Will the ACA’s Medicaid Changes Improve Outcomes for Schizophrenia? A New Jersey Case Study

Tom Pyle MBA, MS (PsyR), CPRP

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Will the ACA’sMedicaid Changes

Improve Outcomes for Schizophrenia?

A New Jersey Case Study

Presentation at the Recovery Workforce Summitof the Psychiatric Rehabilitation Association at Baltimore, MD

Tom Pyle MBA, MS (PsyR), CPRP June 2014

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TopicFee for service managed care… Integration of PH and BH… Medicaid expansion… Health insurance exchanges… Evidence-based practices.. Community integration… Medical model Recovery model…

The biggest change in 50 years…

How will our loved ones be affected?

Joisey...

Joisey...

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Joisey...

11th most populous (8.9 million)

Highest density (1030 psm)

Most urban (90% in urban areas)

Strongest state executive

“Blue” State

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Joisey... Taxes

Real estate taxes: Nation’s highest… Income tax: 1% pays 50%…

Budget gap: $800 million! Public workers vs. pensionersvs. bond holders

Bonds downgraded: A- 49th of 50 states…

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Joisey...

Budget: $ 33 billion

Pension fund: $47 billion short! Needs $5 billion p.a.!

FY Budgeted Revised2011 02012 $485 mm 2013 $1.029 bn 2014 $1.582 bn $696 mm2015 $2.249 bn $681 mm2016 $3.000 bn ?2017 $3.857 bn ?2018 $4.800 bn ?

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Medicaid: An OverviewThe macro view from 30,000 feet…

Medicaid’s 3 Big Changes…

1. Reform “Innovations” (ACOs) “Benchmark” plans

2. Expansion 25% increase

3. Managed care BH ASO Grant FFS Case Capitated

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…Amidst ACA’s 6 Mechanisms…1. Public program changes (Medicaid)2. Private insurance changes3. Health insurance exchanges

4. Cost containment measures5. Quality improvement measures6. Funding measures (e.g., taxes)

...From 4 Perspectives...

1. Beneficiaries

2. Providers

3. Agencies

4. Government

...3 Subtypes of Beneficiaries...

Beneficiaries

1. Enrolled2. To be enrolled3. Not enrolled

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Considered by... 5 Big Outcomes

1. Access2. Availabilit

y3. Quality4. Cost5. Innovatio

n

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Dealing with... 10 Challenges

1. Coverage: As much?2. Providers: Enough?3. Exchanges: Overlap?4. Transitions: Churn?5. “Woodwork Effect”?6. Measures: Of What?7. Outreach: Possible?8. Implement: Complex?9. Deadlines: Too Tight?10.Agency $: Enough?

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How To Evaluate?...

  Enrolled To be enrolled Not enrolled

Access 

     

Availability 

     

Quality 

     

Cost 

     

Innovation 

     

    

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The Whole Story...

Health insurance for all Individual Mandate Corporate Requirement

Help for those who need it Medicaid Subsidies for premiums and cost-sharing

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What is Medicaid?

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An entitlement

Big funder of… Health care for poor, disabled Safety-net hospitals, LT care

Federal-state partnership FMAP: 50% to 83%

What is Medicaid?

What is “FMAP”?

Federal Medical Assistance Percentage: Federal matching funds to state Medicaid programs.

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What is “FMAP”? ...For NJ

Federal Medical Assistance Percentage

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NJ: 50%

FMAP Map 2014(Snyder & Rudowitz, 2014)

What is “FMAP”? ... Under ACA

Federal Medical Assistance Percentage:

For “new eligibles”:

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What is “FMAP”? ... Under ACA

Federal Medical Assistance Percentage:

For “new eligibles”:

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Till 2017: 100%

What is “FMAP”? ... Under ACA

Federal Medical Assistance Percentage:

For “new eligibles”:

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Till 2017: 100%

By 2020: 90%

Medicaid Expansion, June 2014(Henry J. Kaiser Foundation, 2014)

Medicaid: 4 Constituencies

• Eligibility• Enrollment• Coverage• Cost

Consumers

• Rates• Autonomy• Referrals• Administration• Compliance

Providers

• “Rights”• “Access”• Administration• Quality• Cost

Governments

• Administration• Overheads• Compliance• Cash flow

Agencies27

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Medicaid: 5 Functions(Kaiser Commission on Medicaid and the Uninsured)

Health insurance coverage 31 mm children; 16 mm adults; 16 mm E&D

Long-term care assistance 1.6 mm institutionals; 2.8 mm community-based

Assistance to Medicare beneficiaries 9.4 mm E&D (20% of Medicare enrollees)

Safety net funding 16% national health funding; 35% safety net

hospitals

Funding for state capacity FMAP

Health insurance coverage

Assistance to

Medicare beneficiar

ies

Long-term care assistanc

e

Safety net & system fundingFunding for state capacity

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US: Medicaid: FY 2010 Spend(Centers for Medicare and Medicaid, 2012)

$404.1 billion

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By Contrast...

$404.1 billion $33.0 billion

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US: Medicaid as % of…(Foster, 2012)

GDP: 2.8%Health spending:

15%

15%

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US: Segments Paid by Medicaid (Foster, 2012)

US BH Funding: Medicaid’s Share (Substance Abuse and Mental Health Services Administration, 2013)

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US: Medicaid: Acute/LT Care 2009(Kaiser Commission on Medicaid and the Uninsured)

5 x

US: Spending Per Enrollee, 2010(Young, Rudowitz, & Garfield, 2014)

US: Average Spend Per, by Group(Young, Rudowitz, & Garfield, 2014)

US: Average Spend Per, by Group(Young, Rudowitz, & Garfield, 2014)

US: Average Spend Per, by Group(Young, Rudowitz, & Garfield, 2014)

$30,834 (CT)

$15,893 (CA)$15,747 (PA)

$22,595 (DE)

$19,951 (NJ)

From the NJ FY 2015 Budget... (State of New Jersey, 2014)

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Waste, Fraud, Abuse(Kaiser Commission on Medicaid and the Uninsured, 2012)

Overtreatment Failure of care coordination Failure of care process (Tx) Administration complexity Failure of pricing Fraud and abuse

At least 20% of costs

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Overview: Role in state budgets Counter-cyclical to economy

Largest source of federal revenue ( jobs)

Biggest target for state cost controls

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Overview: How Control Costs?(Substance Abuse and Mental Health Services Administration, 2013)

Medicaid an entitlement

States can only... Reduce provider payments “Manage” utilization Restrict eligibility

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Jerseyans with SZ on Medicaid?(NJ DMAHS, 2014)

Aged 84,962Blind 755Disabled 205,419Non ABD Children 742,286NON ABD Adults 452,154

Total 1,485,576

NJ Medicaid, May 2014

20%? (~40,000?)

NJ population 2010

8,900,000 x 1% ~ 90,000

50%? (~45,000?)

Medicaid Overview

3 Big Changes 5 Big Outcomes FMAP: NJ = 50% 2.8% of GDP 15% of all health spending W,F,A = 20% 18% beneficiaries 45% cost 5 Functions 4 Constituencies

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Mechanics of Medicaid

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Eligibility (3 kinds)

Category

Financial

Resource

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1. Eligibility: Category

Children Pregnant women Parents of certain children Seniors Individuals with disabilities

NOT childless non-elderly adults

Mandatory (before ACA):

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2. Financial: By “FPL”

The Federal Poverty Level (HHS)

2014:Family of 1: $11,670Family of 4: $23,850

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Eligibility: FPL by Class (US)(Kaiser Commission on Medicaid and the Uninsured)

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Eligibility: FPL by Class (NJ)(Kaiser Commission on Medicaid and the Uninsured)

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Eligibility: FPL (After ACA)(Kaiser Commission on Medicaid and the Uninsured; Tate, 2012))

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2. Eligibility: Financial2014 Federal Poverty

Limit (FPL)

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2. Eligibility: Financial

Family of 1: $11,670 x 133% =$15,521

Family of 4: $23,850 x 133% =$31,721

2014 Federal Poverty Limit (FPL)

Eligibility: Childless Adults 2014(Henry J. Kaiser Foundation, 2014)

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Eligibility: ACA’s effect(et al., 2013)

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3. Eligibility: Resource (SSI)

< + (To keep SSI,

net worth < $2000)

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Eligibility: Overlap!(Blahous, 2013)

Medicaid: < 138% FPL. Exchanges: > 100% FPL.

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Enrollment

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US: Medicaid Enrollment?(Centers for Medicare and Medicaid et al., 2012)

Before: 62 mm?

(53 mm PYEs)

After:+ 6 mm more?

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Medicaid: Dual Eligibles 2009(Kaiser Commission on Medicaid and the Uninsured)

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Today’s enrollee demographics(Kenen, 2012)

Poor families with children 2/3rd of enrollees 1/3rd of spending

Elderly and disabled 1/3rd of enrollees (70% in nursing homes) 2/3rd of spending

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“Eligibles” Actually Enrolled?(Sommers & Epstein, 2010)

US average: only ~ 2/3rds !

Enrolled eligibles: Highly variable by state

OK 44% MA 80%

NJ 53%

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US: Currently Enrolled by Groups(Kaiser Commission on Medicaid and the Uninsured)

NJ: Total Uninsured Since 2000(Castro, 2012)

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Coverage

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Medicaid: Focuses on...

Services, not programs

Discrete and individual, not comprehensive

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Medicaid: Benefits (Centers for Medicare and Medicaid, 2013)

Doctor visits Emergency care Hospital care Prescription drugs Long-term care Vaccinations Hearing Vision Preventative care for children

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Medicaid: Must Cover...(Substance Abuse and Mental Health Services Administration, 2013)

Inpatient hospital Outpatient hospital EPSDT Nursing facility Home health Physician Rural health clinic Federally qualified health center (FQHC) Laboratory and X-ray Family planning Nurse midwife Certified pediatric and family nurse practitioner Freestanding birth center (when licensed or otherwise recognized by

the state) Transportation to medical care Tobacco cessation and tobacco cessation counseling for pregnant

women and youth under 21 as part of EPSDT

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Coverage(Garfield, Lave, & Donohue, 2010)

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Challenge: Less Coverage?(Garfield, Lave, & Donohue, 2010)

“Benchmark”EssentialBenefitscoverage

under ACA

Excludable

for newbiesunder ACA

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“Rehab Option”: Its Scope(Substance Abuse and Mental Health Services Administration, 2013)

Service Setting Type of Provider Extent of Coverage

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“Rehab Option”: A Distinction(Substance Abuse and Mental Health Services Administration, 2013)

“Habilitative” services: to develop skills never acquired (as among DD population) Only through home/community-based waiver

“Rehabilitative” services: to restore lost functioning (as among PD population) Not limited to clinical treatment

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Medicaid: Costs

Deductibles

Co-pays

(Opportunity costs)

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Medicaid: Styles

Classic Fee-for-Service

Managed care Contractually-defined services… For an enrolled population… In a closed network… Paid by capitation premiums

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Managed Care: 3 Types

1. Managed care organization (MCO)▪ Capitation: Per person per month▪ Risk: Who accepts it? State or vendor?

2. Primary care case management (PCCM)▪ Case management fee

3. Pre-paid Health Plans (PHP)▪ In-patient ▪ Ambulatory