Medicaid Managed LTSS Updates from the States and the Feds

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1 Medicaid Managed LTSS Updates from the States and the Feds Rachel Patterson Christopher & Dana Reeve Foundation July 20, Summer Leadership Institute

2 Agenda Context: Rising health care costs and delivery system reforms Data Update on MLTSS and Duals Demonstrations Federal Update: Medicaid Managed Care Notice of Proposed Rulemaking Areas for Advocacy

3 Source: Bipartisan Policy Center: A Bipartisan Rx for Patient-Centered Care and System-Wide Cost Containment

4 Projections of National Health Expenditures and Their Share of Gross Domestic Product, Dollars in Billions: $6,000 $5,000 $4,000 $3,000 $2,915 $3,093 $3,273 $3,458 $3,660 $3,889 $4,142 $4,416 $4,702 $5,009 $2,000 $1,000 $0 NHE as a Share of GDP: % 18.3% 18.4% 18.4% 18.4% 18.5% 18.8% 19.2% 19.5% 19.9% SOURCE: Kaiser Family Foundation calculations using NHE data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at (see Projected; NHE Historical and projections, , file nhe65-22.zip).

5 National Health Expenditures per Capita, $16,000 $14,663 (2022) $14,000 $12,000 $10,000 $8,000 $9,216 (2013) $6,000 $4,000 $2,851 (1990) $2,000 Per Capita Projected Per Capita $0 SOURCE: Kaiser Family Foundation calculations using NHE data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at (Historical data from National Health Expenditures by type of service and source of funds, file nhe12.zip; Projected data from NHE Historical and projections , file nhe65-22.zip).

6 Medicare and Medicaid as a Share of the Federal Budget, 2012 Defense 19% Social Security 22% Nondefense Discretionary 17% Medicare 1 16% Other 2 13% Net Interest 6% Medicaid 7% Total Federal Spending, FY2012 = $3.5 Trillion Federal Spending on Medicare, FY2012 = $551 Billion NOTE: FY is fiscal year. 1 Amount for Medicare excludes offsetting premium receipts (premiums paid by beneficiaries, amount paid to providers and later recovered, and state contribution (clawback) payments to Medicare Part D). 2 Other category includes other mandatory outlays, offsetting receipts, and negative outlays for Troubled Asset Relief Program (TARP). SOURCE: Congressional Budget Office (CBO) Medicare Baseline, May 2013.

7 "If we cannot get health-care spending under control there's no hope for the federal budget," says William Gale, a senior fellow at the Brookings Institution. "The main hope, if we don't get health spending under control, is global warming gets us all before health-care spending gets us all."

8 Why Health Care Costs Rise The American Economic Review, December 1963 Asymmetry of Information Medical Care Prices Fee-for-service compensation Traditional Insurance Design Moral Hazard Adverse Selection Insurance Premium Death Spiral Kenneth Arrow

9 (More Reasons) Why Health Care Costs Demographics Rise New (and sometimes better) technologies and treatments Higher health industry wages Administrative Complexity High Income Country

10 Tackling Health Costs: Delivery System Reforms Duals Demos (administrative complexity) Electronic Medical Records (complexity and overtreatment) Accountable Care Organizations (aligning incentives) Integrated care (coordination) Cost-sharing (price sensitivity)

11 Managed Care is Supposed to Solve these Problems Coordinated Care End Fee for Service End overutilization The silver bullet The right care at the right time in the right place, no more and no less 2015 Summer Leadership Institute

12 Growth in Medicaid Long-Term Services and Supports Expenditures, FY 2002 FY 2011 (in billions) $93 32% $101 37% $111 $115 41% 42% $123 $125 45% 45% Home and Community- Based Services (HCBS) Institution-Based Services 68% 63% 59% 58% 55% 55% NOTE: Home and community-based care includes state plan home health, state plan personal care services and 1915(c) HCBS waivers. Institutional care includes intermediate care facilities for individuals with intellectual/developmental disabilities, nursing facilities, and mental health facilities. SOURCE: KCMU and Urban Institute analysis of Centers for Medicare & Medicaid Services (CMS)-64 data.

13 Medicaid Long-Term Services and Supports (LTSS) Users Accounted for Nearly Half of Medicaid Spending, FY 2010 Enrollees 94% Expenditures 57% People Who Did Not Use LTSS People Who Used Institutional LTSS 2% 4% 22% 21% 43% Total = Series 66.4 million 1 Total = Series $ billion People Who Used Community-Based LTSS NOTE: Individuals who used both institutional and community-based services in the same year are classified as using institutional services in this figure. SOURCE: KCMU and Urban Institute estimates based on data from FY 2010 Medicaid Statistical Information System (MSIS) and Centers for Medicare & Medicaid Services (CMS)-64 reports. Because the 2010 data were unavailable, 2009 data were used for CO, ID, MO, NC, and WV, and then adjusted to 2010 CMS-64 spending levels.

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15 Comprehensive Medicaid Managed Care Models in the States, 2014 WA OR NV CA ID AZ UT MT WY CO NM ND SD NE KS OK MN WI IA IL MO AR MS MI OH IN KY TN AL VT NY PA WV VA NC SC GA ME NH MA CT RI NJ DE MD DC AK TX LA As of July 1, 2014 FL HI MCO only (26 states including DC) MCO and PCCM (13 states) PCCM only (9 states) No Comprehensive MMC (3 states) NOTES: ID s MMCP program, which is secondary to Medicare, has been re-categorized by CMS from a PAHP to an MCO by CMS but is not counted here as such. CA has a small PCCM program operating in LA county for those with HIV. SOURCE: KCMU survey of Medicaid officials in 50 states and DC conducted by Health Management Associates, October 2014.

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18 Dual eligible beneficiaries as a share of Medicare and Medicaid population and spending, 2008 Dual Eligibles as a Share of the Medicare Population and Medicare Spending, 2008: Dual Eligibles as a Share of the Medicaid Population and Medicaid Spending, 2008: 80% 69% 85% 61% 20% 31% 15% 39% Total Medicare Population, 2008: 46 Million Total Medicare Spending, 2008: $424 Billion Total Medicaid Population, 2008: 60 Million Total Medicaid Spending, 2008: $330 Billion SOURCE: Kaiser Family Foundation analysis of the CMS Medicare Current Beneficiary Survey Cost and Use File, 2008, and Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on data from FY2008 MSIS and CMS Form-64.

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20 MLTSS Themes Increasing adoption across the board All include aging/physical disability, some include people with I/DD Some increased access to HCBS Some include quality measures Some include beneficiary protections Almost all require enrollment Advocates push for protections

21 Cost savings Affordable Care Act What s the Rush? Trend toward coordinated care Delivery system reforms People with I/DD often last group into managed care 2015 Summer Leadership Institute

22 Concerns Few savings available in our system Lack of experience serving people with disabilities Medical model of services Mechanism to cut services 2015 Summer Leadership Institute

23 Managed Care is a Tool Potential Benefits Improved Coordination Prevention, wellness, and reduced health disparities Rebalancing and options for self-direction Concerns Limited choice of providers Medical model of intervention Lack of experience serving people with I/DD Reinvestment of savings, reduced waiting lists Non-medical social services Need for strong state oversight Need for stakeholder input and strong contract 2015 Summer Leadership Institute

24 Medicaid Managed Care Notice of Proposed Rulemaking First regulatory update since 2002 Recognizes LTSS Beneficiary protections Quality measures Stakeholder engagement Information and access

25 Elements of the Rule Enrollment and Disenrollment protections LTSS woven throughout the proposed rule Beneficiary Support System Stakeholder engagement Network adequacy Nondiscrimination Theme: State should or may 2015 Summer Leadership Institute

26 Beneficiary Support System General: Choice Counseling Training for MCOs on community-base services Enrollee assistance understanding MC Outreach to enrollees LTSS: Access point for complaints Grievance & appeal education, representation Review of data to guide state on problem areas 2015 Summer Leadership Institute

27 Comments Strengthen protections Enhance LTSS standards Authorize LTSS consistent with need Ensure robust provider networks Increase stakeholder engagement

28 What next? Get involved in your state Get to know the devil you don t Advocate for, and join, stakeholder groups Look up President s Committee for People with ID report on MLTSS Look up CMS 2013 Guidance on MLTSS 2015 Summer Leadership Institute

29 Areas for Advocacy Enrollment & disenrollment Stakeholder engagement Readiness of and transition planning Enhanced HCBS, including self-direction Quality measures Beneficiary support Ombudsman services Choice counseling Grievance and appeal Continuity of care LTSS network adequacy 2015 Summer Leadership Institute

30 Medicare and Medicaid Personally Important To Majority Of Public How important for you and your family is each of the following? Very important Somewhat important Not too important Not at all important Medicare 54% 23% 12% 10% Medicaid 38% 23% 16% 22% NOTE: Don t know/refused answers not shown. SOURCE: Kaiser Family Foundation/Robert Wood Johnson Foundation/Harvard School of Public Health, The Public s Health Care Agenda for the 113th Congress (conducted January 3-9, 2013)

31 There are people whose job it is to care about the budget Summer Leadership Institute

32 Our job is to care about people 2015 Summer Leadership Institute

33 Questions 2015 Summer Leadership Institute