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
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