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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




Home Health and Personal Care


Physician/ Lab/ X-ray 3.7%

Mental Health

















Other Acute


  • Why are costs going up:

Payments to Medicare


Payments to MCOs


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.


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).

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

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
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?


Children >= 5 MHD




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