Download The ACA*s Medicaid Expansion: Prospects for NJ*s Consumers

Will the ACA’s Medicaid Changes Improve Outcomes
for Schizophrenia? A New Jersey Case Study
Tom Pyle MBA, MS (PsyR), CPRP
Presentation at the Recovery Workforce Summit
of the Psychiatric Rehabilitation Association at Baltimore, MD
Tom Pyle MBA, MS (PsyR), CPRP June 2014
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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?
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11th most populous (8.9 million)
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Highest density (1030 psm)
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Most urban (90% in urban areas)
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Strongest state executive
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“Blue” State
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Taxes
 Real estate taxes: Nation’s highest…
 Income tax: 1% pays 50%…
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Budget gap: $800 million!
 Public workers vs. pensioners
vs. bond holders

Bonds downgraded: A 49th of 50 states…
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Budget:
$ 33 billion

Pension fund: $47 billion short!
 Needs $5 billion p.a.!
FY
2011
2012
2013
2014
2015
2016
2017
2018
Budgeted
0
$485 mm
$1.029 bn
$1.582 bn
$2.249 bn
$3.000 bn
$3.857 bn
$4.800 bn
Revised


$696 mm
$681 mm
?
?
?
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The macro view from 30,000 feet…
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1.
Reform
 “Innovations” (ACOs)
 “Benchmark” plans
2.
Expansion
 25% increase
3.
Managed care
 BH  ASO
 Grant  FFS  Case Capitated
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1.
2.
3.
4.
5.
6.
Public program changes (Medicaid)
Private insurance changes
Health insurance exchanges
Cost containment measures
Quality improvement measures
Funding measures (e.g., taxes)
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1.
Beneficiaries
2.
Providers
3.
Agencies
4.
Government

Beneficiaries
1. Enrolled
2. To be enrolled
3. Not enrolled
1.
2.
3.
4.
5.
Access
Availability
Quality
Cost
Innovation
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1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Coverage:
Providers:
Exchanges:
Transitions:
“Woodwork
Measures:
Outreach:
Implement:
Deadlines:
Agency $:
As much?
Enough?
Overlap?
Churn?
Effect”?
Of What?
Possible?
Complex?
Too Tight?
Enough?
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  
Enrolled
To be enrolled
Not 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
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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%
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Federal Medical
Assistance
Percentage: Federal
matching funds to
state Medicaid
programs.
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Federal Medical
Assistance
Percentage
NJ: 50%
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Federal Medical
Assistance
Percentage:
For “new eligibles”:
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Federal Medical
Assistance
Percentage:
For “new eligibles”:
Till 2017:
100%
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Federal Medical
Assistance
Percentage:
For “new eligibles”:
Till 2017:
100%
By 2020:
90%
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•
•
•
•
Eligibility
Enrollment
Coverage
Cost
•
•
•
•
•
Rates
Autonomy
Referrals
Administration
Compliance
Consumers
Providers
•
•
•
•
•
•
•
•
•
Administration
Overheads
Compliance
Cash flow
Agencies
“Rights”
“Access”
Administration
Quality
Cost
Governments
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Health
insurance
coverage
Long-term
care
assistance
Assistance to
Medicare
beneficiaries
Safety net &
system
funding
Funding for
state capacity

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
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$404.1 billion
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$404.1 billion
$33.0 billion
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GDP:
Health spending:
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32
34
$30,834 (CT)
$22,595 (DE)
$19,951 (NJ)
$15,893 (CA)
$15,747 (PA)
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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
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
Counter-cyclical to economy

Largest source of federal revenue ( jobs)

Biggest target for state cost controls
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
Medicaid  an entitlement

States can only...
 Reduce provider payments
 “Manage” utilization
 Restrict eligibility
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NJ Medicaid, May 2014
Aged
Blind
Disabled
Non ABD Children
NON ABD Adults
Total
84,962
755
205,419
742,286
452,154
NJ population 2010
8,900,000 x 1% ~ 90,000
1,485,576
20%? (~40,000?)
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
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45
Category
Financial
Resource
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Mandatory (before ACA):

Children
Pregnant women
Parents of certain children
Seniors
Individuals with disabilities

NOT childless non-elderly adults




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The Federal Poverty Level
(HHS)
2014:
Family of 1:
$11,670
Family of 4:
$23,850
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49
50
51
2014 Federal Poverty Limit (FPL)
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2014 Federal Poverty Limit (FPL)
Family of 1:
Family of 4:
$11,670
$23,850
x 133% = $15,521
x 133% = $31,721
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<
+
(To keep SSI,
net worth < $2000)
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

Medicaid: < 138% FPL.
Exchanges: > 100% FPL.
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Before:
After:
62 mm?
+ 6 mm more?
(53 mm PYEs)
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60

Poor families with children
 2/3rd of enrollees
 1/3rd of spending

Elderly and disabled
 1/3rd of enrollees (70% in nursing homes)
 2/3rd of spending
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
US average: only ~ 2/3rds !

Enrolled eligibles: Highly variable by state
OK 44%
MA 80%
NJ 53%
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Services, not programs

Discrete and individual, not comprehensive
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Doctor visits
Emergency care
Hospital care
Prescription drugs
Long-term care
Vaccinations
Hearing
Vision
Preventative care for children
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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
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“Benchmark”
Essential
Benefits
coverage
under ACA
Excludable
for newbies
under ACA
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Service Setting
Type of Provider
Extent of Coverage
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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
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
Deductibles

Co-pays

(Opportunity costs)
73

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
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