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Health Care Reform IT’S COMPLEX!. Jeffery Thompson, MD MPH Chief Medical Officer Washington State Medicaid. Medicaid Expenditures by Service, 2007. DSH Payments 5.0%. Inpatient 15.0%. Home Health and Personal Care 15.0%. Physician/ Lab/ X-ray 3.7%. Mental Health 1.5%.

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health care reform it s complex

Health Care ReformIT’S COMPLEX!

Jeffery Thompson, MD MPH

Chief Medical Officer

Washington State Medicaid

medicaid expenditures by service 2007
Medicaid Expenditures by Service, 2007

DSH Payments

5.0%

Inpatient

15.0%

Home Health and Personal Care

15.0%

Physician/ Lab/ X-ray 3.7%

Mental Health

1.5%

Outpatient/Clinic

7.4%

Long-Term

Care

35.1%

ICF/MR

3.9%

Acute

Care

59.9%

Drugs

4.7%

Nursing

Facilities

14.8%

Other Acute

6.7%

  • Why are costs going up:
  • PRIVATE SECTOR CUTS
  • MEDICAL COSTS
  • ELDERLY
  • DISABILITIES

Payments to Medicare

3.5%

Payments to MCOs

19.0%

Total = $319.7 billion

(WA State Medicaid ~$4 billion)

NOTE: Total may not add to 100% due to rounding. Excludes administrative spending, adjustments and payments to the territories.

SOURCE: Urban Institute estimates based on data from CMS (Form 64), prepared for the Kaiser Commission on Medicaid and the Uninsured.

slide4

Median Medicaid/SCHIP Income Eligibility Thresholds, 2009

  • WA State Programs
  • Categorically Needy (70%)
  • Categorically Medical (spend down 70%)
  • SCHIP/Apple Care (300%)
  • General Assistance Unemployable (38%)
  • Basic Health Plan (200%)
  • Aid to Drug and Alcohol (38%)
  • Long Term Care (75%)
  • Family Planning (75%)
  • Maternal Support (185%)
  • Foster Care (wards of the state)

Federal Poverty Line

(For a family of four is $21,200 per year in 2008)

NOTE: Medicaid income eligibility for most elderly and individuals with disabilities is based on the income threshold of Supplemental Security Income (SSI).

SOURCE: Based on a national survey conducted by the Center on Budget and Policy Priorities for KCMU, 2009.

medicaid and health care reform
Medicaid and Health Care Reform
  • Cost Estimates. The Congressional Budget Office (CBO) estimates that the House bill will increase Medicaid/CHIP coverage by 15 million at a cost of $425 billion (2010 to 2019) and an estimated increase in state spending of $34 billion.
  • Medicaid Coverage and Financing. Expands Medicaid to everyone under 133% of FPL with increased Federal funds for this population;
  • Children’s and Adult Health Insurance Program. Current eligibility levels, procedures and methodologies are frozen until 12/31/2013 for adults and 9/30/2019 for children (including CHIP)
  • Benefits and Access. Expands Medicaid to any individual under 26 who aged out of Child Welfare; Creates State-plan option for family planning services
    • Establishes the CLASS Act: a national long term care insurance program funded by payroll deductions, Creates new options for community care and FMAP increases
  • Duals and Long-Term Care. The House bill provides payment of Part B deductibles and cost sharing under Medicaid for Medicare beneficiaries under age 65 with incomes below 150% of poverty, subject to regular Medicaid matching rate.
  • Mandatory Providers Increases. Provider rates Medicaid pays for primary care services (100% Federal funds).
slide6

State Options for Coordination of Care

  • Eligible individuals with chronic conditions’ means an individual who—
  • is eligible for medical assistance under the State plan or under a waiver of such plan: has at least 2 chronic conditions; 1 chronic condition and is at risk of having a second chronic condition; or 1 serious and persistent mental health condition.
  • The term ‘health home services’ means comprehensive and timely high-quality services
    • comprehensive care managed care coordination and health promotion;
    • comprehensive transitional care, including appropriate follow-up, from inpatient to other settings;
    • patient and family support (including author­ized representatives);
    • referral to community and social support serv­ices, if relevant; and
    • use of health information technology to link services, as feasible and appropriate.
    • This will cause us to rethink how care is delivered and accessed
slide7

How do you spend less and get better care?

  • Benefit Reform
    • Pay for what works (EBM, HTA)
    • Reduce utilization of what doesn’t
    • Better Informed Decision (PDA)
  • Payment Reform
    • Pay for Outcomes not services
    • (ACO, Integration)
    • Radiology and Advantaged Imaging
    • “Generics First”
  • Integrate Primary Care and
  • Mental Health/Substance Abuse
    • Pay for team based care
  • Administrative Simplification
    • Reward those that do it better with less
    • overhead
slide8
In 2007, ~ 265,000 eligible youth ages 0 – 18

19,228 (6.5) prescribed a psychotropic

Average Number Agents 1.6 (range 1 – 8)

Quality Thresholds # % users

AAP used in a child less than 5 151 (3%)

2 or more Antipsychotic Agents 807 (17 %)

Doses exceeding 2 times recommendations 31 ( 0.6%)

5 or more Psychotropics 567 (3%)

Gap In Antipsychotic RX > 20 days 1512 ( 38 %)

Let me conclude on a good note: WA is a good state and with King Counties Help it is becoming a Great StateWashington State: What happens when we work together?

slide9

Children >= 5 MHD

0.6%

0.3%

0%

Working Together the Variation is Less?% of Eligible with 5 or More Mental Health Drugs in Children Comparing 2004 and 2008

What can we learn from King County?

  • 2008
  • 2004
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