving performance at agency and plan levels

When Planning for

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When Planning for Medicaid Managed Care

Cl if l• Clarify goals▫ Cost containment▫ Improved access to high performing medical homesp g p g▫ Efficient use of resources, coordinated and integrated

care• Consider the target population• Consider the target population▫ Rural/underserved areas▫ People with disabilitiesC id d d li k• Consider needed linkages ▫ To other systems (long term care, Exchanges) ▫ Among different types of MCOs (physical and mental g yp (p y

health)

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Q estions?Questions?