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  • Historical underfunding of primary care relative to commercial/Medicare has limited Medicaid access in some states.Medicaid paid 66% of Medicare, on average nationally, in 2008.1A strong primary care foundation is critical to a high-performing health system.2Need to prepare for expansion of Medicaid to an additional 16 to 20 million beneficiaries in 2014.
  • Need for upfront funding for demonstrationHIT and other infrastructure supports neededHow to address within risk-based managed care delivery systemPositioning FQHCs and RHCs as ACOsAccess to and analysis of patient-level claims data

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  • 1. Medicaid Investments inPrimary Care: Fitting ThePieces TogetherAAFP 2011 State Legislative ConferenceNovember 4, 2011Dianne HasselmanDirector, Quality and Equality, CHCS www.chcs.org
  • 2. CHCS Mission To improve health care quality for low-income children and adults, people with chronic illnesses and disabilities, frail elders, and racially and ethnically diverse populations experiencing disparities in care. Our Priorities ► Enhancing Access to Coverage and Services ► Improving Quality and Reducing Racial and Ethnic Disparities ► Integrating Care for People with Complex and Special Needs ► Building Medicaid Leadership and Capacity 2
  • 3. Medicaid Fast Facts 60 million People in the United States with Medicaid coverage. $427 billion Projected Medicaid spending for FY 2010.16 - 20 million Additional Medicaid/CHIP beneficiaries by 2019 due to health reform. 41% Births in the United States covered by Medicaid. 28% Children in the United States covered by Medicaid. 50% Medicaid beneficiaries under 65 who are from diverse racial/ethnic groups. 5% Medicaid beneficiaries accounting for 57% of total Medicaid spending. 49% Medicaid beneficiaries with disabilities diagnosed with mental illness. 27% Total mental health care costs financed by Medicaid. $4 billion Estimated costs for children in foster care covered by Medicaid. 71% Medicaid recipients who are enrolled in managed care.
  • 4. Challenges Facing Medicaid in 2011 • Overwhelming and dire budget situation • We’re not through the worst of it • Loss of leadership and staff through early retirement, hiring freezes, and furloughs • Low morale, loss of historical knowledge • Political conflict around implementation of health care reform • Federal mandates, state lawsuits, 2014 approaching quickly • In the midst of all this, unprecedented opportunities and funding for Medicaid transformation 4
  • 5. Federal Investments in Medicaid PrimaryCare • Primary care rate increase or “bump” • Health homes and community health teams • Medicaid preventive care incentives • Payment demonstrations (Pediatric ACOs and bundled payment) • Health information technology and meaningful use • Medicaid adult core measurement set • Comprehensive Primary Care initiative 5
  • 6. Section 1202: PCP “Bump” • In 2013-2014, Medicaid will reimburse primary care providers • Infuses up to $8.3 billion in Medicaid primary care, funded entirely by the federal government • Applies to physicians practicing in family medicine, general internal medicine, and pediatric medicine • Covers evaluation & management codes covered by Medicare and child and adolescent immunizations 6
  • 7. Section 2703: Health Homes• Six new care management/coordination services for eligible Medicaid beneficiaries• State participation is optional• Timing is flexible• Funding for services is an enhanced – but time limited – 90/10 federal-state match• Chronic conditions and geographic locations can be targeted, phased in• Focus on integration of physical and behavioral health care• Related to, but not the same as, medical home 7
  • 8. Accountable Care Organizations• Medicare shared savings program for accountable care organizations regulations released April 2, 2011• Medicaid pediatric demonstration scheduled for 2012-2016• Center for Medicare and Medicaid Innovation opportunities ► Pioneer ACO model opportunity► Significant state interest in exploring ACOs ► Utah, New Jersey, Maine, Colorado, etc. ► Dr. Jeffrey Brenner’s “hot spots”
  • 9. Comprehensive Primary Care Initiative • New and competitive initiative by Center for Medicare and Medicaid Innovation (CMMI) • CMS to pay care management fee to participating practices for Medicare fee-for- service beneficiaries • PMPM average: $20 Years 1/2; $15 Years 3/4 with shared savings opportunity • CMS will fund 100 percent of additional reimbursement for new or enhanced primary care services for Medicaid fee-for-service beneficiaries 9
  • 10. Medicaid Leveraging Federal and StateInvestments • Build capacity for Medicaid expansion in 2014 • Invest in primary care delivery ► Leverage new federal dollars, repurposing existing funds ► Push accountability out towards the point-of-care • Maximize impact of opportunities by creating a coherent strategy for Medicaid transformation ► Link, align or “nest” Medicaid initiatives ► Align activities with other payers • Create stepping stones to a more effective, accountable health are system 10
  • 11. Primary Care Leveraging MedicaidInvestments • Work in partnership to help Medicaid design and implement new primary care initiatives • Outreach to Medicaid director and medical director in organized way • Engage in Medicaid medical home initiatives, encouraging involvement by smaller practices • Work with Medicaid to measure the return on investment of efforts – this is the opportunity to sustain investments • Identify physician champions for Medicaid • Above all, resist the temptation to retreat or withdraw 11
  • 12. Visit CHCS.org to … • Download practical resources to improve the quality and cost-effectiveness of Medicaid services. • Subscribe to CHCS eMail Updates to learn about new programs and resources. • Learn about cutting-edge efforts to strengthen and invest in the primary care infrastructure for the Medicaid program. www.chcs.org 12