Medicaid: Innovations in Coverage, Delivery and Financing · Medicaid: Innovations in Coverage, Delivery and Financing. Sources: National Health Expenditure Projections, Centers for

Rachel Nuzum

Vice President, Federal and State Health Policy

National Conference of State Legislators, Senior Staff Seminar

October, 18

Medicaid: Innovations in Coverage, Delivery and Financing

Sources: National Health Expenditure Projections, Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group. Available at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsProjected.html; CMS. “Medicaid & CHIP December 2015 Enrollment Report”. Dec 2015. www.medicaid.gov/medicaid-chip-program-information/program-information/downloads/december-2015-enrollment-report.pdf; Kaiser State Health Facts; Kaiser Family Foundation. “The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid”. Jan 2016. http://kff.org/health-reform/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid-an-update/.

Accelerated by the Affordable Care Act, Medicaid is now the single largest source of health insurance in the nation.

Medicaid

70.5m(20%)

Medicare55.8m(16%)

CHIP6.1m(2%)

Private195m(55%)

Uninsured26.8m(7%)

2016 Health Insurance Enrollment(estimated)

Source(s): (Left): National Health Expenditure Projections, Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group. (Right): Manatt Health analysis of Kaiser compiled Current Population Survey data; Expansion states include the 28 states and District of Columbia that expanded coverage prior toJuly 2015.

$681 billion in annual program

spending (est., FY2015)

http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsProjected.html

kff.org/other/state-indicator/total-population/?dataView=1&currentTimeframe=0

The Pursuit of Value: Medicaid Delivery System Reforms

State Medicaid program continue to develop, test, and implement a spectrum of delivery system reforms to contain costs and more effectively serve their expanding populations.

➢ Value-based Payments, rate setting, and other requirements for Managed Care Organizations

➢ Fostering the development of Accountable Care Organizations

➢ Instituting episode-based payments or Alternative Payment Models (APMs) in collaboration with other payers

➢ Requiring stronger behavioral and physical

health integration

➢ Increasing number of LTSS beneficiaries in home and community based care and served under managed care arrangements (MLTSS)

➢ Testing approaches to regulating drug prices

Source: S. L. Hayes, S. R. Collins, D. Radley, and D. McCarthy, What’s at Stake: States’ Progress on Health Coverage and Access to Care, 2013–2016,

The Commonwealth Fund, December 2017.

States That Expanded Medicaid Saw the Greatest Reductions in Uninsured Low-Income Adults Ages 19–64

0

10

20

30

40

50

60

Notes: Low-income defined as living in a household with income <200% of the federal poverty level. States are arranged in rank order based on their current data year (2016) value. Louisiana expanded its Medicaid program after January 1,

2016. For the purposes of this exhibit, we count the District of Columbia as a state.

Data source: U.S. Census Bureau, 2013 and 2016 1-Year American Community Surveys, Public Use Micro Sample (ACS PUMS).

States that expanded Medicaid as of January 1, 2016

Percent

2016

2013

States that had not expanded Medicaid as of January 1, 2016

5

*Notes: Adults in Wisconsin are eligible for Medicaid up to 100% of federal poverty. In Maine, a ballot initiative to

expand Medicaid passed in 2017, but no expansion has been implemented to date. In Montana, the ballot

initiative is to prevent sunsetting of the expansion.

Last updated: September 27, 2018

Status of Medicaid Expansion and Work Requirement Waivers Across the States

Expanded (25 + DC)

1115 Expansion Waiver (8)

Not yet expanded (17)

Work Requirement Waiver Submitted (10)

Work Requirement Waiver Approved (3)

Work Requirement Waiver Approval Blocked (1)

Expansion ballot initiative (5)

2018 Mid-Terms: State Ballot Initiatives (Medicaid)

Ballot measures to expand Medicaid expansion have been introduced in three states and

will be voted on this fall:

• Idaho- Proposition 2 expands Medicaid coverage for those under age 65 with income

below 133% FPL, certified July 17, one of two ballot measures for November election

• Nebraska- Medicaid Expansion Initiative expands Medicaid coverage for ages 19-64

with income below 138% FPL, certified on August 24, only ballot measure for

November election

• Utah- Proposition 3 expands Medicaid coverage ages 19-64 with income below 138%

FPL and raises sales tax from 4.7% to 4.85% to fund the state portion of expansion,

certified May 29, one of seven ballot measures for November election

• Montana – Medicaid expansion passed by 2015 legislature has a “sunset” clause

meaning it will expire unless it is reauthorized in 2019.

7

Thank You!

Contact Information:

Rachel Nuzum, VP Federal and State Health Policy

[email protected]

202-292-6722

For more information please visit: www.commonwealthfund.org

mailto:[email protected]

National Association of Medicaid DirectorsFindings from FY 2017 Operations Survey

October 2018

National Association of Medicaid Directors (NAMD): Who are we?

➢ Created in 2011 to support state and territorial Medicaid Directors

➢ Standalone, bipartisan, & nonprofit➢ Core functions include:

o Developing consensus on critical issues and leverage Directors’ influence with respect to national policy debates;

o Facilitating dialogue and peer to peer learning amongst the members; and

o Providing effective practices and technical assistance tailored to individual members and the challenges they face.

➢ NAMD is led by a Board of Directors comprised of 12 Medicaid Directors from across the country. o The Board President is Judy Mohr Peterson

(Hawaii); its Vice President is Kate McEvoy (Connecticut); and its Immediate Past President is Tom Betlach (Arizona).

9

National Association of Medicaid Directors

The Operations Survey: What is it?

➢Now in its sixth year, NAMD’s Operations Survey

provides insights on the circumstances and

challenges Medicaid Directors face as the leaders of

their agencies.

➢The sections of NAMD’s most recent survey were as

follows:

o Agency Structure

o Strategic Priorities

o Section 1115 demonstration waivers

o Roles and responsibilities across Medicaid functions

o Program integrity

o Medicaid leadership and development

10


FY 2017 Survey: Four Key Findings

1. Medicaid Directors reported intensified expectations with regard to their roles in FY 2017, particularly in the areas of public scrutiny, political pressure, and accountability to stakeholders.

2. Medicaid Directors are continuing to prioritize the transition from volume-based to value-based care in their programs, in addition to investment in data systems, information technology, and behavioral health reform.

3. While increasing from the last iteration of NAMD’s Operations Survey, Medicaid Director tenure remains low, with implications for Medicaid agency operations.

4. Operating a program as complex as Medicaid entails extensive collaboration with a vast network of public and private partners.


11

Medicaid in the Context of State Government

National Association of Medicaid Directors12

Where/how were Medicaid agencies positioned in state government in FY 2017?

More than two-

thirds (31) of the

Medicaid agencies

surveyed were a

division or sub-

division of a larger

umbrella agency.

13


To whom did the Medicaid Director report in FY 2017?

➢Governor (6 states)

➢ Secretary of Health (or Human Services) or

Commissioner of Health (or Human Services)

(21 states)

➢Other (19 states)

14


30 out of the 45 Medicaid Directors reported that they

were political appointees in FY 2017 – seven required

confirmation, and 23 did not.

Structural Changes to Medicaid Agencies in FY 2017

➢ 15 Medicaid Directors reported a change in their states’

leadership at either the Medicaid Director, cabinet, or

Governor level.

➢ Other major structural changes reported in FY 2017

included:

o The integration of Medicaid into an umbrella department;

o The consolidation of numerous health and human services

agencies into one agency or department;

o The reassignment of a population and/or service category to

a different department; and

o The reorganization of reporting structures and, by extension,

the creation of new positions within the agency.National Association of Medicaid Directors

15

A Closer Look at Medicaid Directors


A Closer Look at Medicaid Directors

➢ 30 Directors reported holding positions within the

agency other than Director.o Nine Directors served as a Deputy Director.

o Other positions included: Interim Medicaid Director, General Counsel, Quality

Director, Chief Financial Officer, Policy Director, Chief of Staff, Provider Enrollment

Chief, Program Integrity Chief, Community Support Manager, etc.

➢ Jobs held before coming to the agency:

Other state departments Other public sector Private sector Other

Other positions or agencies:

• State Budget Director

• Assistant Attorney General

• Governor’s office

• Department of Health

• Administration on Aging

• Children Health Care/Adolescent Health

Care

• Mental Health/Behavioral Health

• Veterans Administration

Other:

• State legislature

Military

Capitol Hill

Advocacy/community

organizing

Government relations/lobbying

Hospital association

Healthcare technologies

Consultant firm

Health insurance

Hospital administration

Clinician/physician

Attorney

17


Medicaid Director Tenure as of April 2018

18National Association of Medicaid Directors

Median Medicaid Director Tenure: Comparisons to Past Years (cont’d)

19


Medicaid Director Salary

20


The Impact of FY 2017 on Medicaid Leadership

➢ Heightened attention surrounding health care reform in 2017 raised the stakes for Medicaid Directors.

➢ As they worked to prepare for various models of reform proposed under the American Health Care Act (AHCA) and the Better Care Reconciliation Act (BCRA), Directors:o Met intensively with their Governors, senior leadership at

sister state agencies, state legislatures, and stakeholders;

o Oversaw predictive impact assessments; and

o Requested legislative flexibility to move dollars between state fiscal years/budget accounts.


21

How did Medicaid Director expectations change in FY 2017?

22


Medicaid Agency Staff

➢ On average, the Medicaid Directors surveyed were

responsible for 1,050 full-time employees (FTEs) within

their agencies in FY 2017, with 21 Directors reporting 500

or more FTEs in their Medicaid agencies.

o 21 states reported an anticipated increase in FTEs for FY 2018;

3 states reported a decrease; and16 states reported no change.

➢ A full capture of staff metrics include the following:

23National Association of Medicaid Directors

Strategic Priorities of Medicaid Directors


➢Consistent with past years’ data, the

most common priorities across states

were:

o Delivery system and payment reform

(20 states);

o Data systems and information

technology (IT) (20 states); and

o Behavioral health reform (18 states).


25

Strategic Priorities Reported by Directors in FY 2017 for Coming Year

Strategic Priorities Reported by Directors in FY 2017 for Coming Year (cont’d)


26

Delivery System and Payment Reform

➢ As they continue to improve value by realigning incentives and rewarding performance, Directors indicated plans to pursue and/or implement varied innovation models, including:o Alternative payment models (APMs), such as patient-

centered medical homes (PCMHs) and accountable care organizations (ACOs); bundled payments; and other population-based payment models;▪ These included Medicaid APMs with the Advanced Alternative Payment Model option available

under the Medicare Access and CHIP Reauthorization Act (MACRA).

o Delivery System Reform Incentive Payment (DSRIP) waiver implementation; and

o State Innovation Model (SIM) program implementation.


27

Data Systems and IT➢ 14 Directors indicated their agencies are (or soon

will be) undertaking a modular replacement of their

Medicaid Management Information Systems (MMIS).

➢ Seven Directors described their agencies’ plans to

optimize systems platforms for eligibility and

enrollment by:

o Computerizing historically manual processes;

o Integrating Medicaid data with that of the Supplemental

Nutrition Assistance Program (SNAP) and Temporary

Assistance for Needy Families (TANF); and/or

o Building various interactive platforms for providers and

members, such as web portals.


28

Behavioral Health Reform

➢ Reforms cited by Directors for the coming year included:

o Integrating physical and behavioral health services, encompassing

changes at the agency level, changes to managed care contracts,

and changes at the point of care;

o Better leveraging Prescription Drug Monitoring Programs (PDMPs) to

support appropriate prescribing;

o Investing in community-based services for mental health

treatment;

o Coordinating with partners in the criminal justice system;

o Targeting investments for individuals with high acuity needs; and

o Expanding SUD treatment capacity through SUD Institutions of

Mental Disease (IMD) 1115 demonstration waivers.


29

Interesting Insights from Strategic Priorities

➢ More than a quarter of states (13) cited internal

operational optimization as one of their top

three priorities for the coming year.

➢ Eight Directors named planning, implementation,

or evaluation of their Section 1115 waivers as

one of their top three strategic priorities for the

coming year.

o Even if not always considered a top strategic priority,

more than 80 percent of Directors surveyed (38)

indicated that they planned to seek further flexibility

from a Section 1115 waiver in FY 2018.


30

What waivers are Medicaid agencies pursuing now?

31


Program Integrity


Which program integrity initiatives, projects, etc. did Directors find most

effective in FY2017?

➢ Data mining

➢ Provider training and education

➢ Systematic audits

➢ Onsite visits

➢ Modifications to payment structures

➢ Hiring staff with program integrity expertise

➢ Collaborating with extra-agency entities, such as:o Managed care organizations (MCOs) (27 states)

o Medicaid Fraud Control Units (22 states)

o Federal/Medicare contractors (12 states)

o State Attorney General’s Office (ten states)

o Data analytics vendors (eight states) National Association of Medicaid Directors

33

What program integrity initiatives, projects, and activities are Directors planning for the

future?

➢ Data/systems:

o Case management systems

o Bringing in vendors

o New algorithms to detect fraud

and abuse

o Data sharing with partners

o Data mining

➢ Providers:

o Provider education/provider self-

audits

o Provider information tool

o Implementing provider payment

suspension

➢ Managed care:

o Enhance MCO monitoring and

oversight

➢ Staffing:

o Investing in PI staff

o Restructuring PI office(s)

➢ Enhancing PI capacity for

complex populations:

o LTSS/HCBS

o Behavioral health/SUD

➢ Other:

o Relationships/stakeholder

engagement

34


Operational Jurisdiction of Medicaid Programs and Functions


Medicaid Functions Operated or Co-Operated by Contractors


36


For more information:

www.medicaiddirectors.org

[email protected]

http://www.medicaiddirectors.org/

mailto:[email protected]

National Conference of State Legislatures

Medicaid: Innovations in Coverage, Delivery and

Financing

Joan Alker

Executive Director, Research Professor

Georgetown University Center for Children

and Families

Rate of Uninsured Children, 2008-2017

Source: CCF analysis of ACS single-year estimates 40

9.7

9.08.5

7.97.5 7.5

6.3

5.14.7

5.0

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Rate of Uninsured Children, 2008-2017

**

*

*

**

*

*

Potential Exemption Status from Work

Requirements Among Non-Dual, Non-SSI,

Nonelderly Adults

41Source: Kaiser Family Foundation analysis of March 2017 Current Population Survey

Reporting in AR Works

42Source: Kaiser Family Foundation analysis of Arkansas Department of Human Services,

“Reporting Work Activities and Exemptions for Arkansas Works”

Number of Enrollees Who Did Not Meet

Work and Reporting Requirements

43Source: Kaiser Family Foundation analysis of Arkansas Works Program, State Data from the

Arkansas Department of Human Services as of September 9, 2018.

44

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up for our newsletter!

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and Families

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Documents

Medicaid: Innovations in Coverage, Delivery and Financing · Medicaid: Innovations in Coverage, Delivery and Financing. Sources: National Health Expenditure Projections, Centers for