Some Speech Titles Are Better Spoken Than Written. Hot Issues in Health Care December 5, 2017 Alan Weil Editor-in-Chief Health Affairs
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1 Some Speech Titles Are Better Spoken Than Written Hot Issues in Health Care December 5, 2017 Alan Weil Editor-in-Chief Health Affairs
2 Because Whither: (adv) to what situation, position, degree or end Wither: (v) to lose vitality, force or freshness So I ask: Whither (or Wither) Medicaid managed care?
3 What I m Going To Cover What do I mean by managed care? The phases of MMC The evolving rationale for MMC Looking forward
4 The Phases of MMC MMC Beta (1970s) MMC 1.0 (1990s) MMC 2.0 (2000s) MMC 3.0
5 MMC Beta D Onofrio et al., Public Health Report (1977)
6 The Early Rationale (1.0) Improved access, especially to primary care Reduced institutional care Budget savings Budget certainty
7 State Ceded to MCOs Provider enrollment Provider payment rates Claims payment Utilization controls
8 States Took On MCO selection MCO rate setting Beneficiary enrollment in MCOs But none of the old functions went away...
9 And Then States Realized They Had To Also Handle MCO contract oversight MCO shadow claims MCO transitions Carve outs Coverage adjudication
10 And They Did And some even got pretty good at it!
11 And So Did The MCOs
12 Growth in the Share of Medicaid Beneficiaries Enrolled in Managed Care, Percent enrolled in managed care I WAS HERE Figure % 47.8% 53.6% 55.6% 55.8% 23.2% 29.4% 9.5% 11.8% 14.4% Millions of People: Note: Includes full-risk and PCCM arrangements. SOURCE: CMS, 2001.
13 Medicaid Managed Care Enrollment, by State, 2000 WE WERE HERE Figure 2 <25 percent (7 states) National Average = 55.8% 25 to <75 percent (29 states + DC) 75+ percent (14 states) Note: Includes full-risk and PCCM arrangements. SOURCE: CMS, 2001.
14 But...50% of Enrollees 50% of $ Disabled 15% Elderly 9% Disabled 42% Adults 27% Elderly 21% Children 48% Adults 15% Children 21% Enrollees Total = 68.0 Million Expenditures Total = $397.6 Billion SOURCE: KCMU/Urban Institute estimates based on data from FY 2011 MSIS and CMS-64. MSIS FY 2010 data were used for FL, KS, ME, MD, MT, NM, NJ, OK, TX, and UT, but adjusted to 2011 CMS-64.
15 The Evolving Rationale (2.0) Accountability for outcomes Care management Reallocation of resources Medicare integration Oh yes, and money and ideology and politics
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20 Figure 1 Comprehensive Medicaid Managed Care Penetration WE ARE HERE by State, October 2010 WA OR NV CA ID UT AZ MT WY CO NM ND SD NE KS OK MN WI IA IL MO AR MS VT NY MI PA OH IN WV VA KY NC TN SC AL GA ME NH MA CT RI NJ DE MD DC TX LA AK FL HI U.S. Overall = 65.9% NOTE: Includes enrollment in MCOs and PCCMs. Most data as of October SOURCE: KCMU/HMA Survey of Medicaid Managed Care, September % - 50% (9 states) 51% - 65% (15 states) 66% - 80% (17 states and DC) 80%+ (9 states)
21 The New State Challenges Quality oversight Disruption Risk adjustment No agreed upon yardstick to measure success
22 MACPAC on Managed Care
23 MMC 3.0 Addressing social and clinical needs of the most vulnerable and sometimes medically complex patients
24 Where Are the Dollars? Acute Care Long-Term Care $16,643 $6,137 $13,249 $9,158 $2,463 $2,399 $3,247 $3,234 $10,505 $4,091 Children Adults Individuals with Disabilities Elderly SOURCE: Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on data from FY 2011 MSIS and CMS-64 reports. Because 2011 data were unavailable, 2010 MSIS data were used for FL, KS, ME, MD, MT, NM, NJ, OK, TX, and UT. Data for these states were adjusted to 2010 spending levels.
25 Exhibit 3 Adults with High Needs Have Unique Demographic Characteristics Total adult population Three or more chronic diseases, no functional limitations Three or more chronic diseases, with functional limitations (high need) 55% 52% 58% 63% 67% 77% 72% 52% 83% 83% 31% 28% 30% 27% 28% 41% 26% 38% 17% 16% 14% Age 65+ Female White race No high school degree Income below 200% FPL Public insurance Fair or poor health status Notes: Noninstitutionalized civilian population age 18 and older. Public insurance includes Medicare, Medicaid, or combination of both programs (dual eligible). Data: Medical Expenditure Panel Survey (MEPS). Analysis by C. A. Salzberg, Johns Hopkins University. Source: S. L. Hayes, C. A. Salzberg, D. McCarthy, D. C. Radley, M. K. Abrams, T. Shah, and G. F. Anderson, High-Need, High-Cost Patients: Who Are They and How Do They Use Health Care? The Commonwealth Fund, August 2016.
26 What Should A State Make? What Should A State Buy? Provider panels & payment? Data analytics & care management? Social services? Social change?
27 Whither Managed Care?
28 Follow us
29 Acute-Care Benefit Carve-Outs in Medicaid MCOs Number of states reporting carve-out: Dental care 25 Outpatient behavioral health Inpatient behavioral health Outpatient substance abuse 19 Non-emergency transportation Prescription drugs Inpatient detoxification 12 Vision care 5 Other 15 NOTE: 36 states contract with MCOs. SOURCE: KCMU/HMA Survey of Medicaid Managed Care, September 2011.
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