1. Medicaid’s Changing Landscape
Mississippi Association of Health Plans Annual Meeting
Toby Douglas, SVP Medicaid Solutions
October 19, 2016

2. HEALTH INSURANCE MARKETPLACE
Medicaid Fast Facts
58M
2013
75M
2016
~25% of Americans
Enrollees:
MEDICAID
<5% of Americans are insured through ACA marketplace exchanges
HEALTH INSURANCE MARKETPLACE
60% increase
since 2013
73% of Medicaid beneficiaries enrolled in a managed care plan
42 states have some form of risk-based managed care
MEDICAID MANAGED CARE
Source: PwC Healthcare

3. Managed Care Spending in Medicaid
Managed care spending in Medicaid has been growing rapidly
~$240 billion of the $525 billion total Medicaid expenditures were attributed to managed care in 2015
Moving complex populations to managed care,
will add: another $175-$200 billion
and will: consist mainly of LTC, SPMI, and IDD
Source: PwC Healthcare

4. Managed Care Spending in Medicaid
spending represents 45% of overall
Medicaid expenditures
MCO expenditures
as a percent of total have nearly tripled
since FFY 2006
Source: PwC Healthcare

5. 28 states 12 states 1.8 million members 11.4 million members
Centene’s Growth
2011
Present
28 states
with government sponsored healthcare programs
11.4 million members
Medicaid
(24 states)
Exchanges
(15 States)
Medicare
(12 States)
Correctional
(8 States)
2 international markets
includes 2.8 million TRICARE eligibles
$39.4 – 40.0 billion
expected total revenue for 2016
12 states
with government sponsored healthcare programs
Medicaid
(11 states)
Medicare
(5 States)
Exchanges
(1 State - MA)
1.8 million members
$5.3 billion
total revenue (actual)

6. National Trends

7. Medicaid MLTSS Spending in Context (2015)
Total Medicaid Spending ($525 Billion)
Total LTSS Spending ($166 Billion)
Est. MLTSS
Spending
($36.2 Billion)
Source: HMA Estimate
Spending for LTSS represented around 32% of all Medicaid spending in (based on data through end of 2015)
For 2015, estimated annual MLTSS spending surpassed $36 billion, 21% of all LTSS, nearing 7% of all Medicaid spending
Source: HMA

8. Projected LTSS and MLTSS Growth (2020)
Overall users of LTSS in the Medicaid program are anticipated to increase by roughly 1 million (25% increase) from 2012 through 2020
Another 1.2 million anticipated by 2030, as the over-65 population experiences significant growth
MLTSS enrollment will more than double (613,000 to 1.6 million) from 2014 to 2017, with more than 300,000 added in 2015 (up to 960,000)
By 2020, enrollment is likely to exceed 2.5 million MLTSS beneficiaries, over 2.5 times today’s enrollment. By 2030, MLTSS could top 4.6 million, more than 4.5 times today’s enrollment
Source: HMA

9. Growth of Managed SMI
The prevalence of severe, persistent mental illness (SMI) in the U.S. is around 4%, or nearly 12 million individuals1
Among Medicaid adults ages not receiving institutional care, prevalence of SMI is roughly 10% or higher, with another 8% of adults considered to have “moderate” mental illness2
Spending in Medicaid for services for individuals with serious and persistent mental illnesses is roughly $50 billion
1 Source: D. Braddock. (2014). Boulder, CO: University of Colorado, Coleman Institute for Cognitive Disabilities.
2 (June 2015)
Source: HMA

10. Various other permutations
Models for Managed SMI
SMI carved out, management contracted to public BH entities, with or without risk
SMI carved in, with risk
SMI carved out, management contracted to single statewide entity, with risk
SMI carved out, management contracted to multiple entities with risk
Several Possible
Managed SMI
Models
Various other permutations
Source: HMA

11. Growth of Managed DD Services
The prevalence of individuals with an intellectual or developmental disability (I/DD) in the U.S. is around 1.5%, or nearly 5 million individuals,1 of which about 1.3 million receive Medicaid-funded services
Though many persons with DD are also eligible for Medicare, which funds acute care services, Medicaid funds the vast majority of DD care, at nearly $50 billion annually
Historically carved out, states are now clearly moving to introduce risk into the financing arrangements
1 Source: D. Braddock. (2014). Boulder, CO: University of Colorado, Coleman Institute for Cognitive Disabilities. 2
Source: HMA

12. Medicaid Managed Care for I/DD
Kansas is the first state to fully move individuals with I/DD to comprehensive managed care
KanCare implemented Jan. 2013; implementation for I/DD delayed until following concern from patient advocates
MCOs are accountable for functional, physical and behavioral health outcomes KS AZ
Arizona also has comprehensive I/DD managed care, but all enrollees served through state entity (DES-DDD)
IA is the second state to fully move individuals with I/DD to comprehensive managed care in 2016 IA NY TX TN NH
Several other states are in the process of transitioning the I/DD population to full managed care
Source: HMA and Centene

13. Serving Complex Members
The differences between who we serve today
and more complex members are dramatic:
Now serving members who can be with the plan for life who are often frequent users of multiple specialty healthcare providers
Complex members often seek choice, control and independence at a different level
Plans are being forced to think through a new integrated model of care
A new framework for the services we must deliver: medical, social, nutritional, housing, employment
New intellectual assets: people who understand this population
New systems for tracking and measuring performance
New ways of assembling, organizing, and paying providers into new kinds of delivery systems
Source: HMA

14. Changing Dynamics
Palliative Care
Telehealth

15. Home-Based Palliative Care (HBPC)
107 referrals, 79 enrolled into HBPC (73.8%)
34 Cancer, 15 ESRD, 5 CHF, 5 Neuro, 4 COPD, 3 ESLD, 13 Others
ALOS=4 months
Avoidable Acute Admits=69, Avoidable ER visits=19
40% enrollment in hospice, Mean time in hospice=22.4 days, Median time in hospice=8 days
Death rate in home= 67% vs national average is 25.4%
Net savings per enrollee=$14,550

16. ELECTRONIC CONSULTATION
Telehealth Solutions
Electronic Consultation – will provide a HIPAA-compliant platform to facilitate primary care practitioner/specialist communication with very rapid turnaround
Store-and-Forward Technology – (Specifically diabetic retinopathy and dermatology) will allow for efficient transfer of medical imaging to specialists with consultative reports diagnosis and treatment recommendations within 48 hours. Patient can remain in their own communities and home clinics.
Live Video – will provide real-time consultations between our members and distant-site specialists and include their own primary care practitioners to achieve the most-optimal patient-centered medical-home based care
ELECTRONIC CONSULTATION
STORE - AND - FORWARD
LIVE
VIDEO

17. Telehealth Goals
Increase provider and member satisfaction through the offering of easy, secure and efficient programs and services
Increase access to quality specialists and optimize face to face visits
Develop new models of care that build capacity within the community, reinforce existing programs and increase the ability of PCPs to manage basic specialty services
Improve the management of disease/chronic illness among high-risk members
Ensure that service offerings enhance the affordability of the network and do not increase care delivery costs
Reduction in ER utilization and long-distance travel expense

18. Future Matters/Themes
Managed Care regulation
(transparency and accountability)
Access pressures
Telehealth
Consumer engagement
Whole person care
Quality
Value Based payments
Managed care interaction with the end of supplemental payments as we know it
Duals managed care growth
Medicaid/Exchange interaction
More consolidation of infrastructure/plans
Medicaid Significance growing leaps and bounds!