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Will the ACA’s Medicaid Changes Improve Outcomes for Schizophrenia? A New Jersey Case Study Tom Pyle MBA, MS (PsyR), CPRP
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Presentation at the Recovery Workforce Summit of the Psychiatric Rehabilitation Association at Baltimore, MD Tom Pyle MBA, MS (PsyR), CPRP June 2014 2
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Fee for service managed care… Integration of PH and BH… Medicaid expansion… Health insurance exchanges… Evidence-based practices.. Community integration… Medical model Recovery model… The biggest change in 50 years… How will our loved ones be affected? 3
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11 th most populous (8.9 million) Highest density (1030 psm) Most urban (90% in urban areas) Strongest state executive “Blue” State 6
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Taxes Real estate taxes: Nation’s highest… Income tax: 1% pays 50%… Budget gap: $800 million! Public workers vs. pensioners vs. bond holders Bonds downgraded: A- 49 th of 50 states… 7
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Budget: $ 33 billion Pension fund: $47 billion short! Needs $5 billion p.a.! 8
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The macro view from 30,000 feet… 9
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1. Reform “Innovations” (ACOs) “Benchmark” plans 2. Expansion 25% increase 3. Managed care BH ASO Grant FFS Case Capitated 10
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1. Public program changes (Medicaid) 2. Private insurance changes 3. Health insurance exchanges 4. Cost containment measures 5. Quality improvement measures 6. Funding measures (e.g., taxes) 11
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1. Beneficiaries 2. Providers 3. Agencies 4. Government 12
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Beneficiaries 1.Enrolled 2.To be enrolled 3.Not enrolled 13
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14 1. Access 2. Availability 3. Quality 4. Cost 5. Innovation
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1. Coverage: As much? 2. Providers: Enough? 3. Exchanges: Overlap? 4. Transitions: Churn? 5. “Woodwork Effect”? 6. Measures: Of What? 7. Outreach: Possible? 8. Implement: Complex? 9. Deadlines: Too Tight? 10. Agency $: Enough? 15
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16 EnrolledTo be enrolledNot enrolled Access Availability Quality Cost Innovation
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Health insurance for all Individual Mandate Corporate Requirement Help for those who need it Medicaid Subsidies for premiums and cost-sharing 17
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An entitlement Big funder of… Health care for poor, disabled Safety-net hospitals, LT care Federal-state partnership FMAP: 50% to 83% 19
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Federal Medical Assistance Percentage: Federal matching funds to state Medicaid programs. 20
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Federal Medical Assistance Percentage 21 NJ: 50%
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Federal Medical Assistance Percentage: For “new eligibles”: 23
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Federal Medical Assistance Percentage: For “new eligibles”: 24 Till 2017: 100%
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Federal Medical Assistance Percentage: For “new eligibles”: 25 Till 2017: 100% By 2020: 90%
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Eligibility Enrollment Coverage Cost Consumers Rates Autonomy Referrals Administration Compliance Providers “Rights” “Access” Administration Quality Cost Governments Administration Overheads Compliance Cash flow Agencies 27
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Health insurance coverage 31 mm children; 16 mm adults; 16 mm E&D Long-term care assistance 1.6 mm institutionals; 2.8 mm community-based Assistance to Medicare beneficiaries 9.4 mm E&D (20% of Medicare enrollees) Safety net funding 16% national health funding; 35% safety net hospitals Funding for state capacity FMAP Health insurance coverage Assistance to Medicare beneficiaries Long-term care assistance Safety net & system funding Funding for state capacity 28
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$404.1 billion 29
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$404.1 billion 30 $33.0 billion
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$30,834 (CT) $15,893 (CA) $15,747 (PA) $22,595 (DE) $19,951 (NJ)
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Overtreatment Failure of care coordination Failure of care process (Tx) Administration complexity Failure of pricing Fraud and abuse At least 20% of costs 40
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Counter-cyclical to economy Largest source of federal revenue ( jobs) Biggest target for state cost controls 41
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Medicaid an entitlement States can only... Reduce provider payments “Manage” utilization Restrict eligibility 42
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43 NJ Medicaid, May 2014 20%? (~40,000?) NJ population 2010 8,900,000 x 1% ~ 90,000 50%? (~45,000?)
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3 Big Changes 5 Big Outcomes FMAP: NJ = 50% 2.8% of GDP 15% of all health spending W,F,A = 20% 18% beneficiaries 45% cost 5 Functions 4 Constituencies 44
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CategoryFinancialResource 46
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Children Pregnant women Parents of certain children Seniors Individuals with disabilities NOT childless non-elderly adults 47 Mandatory (before ACA):
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The Federal Poverty Level (HHS) 48 2014: Family of 1: $11,670 Family of 4: $23,850
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2014 Federal Poverty Limit (FPL) 52
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Family of 1: $11,670x 133% =$15,521 Family of 4: $23,850x 133% =$31,721 2014 Federal Poverty Limit (FPL) 53
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< + 56 (To keep SSI, net worth < $2000)
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Medicaid: < 138% FPL. Exchanges: > 100% FPL. 57
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Before: 62 mm? (53 mm PYEs) 59 After: + 6 mm more?
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Poor families with children 2/3 rd of enrollees 1/3 rd of spending Elderly and disabled 1/3 rd of enrollees (70% in nursing homes) 2/3 rd of spending 61
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US average: only ~ 2/3rds ! Enrolled eligibles: Highly variable by state OK44% MA 80% NJ 53% 62
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Services, not programs Discrete and individual, not comprehensive 66
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Doctor visits Emergency care Hospital care Prescription drugs Long-term care Vaccinations Hearing Vision Preventative care for children 67
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Inpatient hospital Outpatient hospital EPSDT Nursing facility Home health Physician Rural health clinic Federally qualified health center (FQHC) Laboratory and X-ray Family planning Nurse midwife Certified pediatric and family nurse practitioner Freestanding birth center (when licensed or otherwise recognized by the state) Transportation to medical care Tobacco cessation and tobacco cessation counseling for pregnant women and youth under 21 as part of EPSDT 68
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70 “Benchmark” Essential Benefits coverage under ACA Excludable for newbies under ACA
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Service Setting Type of Provider Extent of Coverage 71
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“Habilitative” services: to develop skills never acquired (as among DD population) Only through home/community-based waiver “Rehabilitative” services: to restore lost functioning (as among PD population) Not limited to clinical treatment 72
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73 Deductibles Co-pays (Opportunity costs)
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74 Classic Fee-for-Service Managed care Contractually-defined services… For an enrolled population… In a closed network… Paid by capitation premiums
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1. Managed care organization (MCO) ▪ Capitation: Per person per month ▪ Risk: Who accepts it? State or vendor? 2. Primary care case management (PCCM) ▪ Case management fee 3. Pre-paid Health Plans (PHP) ▪ In-patient ▪ Ambulatory 75
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