Sundwall medicaid


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Sundwall medicaid

  1. 1. Premier Conference David N. Sundwall, M.D. Vice Chair, MACPAC (Medicaid and CHIP Payment and Access Commission) Winning Under Reform Nashville, TN June 15, 2011 Medicaid Under Fire: Partnering Under Reform
  2. 2. Presentation Outline <ul><li>I. Overview </li></ul><ul><li>II. MACPAC </li></ul><ul><li>III. MACPAC Reports to Congress March 2011 </li></ul><ul><li>June 2011 </li></ul><ul><li>IV. Future Directions Managed Care </li></ul><ul><li>ACOs (Accountable Care Organization) Other innovations? </li></ul>
  3. 3. I. Overview <ul><li>Medicaid in the spotlight: </li></ul><ul><li>Increased costs </li></ul><ul><li>Increased enrollment due to recession (“counter cyclical”) </li></ul><ul><li>Expansions of Medicaid under PPACA </li></ul><ul><li>Politics </li></ul><ul><ul><li>a. Democrats - Part of the solution to address the problems of the uninsured is to expand Medicaid </li></ul></ul><ul><ul><li>b. Republicans - Part of the problem is with unsustainable government spending and “hyper-regulation ” </li></ul></ul>
  4. 4. Key Medicaid and CHIP Facts <ul><li>People </li></ul><ul><li>Medicaid provides health care coverage for 68 million low income people including: </li></ul><ul><ul><ul><ul><li>33 million children </li></ul></ul></ul></ul><ul><ul><ul><ul><li>11 million blind or disabled individuals </li></ul></ul></ul></ul><ul><ul><ul><ul><li>17 million non-disabled adults (e.g., pregnant women, parents of Medicaid-enrolled children) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>6 million seniors with Medicare </li></ul></ul></ul></ul>CHIP covers 8.1 million children — 90 percent have family incomes below 200 percent of the federal poverty level ($37,060 for a family of 3)
  5. 5. Key Medicaid and CHIP Facts – cont. <ul><li>Expenditures </li></ul><ul><li>Medicaid federal and state expenditures were over $400 billion in FY 2010 and account for: </li></ul><ul><ul><ul><ul><li>8.1 percent of total federal outlays </li></ul></ul></ul></ul><ul><ul><ul><ul><li>33 percent of all nursing home expenditures </li></ul></ul></ul></ul><ul><ul><ul><ul><li>36 percent of all home health care expenditures </li></ul></ul></ul></ul><ul><ul><ul><ul><li>25 percent of all mental health and substance abuse treatment spending </li></ul></ul></ul></ul>CHIP federal and state expenditures in FY 2010 were $11 billion
  6. 7. <ul><li>MACPAC – the Medicaid and CHIP Payment and Access Commission ( </li></ul><ul><li>Legislative History </li></ul><ul><li>Established in February 2009 (Children’s Health Insurance Program Reauthorization Act) </li></ul><ul><li>Expanded and funded in March 2010 (Patient Protection and Affordable Care Act) </li></ul><ul><li>Commission </li></ul><ul><li>Appointed by the Comptroller General of the United States to 3-year terms </li></ul><ul><li>17 Commissioners represent broad spectrum of interests and expertise on Medicaid and CHIP </li></ul>
  7. 8. MACPAC - continued <ul><li>Goals </li></ul><ul><li>Serve as a federal non-partisan and analytic resource on Medicaid and CHIP policy for the Congress </li></ul><ul><li>Review federal and state Medicaid and CHIP policies and data sources </li></ul>
  8. 9. MACPAC Duties <ul><li>Review Medicaid and CHIP policy issues: </li></ul><ul><ul><li>Payment policies </li></ul></ul><ul><ul><li>Access to care issues </li></ul></ul><ul><ul><li>Eligibility </li></ul></ul><ul><ul><li>Quality of care </li></ul></ul><ul><ul><li>Interactions between Medicaid and Medicare </li></ul></ul><ul><ul><li>Data policy analysis and program accountability </li></ul></ul><ul><li>Create early-warning system to identify provider shortage areas and other factors that adversely affect appropriate access. </li></ul>
  9. 10. MACPAC Duties - continued <ul><li>Review and comment on Secretarial reports and regulations that relate to policies under Medicaid and CHIP </li></ul><ul><li>Review federal and state Medicaid and CHIP policies and data sources </li></ul>
  10. 11. III. MACPAC Report to Congress <ul><li>Overview of MACPAC’s March 2011 Report to the Congress </li></ul><ul><li>Chapters 1-3: Background and overview of Medicaid and CHIP </li></ul><ul><li>Chapters 4-6: Foundation for MACPAC’s initial approach to addressing payment, access and data </li></ul><ul><ul><li>- Evolving framework for Commission to examine access to care </li></ul></ul><ul><ul><li>- Initial approach for examining Medicaid provider fee-for-service payment policy across states and providers </li></ul></ul><ul><ul><li>- Outlines federal data sources, issues and potential areas for improvement for policy and accountability </li></ul></ul>
  11. 12. III. MACPAC Report to Congress - continued <ul><li>Medicaid and CHIP Program Statistics (MACStats): original MACPAC data analysis </li></ul><ul><li>… perhaps the most useful and valuable contribution of the MACPAC </li></ul><ul><li>to date. </li></ul>
  12. 13. <ul><li>Enrollees </li></ul><ul><ul><li>Enrollee characteristics and health needs </li></ul></ul><ul><ul><li>Eligibility requirements </li></ul></ul><ul><li>Access </li></ul><ul><ul><li>Appropriateness of services and settings </li></ul></ul><ul><ul><li>Efficiency, economy, and quality of care </li></ul></ul><ul><ul><li>Health outcomes </li></ul></ul>Chapter 4: Examining Access to Care in Medicaid and CHIP <ul><ul><ul><li>Framework for monitoring access to care </li></ul></ul></ul><ul><ul><ul><li>Will evolve over time to address changing health care practice patterns </li></ul></ul></ul>Challenges in Current Political Climate: just one example . . .
  13. 14. Preview of the June 2011 Report <ul><li>Current, baseline information on Medicaid managed care: </li></ul><ul><ul><li>Medicaid managed care in the context of the U.S. health care system </li></ul></ul><ul><ul><li>Populations enrolled in Medicaid managed care </li></ul></ul><ul><ul><li>Managed care models </li></ul></ul><ul><ul><li>Payment policies </li></ul></ul><ul><ul><li>Access and quality </li></ul></ul><ul><ul><li>Program accountability, integrity and data </li></ul></ul><ul><ul><li>Future issues facing Medicaid managed care </li></ul></ul><ul><li>MACStats tables and figures include: </li></ul><ul><ul><li>Trends in Medicaid enrollment and spending </li></ul></ul><ul><ul><li>Current health characteristics, enrollment, and benefit spending among Medicaid populations </li></ul></ul><ul><ul><li>Medicaid managed care enrollment </li></ul></ul>
  14. 15. IV. Future Directions . . . <ul><li>Context: </li></ul><ul><li>“ Taming the Medicaid Monster”…. </li></ul><ul><li>(headline on the front page of the Salt Lake Tribune, November 2010) </li></ul>
  15. 16. IV. Future Directions . . . States activities – “WAIVERS” ( from lots of requirements or proposed policies under the PPACA) <ul><li>1) Movement to more “managed care” (risk-based) for all categories of eligible beneficiaries, </li></ul><ul><li>e.g. Utah’s waiver for an “HMO-like ACO”, +: allow state to provide a “premium subsidy to purchase private insurance on the Health Insurance Exchange, in lieu of Medicaid for those who qualify ; and set a cap on state spending for Medicaid (can’t grow faster than the state budget) </li></ul><ul><li>2) Create alternative delivery systems and/or payment policies , e.g., “Accountable Care Organizations” (ACOs), and “medical homes,” to better coordinate care and hopefully reduce expenditures. </li></ul>
  16. 17. IV. Future Directions . . . Continued – Federal activities <ul><li>1) BUDGET ? </li></ul><ul><li>2) Amendments to PPACA - Amend the PPACA to repeal the “Maintenance of Effort” (MOE) requirement of states, i.e. allow flexibility to limit eligibility (S.868) </li></ul><ul><li>3) Block grant ? ( see Kaiser Family Foundation analysis) </li></ul><ul><li>4) Status of PPACA due to litigation/Supreme Court consideration in 2012 - ? </li></ul>