An increasing number of states are expanding managed care. This webinar provides a straightforward overview and history of the Medicaid Managed Care program and how it applies to physicians, practices, and patients.
Carisa Magee, Manager, Medicaid/CHIP Program Policy Texas Health and Human Services Commission, presented an overview of Medicaid at the "Designing Healthcare in Texas" conference hosted by One Voice Texas, Harris County Healthcare Alliance and Kinder Institute on June 3, 2014.
Brief presentation regarding key topics in the USA healthcare industry. Some of the basic topics include: MACRA, ICD 10, Meaningful Use and a very brief comment about diabetes as a chronic condition.
Virginia AFP's lobbyist Hunter Jamerson's presentation from the 2013 SLC on the unique Medicaid reform approach being followed in the state of Virginia.
Monthly series covering key subjects regarding healthcare business in the USA. This seminar covers: Affordable Care Act section 1557, HIPAA Security, Medicare Payment models and Chronic conditions.
Ottawa, 25 May 2011 -- Canada 2020 hosted a panel discussion on Health Care 2014: Creating a Sustainable Health Care System. With the current Federal-Provincial health care agreement expiring in March, 2014, Canada 2020 wanted to contribute to the debate over the shape of a future agreement.
This is the presentation by Michael Kirby, Chair, Mental Health Commission of Canada. Visit www.canada202.ca for details.
Medicare 101 - 2021 Update from Erin HartMary Hagan
Medicare 101 – 2019 Update
Medicare Benefit Education Topics
Health benefits options for retirees and people over 65
Medicare and Medicaid benefits
Structuring an Eldercare program for your employees
Patient Advocacy – what is it?
Carisa Magee, Manager, Medicaid/CHIP Program Policy Texas Health and Human Services Commission, presented an overview of Medicaid at the "Designing Healthcare in Texas" conference hosted by One Voice Texas, Harris County Healthcare Alliance and Kinder Institute on June 3, 2014.
Brief presentation regarding key topics in the USA healthcare industry. Some of the basic topics include: MACRA, ICD 10, Meaningful Use and a very brief comment about diabetes as a chronic condition.
Virginia AFP's lobbyist Hunter Jamerson's presentation from the 2013 SLC on the unique Medicaid reform approach being followed in the state of Virginia.
Monthly series covering key subjects regarding healthcare business in the USA. This seminar covers: Affordable Care Act section 1557, HIPAA Security, Medicare Payment models and Chronic conditions.
Ottawa, 25 May 2011 -- Canada 2020 hosted a panel discussion on Health Care 2014: Creating a Sustainable Health Care System. With the current Federal-Provincial health care agreement expiring in March, 2014, Canada 2020 wanted to contribute to the debate over the shape of a future agreement.
This is the presentation by Michael Kirby, Chair, Mental Health Commission of Canada. Visit www.canada202.ca for details.
Medicare 101 - 2021 Update from Erin HartMary Hagan
Medicare 101 – 2019 Update
Medicare Benefit Education Topics
Health benefits options for retirees and people over 65
Medicare and Medicaid benefits
Structuring an Eldercare program for your employees
Patient Advocacy – what is it?
Value-Based Payments and Managed Care Contracting - Crash Course Webinar SeriesEpstein Becker Green
Epstein Becker Green Webinar with Attorney Basil Kim - Value-Based Payments Crash Course Webinar Series - May 31, 2016.
As value-based payment relationships continue to grow in prevalence and complexity, a question remains: How do I effectively capture this arrangement on paper?
Topics include:
* Some of the key strategic questions to deliberate with regard to contracting in a value-based payment relationship
* Considerations for contracting under a value-based payment framework.
http://www.ebglaw.com/events/value-based-payments-and-managed-care-contracting-value-based-payments-crash-course-webinar-series/
These materials have been provided for informational purposes only and are not intended and should not be construed to constitute legal advice. The content of these materials is copyrighted to Epstein Becker & Green, P.C. ATTORNEY ADVERTISING.
Risk-Based Contracting: Background, Assessment, and ImplementationPYA, P.C.
PYA Principal Bob Paskowski presented “Risk-Based Contracting: Assessments and Implementation,” at the National Association of Managed Care Physicians Fall Managed Care Forum, November 10-11, 2016. The presentation allows participants to:
Understand the different types and core elements of risk-based contracting (RBC).
Prepare for additional discussions with key stakeholders regarding RBC assessment and readiness.
Make informed decisions as to next steps while evaluating associated financial risks.
Chapter 10 Government Health Insurance Programs .docxketurahhazelhurst
Chapter 10:
Government Health Insurance
Programs: Medicaid, CHIP,
and Medicare
Chapter Overview
• Chapter 10 provides a basic overview of the
major public health insurance programs in the
United States, including changes to the
programs under the Affordable Care Act.
• Chapter 10 focuses on:
– Medicaid
– Children’s Health Insurance Program
– Medicare
Entitlements v. Block Grants
• Entitlement: Everyone who is eligible for and
enrolled in the program is legally entitled to receive
benefits from the program. Beneficiaries may not be
refused service for lack of funds or other reasons.
• Block Grants: A defined sum of money (often from
the federal government to the states) that is allocated
for a particular program over a certain amount of
time. Beneficiaries may be refused service for lack of
funds or other reasons.There is no legal entitlement to
the benefits.
Medicaid
• Overview: A federal-state public health insurance
program for the indigent.
• Program administration
– Federal: Center for Medicare and Medicaid
Services (CMS) outlines mandatory and optional
populations and benefits covered under Medicaid
– State: state Medicaid agencies run programs, select
which optional populations and benefits to cover in
the state program
• All states participate in Medicaid
Medicaid – Eligibility
• Medicaid generally covers low-income
• Pregnant women
• Children
• Adults in families with dependent children
• Individuals with disabilities
• Elderly
• Must meet 5 eligibility requirements: Categorical,
Income level, Resources, Residency and Immigration
status
Medicaid — Benefits
• Medicaid covers extensive acute care and Long-Term
Care benefits
– Some benefits are mandatory, others are optional
– Early and Periodic Screening Diagnostic and
Testing services are a comprehensive set of
mandatory services for children
• Deficit Reduction Act of 2006 (DRA) created a new
benefit option that allows states to use one of 5
benchmark or benchmark equivalent options to set
their benefit package
Medicaid — Financing
• Medicaid is jointly financed by the federal and state
governments
• Matching system
– Federal Medical Assistance Percentage determines the
matching rate; rate is tied to each state’s per capita
income with poorer states receive a higher federal
match, and must be at least 50/50
• Beneficiary cost-sharing
– Prior to DRA, very limited cost-sharing allowed
– DRA provides expanded cost-sharing options
Medicaid –
Provider Reimbursement
• Reimbursement levels vary by state and type of
provider
– States have a lot of discretion in setting rates
• Fee-for-service provides paid on a state-determined
fee schedule
• Managed care providers paid according to contracts
between the state and the managed care organization
• Medicaid reimbursement is typically much lower than
private insurance or Medicare reimbursement
Medicaid — Waivers
• States may appl ...
Health and Human Services in State and Local GovernmentJon Yoffie
HEALTH & HUMAN SERVICES. It’s now the single largest cost center for governments; we’re not getting any younger and healthcare isn’t getting any cheaper. So help governments focus on cost containment—through consolidation of services delivery, price controls, IT modernization, the leveraging of Big Data and new business intelligence solutions. Governing Institute Director Julia Burrows walks you through a market overview, key data and indicator
Medicaid: What You Need to Know (CSH and Foothold)Ronan Martin
In our first session, Foothold Technology Director of Client Services, Paul Rossi and Senior Advisor, David Bucciferro, along with Sue Augustus from CSH, will bring us back to basics of all things Medicaid. They will cover topics ranging in commonly used terms, coverage and eligibility and the differences between Medicaid and Medicare. This webinar series is designed for beginners and experts alike. Beginners will walk away with a strong foundation and experts will have the opportunity to contribute to the conversation.
mHealth Israel_US Health Insurance Overview- An Insider's PerspectiveLevi Shapiro
Presentation about the US Health Insurance Sector by Lori Rund, VP, Product Management and Market Intelligence at Health Alliance Plan, a managed care organization owned by the Henry Ford Health System, with 650,000 lives. Lori is responsible for the identification, concept building, researching and business case developments for new products, services and markets. She develops and leads comprehensive market intelligence functions to help the organization better understand industry trends and identify business opportunities.
Prior to joining Health Alliance Plan, Lori was Director of Product Development and Market Intelligence at Health Alliance Medical Plans in Illinois and Director of Market Research and Strategy at Carle Clinic Association, also in Illinois.
How do medicaid waivers expand the possibilities of whole person care 032117Jennifer D.
With the changing landscape in healthcare right now it's important to know how Medicaid Waivers and Whole Person Care can help secure positive outcomes.
The Strong Start initiative is an initiative to reduce preterm births and early elective deliveries while improving outcomes for newborns and pregnant women.
Under this initiative, the Innovation Center will award up to $43 million through a competitive process to providers, States, managed care plans, and conveners to achieve better care, improved health, and lower costs for these women and their newborns.
CMS Innovation Center and Center for Medicaid and CHIP Services staff will be hosting a webinar that will discuss how applicants can prepare their budget for the Strong Start Medicaid funding opportunity.
More at: http://innovations.cms.gov/resources/Duals_rahnfr_apply.html
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
Strong Start is an initiative to reduce preterm births and early elective deliveries while improving outcomes for newborns and pregnant women.
Under this initiative, the Innovation Center will award up to $43 million through a competitive process to providers, States, managed care plans, and conveners to achieve better care, improved health, and lower costs for these women and their newborns.
CMS Innovation Center and Center for Medicaid and CHIP Services staff will be hosting a webinar that will discuss how applicants can prepare their budget for the Strong Start Medicaid funding opportunity.
More at: http://innovations.cms.gov/resources/StrongStart_McaidFundOpp.html
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
CPT E/M codes are changing January 1, 2021. This webinar unpacks those changes for you, outlining everything you need to know including:
How to navigate all the changes
What these mean for reimbursement
What you need to know to make sure your providers and coders are ready.
Telemedicine has moved to the forefront of healthcare, opening up opportunities for both practices and their patients. To help unpack some of the enormous amounts of new information, This presentation focuses on:
- Relaxing of Regulatory Issues
- How Telemedicine Can Help Your Practice
- Challenges
- The Future of Telemedicine
This episode continues our COVID-19 COVID-19 Insights Webinar discussing CMS changes, available grants and loans, existing opportunities in telehealth, and more state openings for elective surgeries.
The COVID-19 pandemic continues to present challenges to healthcare practices. This presentation covers the reinstatement of elective surgeries in a few states, the greater adoption of remote tracking, and new developments with the FCC’s Telehealth Program.
It also goes over the technology CareOptimize has developed to help streamline COVID-19 monitoring and reporting, its genesis, and how this utility can help your practice post-pandemic.
This webinar continues the COVID-19 Insights webinar series. Topics include the loans and grants being offered by the government, how they differ, and how they may benefit your practice, including SBA Loans and Grants, HHS Grants, Medicare Advance/Accelerated Payments, and Telehealth Funding. The webinar also goes over the CareOptimize technology developed to assist with streamlining COVID-19 monitoring and reporting.
Does it feel like you’re falling behind on the latest CMS regulatory updates? You’re not alone. The CareOptimize COVID-19 Insights webinar is designed to keep you informed of everything going on with CMS as healthcare practices continue to adjust. Along with CMS updates, this webinar goes over SBA loans and Fee-for-service Advance/Accelerated Medicare payments.
CareOptimize COVID-19 Webinar series episode 2 continues with the most up-to-date news from CMS along with other regulatory changes affecting the healthcare industry. The primary focus is on a trio of distinct provider models and how each of them is managing their practices while adapting to the challenges of the pandemic. We also go over the technology CareOptimize has developed aimed at streamlining COVID-19 monitoring and reporting.
MIPS continues to be a major risk, with practices who do not participate subject to a 5% penalty. This webinar covers:
Rule clarification and changes that have occured since January 1st.
Measure clarification and changes that have occured since January 1st. Your measure calculations may be changing as a result.
Where your practice should be at this point in the year.
How we can help support unique workflows and provider documentation.
In the day and age of value based medicine, it is critical to optimize your reimbursements with more accurate coding.This webinar uses specific examples to demonstrate the intricacies of accurate coding and how you can actually benefit. Questions answered include:
• How is global service reporting changing?
• What procedures require reporting?
• Who is required to report?
• When do new requirements take effect?
MACRA is quickly approaching year 2. CMS recently released their 2018 Proposed Rule, and there are some significant changes everyone should be aware of.
Rather than wading through the 1,058 pages of the Proposed Rule, join CareOptimize for a look at the most important takeaways.
In less than 30 minutes, you'll learn:
Are any of your clinicians now exempt?
What is a Virtual Group, and will it save you money?
Are your practice's priorities aligned with the newly weighted categories?
How can the Proposed Rule increase your 2018 bonus?
Accountable Care Organizations (ACOs) have been part of the healthcare landscape for a while and remain an integral part of the move toward value-based medicine. CMS recently introduced a new model in the MSSP (Medicare Shared Savings Program), ACO Track 1+.
This presentation gives a broad overview of ACOs and explains the basics of the new Track 1+ model. Topics include:
- ACOs and their role in MACRA/MIPS
- Meeting or exceeding the standards
- Why the risk might be worth it
MIPS is here. Are You Ready? CareOptimize Is.
See how the MIPS Management Solution empowers practices like yours to:
1. Know provider scores in real-time and compare those to your peers across the country
2. Provide scorecards for each MIPS category
3. Model different scenarios to determine your highest MIPS score
4. Automatically submit to CMS
5. Choose which level of assistance is best for your organization
... And More!
Let's face it, changes are coming. Healthcare is about to undergo another big shift once the new administration comes in. Between the sure things and the big questions, CareOptimize has found a bit of clarity. Join us to learn what our experts advise you to do to stay on top of it all.
Are you:
Keeping up to date with your risk scoring?
Missing out on reimbursement premiums?
Ensuring accurate health profiles for your patients?
Proper risk adjustment is important, not only to ensure your patients' quality of care, but also to improve your bottom line. This CareOptimize presentation will take you from the basic tenets of risk adjustment to specific ways you can increase your risk scores and get the highest premium payments.
Meaningful Use: Programs, Penalities, and PaymentsBen Quirk
Meaningful Use is not dead!
MIPS may be just around the corner, but MU is still very much in the picture. There is enough time, however, for your practice to optimize 2016 reporting and increase 2018 payments and avoid penalties.
This presentation takes you through the steps needed to successfully attest for 2016 and be prepared for upcoming changes.
CMS has stopped being nice about ICD10. As of October 1, 2016, the grace period for not using specific codes for certain diagnoses is gone. If you are not precise with these codes, your denial rates will go up.
This presentatio helps you learn how you can avoid high denial rates and also explains:
- Key changes and revisions
- Written guidance from CMS and OIG that may negate a new guideline
- Chapter specific changes
- How to tell when you need documentation and when you don’t
2016 MIPS Final Rule: What you need to know NOWBen Quirk
Find out why you need to pay attention to this Final Rule and what adjustments you need to make to ensure you end up on the winning side of MIPS. It's a complicated program, and results from the Final Rule don't make it any easier.
With patient responsibility becoming an increasing part of clinics AR, you need to make sure you have an effective strategy in place. Learn how to maximize your collections without negatively impacting your relationships with your patients.
Navigating Challenges: Mental Health, Legislation, and the Prison System in B...Guillermo Rivera
This conference will delve into the intricate intersections between mental health, legal frameworks, and the prison system in Bolivia. It aims to provide a comprehensive overview of the current challenges faced by mental health professionals working within the legislative and correctional landscapes. Topics of discussion will include the prevalence and impact of mental health issues among the incarcerated population, the effectiveness of existing mental health policies and legislation, and potential reforms to enhance the mental health support system within prisons.
India Clinical Trials Market: Industry Size and Growth Trends [2030] Analyzed...Kumar Satyam
According to TechSci Research report, "India Clinical Trials Market- By Region, Competition, Forecast & Opportunities, 2030F," the India Clinical Trials Market was valued at USD 2.05 billion in 2024 and is projected to grow at a compound annual growth rate (CAGR) of 8.64% through 2030. The market is driven by a variety of factors, making India an attractive destination for pharmaceutical companies and researchers. India's vast and diverse patient population, cost-effective operational environment, and a large pool of skilled medical professionals contribute significantly to the market's growth. Additionally, increasing government support in streamlining regulations and the growing prevalence of lifestyle diseases further propel the clinical trials market.
Growing Prevalence of Lifestyle Diseases
The rising incidence of lifestyle diseases such as diabetes, cardiovascular diseases, and cancer is a major trend driving the clinical trials market in India. These conditions necessitate the development and testing of new treatment methods, creating a robust demand for clinical trials. The increasing burden of these diseases highlights the need for innovative therapies and underscores the importance of India as a key player in global clinical research.
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
R3 Stem Cells and Kidney Repair A New Horizon in Nephrology.pptxR3 Stem Cell
R3 Stem Cells and Kidney Repair: A New Horizon in Nephrology" explores groundbreaking advancements in the use of R3 stem cells for kidney disease treatment. This insightful piece delves into the potential of these cells to regenerate damaged kidney tissue, offering new hope for patients and reshaping the future of nephrology.
CHAPTER 1 SEMESTER V PREVENTIVE-PEDIATRICS.pdfSachin Sharma
This content provides an overview of preventive pediatrics. It defines preventive pediatrics as preventing disease and promoting children's physical, mental, and social well-being to achieve positive health. It discusses antenatal, postnatal, and social preventive pediatrics. It also covers various child health programs like immunization, breastfeeding, ICDS, and the roles of organizations like WHO, UNICEF, and nurses in preventive pediatrics.
Telehealth Psychology Building Trust with Clients.pptxThe Harvest Clinic
Telehealth psychology is a digital approach that offers psychological services and mental health care to clients remotely, using technologies like video conferencing, phone calls, text messaging, and mobile apps for communication.
Welcome to Secret Tantric, London’s finest VIP Massage agency. Since we first opened our doors, we have provided the ultimate erotic massage experience to innumerable clients, each one searching for the very best sensual massage in London. We come by this reputation honestly with a dynamic team of the city’s most beautiful masseuses.
One of the most developed cities of India, the city of Chennai is the capital of Tamilnadu and many people from different parts of India come here to earn their bread and butter. Being a metropolitan, the city is filled with towering building and beaches but the sad part as with almost every Indian city
CRISPR-Cas9, a revolutionary gene-editing tool, holds immense potential to reshape medicine, agriculture, and our understanding of life. But like any powerful tool, it comes with ethical considerations.
Unveiling CRISPR: This naturally occurring bacterial defense system (crRNA & Cas9 protein) fights viruses. Scientists repurposed it for precise gene editing (correction, deletion, insertion) by targeting specific DNA sequences.
The Promise: CRISPR offers exciting possibilities:
Gene Therapy: Correcting genetic diseases like cystic fibrosis.
Agriculture: Engineering crops resistant to pests and harsh environments.
Research: Studying gene function to unlock new knowledge.
The Peril: Ethical concerns demand attention:
Off-target Effects: Unintended DNA edits can have unforeseen consequences.
Eugenics: Misusing CRISPR for designer babies raises social and ethical questions.
Equity: High costs could limit access to this potentially life-saving technology.
The Path Forward: Responsible development is crucial:
International Collaboration: Clear guidelines are needed for research and human trials.
Public Education: Open discussions ensure informed decisions about CRISPR.
Prioritize Safety and Ethics: Safety and ethical principles must be paramount.
CRISPR offers a powerful tool for a better future, but responsible development and addressing ethical concerns are essential. By prioritizing safety, fostering open dialogue, and ensuring equitable access, we can harness CRISPR's power for the benefit of all. (2998 characters)
Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
Medical Technology Tackles New Health Care Demand - Research Report - March 2...
Medicaid Managed Care
1. Medicaid
Managed
Care
Wednesday,
April
23,
2014
Disclaimer:
Nothing
that
we
are
sharing
is
intended
as
legally
binding
or
prescrip7ve
advice.
This
presenta7on
is
a
synthesis
of
publically
available
informa7on
and
best
prac7ces.
2. Medicaid
Managed
Care
• Allow
states
to
pay
a
capitated
rate
per
enrollee
• Shi6
the
risk
to
the
managed
care
organiza:ons
• Ul:mately
decrease
costs
and
improve
care
to
those
that
would
not
otherwise
seek
care
3. Medicaid
Managed
Care
• In
the
past,
Medicaid
has
been
a
fee
for
service.
Managed
Care
programs
have
become
more
common
over
the
past
15
years.
• Under
the
managed
care
plans,
the
pa:ent
receives
most
or
all
of
their
services
from
organiza:ons
that
have
contracts
with
the
state
• Almost
50
million
people
receive
care
via
a
managed
care
system
either
voluntarily
or
mandatory
basis
4. Two
Classifica:ons
of
Medicaid
Managed
Care
Plans
• Commercial
managed
care
plans
–
non-‐medicaid
popula:on
(Medicaid
plans
where
less
than
75
percent
are
medicaid
Enrollees;
these
usually
fall
under
a
marke:ng
)
• Medicaid
dominant
HMO's
which
primarily
serve
Medicaid
enrollees
(75-‐100
percent
enrollees
are
Medicaid
beneficiaries)
5. Three
types
of
Medicaid
Managed
Care
En::es
• Managed
Care
Organiza:on
MCO
-‐
companies
agree
to
provide
most
Medicaid
benefits
in
exchange
for
a
monthly
fee
from
the
state
• Limited
Benefit
Plans
-‐
limited
in
that
they
only
provide
one
or
two
Medicaid
benefits
(like
mental
or
dental)
• Primary
Care
Case
Managers
-‐
individual
or
groups
of
providers
act
as
primary
care
providers
to
help
coordinate
referrals
and
other
medical
services
6. MCO
Medicaid
Managed
Care
En::es
• By
2010,
these
MCOs
provided
coverage
for
53%
of
all
Medicaid
beneficiaries
in
35
of
the
50
states,
plus
DC
and
Puerto
Rico
• The
idea
is
for
the
state
to
pay
appropriately
higher
rates
for
enrollees
who,
based
on
their
demographic
or
other
observable
characteris:cs,
are
likely
to
have
higher
costs,
and
likewise
lower
rates
for
those
likely
to
have
lower
costs
according
to
the
actuarial
data
collected
7. PCCM
Medicaid
Managed
Care
En::es
in
the
US
Ob/Gyn
Nurse
Prac??oner
FQHC
Physician
Group/
Clinic
Physician
Specialist
Physician
Assistant
Nurse
Midwife
Other
27
Yes
23
Yes
24
Yes
22
Yes
18
Yes
14
Yes
12
Yes
14
Yes
h[p://kff.org/medicaid/state-‐indicator/primary-‐care-‐providers-‐in-‐pccm-‐programs/
8. Rates
based
on
Demographic
Data
Rate
adjustments
based
on
Demographic
Data
• “age
18-‐45,
female,
non-‐disabled,
TANF-‐eligible
• “age
45-‐65,
male,
disabled”
• “infants”
(age
0-‐1)
and
“children”
(age
1-‐17).
• “pregnant
women”
• “residents
of
different
parts
of
the
state
based
on
regional
varia:on
in
costs”
h[p://www.forbes.com/sites/aroy/2012/10/18/benefits-‐and-‐challenges-‐of-‐medicaid-‐managed-‐care/
9. Rates
based
on
Demographic
Data
with
Risk
Based
Data
• Risk
Adjustment
based
on
Chronic
Disease
• Diagnoses
for
specific
pa:ents
deduced
from
their
past
claims
such
as
– Diabetes
– Heart
disease
– Hypertension
– other
condi:ons
that
affect
costs
in
a
somewhat
predictable
way
h[p://www.forbes.com/sites/aroy/2012/10/18/benefits-‐and-‐challenges-‐of-‐medicaid-‐managed-‐care/
10. State
Op:ons
in
choosing
Medicaid
Managed
Care
En::es
• Authori:es
allow
states
to
par:cipate
at
the
county
or
parish
level
rather
than
the
whole
state
• Comparability
of
Services
lets
the
states
provide
different
benefits
to
people
enrolled
at
different
levels
• Freedom
of
choice
allows
states
choose
between
managed
care
plans
or
primary
care
plans
• Ul:mately,
States
pay
a
company
to
do
this
for
the
state
government
so
states
would
not
absorb
as
much
of
the
costs
Medicaid.gov
11. State
Op:ons
in
choosing
Medicaid
Managed
Care
En::es
States
are
required
to
have
a
quality
program,
provide
appeal
and
grievance
rights.
States
can
implement
managed
care
delivery
through
one
of
3
federal
authori:es:
• State
plan
authority
• Waiver
authority
sec:on
1915
a
and
b
• Waiver
authority
sec:on
1115
Medicaid.gov
12. State
Op:ons
in
choosing
Medicaid
Managed
Care
En::es
h[p://kff.org/medicaid/report/why-‐does-‐medicaid-‐spending-‐vary-‐across-‐states/
• Nearly
all
states
operate
comprehensive
Medicaid
managed
care
programs.
Across
all
50
states
and
DC,
only
three
states
reported
that
they
did
not
have
Medicaid
managed
care
as
of
October
2010.
• Overall,
36
of
the
48
states
with
comprehensive
managed
care
programs
reported
contrac:ng
with
MCO’s
and
31
reported
opera:ng
a
PCCM
program.
13. State
Op:ons
in
choosing
Medicaid
Managed
Care
En::es
h[p://kff.org/medicaid/report/why-‐does-‐medicaid-‐spending-‐vary-‐across-‐states/
14. State
Op:ons
in
choosing
Medicaid
Managed
Care
En::es
h[p://kff.org/medicaid/report/why-‐does-‐medicaid-‐spending-‐vary-‐across-‐states/
15. State
Op:ons
in
choosing
Medicaid
Managed
Care
En::es
h[p://www.cms.gov/Research-‐Sta:s:cs-‐Data-‐and-‐Systems/Computer-‐Data-‐and-‐Systems/
MedicaidDataSourcesGenInfo/Downloads/2010December31f.pdf
16. State
Op:ons
in
choosing
Medicaid
Managed
Care
En::es
h[p://www.cms.gov/Research-‐Sta:s:cs-‐Data-‐and-‐Systems/Computer-‐Data-‐and-‐Systems/
MedicaidDataSourcesGenInfo/Downloads/2010December31f.pdf
17. State
Op:ons
in
choosing
Medicaid
Managed
Care
En::es
• California
– Managed
care
serves
about
6.6M
Medi-‐Cal
beneficiaries
in
58
coun:es.
This
is
about
70%
of
the
total
Medi-‐Cal
popula:on
– Many
flavors
and
varies
across
many
regions
– Mostly
fee
for
service
with
the
choice
of
a
few
commercial
plans
h[p://www.dhcs.ca.gov/provgovpart/Documents/MMCDModelFactSheet.pdf
• Florida
– Fees
vary
from
county
to
county
– In
2011,
the
Florida
Legislature
created
a
new
program
called
Statewide
Medicaid
Managed
Care
(SMMC).
– There
are
two
different
parts
that
make
up
the
SMMC
program:
• The
Managed
Medical
Assistance
(MMA)
Program
• The
Long-‐term
Care
(LTC)
Program
h[ps://www.flmedicaidmanagedcare.com/MMA/ProgramInforma:on.aspx
18. Dual
Eligible
Beneficiaries
h[p://kff.org/medicaid/report/why-‐does-‐medicaid-‐spending-‐vary-‐across-‐states/
• Poorest
and
Sickest
• In
FFY
2009,
dual
eligible
beneficiaries
represented
only
15
percent
of
Medicaid
enrollment
but
accounted
for
38
percent
of
Medicaid
spending
• The
cost
of
caring
and
the
lack
of
coordina:on
between
Medicare
and
Medicaid
pa:ents
•
In
April
2011,
CMS
awarded
design
contracts
to
15
states
to
develop
service
delivery
and
payment
models
to
integrate
care
for
dual
eligible
beneficiaries
• This
ini:a:ve
was
expanded
in
July
2011,
when
CMS
released
a
le[er
outlining
its
proposed
capitated
and
managed
fee-‐for-‐service
models
to
integrate
Medicare
and
Medicaid
benefits
and
align
financing
• Twenty-‐five
states,
including
the
15
that
received
design
contracts,
have
submi[ed
proposals
to
CMS
to
test
one
or
both
of
the
proposed
model
• Used
to
be
able
to
go
wherever
they
wanted,
but
now
under
the
dual
program
the
pa:ent
is
being
swayed
to
choose
someone
in
the
network
21. Providers
Taking
on
Medicaid
Pa:ents
• Increase
in
commercial
has
driven
likelihood
that
physicians
would
accept
medicaid
pa:ents
• However,
the
medicaid
dominant
prac:ces
that
already
accepted
medicaid
were
not
affected
by
the
increase
in
Managed
Medicaid
22. Providers
Taking
on
Medicaid
Pa:ents
• More
Younger,
Male,
and
foreign
medical
graduates
were
more
likely
to
accept
medicaid
managed
care
beneficiaries
• However,
there
was
a
decreased
acceptance
rate
by
board
cer:fied
physicians.
This
makes
cri:cs
ques:on
the
quality
of
care
• Physicians
in
large
groups,
university
clinics,
and
employed
by
hospitals
were
more
likely
to
accept
medicaid
pa:ents
under
managed
care
plans
23. Providers
Taking
on
Medicaid
Pa:ents
• There
were
fewer
medicaid
managed
care
pa:ents
accepted
in
markets
where
there
were
federally
qualified
health
centers
• Generally
speaking,
the
medicaid
fees
increased
in
areas
where
an
MCO
was
implemented
that
already
had
medicaid
services
• Some
providers
are
opera:ng
within
the
confines
of
a
Medicaid
Managed
Care
Agreement,
that
is
branded
by
the
payer
(Humana,
Aetna,
BCBS)
and
they
may
not
even
realize
it
24. Impacts
• Pa:ents
would
have
been
pushed
over
to
managed
care
plans
or
told,
“you
can
keep
you
your
doctor
for
20
years”
in
the
past,
but
the
restric:ons
to
the
provider
network
will
now
decrease
the
op:ons
• Would
have
said
switch
now,
but
states
are
leaning
toward
s:ck
with
your
provider
but
switch
later
25. Final
Discussion
Points
• Medicaid
dominant
markets
resulted
in
an
increase
in
ED
u:liza:on
and
decreased
outpa:ent,
acute
care,
and
surgery
• Physicians
are
not
encouraged
to
implement
MCOs
but
the
medicaid
pa:ent
popula:on
does
increase
already
in
the
network
• Most
states
use
a
take
it
or
leave
it
approach
• Aside
from
seong
adjustment
factors
based
on
beneficiary
characteris:cs,
most
states
set
“take-‐it-‐or-‐leave-‐it”
rate
schedules
for
each
cohort,
and
others
nego:ate
individually
with
each
prospec:ve
MCO
• States
may
need
to
increase
reimbursement,
decrease
admin
costs
of
those
in
the
networks,
and
revise
contracts
to
include
incen:ves
to
reduce
costs
for
low-‐income
pa:ents
26. References
• h[p://www.cms.gov/Research-‐Sta:s:cs-‐Data-‐and-‐Systems/Computer-‐Data-‐and-‐Systems/
MedicaidDataSourcesGenInfo/index.html
• h[p://www.cms.gov/CCIIO/Resources/Fact-‐Sheets-‐and-‐FAQs/Downloads/medicaid-‐mco-‐enrollee-‐
outreach-‐faq-‐2-‐21-‐14.pdf
• h[p://www.cms.gov/Research-‐Sta:s:cs-‐Data-‐and-‐Systems/Computer-‐Data-‐and-‐Systems/
MedicaidDataSourcesGenInfo/Downloads/Dec10-‐1115f.pdf
• h[p://www.cms.gov/Research-‐Sta:s:cs-‐Data-‐and-‐Systems/Computer-‐Data-‐and-‐Systems/
MedicaidDataSourcesGenInfo/Downloads/Dec10DualEligiblesf.pdf
• h[p://www.cms.gov/Research-‐Sta:s:cs-‐Data-‐and-‐Systems/Computer-‐Data-‐and-‐Systems/
MedicaidDataSourcesGenInfo/Downloads/2010December31f.pdf
• h[ps://www.flmedicaidmanagedcare.com/MMA/ProgramInforma:on.aspx
• h[p://www.dhcs.ca.gov/provgovpart/Documents/MMCDModelFactSheet.pdf
• h[p://www.forbes.com/sites/aroy/2012/10/18/benefits-‐and-‐challenges-‐of-‐medicaid-‐managed-‐
care/
• h[p://kff.org/medicaid/report/why-‐does-‐medicaid-‐spending-‐vary-‐across-‐states/
• Academyhealth.org
• The
primary
data
sources
for
Medicaid
sta:s:cal
data
are
the
Medicaid
Sta:s:cal
Informa:on
System
(MSIS),
the
Medicaid
Analy:c
eXtract
(MAX)
files,
and
the
CMS-‐64
reports.
The
following
is
a
general
explana:on
of
these
reports
and
the
types
of
program
and
financial
data
collected
from
the
states.