September 24, 2014 Pam Coleman - PowerPoint Presentation

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September 24, 2014Pam ColemanSenior Consultant

Medicaid Managed Care

Trends and OpportunitiesSlide2

About Sellers DorseySellers Dorsey is a national healthcare consulting firm that navigates the ever-changing landscape within the public and private sector. Together with its clients, Sellers Dorsey realizes opportunities that enhance the bottom-line and ultimately improve the lives of people.

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About the presenterPam Coleman, Senior Consultant, leads projects focusing on long term services and supports, a rapidly growing area of healthcare. She brings a deep background in managed care techniques in delivering LTSS to a diverse population. Pam frequently presents at national conferences on complex care populations and integrated delivery systems. Most recently Pam served as the Senior Vice President of Government Programs at

OptumHealth

after dedicating 26 years to the Texas Health and Human Services Commission

.

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Today we will: 4

Review Medicaid Managed Care growth.

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Today we will: 5

Review a “top ten list” of market trends.

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Review Medicaid Managed Care growth.

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Today we will: 6

Review a “top ten list” of market trends.

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Highlight select opportunities to leverage emerging trends.

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Review Medicaid Managed Care growth.

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Medicaid Population and Spending - 2012

Total Medicaid Population:

50M Members

Source: Slide8

Medicaid Population and Spending - 2012

Total Medicaid Population:

50M Members

Temporary Assistance

to Needy Families

(TANF)

36M Members

$163B Spend

Source: Slide9

Medicaid Population and Spending - 2012

Total Medicaid Population:

50M Members

Temporary Assistance

to Needy Families

(TANF)

36M Members

$163B Spend

Aged Blind

and Disabled

(ABD)

14M Members

$265B Spend

Source: Slide10

Medicaid Population and Spending - 2012

Total Medicaid Population:

50M Members

Temporary Assistance

to Needy Families

(TANF)

36M Members

$163B Spend

Aged Blind

and Disabled

(ABD)

14M Members

$265B Spend

Children

25M Members

$80B Spend

$3,246 PMPY

Source: Slide11

Medicaid Population and Spending - 2012

Total Medicaid Population:

50M Members

Temporary Assistance

to Needy Families

(TANF)

36M Members

$163B Spend

Aged Blind

and Disabled

(ABD)

14M Members

$265B Spend

Children

25M Members

$80B Spend

$3,246 PMPY

Adults (pre-expansion)

11M Members

$56B Spend

$4,841 PMPY

Source: Slide12

Medicaid Population and Spending - 2012

Total Medicaid Population:

50M Members

Temporary Assistance

to Needy Families

(TANF)

36M Members

$163B Spend

Aged Blind

and Disabled

(ABD)

14M Members

$265B Spend

Children

25M Members

$80B Spend

$3,246 PMPY

Adults (pre-expansion)

11M Members

$56B Spend

$4,841 PMPY

Dual Eligibles

9M Members

$160B Spend

$19,758PMPY

Source: Slide13

Medicaid Population and Spending - 2012

Total Medicaid Population:

50M Members

Temporary Assistance

to Needy Families

(TANF)

36M Members

$163B Spend

Aged Blind

and Disabled

(ABD)

14M Members

$265B Spend

Children

25M Members

$80B Spend

$3,246 PMPY

Adults (pre-expansion)

11M Members

$56B Spend

$4,841 PMPY

Dual Eligibles

9M Members

$160B Spend

$19,758PMPY

Non Duals

5M Members

$104B Spend

$17, 337 PMPY

Source: Slide14

Growth Predictions for Medicaid Managed CareCurrently two-thirds of Medicaid members are served through managed care20% growth in Medicaid managed care in 2014

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28 states with Managed LTSS by 2015

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75

Million Medicaid members in Medicaid managed care by 2020 (compared with 40 Million in 2014)

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All but Alaska and Wyoming have all or a portion of their Medicaid population in a managed care system (includes PCCM)

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Avalere -

Analysis: Medicaid Plans Expected to Grow 20% This Year Under ACA Expansion – January 2014

http://www.ahcancal.org/News/news_releases/Pages/Surge-of-Medicaid-Managed-Care-is-Fraught-with-Problems-Unless-Root-Concerns-are-Addressed.aspx

HMA projections

HMA

, based on CMS, Office of the Actuary, September 2013 “

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-and-Systems/Downloads/2011-Medicaid-MC-Enrollment-Report.pdfSlide15

ABD environment as of November 2013

Managed Care for Seniors and Persons with Disabilities

Existing ABD (29)

Transitioning to ABD (4)

Remaining FFS (17)Slide16

Source: Kaiser Family Foundation – August 28, 2014

Current Status of State Medicaid Expansion Decisions

Implementing Expansion (28)

Open Debate (2)

Not Moving Forward Now (17)Slide17

Source: Kaiser Family Foundation – August 28, 2014

Medicare Medicaid Integration Program

States PursuingSlide18

Medicare Medicaid Integration Program (Capitated vs FFS)

Capitated

Fee for Service

*Washington pursuing FFS and capitatedSlide19

Source: Kaiser Family Foundation – August 28, 2014

Medicare Medicaid Integration Program (MOUs)

With MOU

Without MOUSlide20

Medicare Medicaid Integration Program (Enrolling)

Currently Enrolling*

Not Enrolling

* Washington enrolling in FFSSlide21

Trends

in

Medicaid Managed CareSlide22

Trend 1: Movement to Managed Long Term Services and SupportsCurrently 24 states have implemented MLTSSMLTSS includes nursing facility and community based services and supports

Goal is to integrated physical, behavioral, and LTSS in a person centered plan of care

Requirements for service coordination

Assessment of all members to determine unmet needs

Flexibility in services – in lieu of services

Focus on

serving

members in the most integrated setting and transitioning persons out of institution

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Trend 2: New Medicaid Populations for Managed CareMedicare Medicaid dual eligible populationAdults with disabilitiesChildren with Special Health Care Needs

Persons with Intellectual and Developmental Disabilities

Foster Care Children

Medicaid Expansion population

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Trend 3: Focus on Quality Improvement and PerformanceBegins with the contract - Value based purchasing conceptsPerformance incentives and disincentiveShared savings models

New quality measures for MLTSS are under development

Evidence-based, best practices to detect both under and overutilization of LTSS

Member and Provider Complaints and Grievances analyses

Member Satisfaction Survey

MLTSS-oriented Performance Improvement Projects

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Trend 4: Person Centered Service IntegrationSection 2402(a) of the Affordable Care Act requires the Secretary to ensure all states receiving federal funds develop service systems that are

responsive to the needs and choices

of beneficiaries receiving home and community-based long-term services (HCBS),

maximize independence

and

self-direction

, provide support coordination to assist with a

community-supported life, and achieve a more consistent and coordinated approach to the administration of policies and procedures across public programs providing HCBS.

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Trend 5: Carve-Ins Instead of Carve-OutsMost Medicaid Directors agree that services should be carved-in when possibleCarve-ins support trend of integration of care

Widespread view that medical issues cannot be addressed without also addressing behavioral issues, pharma, and community supports

Integration hindered by lack of progress in developing EMRs among providers of behavioral health services

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Trend 6: Increased Regulatory RequirementsIncrease focus on fraud and abuseIncrease regulations around rate setting methodology

Increased focus on quality ratings and outcomes

Increased focus on Network Adequacy

Increased focus on readiness review processes

Expansion of reporting requirements

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Trend 7: Rate SettingRisk adjustment programs that account for both clinical and community support needsRates that are actuarially soundMedical expenses to include care coordination, health homes, and other similar activities

Rates that consider new medical technologies

Rates that consider new medications like Sovaldi

MLR requirements should consider MLTSS and

pass-

throughs

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Trend 8: Focus on High Cost Members and Services5% of Medicaid Managed care membership drives 50% of the expensesNeed for MCOs to target these high cost, high risk members for in-home interventions

Biggest cost drivers are ED and inpatient services

Focus also on post-acute care and short term interventions

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Trend 9: Information Systems, Technology, and ReportingComprehensive, accessible, and integrated real time electronic health records and care management platformsIT hardware for field-based staff (laptops, cell phones, portable printers/faxes, etc.)

Electronic Verification Systems for home-based services

Risk stratification and

Comprehensive performance reporting metrics

Telemedicine

, and

telepysch

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Trend 10: The Future of Medicaid Managed CareThe total cost of Medicaid will continue to increase and there are increased pressure to reduce costs

Managed care saving typically represent 3-4%

Managed care produces short-term savings yet there remains concerns about the long-term trend toward increased costs

The movement to ACOs, Health Homes and other initiatives will continue but the results of these models remains unclear

There will continue to be a movement away from FFS to more integrated models of service delivery

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OPPORTUNITIES:

The Future of Medicaid Managed CareSlide33

OPPORTUNITIES: The Future of Medicaid Managed CareInnovative programs for new managed care populationsStakeholder engagement and consumer outreachCare management interventions for high cost, high risk members

Integration of Medicare and Medicaid services

Person-centered care models that integration of physical, behavioral, social and community services and supports with the member in the pilot seat

Supportive models for moving persons out of institutions with creative ideas funding housing

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OPPORTUNITIES: The Future of Medicaid Managed CareProvider engagement and payment reforms that move away from FFS and offer shared savings or performance incentives/disincentivesNew strategies for detecting and preventing fraud and abuse

IT enhancements that allow for sharing of data between providers, health plans and the state

Improvements in RFPs and MCO contracts to establish value based performance and purchasing

States will always be looking for the next best approach for cost containment and improved outcomes for Medicaid beneficiaries

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Questions?Sellers Dorseysellersdorsey.comPam Coleman

Senior Consultant

Sellers Dorsey

pcoleman@sellersdorsey.com

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