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