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Medicaid’s 3 Big Changes: Consequences for Consumers

Presentation for Consumer Providers Association of New Jersey Tom Pyle, Advisor August 2013. Medicaid’s 3 Big Changes: Consequences for Consumers. What’s coming…. What’s coming…. Topic: National & State Change. The biggest changes in 50 years… How will consumers be affected?

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Medicaid’s 3 Big Changes: Consequences for Consumers

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  1. Presentation for Consumer Providers Association of New Jersey Tom Pyle, Advisor August 2013 Medicaid’s 3 Big Changes: Consequences for Consumers

  2. What’s coming…

  3. What’s coming…

  4. Topic: National & State Change The biggest changes in 50 years… How will consumers be affected? What should CPANJ advocate?

  5. ...To Ask Lynn Kovich What 3 Key Questions...

  6. The Whole Thing, in 20 Words... The national thing... The state thing... Comprehensive Waiver Consolidation: 8  1 B H to managed care Contracted  FFS Medicaid rate setting Merger of services MH + SUD • Health insurance for all • Individual Mandate • Corporate Requirement • Help for those who need it • Medicaid • Subsidies

  7. The Whole Thing, in 20 Words... The national thing... The state thing... Comprehensive Waiver Consolidation: 8  1 B H to managed care Contracted  FFS Medicaid rate setting Merger of services MH + SUD • Health insurance for all • Individual Mandate • Corporate Requirement • Help for those who need it • Medicaid • Subsidies

  8. The Whole Thing, in 20 Words... The national thing... The state thing... Comprehensive Waiver Consolidation: 8  1 B H to managed care Contracted  FFS Medicaid rate setting Merger of services MH + SUD • Health insurance for all • Individual Mandate • Corporate Requirement • Help for those who need it • Medicaid • Subsidies

  9. The Whole Thing, in 20 Words... The national thing... The state thing... Comprehensive Waiver Consolidation: 8  1 B H to managed care Contracted  FFS Medicaid rate setting Merger of services MH + SUD • Health insurance for all • Individual Mandate • Corporate Requirement • Help for those who need it • Medicaid • Exchanges • Subsidies

  10. The Whole Thing, in 20 Words... The national thing... The state thing... Comprehensive Waiver Consolidation: 8  1 B H to managed care Contracted  FFS Medicaid rate setting Merger of services MH + SUD • Health insurance for all • Individual Mandate • Corporate Requirement • Help for those who need it • Medicaid • Exchanges • Subsidies

  11. The Whole Thing, in 20 Words... The national thing... The state thing... Comprehensive Waiver Consolidation: 8  1 B H to managed care Contracted  FFS Medicaid rate setting Merger of services MH + SUD • Health insurance for all • Individual Mandate • Corporate Requirement • Help for those who need it • Medicaid • Exchanges • Subsidies

  12. Medicaid’s 3 Big Changes • Reform • “Innovations” (ACOs) • “Benchmark” plans • Expansion • 25% increase • Managed care • BH  ASO • Grant  FFS  Case Capitated

  13. Medicaid’s 3 Big Changes • Reform • “Innovations” (ACOs) • “Benchmark” plans • Expansion • 25% increase • Managed care • BH  ASO • Grant  FFS  Case Capitated

  14. Medicaid’s 3 Big Changes • Reform • “Innovations” (ACOs) • “Benchmark” plans • Expansion • 25% increase • Managed care • BH  ASO • Grant  FFS  Case Capitated

  15. ...From the Perspective of... • Beneficiaries • Providers • Agencies • Government

  16. Considered by... 5 Big Outcomes Access Availability Quality Cost Innovation

  17. Considered by... 5 Big Outcomes Access Availability Quality Cost Innovation

  18. Considered by... 5 Big Outcomes Access Availability Quality Cost Innovation

  19. Considered by... 5 Big Outcomes Access Availability Quality Cost Innovation

  20. Considered by... 5 Big Outcomes Access Availability Quality Cost Innovation

  21. Dealing with... 10 Challenges • Coverage: As much? • Providers: Enough? • Exchanges: Overlap? • Transitions: Churn? • “Woodwork Effect”? • Measures: Of What? • Outreach: Possible? • IT: Too Complex? • Deadlines: Too Tight? • Agency $: Enough?

  22. Dealing with... 10 Challenges • Coverage: As much? • Providers: Enough? • Exchanges: Overlap? • Transitions: Churn? • “Woodwork Effect”? • Measures: Of What? • Outreach: Possible? • Implement: Complex? • Deadlines: Too Tight? • Agency $: Enough?

  23. ...and 1 Big Challenge

  24. What is Medicaid?

  25. What is Medicaid? • An entitlement • Big funder of… • Health care for poor, disabled • Safety-net hospitals, LT care • Federal-state partnership • FMAP: 50% to 83%

  26. What is Medicaid? • An entitlement • Big funder of… • Health care for poor, disabled • Safety-net hospitals, LT care • Federal-state partnership • FMAP: 50% to 83%

  27. What is Medicaid? • An entitlement • Big funder of… • Health care for poor, disabled • Safety-net hospitals, LT care • Federal-state partnership • FMAP: 50% to 83%

  28. What is “FMAP”? Federal Medical Assistance Percentage: % of Federal matching funds to state Medicaid.

  29. What is “FMAP”? ...For NJ Federal Medical Assistance Percentage NJ: 50%

  30. What is “FMAP”? ... Under ACA Federal Medical Assistance Percentage: For “new eligibles”:

  31. What is “FMAP”? ... Under ACA Federal Medical Assistance Percentage: For “new eligibles”: Till 2017: 100%

  32. What is “FMAP”? ... Under ACA Federal Medical Assistance Percentage: For “new eligibles”: Till 2017: 100% By 2020: 90%

  33. Medicaid: SMI Jersyansaffected?(Substance Abuse and Mental Health Services Administration, 2013a) 10% (~42,000?)

  34. Medicaid: Expenditures FY 2010 (Centers for Medicare and Medicaid, 2012) $404.1 billion

  35. By Contrast... $404.1 billion $33.0 billion

  36. Medicaid as % of…(Foster, 2012) GDP: 2.8% Health spending: 15% 15%

  37. Segments % paid by Medicaid (Foster, 2012)

  38. BH Funding: Medicaid’s Share (Substance Abuse and Mental Health Services Administration, 2013)

  39. Medicaid: Acute/LT Care 2009(Kaiser Commission on Medicaid and the Uninsured) 5 x

  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... (~ $80 billion?...)

  41. 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... (~ $80 billion?...)

  42. Enrollment & Shares, 2010(Centers for Medicare and Medicaid et al., 2012) ~ 60 mm

  43. Overview: Role in state budgets • Counter-cyclical to economy • Largest source of federal revenue ( jobs) • Biggest target for state cost controls

  44. Overview: How Control Costs?(Substance Abuse and Mental Health Services Administration, 2013) • Medicaid  an entitlement • States can only...

  45. Overview: How Control Costs?(Substance Abuse and Mental Health Services Administration, 2013) • Medicaid  an entitlement • States can only... • Reduce provider payments

  46. Overview: How Control Costs?(Substance Abuse and Mental Health Services Administration, 2013) • Medicaid  an entitlement • States can only... • Reduce provider payments • “Manage” utilization

  47. 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

  48. Health insurance coverage Medicaid: 5 Components(Kaiser Commission on Medicaid and the Uninsured) • Long-term care assistance • Funding for state capacity • 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 & system funding • 16% national health funding; 35% safety net hospitals • Funding for state capacity • FMAP • Safety net & system funding • Assistance to Medicare beneficiaries

  49. Health insurance coverage Medicaid: 5 Components(Kaiser Commission on Medicaid and the Uninsured) • Long-term care assistance • Funding for state capacity • 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 & system funding • 16% national health funding; 35% safety net hospitals • Funding for state capacity • FMAP • Safety net & system funding • Assistance to Medicare beneficiaries

  50. Health insurance coverage Medicaid: 5 Components(Kaiser Commission on Medicaid and the Uninsured) • Long-term care assistance • Funding for state capacity • 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 & system funding • 16% national health funding; 35% safety net hospitals • Funding for state capacity • FMAP • Safety net & system funding • Assistance to Medicare beneficiaries

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