2. Agenda
The rationale for Medicaid Expansion
Opportunities, Risk, and Mitigation
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Impact on Stakeholders of Healthcare Industry
The changes in the Medicaid program
Effect of Medicaid Expansion on Pharmaceutical Industry
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Medicaid Expansion funding
Opportunities for the Consulting Industry77
3. Key Details About Medicaid
•Jointly funded and administered by Federal government and States
•Largest source of funding for medical and health-related services for 60M
limited-income individuals- 16.6% of spending in healthcare in the USA
Rationale for Medicaid Expansion
The Rationale for Medicaid Expansion
Medicaid Expansion will reduce the
number of uninsured in USA by
48%
4. • The ACA called for nationwide expansion of Medicaid eligibility
• Upheld by Supreme Court but not allowed to force states to adopt and
not allowed to take away the existing Medicaid funding
• Jan 2014, Medicaid will increase eligibility limits for adults to 133% of
FPL - $14,856 for one person , $30,675 for a family of four
• The CBO estimates 11 Million Americans will gain coverage by 2022
• Funding mostly by Fed over 2013-2022 . Saving for States by $10
Billion
What is Medicaid Expansion Program?
In Billion Dollars
5. Changing Nature of Medicaid
• Medicaid Expansion for the newly eligible will
be funded mostly by Fed and the Fed Share
will be set at 90 % from 2020. Currently Fed
sponsors 60%
• Newly Eligible Medicaid Population will be
unmarried , have median age of 31 , and will
have median income of $7261 for a single
individual
6. Other Changes in Medicaid…
Changes from existing Medicaid
Expanded to include newly eligible , who have income below
133 % FPL and changes to category of children , pregnant
women and families
MAGI Methodology will be used to determine eligibility for
“newly eligible” using Health Benefit Exchange web portal
States to cover smoking cessation programs and fiscal
incentive to cover prevention service without enrollees
paying any cost sharing
Creation of Centre of Medicare and Medicaid Innovations to
test new payment and healthcare delivery models
7. Medical Expansion Funding
• Fed would be funding most of the expansion
92% , while the remaining 8% funded by
State
• Over the 2013 to 2022 period, an additional
$781 billion will be spent on newly eligible
• Under the Medicaid Expansion Act, reduced
spending on uncompensated care and net
saving of over 10 billion dollars for State
In Billion Dollars
8. Unique Opportunities and Risks for
Pharmaceutical Industry
New Market entry Strategy
•Changing Customer Demographic
•New capability development
•New Sales Force and Marketing Strategy , Stronger Value Proposition
•Increase in number of people with chronic condition under Medicaid expansion
Reduction in Payer Profitability and pass through to Pharmaceutical Companies
•Pharmaceutical Companies need to communicate the efficacy of their drugs
Strong Fed and State Power
•Medicaid expansion is funded by Fed so existing models of lobbying may change
Healthcare Data Explosion
•Increased number of people , digitalization , accountability will provide unique
opportunity to analyze terabytes of data and provide competitive edge
New Fees
•IRS now imposes an annual fee on manufacturers and importers of branded drugs:
•Excise tax on pharmaceutical companies based on market share – $ 2.5 billion
9. Quantifying the Benefits
Number of newly eligible : 20 Million
Average spent on drugs per year : 333$
Pre 2014 rebate : 15% on AMP
Post 2014 rebate : 23% on AMP
New spend on drugs : 333*(1- 23%)/(1-15%) = 302
Net Benefits
20 Million20 Million $302$302 $ 60 Billion
A 60 Billion Dollar OpportunityA 60 Billion Dollar Opportunity
10. Opportunities for Healthcare Consulting
Firms for Pharmaceutical Industry
• Healthcare reform strategy
development/deployment
• Medicaid expansion segmentation /
targeting / positioning strategy
• Healthcare Analytics
• Statewide cost benefit analysis of Medicaid
• Marketing and Sales force strategy
• AMP , Rebate % determination strategy
