NEW YORK’S MEDICAID AGENDA Expanding Coverage, Buying Value United Hospital Fund Conference Medicaid in 2008 and Beyond July 10, 2008 Deborah Bachrach, Esq. Medicaid Director Deputy Commissioner Office of Health Insurance Programs New York State Department of Health

1 New York Medicaid in Perspective Key Facts and Figures

2 Medicaid Represents 31% Of State Budget ($124B) Medicaid* $39.0B (31%) Higher Education $8.2B (7%) STAR $5.0B (4%) Debt Service $4.6B (4%) Health/Pension Benefits $4.6B (4%) Health $5.3B (4%) Transportation $6.8B (5%) All Other $28.0B (21%) School Aid $23.1B (19%) Source: NYS Executive Budget *Does not include off-line payments (DSH, IGT, UPL, etc.)

3 Medicaid Represents 28% Of Health Care Spending In NYS Commercial Insurance/Self pay $84.8B (50%) Medicaid $47.3B (28%) Medicare $30.3B (18%) Public Health $5.6B (3%) Source: 2008 Health Care expenditures projected by the Division of the Budget using actual 2004 data and historical growth trends from the CMS, Office of the Actuary, National Health Statistics Group; Estimated size of 2007 NYS Economy based on 2007 NYS Personal Income estimate

4 Medicaid Expenditures By Service Type* Source: DOH/OHIP Datamart *Does not include off-line payments **Includes Transportation, Case Management, OMR Developmental Center and OMR Group Homes, etc. $6.0B Physician & Clinics Pharmacy Institutional Long Term Care Non-Institutional Long Term Care Community Rehab Managed care/ Family Health Plus $6.2B $2.8B $3.5B $6.7B $4.0B $6.8B $4.1B All Other** Hospital Inpatient

5 Almost 40% Of Children And 20% Of Adults Rely On Public Coverage 53% 6% 2% 7% 32% 8% 67% 17% 15% 6% 9% Source: Vital statistics 2006 Annual Report, DOH/OHIP Datamart, CHPlus Uninsured

6 Special Needs Populations Represent 20% Of Beneficiaries, But 75% Of Expenditures *Special Need populations are HIV, MR/DD, Mental Health, Chemical Dependence, LTC and Chronic Care. Note: Enrollees include persons enrolled at anytime in Calendar Year 2006 Source: DOH/OHIP Datamart Avg. Costs per Enrollee Total Medicaid Population$7,719 Non-Special Population $2,402 Special Need Populations $28,294

7 Most Enrollees Are In Managed Care, Most Expenditures Are In Fee-For-Service *Includes Managed Care premiums and carve out costs. Note: Enrollees include persons enrolled at anytime in Calendar Year 2006 Source: DOH/OHIP Datamart

8 Highest Needs Patients Are Not Well-Connected To Delivery System Eligible patients have significant medical needs  76% have a chronic disease  52% have multiple chronic diseases  69% have a history of mental illness  73% have a history of substance use  54% have a history of mental illness and substance use But are not well-connected to delivery system  24% no primary/specialty care visit prior 12 months  65% have had ED visit in prior 12 months

9 NYS Performs Poorly On Key Quality Indicators State Scorecard on Health System Performance 2007 AHRQ National Healthcare Quality Report Source: 2007 AHRQ Report Care Measure National Ranking Percentage of Uninsured Adults21st Quality of Health Care30th Public Health Indicators30th Avoidable Hospital Use39th Source: Commonwealth Fund 2007

10 Administration of NY Medicaid January 1, 2007 No clear mission Irrational organizational structure Limited use of data Antiquated and opaque reimbursement structures Great staff (but not enough)

11 NY Medicaid 18 months later...

12 A New Mission Ensure that eligible New Yorkers are able to get and keep coverage Buy value – quality, cost-effective care – for Medicaid beneficiaries Advance health system reform

13 A New Infrastructure Establishing the Office of Health Insurance Programs

14 New Relationships Improved relationship with OASAS, OMH, OMRDD,OTDA, OCFS and OMIG Rethinking relationship with LDSSs Working on CMS relationship Partnering with UHF Medicaid Institute, NYS Health Foundation, and Center for Health Care Strategies

15 A New Commitment To Coverage Broadening Coverage And Making It Accessible Expansion of CHPlus FHPlus Buy-in and Premium Assistance Programs Streamlining enrollment and renewal procedures Eliminating vestiges of welfare Establishment of State Enrollment Center Enhanced outreach to eligible but uninsured New Yorkers Reforming $847 million Hospital and D&TC Indigent Care Pools Initiating Partnership for Coverage

16 A New Focus On Ambulatory Care Reducing inpatient rates by $220 million Updating inpatient rate methodology Investing $300 million in outpatient reimbursement rates Enhanced payments for evening/weekend hours and for doctors in medically underserved areas Implementing new outpatient payment methodology Developing new care models for high need, high cost beneficiaries Rolling out Doctors Across New York Licensure reform $100 million in HEAL primary care grants

17 A New Commitment To Quality Primary care standards for all clinics and physicians Medicaid FFS and MMC will no longer pay for “never events” Selective contracting for breast cancer and bariatric surgery Retrospective and concurrent utilization review Additional drugs subject to Clinical Drug Review Program Medication Therapy Management Prescriber Education Report cards on DME providers

18 Medicaid Managed Care Raises the Bar Medicaid Managed Care Raises the Bar Medicaid Stood Still Pre-1995 Medicaid Stood Still Medicaid FFS & Managed Care Raise the Bar 2007 & Beyond Medicaid FFS & Managed Care Raise the Bar Medicaid FFS & Managed Care Raise the Bar 2007 & Beyond Medicaid FFS & Managed Care Raise the Bar Improves Access, Quality, & Accountability Value Quality Accountability Transparency Medicaid Fee-For-Service Medicaid Managed Care Working In Tandem To Raise The Bar Access Efficiency

19 Real And Lasting Health Care Reform Means … Building on the 2007 and 2008 reforms Operating within budget constraints Advancing a state strategy Advancing a federal strategy

And Beyond … A State Strategy Implement sustainable coverage expansions Reallocate resources from inpatient to outpatient care Reform inpatient reimbursement methodology Increase focus on unnecessary hospitalizations Increase focus on quality and efficiency Begin long term care reform Scrutinize all Medicaid spending to ensure that buying the right care in the right setting at the right price

And Beyond … A Federal Strategy Coverage Plan FMAP Reform 1115 Waivers State Plan Amendments Dual Eligibles Prescription Drugs/Purchasing Discounts Medicaid Data

22 Medicaid Is … Important to patients Important to taxpayers Important to NY’s health care system IMPORTANT TO GET RIGHT