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Medicaid Reform Initiatives for Quality Care Delivery

This text provides an overview of the process of Medicaid reform, discussing key initiatives, challenges, and goals related to quality care delivery. It delves into topics such as creating scorable options, exploring Medicaid eligible populations, the acute care delivery system, long-term care, quality, and information technology in Medicaid. The text also addresses program administration, financing, IT, fraud, and abuse, highlighting key areas for improvement and consideration.

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Medicaid Reform Initiatives for Quality Care Delivery

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  1. Medicaid: My Life as a Commissioner Carol D. Berkowitz, M.D. Medicaid Summit Chicago, IL November 3, 2005

  2. A Year of Forming Coalitions • Meeting with AMSPDC and NACHRI 11/04 • AMA Interim Meeting: ACP, ACOG, AAFP endorse principles 12/04; also endorsed by NAPNAP • Meeting with AMA leadership 03/05: endorse all but entitlement notion • Meeting with Mark McClellan 04/05: work together for quality • Appointment to Medicaid Advisory Commission 07/05

  3. Make up of the commission • Voting members: 15 • Co-chairs: former Gov. Sundquist (TN) and King (ME) • No physicians • Former Medicaid directors • Economist • New additions: Gov. Manchin (WV-D), Gov. Bush (FL-R) • Non-voting members: 15 • 4 physicians • Julie Beckett

  4. Charge to the Commission • Recommend $10 billion in scoreable options by September 1, 2005 • Recommend reform/modernization by December 31, 2006 • Funded for 6 meetings per year • Have had 3 meetings to date • All in DC (plan to move around the country) • Always time allotted for public comment

  5. Creating Scorable Options: 09/01/2005$10 billion over 5 years • Reform Rx reimbursement formula (AWP to AMP): $4.3B • Extend Medicaid drug rebate to MCO: $2B • Change start date of penalty period for asset transfers: $1.4B • Increase “Look-Back” from 3 to 5 years: $100M • Tiered co-pays for prescription drugs:$2B • Reform of MCO provider tax requirement:$1.2B

  6. New York Times: August 18, 2005

  7. Topics to be explored in depth • Medicaid eligible populations • Medicaid acute care delivery system • Long term care delivery system • Quality and information technology in Medicaid • Program administration: Financing, IT and fraud and abuse • Consideration of best practices

  8. Medicaid eligible populations • Children and pregnant women • Assist Medicare beneficiaries with Medicare cost-sharing • People in nursing home (<300% SSI payment) • Working disabled without SSI • “Medically needy” • Disease specific groups

  9. Medicaid eligible populations • Adoption and foster care children who are eligible for Title IV-E • 1/3 of all births in the U.S. • Growth in Medicaid • Capture of Medicaid eligible children during SCHIP outreach: 40-50% of children Medicaid eligible • Loss of parental coverage in low-income workers: for every 1% increase in premiums, 200,000-400,000 individuals lose insurance

  10. Medicaid eligible populations: Questions to address • Should there be minimum national standards? Existing ones OK? • Level of state flexibility? • Should Medicaid remain as “entitlement” program (no-cap)? • How should Medicaid enrollment growth be dealt with?

  11. Medicaid Acute Care Delivery System • Mandatory items and services (includes EPSDT) • Optional items and benefits ( e.g., RX, dental, PCCM) • “Cadillac” analogy: Medicaid offers more than private insurers • SCHIP without EPSDT mandate

  12. Medicaid Acute Care Delivery System:4 Guidelines for States • Benefit must be sufficient in amount, duration and scope (e.g., can’t be 1 inpatient day) • Comparability for all Medicaid eligible groups (not kids!) • “Statewideness” • Freedom of choice for participant

  13. Medicaid Acute Care Delivery System:Questions to address • National standards? • “Cost sharing”? • What should states be able to do? • Make Medicaid more like SCHIP?

  14. Long Term Care Delivery System • Medicaid long-term care • Must cover nursing facility services adults > 21 years • Home health for adults nursing home eligible • Waivers in long-term care • 1915 (c) HCBS Waiver program (cost neutral) • Dual eligible • 74% to 100% FPL • Impact of MMA

  15. Long Term Care Delivery System:Questions to address • National standards? • State discretion versus need for federal approval? • What mechanisms can be used to expand non-Medicaid LTC financing? • Service delivery and finance coordination for dual eligible? • Worry about “woodwork” effect – offer community services and folks cared for by families will “come out of the woodworks”.

  16. Quality and information technology in Medicaid • FFS doesn’t lend itself to quality initiatives • MCOs use of measures • HEDIS • CAHPS: Consumer Assessment of Healthcare Providers and Systems • NCQA Accreditation • Easier to work with 6-10 MCOs than hundreds of thousands of providers

  17. Quality and Information Technology in Medicaid:Questions to address • Require new quality initiatives in Medicaid? Should they be required? • Medicaid’s role in systems-level quality (e.g., medical errors, practice standards)? • Federal government’s role in financing HIT systems in Medicaid?

  18. Program Administration: Financing, IT, and Fraud and Abuse • Overview re Medicaid financing • Concern about Medicaid “maximization” • Fraud and abuse: state, provider, and recipient

  19. Program Administration: Financing, IT, and Fraud and Abuse • FMAP: complex formula, varies 50-80%, depends on per capita income (MD, VA 50%; Mississippi 77.08%) • Administrative services are all 50-50 • Certain services incentivized: Family planning FMAP 90%, IHS 100% • SCHIP with enhanced match ratio • DSH, IGT and UPL

  20. Program Administration: Financing, IT, and Fraud and Abuse • Other Medicaid purposes beyond paying for beneficiaries • GME/IME (though no one could say how much) • Subsidize public providers for other services • Special education ($11 b) • Foster care support • Juvenile justice system

  21. Program Administration: Financing, IT, and Fraud and Abuse • Maximization • IGTs: some are permitted by federal law • No REAL way to determine how much “creative financing” is going on • Lots of unfunded federal mandates that states must adhere to • No Child Left Behind • Bioterrorism preparedness • HIPAA • Special education

  22. Program Administration: Financing, IT, and Fraud and Abuse • Federal task force in many states: Medicaid, FBI, DEA, Postal IG, Treasury, state AG, federal US Atty • Don’t want to make the system too burdensome • Medicaid/Medicare Data Match Projects (California model) • Probably BIG headlines, not large pots of money

  23. Best Practices • Disease Management as a Vehicle for Getting Value in Medicaid • Arizona Access model • ARKids First • ALLKids

  24. Personal reflections • Need to hear from low income families re the system (disabled and CSHCN well-represented) • Thinking outside the box: MediKids or Kids Come First Act (S. 114) • Too much fragmentation: One person can be covered through 3 different pots • Can’t be just driven by the $$, need to consider the people • What’s the role of private insurance and employers (including small businesses and some LARGE employers

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