Redesigning Medicaid: West Virginia and Mountain Health Choices Carol Irvin June 2010 AcademyHealth Annual Research Meeting Boston, MA Purpose of Talk West Virginia, g , a resource-constrained state,, has not pursued an insurance expansion Instead, redesigned the Medicaid program to Instead instill personal responsibility and behavior changes g – Improve health status – Rationalize the use of services – Bend the cost curve 2 Research Team Funded by the Robert Wood Johnson Foundation – Brian Quinn, Project Officer The West Virginia University Institute for Health Policy Research (IHPR) – Michael Hendryx – Sally Richardson – Johnna Beane Mathematica Policy Research – Carol Irvin – Margo Rosenbach – James Mulligan 3 Antecedents to Reform Proactive governor g – Tired of hearing West Virginia was at the bottom of most health indicators – Wanted W t d people l to t care about b t their th i health h lth – take t k personal responsibility Policymaker concerns about Medicaid – Reign in costs – Provide quality care 4 West Virginia’s Redesign Federal g grants for – Medical homes – Health information technology – Outreach Medicaid State Plan Amendment in May y 2006 (DRA of 2005) – Established Mountain Health Choices for low-income families and children – Began the pilot test March 2007 and was statewide by November 2007 – Offered two different benefit plans for low-income adults and children 5 Overview of Mountain Health Choices The Basic Plan – The default plan p – Traditional Medicaid benefits with some new restrictions: • No N more th than 4 prescriptions i ti iin a month th • Fewer mental health services and new provider p policies The Enhanced Plan – Traditional Medicaid benefits (no restrictions on prescriptions) – New services • Weight management • Nutrition services 6 Other Key Program Features Member Agreement – Must complete to enroll in the Enhanced Plan – Must comply to maintain enrollment in the Enhanced Plan Plan lock in until eligibility is redetermined Earn rewards through health care choices (not implemented) – Mechanism for developing personal responsibility – An account for purchases of additional benefits – Grows when health care is used appropriately 7 Plan Selection – First Step to Personal Responsibility Make an appointment with the PCP for a health assessment No Yes N No Attend health assessment appointment with PCP Yes Sign Health Improvement Plan and Member Agreement and select either the Enhanced or Basic Plan No Default into the Basic Plan Yes Provider submits the signed g Health Improvement Plan and Member Agreement and the benefit plan selection No Y Yes Select Basic Plan Select Enhanced Plan 8 Low Enrollment in the Enhanced Plan Plan Total Children Adults Total 149,473 132,477 16,996 (100.0%) (100.0%) (100.0%) 130,803 115,471 15,332 (87 5%) (87.5%) (87 2%) (87.2%) (90 2%) (90.2%) 18,670 17,006 1,664 (12.5%) (12.8%) (9.8%) Basic Enhanced Source: Data run provided by West Virginia Department of Health and Human Resources Bureau for Medical Services in March 2009. 9 Some Lack Basic Program Knowledge Not Aware of Two Benefit Plans Advocates and providers skeptical that so many beneficiaries would select the Basic Plan Percent 50 40 30 20 10 0 43 33 13 5 Source: Gurley-Calvez et al. 2009 10 Some May Not Be in the Appropriate Plan Usually Needs More than 4 Prescriptions per Month P Percent t 80 Advocates and providers concerned that some people in the Basic Plan need the benefits of the Enhanced Plan 71 60 40 20 29 20 0 Source: Gurley-Calvez et al. 2009 11 24 Conclusions Complex enrollment for the Enhanced Plan – Many points for defaulting into the Basic Plan West Virginia lacks mechanisms to support informed choice – Limited outreach to beneficiaries and providers – Beneficiaries B fi i i and d providers id did nott know k how h compliance with the member agreement would be tracked – Advocacy community lacked resources to fill the void Incomplete implementation of incentive structure 12 Fiscal Implications, the Unanswered Questions Tiered benefits can work from the state perspective if beneficiaries enroll in the most appropriate plan available – West Virginia may have cut program costs in the short term, but what will health care costs be in the long g term? Need an enrollment process that matches beneficiaries to the appropriate benefit plan – Will administrative costs of this process outweigh the savings on health care costs? 13 For More Information Please contact: – Carol Irvin • cirvin@mathematica-mpr.com • 617-301-8972 14