Alabama Medicaid. APHCA Compliance Academy and Networking Forum. May 24, 2018

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1 Alabama Medicaid APHCA Compliance Academy and Networking Forum May 24, 2018 ROBERT MOON, MD CHIEF MEDICAL OFFICER ALABAMA MEDICAID AGENCY 1

2 AGENDA Medicaid Overview Political Environment Pivot Plan Questions 2

3 Medicaid Overview 3

4 Who Does Alabama Medicaid Serve? FY 2016 by Date of Service Disabled and Blind Children Aged Other Categories Any Age Age 0-18 Age 65 and Over Age Determined by the Social Security Office and have automatic Medicaid eligibility. Children in families below 146% of the Federal Poverty Rate. Adults who are in poverty. Almost all are also covered by Medicare Other adults including pregnant women, parent caretakers, and family planning services % of Expenditures % of Expenditures % of Expenditures % of Expenditures 45% 25% 18% 12% % of Members % of Members % of Members % of Members 22% 51% 9% 18% $10,644 Per Member Per Year $2,556 Per Member Per Year $10,440 Per Member Per Year $3,456 Per Member Per Year 4

5 FY 2017 Medicaid Expenditure Analysis Benefit Payments and Administrative Costs (in millions) Admin $279 4% Non Operating & Major Projects $110 Operating Costs $169 Other $912 14% Alternative Care $365 6% Hospitals $2,236 34% Mental Health $479 7% Total Expenditures $6.490 Billion Physicians $555 9% Pharmacy $718 11% Nursing Home $946 15% 5

6 FY 2017 Medicaid Funding Analysis State and Federal Funding (in millions) FY 17 Source of Funds: $6.490 Billion State Funds $1,946 30% General Fund $732 11% Other State Share Sources $1,214 19% Federal Funds $4,544 70% 6

7 Medicaid Funding Analysis General Fund Share: FY 15 FY 19 $800 $685 State General Fund Usage: FY 15 - FY 19 (in Millions) $722 $732 $806 $757 $600 $400 $200 $- FY 15 FY 16 FY 17 FY 18 FY 19 Appropriated General Fund Dollars 7

8 Average Monthly Enrollees Annual Expenditures Per Enrollee Enrollment and Annual Cost Per Enrollee ,200,000 $7,000 1,100,000 $6,027 $6,238 $5,741 $5,989 $5,895 $5,714 $5,783 $6,066 $6,352 $6,000 1,050,117 1,043,551 $5,000 1,000,000 1,012,125 1,021, , , , , ,594 Annual Compound Growth Rate of Enrollees 3.1% $4,000 $3, , ,187 $2, , $1,000 Number of Monthly Average Enrollees Annual Cost per Enrollee 8

9 Monthly Average Eligibles * 1,100,000 Alabama Medicaid Agency Monthly Average Eligibles 1,050,000 1,000, , , , , * Overall Total Total Without PlanFirst * Fiscal Year to date 9

10 FY 2016 Percent of Population Annually Eligible for Medicaid by County Highest Percentage Wilcox 55% Perry 53% Greene 52% Dallas 50% Lowndes 49% Lowest Percentage Shelby 13% Madison 18% Lee 19% Baldwin 19% Limestone 20% 10

11 Federally Qualified Health Centers (FQHCs) There are 126 FQHCs enrolled as Medicaid providers. Number of FQHC Recipients by County: FY 2017 FQHC Cost and Utlization Summary FY 2015 FY 2016 FY 2017 Amount Paid $45,744,259 $43,356,120 $43,888,819 Unique Recipients 104,158 99,665 99,085 Encounters 310, , ,472 Average Cost per Recipient $439 $435 $443 Average Cost per Encounter $147 $149 $153 11

12 Political Environment 12

13 Alabama Medicaid Workforce Initiative Section 1115 Waiver Demonstration Comment period ended April 2, 2018 Working to submit in the next few weeks 13

14 Pivot Plan 14

15 A Pivot Plan Organization Is NOT an RCO Does NOT take on full risk Does NOT pay providers Does NOT require TPA support (claims payment, risk management, prior authorization, etc.) like an RCO Does NOT require RCO scale upfront investments 15

16 A Pivot Plan Organization Includes the Patient 1 st population, maternity population, and possibly others Is responsible for an enhanced case management system Will have incentives, along with Primary Care Providers, for better outcomes Will have clinical and administrative incentive metrics focused on ambulatory care Will be solely responsible for a pre-defined region 16

17 A Pivot Plan Organization Will have funded quality improvement projects focusing on population priorities such as Substance Abuse Infant Mortality Obesity and Obesity Prevention 17

18 A Pivot Plan Organization Metrics and Benchmarks will focus on items under the control of the Pivot Organization and Primary Care Physicians such as: Well child visits Immunization rates BMI measurements Substance Abuse Care Coordination Prenatal and Post Partum Care Case Management 18

19 A Pivot Plan Organization Future additional functions can be added to this versatile platform Targeted population programs More standardized specialist support Provider supports Public Health Initiatives More 19

20 Pivot Plan Payment Principles Paying for activity Capped budget Earning incentive Using Case Management resources wisely

21 Primary Care Physician Payments Quality Metric Performance Cost Effectiveness PCMH Activities Above payments are achievable if the physician participates with the Pivot Plan Organization Pivot Participation Payment This will take the FFS payment to the current bump rate Base Fee For Service Current Medicaid FFS schedule for those physicians who choose not to participate with the Pivot Plan Organization 21

22 Pivot Plan Physician Incentive Payment Timelines Pivot Physician Incentive Payment Timelines Fall 2018 Winter 2019 Spring 2019 Summer 2019 Fall 2019 Winter 2020 Spring 2020 Summer 2020 Base Timeline Model For July 2020 Payment Patient Attribution Quality Cost Effectiveness PCMH July-18 August-18 September-18 October-18 November-18 December-18 January-19 Data Source Month February-19 March-19 April-19 May-19 June-19 July-19 August-19 September-19 October-19 November-19 December-19 Previous 24 Months Calendar Year w 6 Months Roll Out 12 Months Data w 3 Months Roll Out Quarterly Payment Date January-20 February-20 March-20 April-20 May-20 June-20 July-20 August-20 September-20 Calculated Payments Quality Data Range for First Caculated Payment (July 2020) Cost Effectiveness Data Range For First Calculated Payment (Jan 2020) PCMH Payments made quartly beginning Oct 18. Payments prior to caclulated payments above are distributed to all participating providers.

23 Current Health Homes Data Needs Are inconsistently supported by their organizations Require a high quality analytics staff which is both expensive and difficult to reproduce Function under limitations from the state A new data plan will be utilized to provide actionable data in a timely way. 23

24 Board Structure Boards can be as large as the Pivot Plan Organization desires but must include the following: 50% of the board (regardless of size) must be primary care physicians who practice in the region and participate with the Pivot Plan Organization Hospitals (2 positions) Community Mental Health Center Substance Abuse Treatment facility Federally Qualified Health Center Consumer Representative Included entities can employ no more than one board physician per entity 24

25 Proposed Pivot Plan Network Map (with number of delivering hospitals by county) CMS Rural Designation Region Populations No Yes Total Southwest 101,295 25, ,622 Jefferson/Shelby 120, ,073 East 65,629 45, ,855 Northeast 99,690 7, ,091 Southeast 38,223 68, ,327 Central 55,642 48, ,369 Northwest 39,753 62, ,979 Total 520, , ,315

26 Questions 26