Medicaid Managed Care
Trends and Opportunities
September 24, 2014
Pam Coleman
Senior Consultant
About Sellers Dorsey
Sellers 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 presenter
Pam 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:
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Review Medicaid Managed Care growth.
Today we will:
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1
Review Medicaid Managed Care growth.
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Review a “top ten list” of market trends.
Today we will:
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1
Review Medicaid Managed Care growth.
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Review a “top ten list” of market trends.
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Highlight select opportunities to leverage emerging trends.
Medicaid Population and Spending - 2012
Total Medicaid Population: 50M Members
Source:
Medicaid Population and Spending - 2012
Total Medicaid Population: 50M Members
Temporary Assistance
to Needy Families
(TANF)
36M Members
$163B Spend
Source:
Medicaid Population and Spending - 2012
Total Medicaid Population: 50M Members
Source:
Temporary Assistance
to Needy Families
(TANF)
Aged Blind
and Disabled
(ABD)
36M Members
$163B Spend
14M Members
$265B Spend
Medicaid Population and Spending - 2012
Total Medicaid Population: 50M Members
Temporary Assistance
to Needy Families
(TANF)
Aged Blind
and Disabled
(ABD)
36M Members
$163B Spend
14M Members
$265B Spend
Children
25M Members
$80B Spend
$3,246 PMPY
Source:
Medicaid Population and Spending - 2012
Total Medicaid Population: 50M Members
Temporary Assistance
to Needy Families
(TANF)
Aged Blind
and Disabled
(ABD)
36M Members
$163B Spend
14M Members
$265B Spend
Children
25M Members
$80B Spend
$3,246 PMPY
Source:
Adults (preexpansion)
11M Members
$56B Spend
$4,841 PMPY
Medicaid Population and Spending - 2012
Total Medicaid Population: 50M Members
Temporary Assistance
to Needy Families
(TANF)
Aged Blind
and Disabled
(ABD)
36M Members
$163B Spend
14M Members
$265B Spend
Children
25M Members
$80B Spend
$3,246 PMPY
Source:
Adults (preexpansion)
11M Members
$56B Spend
$4,841 PMPY
Dual Eligibles
9M Members
$160B Spend
$19,758PMPY
Medicaid Population and Spending - 2012
Total Medicaid Population: 50M Members
Temporary Assistance
to Needy Families
(TANF)
Aged Blind
and Disabled
(ABD)
36M Members
$163B Spend
14M Members
$265B Spend
Children
25M Members
$80B Spend
$3,246 PMPY
Source:
Adults (preexpansion)
11M Members
$56B Spend
$4,841 PMPY
Dual Eligibles
Non Duals
9M Members
5M Members
$104B Spend
$17, 337 PMPY
$160B Spend
$19,758PMPY
Growth Predictions for Medicaid Managed Care
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Currently two-thirds of Medicaid members are served through managed
care
20% growth in Medicaid managed care in 20141
28 states with Managed LTSS by 20152
75 Million Medicaid members in Medicaid managed care by 2020
(compared with 40 Million in 2014) 3
All but Alaska and Wyoming have all or a portion of their Medicaid
population in a managed care system (includes PCCM) 4
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.pdf
Managed Care for Seniors and Persons with Disabilities
Existing ABD (29)
Transitioning to ABD (4)
Remaining FFS (17)
ABD environment as of November 2013
Current Status of State Medicaid Expansion Decisions
Implementing Expansion (28)
Open Debate (2)
Not Moving Forward Now (17)
Source: Kaiser Family Foundation – August 28, 2014
Medicare Medicaid Integration Program
States Pursuing
Source: Kaiser Family Foundation – August 28, 2014
Medicare Medicaid Integration Program (Capitated vs FFS)
Capitated
Fee for Service
*Washington pursuing FFS and capitated
Medicare Medicaid Integration Program (MOUs)
With MOU
Without MOU
Source: Kaiser Family Foundation – August 28, 2014
Medicare Medicaid Integration Program (Enrolling)
Currently Enrolling*
Not Enrolling
* Washington enrolling in FFS
Trends in Medicaid Managed Care
Trend 1:
Movement to Managed Long Term Services and Supports
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Currently 24 states have implemented MLTSS
MLTSS 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 Care
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Medicare Medicaid dual eligible population
Adults with disabilities
Children 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 Performance
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Begins with the contract - Value based purchasing concepts
Performance incentives and disincentive
Shared 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 Integration
Section 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-Outs
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Most Medicaid Directors agree that services should be carved-in when possible
Carve-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 Requirements
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Increase focus on fraud and abuse
Increase 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 Setting
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Risk adjustment programs that account for both clinical and community support
needs
Rates that are actuarially sound
Medical 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 Services
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5% of Medicaid Managed care membership drives 50% of the expenses
Need 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 Reporting
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Comprehensive, accessible, and integrated real time electronic health records and
care management platforms
IT 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 Care
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The 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 Care
OPPORTUNITIES:
The Future of Medicaid Managed Care
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Innovative programs for new managed care populations
Stakeholder engagement and consumer outreach
Care 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 Care
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Provider engagement and payment reforms that move away from FFS and offer
shared savings or performance incentives/disincentives
New 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 Dorsey
sellersdorsey.com
Pam Coleman
Senior Consultant
Sellers Dorsey
pcoleman@sellersdorsey.com
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