Top 10 Medicaid Spends and Trends That Need to be Fixed

Jeffery Thompson, MD MPHWashington State Medicaid

Washington State Medicaid will pay vaginal rates for •DRG 371‐CESAREAN SECTION W/O CC and •DRG 373‐VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES

10: Medicaid delivers 50% of U.S. infants –we can do better than a 10% increase in C-

sections annually

9: Medicaid’s pharmacy budget is 85% brand – we need better value with generics

8: Medicaid Clients use the ER for non-Emergent Conditions: Changes in benefits can the management needed but we need to

give communities tools

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Medicaid Purchasing Administration ER Proposal > 3 Emergency Room Non‐Emergent Visit Frequency  

7: Medicaid is the largest payer of Mental Health Drugs and Substance Abuse Treatment– we can do better by giving provider feedback and using

EMR effectively

The MMDLN Motto Shameless Sharing and Stealing

6: Medicaid’s spends 25% of the pharmacy budget on AAP – we need to define “Too Much”

5: Medicaid’s Medical Homes are models for better value: if you can change client,

provider and system behaviors

4: Medicaid has high readmission rates –we need to keep them out of hospitals

3: Five percent of our clients are responsible for 50 percent of our costs –

we need better chronic care management.

2: Twenty percent of Medicaid providers see 80% of our patients

And the No. 1 spend and trend that needs

to be fixed….

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1: Medicaid wastes approximately one-third of its spending on services have lower value: Evidence

Benefits, Rates and Policies are Possible

Zero co-payments• Vaccines • Generic Drugs• Low cost •Technology with evidence Higher Co-payments

• Brand drugs with generics• Least costly brand• New technology without

evidence

Zero 25% 50% 75% 95%Increasing Cost Sharing or change the Rates

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Take your Medical Director to Lunch

Questions?