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Medicaid: My Life as a Commissioner

Medicaid: My Life as a Commissioner. Carol D. Berkowitz, M.D. Medicaid Summit Chicago, IL November 3, 2005. A Year of Forming Coalitions. Meeting with AMSPDC and NACHRI 11/04 AMA Interim Meeting: ACP, ACOG, AAFP endorse principles 12/04; also endorsed by NAPNAP

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Medicaid: My Life as a Commissioner

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  1. Medicaid: My Life as a Commissioner Carol D. Berkowitz, M.D. Medicaid Summit Chicago, IL November 3, 2005

  2. A Year of Forming Coalitions • Meeting with AMSPDC and NACHRI 11/04 • AMA Interim Meeting: ACP, ACOG, AAFP endorse principles 12/04; also endorsed by NAPNAP • Meeting with AMA leadership 03/05: endorse all but entitlement notion • Meeting with Mark McClellan 04/05: work together for quality • Appointment to Medicaid Advisory Commission 07/05

  3. Make up of the commission • Voting members: 15 • Co-chairs: former Gov. Sundquist (TN) and King (ME) • No physicians • Former Medicaid directors • Economist • New additions: Gov. Manchin (WV-D), Gov. Bush (FL-R) • Non-voting members: 15 • 4 physicians • Julie Beckett

  4. Charge to the Commission • Recommend $10 billion in scoreable options by September 1, 2005 • Recommend reform/modernization by December 31, 2006 • Funded for 6 meetings per year • Have had 3 meetings to date • All in DC (plan to move around the country) • Always time allotted for public comment

  5. Creating Scorable Options: 09/01/2005$10 billion over 5 years • Reform Rx reimbursement formula (AWP to AMP): $4.3B • Extend Medicaid drug rebate to MCO: $2B • Change start date of penalty period for asset transfers: $1.4B • Increase “Look-Back” from 3 to 5 years: $100M • Tiered co-pays for prescription drugs:$2B • Reform of MCO provider tax requirement:$1.2B

  6. New York Times: August 18, 2005

  7. Topics to be explored in depth • Medicaid eligible populations • Medicaid acute care delivery system • Long term care delivery system • Quality and information technology in Medicaid • Program administration: Financing, IT and fraud and abuse • Consideration of best practices

  8. Medicaid eligible populations • Children and pregnant women • Assist Medicare beneficiaries with Medicare cost-sharing • People in nursing home (<300% SSI payment) • Working disabled without SSI • “Medically needy” • Disease specific groups

  9. Medicaid eligible populations • Adoption and foster care children who are eligible for Title IV-E • 1/3 of all births in the U.S. • Growth in Medicaid • Capture of Medicaid eligible children during SCHIP outreach: 40-50% of children Medicaid eligible • Loss of parental coverage in low-income workers: for every 1% increase in premiums, 200,000-400,000 individuals lose insurance

  10. Medicaid eligible populations: Questions to address • Should there be minimum national standards? Existing ones OK? • Level of state flexibility? • Should Medicaid remain as “entitlement” program (no-cap)? • How should Medicaid enrollment growth be dealt with?

  11. Medicaid Acute Care Delivery System • Mandatory items and services (includes EPSDT) • Optional items and benefits ( e.g., RX, dental, PCCM) • “Cadillac” analogy: Medicaid offers more than private insurers • SCHIP without EPSDT mandate

  12. Medicaid Acute Care Delivery System:4 Guidelines for States • Benefit must be sufficient in amount, duration and scope (e.g., can’t be 1 inpatient day) • Comparability for all Medicaid eligible groups (not kids!) • “Statewideness” • Freedom of choice for participant

  13. Medicaid Acute Care Delivery System:Questions to address • National standards? • “Cost sharing”? • What should states be able to do? • Make Medicaid more like SCHIP?

  14. Long Term Care Delivery System • Medicaid long-term care • Must cover nursing facility services adults > 21 years • Home health for adults nursing home eligible • Waivers in long-term care • 1915 (c) HCBS Waiver program (cost neutral) • Dual eligible • 74% to 100% FPL • Impact of MMA

  15. Long Term Care Delivery System:Questions to address • National standards? • State discretion versus need for federal approval? • What mechanisms can be used to expand non-Medicaid LTC financing? • Service delivery and finance coordination for dual eligible? • Worry about “woodwork” effect – offer community services and folks cared for by families will “come out of the woodworks”.

  16. Quality and information technology in Medicaid • FFS doesn’t lend itself to quality initiatives • MCOs use of measures • HEDIS • CAHPS: Consumer Assessment of Healthcare Providers and Systems • NCQA Accreditation • Easier to work with 6-10 MCOs than hundreds of thousands of providers

  17. Quality and Information Technology in Medicaid:Questions to address • Require new quality initiatives in Medicaid? Should they be required? • Medicaid’s role in systems-level quality (e.g., medical errors, practice standards)? • Federal government’s role in financing HIT systems in Medicaid?

  18. Program Administration: Financing, IT, and Fraud and Abuse • Overview re Medicaid financing • Concern about Medicaid “maximization” • Fraud and abuse: state, provider, and recipient

  19. Program Administration: Financing, IT, and Fraud and Abuse • FMAP: complex formula, varies 50-80%, depends on per capita income (MD, VA 50%; Mississippi 77.08%) • Administrative services are all 50-50 • Certain services incentivized: Family planning FMAP 90%, IHS 100% • SCHIP with enhanced match ratio • DSH, IGT and UPL

  20. Program Administration: Financing, IT, and Fraud and Abuse • Other Medicaid purposes beyond paying for beneficiaries • GME/IME (though no one could say how much) • Subsidize public providers for other services • Special education ($11 b) • Foster care support • Juvenile justice system

  21. Program Administration: Financing, IT, and Fraud and Abuse • Maximization • IGTs: some are permitted by federal law • No REAL way to determine how much “creative financing” is going on • Lots of unfunded federal mandates that states must adhere to • No Child Left Behind • Bioterrorism preparedness • HIPAA • Special education

  22. Program Administration: Financing, IT, and Fraud and Abuse • Federal task force in many states: Medicaid, FBI, DEA, Postal IG, Treasury, state AG, federal US Atty • Don’t want to make the system too burdensome • Medicaid/Medicare Data Match Projects (California model) • Probably BIG headlines, not large pots of money

  23. Best Practices • Disease Management as a Vehicle for Getting Value in Medicaid • Arizona Access model • ARKids First • ALLKids

  24. Personal reflections • Need to hear from low income families re the system (disabled and CSHCN well-represented) • Thinking outside the box: MediKids or Kids Come First Act (S. 114) • Too much fragmentation: One person can be covered through 3 different pots • Can’t be just driven by the $$, need to consider the people • What’s the role of private insurance and employers (including small businesses and some LARGE employers

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