THE
COMMONWEALTH
FUND
Reforming the Health Care Delivery System – The
Role of States
Rachel Nuzum
Vice President, Federal and State Health Policy
The Commonwealth Fund
Progressive States Network
Payment and Delivery System Reform webinar
July 15, 2013
Health care spending consuming larger
proportions of state budgets
2
Total State Expenditures by Function,
Estimated Fiscal 2012
Elementary &
Secondary
Education
19.8%
Medicaid
23.9%
Higher
Education 9.9%
Medicaid spending increases as a
percentage of total state expenditures
23.7%
23.9%
2011
Estimated 2012
22.2%
Transportation
8.1%
Public
Assistance 1.4%
Corrections
3.2%
2010
All Other
33.7%
Source: “Summary: NASBO State Expenditure Report (Fiscal 2010-2012 Data).” The National Association of State Budget Officers. December 20,
2012. http://www.nasbo.org/publications-data/state-expenditure-report/state-expenditure-report-fiscal-2010-2012-data
3
Estimated Change in Medicaid Enrollment, Uninsured Adults <133% FPL
and Spending Over 2013-2022 as a Result of the Medicaid Expansion*
Percent
50
29.8%
26%
25
21%
16.2%
12.3%
2.9%
0
Increase in Medicaid
Enrollment 2022
0.3%
State Spending
Federal Spending
Total Spending
Total change in Medicaid expenditure relative to no ACA baseline
-25
-50
Reduction in
Uninsured Adults
<133% FPL
Incremental impact of Medicaid expansion
- 47.6%
*Scenario assumes all states expand Medicaid. Compared to no ACA baseline. Projections based on an average take-up rate of 60.5% among
newly eligible uninsured and 23.4% among currently eligible but not enrolled individuals. FPL refers to Federal Poverty Level.
Source: J. Holahan, M. Buettgens, C. Carroll, S. Dorn, The Cost and Coverage Implications of the ACA Medicaid Expansion. Kaiser Family
Foundation. November 2012.
4
The Affordable Care Act
Reduced Payments for
Avoidable Complications
Value Based Purchasing
Accountable
Care Organizations
Medicare Advantage
Plan Bonuses
Bundled Payments
Hospital Inpatient
Quality Reporting
Physician Quality
Reporting System
Medical Homes
Meaningful Use
ACA: Payment and Health System Reforms:
Improving Outcomes and Lowering Cost
• Payment reforms to support and stimulate system innovation
– Primary care: enhance payment and “medical homes”
– Accountable care organizations: provider networks accountable for
outcomes and total costs
– More “bundled” payments: total costs of care episode
– Pay for value: reduced payment for infections, readmissions
• Partnership with State Medicaid and Private Payers
• Federal Innovation Center: support private and state initiatives
• Investment in Information Systems & Data: guide and inform
5
6
State Policy Levers
• ACA reforms provide a foundation + new resources, tools
– State policy and care system leaders’ action to move forward
• Key opportunities to build on momentum
– Payer partnership with Medicare, Medicaid, private
– Build innovation into state supported programs
– Transparent all-payer data on quality and costs
– Targets and benchmarks: populations and geographic areas
• Strategic action for public health as well as delivery systems
• Oversight to hold care systems and insurers accountable
– Licensure and regulatory authority
– Malpractice and other market reforms
State Innovation Models (SIM) Initiative
•
CMMI launched SIM in July 2012 to assist states in planning, designing, and
testing new payment and delivery system models to advance broad health
system transformation.
•
Emphasis on state flexibility while improving population health through multipayer models that integrate public health and community resources.
7
Medicaid as a driver of payment and delivery system reform
Medicaid cost trends impact program expansion decisions and sustainability of
program. Major interest in multi-payer initiatives and ongoing payment and
delivery system reforms at the state level.
•
CO, MN, VT pioneering innovative models to align
incentives, better coordinate care, reduce total
costs, and improve outcomes
•
Convened Medicaid directors and federal officials
from CMCS and CMMI to articulate major state
barriers and potential federal actions to better
support state efforts
•
CMMI awarded $300 million in State Innovation
Model grants to support the development of multipayer payment and delivery system transformation
9
Related Resources
•
“Payment and Delivery System Reform in Medicaid: Progress Challenges, and Opportunities to Move Forward.” National
Association of Medicaid Directors. February 11, 2013. http://medicaiddirectors.org/node/694
•
“Aligning Incentive in Medicaid: How Colorado, Minnesota, and Vermont are Reforming Care Delivery and Payment to
Improve Health and Lower Costs.” Silow-Carroll, S., Edwards, J. N., and Rodin, D. The Commonwealth Fund. March 1,
2013. http://www.commonwealthfund.org/Publications/Case-Studies/2013/Mar/Aligning-Incentives-in-Medicaid.aspx
•
“High-Performance Health Care for Vulnerable Populations: A Policy Framework for Promoting Accountable Care in
Medicaid.” Bachrach, D., Bernstein, W., and Karl, A. The Commonwealth Fund. November 16, 2012.
http://www.commonwealthfund.org/Publications/Fund-Reports/2012/Nov/High-Performance-for-VulnerablePopulations.aspx
•
“Care Management for Medicaid Enrollees through Community Health Teams.” Takach, M. and Buxbaum, J. The
Commonwealth Fund. May 21, 2013. http://www.commonwealthfund.org/Publications/Fund-Reports/2013/May/CareManagement.aspx
•
“State Medicaid Directors Driving Innovation: Payment Reform.” National Association of Medicaid Directors. July 20, 2012.
http://medicaiddirectors.org/node/472
•
“Building Medical Homes: Lessons from Eight States with Emerging Programs.” Kaye, N., Buxbaum, J. and Takach, M.
The Commonwealth Fund. December 2, 2011. http://www.commonwealthfund.org/Publications/FundReports/2011/Dec/Building-Medical-Homes.aspx
•
“Community Care of North Carolina: Building Community Systems of Care through State and Local Partnerships.”
McCarthy, D. and Mueller, K. The Commonwealth Fund. June 22, 2009.
http://www.commonwealthfund.org/Publications/Case-Studies/2009/Jun/Community-Care-of-North-Carolina--BuildingCommunity-Systems-of-Care-Through-State-and-Local-Partner.aspx
10
Acknowledgements
Jordan Kiszla
Program Associate
Federal and State Health Policy
Cathy Schoen
Senior Vice President
Policy, Research, and Evaluation