MEDICAID REFORM PROPOSAL Stakeholder Meeting August 24, 2004.
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Transcript of MEDICAID REFORM PROPOSAL Stakeholder Meeting August 24, 2004.
MEDICAID REFORM PROPOSAL
Stakeholder MeetingAugust 24, 2004
Georgia Department of Community Health
2
Medicaid Growth is Unsustainable!
• In FY2005, Medicaid will require 43% of all new state revenue
• By FY2008, Medicaid will require over 50% of all new state revenue.
• By FY2011, Medicaid will require 60% of all new state revenue.
$0.0
$200.0
$400.0
$600.0
$800.0
$1,000.0
$1,200.0
in m
illi
on
s
FY05 FY06 FY07 FY08 FY09 FY10 FY11
New State Revenues New Medicaid Need
FY05 FY06 FY07 FY08 FY09 FY10 FY11
New Revenue (Discretionary)
60% 56% 55% 52% 47% 46% 40%
New Revenue (Medicaid)
43% 44% 45% 48% 53% 54% 60%
Georgia Department of Community Health
3
Percent of All New Revenue Required by the Medicaid
Program
35%
40%
45%
50%
55%
60%
65%
FY05 FY06 FY07 FY08 FY09 FY10 FY11
New Revenue Available for Other State InvestmentsNew Revenue Required by Medicaid
Georgia Department of Community Health
4
Utilization Management is a Necessity
$1
$101
$201
$301
$401
$501
$601
$701
FY05 FY06 FY07 FY08 FY09 FY10 FY11
(in M
illio
ns)
Medicaid utilization drives more than 35% of total growth year over year
Utilization Growth
Enrollment & Price Growth
From FY05 to FY10 utilization is expected to increase in the following major categories of service:
Inpatient Admissions = 23%
Physician Visits = 42%
Prescriptions = 30%
Outpatient Hospital Visits = 34%
Georgia Department of Community Health
5
Quality Indicators HealthCheck Comparative
Data
50.0%
55.0%
60.0%
65.0%
70.0%
75.0%
Participation Screenings0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
18.0%
20.0%
Lead
National Data Georgia Data
Georgia and National data is current except where noted below.
National Participation & Screenings are FFY 98
National Lead Screening is FFY 0268.0%
70.0%
72.0%
74.0%
76.0%
78.0%
80.0%
Immunizations
Georgia Department of Community Health
6
Quality Indicators ER Utilization Per 1,000
0
100
200
300
400
500
600
700
800
900
1000
Georgia Better Health Care FY2001 APHSA Medicaid MC Plans HEDIS Benchmark FY2001
State Health Benefit Plan FY2003 Medstat Employer (Commercial) Client Data FY2003
Georgia Department of Community Health
7
Why Medicaid Reform? To focus on system-wide improvements
in performance and quality To consolidate fragmented systems of
care To control unsustainable trend rate in
Medicaid expenditures To adopt a “management of care”
approach to achieve the greatest value for the most efficient use of resources
Georgia Department of Community Health
8
Goals of Reform Improve health care status of member
population Establish contractual accountability for
access to and quality of healthcare Lower cost through more effective
utilization management Budget predictability and administrative
simplicity
Georgia Department of Community Health
9
Vision
To create a statewide, full-risk organized system of care for
Medicaid and PeachCare members that incorporates Georgia-specific
initiatives as well as “best practices” for the provision and
purchasing of healthcare.
Georgia Department of Community Health
10
Strategy
A successful model for the “management of care” for Georgia Medicaid involves:
An organized system of care Responsibility for case oversight A network of contractually accountable
providers to ensure both quality and cost containment
Medically based guidelines for appropriate treatment leading to healthy outcomes
Georgia Department of Community Health
11
Population-based Strategy
Enrollment by Subprogram
79%1,048,697
21%275,105
CMOPopulations
All Other
Expense by Subprogram
61%$3.5 Billion
39%$2.2 Billion
DCH will apply different strategies for reform based upon the unique needs of our populations.
Part I will include Low-income Medicaid adults and children PeachCare for Kids, Right from the Start Medicaid and Refugees Part II will include the Elderly and Disabled, Medically Fragile Children and Foster Children
Georgia Department of Community Health
12
The Plan – Part I Regionalized approach – 6 geographic regions Competitive procurement for up to 2 care
management organizations (CMOs) in each region
CMOs will: Be licensed by Georgia Department Of Insurance
as risk-bearing entities Be subject to net worth and solvency standards Have demonstrated ability to provide all covered
healthcare services and an adequate provider network
Georgia Department of Community Health
13
Proposed CMO Regions & Eligible Member Counts – Avg. Member/Month – FY 2004
DADE
CHATTOOGA
WALKER
CHEROKEE
HARALSON
GORDON
DOUGLAS
RABUN
JACKSON
MURRAYGILMER
FORSYTH
CATOOSA FANNIN
LUMPKIN
BARTOW
PICKENS
FLOYD
PAULDING
COBBPOLK
UNIONTOWNS
FRANKLIN
WHITE
STEPHENS
DAWSONHALL
OGLETHORPE
BANKS
COWETA
MADISON
GWINNETT
CLAYTON
CLARKE
HART
FULTON
HEARD
DEKALB
FAYETTE
LAMAR
HENRY
NEWTON
SPALDING
CARROLL
TROUP
HANCOCK
PIKE
MORGAN
JEFFERSON
BARROW
WALTONOCONEE
ELBERT
GREENE
WILKES
JASPERBUTTS
UPSON
LINCOLN
WARREN
PUTNAM
COLUMBIA
BURKE
WASHINGTON
BALDWINJONES
MONROE
WILKINSONBIBB
CRAWFORD TWIGGS
BLECKLEY
EMANUELJOHNSON
JENKINSSCREVEN
BULLOCH
DODGE
HOUSTON
PEACH
TALBOTHARRIS
MUSCOGEE
CHATTAHOOCHEEMARION
STEWART SUMTER
SCHLEYDOOLY
PULASKI
WILCOXTELFAIR
WHEELER
BEN HILLLEETERRELL
RANDOLPH
QUITMAN
WORTHDOUGHERTYCALHOUNCLAY
CRISP
TURNER
TIFT
COFFEE
JEFF DAVIS
TREUTLEN
TOOMBS
APPLING
TATTNALL
WAYNEBACON
COLQUITTMITCHELL
EARLY BAKER
SEMINOLE
DECATUR GRADY THOMAS BROOKS
COOK
LOWNDES
ECHOLS
LANIER
ATKINSON
WARE
PIERCE
BRANTLEY
CHARLTON CAMDEN
GLYNN
LONG
LIBERTY
BRYAN
MCINTOSH
EFFINGHAM
CHATHAM
CANDLER
EVANS
IRWIN
BERRIEN
MILLER
RICHMOND
TAYLOR
CLINCH
TALIAFERROMCDUFFIE
MACONMONTGOMERY
WEBSTER
GLASCOCK
ROCKDALE
MERIWETHER
HABERSHAM
WHITFIELD
LAURENS
Atlanta
North
East
Central
Southeast
Southwest
155,940
499,334
79,851
148,995
114,624131,336
Rev. 12/20/04
Georgia Department of Community Health
14
The Plan – Part IAdditional preferred attributes for considerationof CMOs:
Incorporate technological advances (i.e. electronic prescribing and telemedicine)
Focus on the education and empowerment of the Medicaid member
Introduce elements of consumerism to Medicaid members to drive better healthcare choices (i.e. financial incentives and quality information)
Incorporate disease and case management functions as part of their medical management strategy
Georgia provider-owned/sponsored organizations
Georgia Department of Community Health
15
The Plan – Part I
Required enrollment for: Low-income Medicaid adults and children PeachCare for Kids Right from the Start Medicaid Refugees
CMO enrollment mandatory, but: Enrollees will have 30 days to select one of at least two
CMOs Enrollees will have 90 days to change CMO without cause;
thereafter, will remain in selected CMO until one-year anniversary
Georgia Department of Community Health
16
The Plan – Part ICMOs will be responsible for providing allcovered Medicaid services, which include:
Physician visits, laboratory and diagnostic testing, and inpatient and outpatient hospitalization
Mental health and substance abuse treatment Pregnancy-related services Prescription drugs Dental and vision care services (to eligible populations) Screening and preventive services (to eligible
populations) Durable Medical Equipment
Georgia Department of Community Health
17
The Plan – Part I
CMOs will not be responsible for: ICFMR- Intermediate Care Facility/Mentally
Retarded HCBS- Home and Community-based
Services under a 1915 (c) waiver Other long-term services
Georgia Department of Community Health
18
Healthcare Delivery and Access Standards
DCH will protect the patient/provider relationship by contractually requiring
CMOs: To have sufficient numbers of providers of
both primary and specialty care To include sufficient numbers of safety-net
providers and rural and critical access hospitals
To have a culturally appropriate mix of providers
Georgia Department of Community Health
19
Rights of Members
DCH will contractually require CMOs to provide
to members: Bi-lingual written materials and oral
interpretation services Clear information on grievance and appeal
rights Multiple means to access CMO member
services
Georgia Department of Community Health
20
Rights of Providers
DCH will contractually require CMOs to provide
healthcare providers with: Prompt payment and adherence to State
reimbursement policies Expedited grievance and appeal processes Multiple means to access CMO provider
resources
Georgia Department of Community Health
21
Quality Management
DCH will require CMOs to have an internalprogram that monitors and assures DCH-mandated:
Levels of service quality and efficiency Outcomes and health status targets
Contractual obligations will prevent the CMOs from sub-optimal provision of healthcare
Georgia Department of Community Health
22
Quality ManagementDCH will require CMO reporting on:
Well child visits and childhood immunizations Rates of breast cancer and cervical cancer
screening Rates of diabetic eye exams and HgbA1c testing Early initiation of prenatal care and incidence of
C-Sections Appropriateness of emergency room utilization Incidence of avoidable procedures Other possible quality indicators
Georgia Department of Community Health
23
Reform Strategy – Part IIWho is not included in the CMOs:
Elderly and Disabled Medically Fragile Children Foster Children
And what is our strategy for them?…An overview of Part II
Georgia Department of Community Health
24
Care Management for Elderly and Disabled – Part
IIAn initial strategy of statewide diseasemanagement programs focusing on:
Congestive Heart Failure Diabetes Chronic Obstructive Pulmonary Disease
Programs to reach and manage both Medicaid and SHBP members
Programs could be implemented as early as July 1, 2005
Georgia Department of Community Health
25
Care Management for Elderly and Disabled – Part
II A longer-term, more comprehensive strategy in development
for 275,105 Medicaid members in Elderly and Disabled sub-programs
Will be consistent with new policy direction of DHR Will be coordinated with the Governor’s Office and DHR Will combine vigorous assessment and case management with
traditional fee-for-service reimbursement to providers Vouchers for self-directed care could be made available for
those eligible and able to manage Health outcomes improved and utilization reduced through
oversight and management by a statewide ASO vendor Vendor incentivized to attain outcomes and cost goals Program could be moved to full risk over time
Georgia Department of Community Health
26
Timeframe Development of System of Organized Care Model - September 1 – October
30 Statewide consensus building Development of SPA & RFP/Contract
Administrative Functions Submit SPA & RFP/Contract to CMS for review (CMS approval
mandatory and can take 90+ days) Release RFP (target is 1st week of January 2005, pending CMS approval) Evaluation of RFP responses Contract decisions made Contracts negotiated and signed Readiness evaluation
Implementation – January 1, 2006 Implement CMOs in two/three regions, with remaining two/three
regions phased in during the next 6 – 12 months
Georgia Department of Community Health
27
Conclusion
Current trend for the Medicaid program is unsustainable
A more efficient and effective system for appropriate utilization management is necessary
This plan will create a more organized and accountable system of care
Quality outcomes must be a primary goal
Georgia Department of Community Health
28
Questions & Comments