managing the medicaid enrollment surge starts today ......under aca, by jan. 1, 2014, medicaid will...

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Managing the Medicaid enrollment surge starts today: Strategies for success by 2014

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IntroductionAt a time when states are wrestling with increased costs and a growing need for state services, they also are being asked to expand their Medicaid programs in just a few years under federal health care reform. Some states are beginning the expansion planning process, but most state Medicaid directors are stymied as they balance putting out today’s fires while trying to prepare for a larger health care program that will include new enrollees with unknown needs.

“The role of Medicaid as envisioned by the Affordable Care Act (ACA) is to make Medicaid an integral part of the nation’s health care structure and be the floor for all low-income individuals,” said Kathy Kuhmerker, vice president, The Lewin Group and former New York State Medicaid director. “This raises a number of issues for Medicaid directors because even though federal funds will fully cover newly eligible individuals for a period of time, all but a handful of states will be forced to increase their Medicaid expenditures going forward.”

Under ACA, by Jan. 1, 2014, Medicaid will be expected to cover all adults living below 133 percent of the federal poverty level (FPL up to $29,330 per year for a family of four),1 including childless adults under the age of 65—a population that has not been covered by Medicaid in most states in the past. ACA also provides a new premium subsidy program for people living below 400 percent of the FPL ($88,000 for a family of four). The federal government will pay 100 percent of the costs for newly eligible adults up to 133 percent of the federal poverty level through 2016. In 2017, the percentage of costs paid by the federal government will begin a phase-down to reach 90 percent by 2020.

To estimate the effects of ACA on state Medicaid programs, The Lewin Group employs its Health Benefits Simulation Model (HBSM), which is a micro-simulation model of the U.S. health care system. HBSM is a fully integrated platform for simulating policies and has been adapted to simulate the impact of ACA on major stakeholders. Using this model, The Lewin Group estimates that ACA will increase Medicaid spending by $421.3 billion between 2014 and 2019, with states paying out $17.4 billion, an average increase of 1.1 percent.

Today, states are under unprecedented fiscal pressures. Overall Medicaid enrollment has increased by 13.6 percent, while overall spending has increased by 7.1 percent nationwide from 2007 to 2009.2

The system pressure may seem overwhelming, especially when coupled with the prospect of increased state Medicaid spending and other challenges, including deciding whether to establish health insurance exchanges, conducting risk assessments that will help plan appropriately for the future, and devising an eligibility system that meets federal requirements and works with other state databases. As one expert noted, “States will face significant challenges implementing the new law—in part due to the extremely constrained financial and staff resources available to them.”3

Using data insight available today to create the plan for delivering efficient, high-quality care to a growing Medicaid population

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Managing the Medicaid Enrollment Surge Starts Today White Paper

Further, each state differs in terms of how it will address these challenges and how the health reform mandate will affect its programs. For example, The Lewin Group estimates that states currently covering most childless adults living below 133 percent of the FPL (e.g., Arizona, Delaware, Hawaii, New York, Massachusetts, and Vermont) are likely to see reduced spending and enrollment. Alternatively, states that currently have very limited coverage for adults (e.g., Alabama and Mississippi) are likely to see higher percentage increases in state government spending.

Still, regardless of where states fall on the spending spectrum, most will have to answer these questions: How does my state juggle existing program challenges and cost considerations? How do we prepare for an unknown number of new enrollees with different health care needs than the current Medicaid enrollees?

To be successful, each state needs to understand how the new ACA eligibility requirements will affect its Medicaid program. For example, fewer than 100,000 of the 12.3 million newly eligible enrollees will be children4, which means the majority of newly eligible enrollees will be adults with unknown health status and care needs. Preparing for the future means that states must consider which individuals are likely to enroll in the program after new eligibility requirements kick in, what risks and program challenges those enrollees are likely to bring, and what service delivery alterations and technology enhancements will be needed to facilitate necessary changes, improve care, and contain costs. Most likely, existing programs and care delivery systems will not be sufficient for 2014.

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Figure ES-1 Percent Change in State Medicaid Spending for 2014 through 2019 by State

7.8%7.0%

6.7%6.0%

5.6%5.6%

4.3%

AlabamaSouth Carolina

LouisianaMississippi

New HampshireWest Virginia

UtahMissouriNevada

ColoradoTexas

KentuckyArkansas

TennesseeMontana

North CarolinaIdaho

GeorgiaOhio

IndianaOregon

MichiganConnecticut

IllinoisDistrict of Columbia

NebraskaFlorida

IowaSouth DakotaNorth Dakota

OklahomaNew Jersey

WyomingCalifornia

KansasWashington

MaineAlaska

VirginiaWisconsin

Rhode IslandMaryland

PennsylvaniaNew Mexico

MinnesotaMassachusetts

HawaiiVermont

DelawareNew YorkArizona

4.2%4.2%

4.0%4.0%4.0%

3.7%3.7%3.6%3.5%3.4%3.3%

3.1%3.1%3.1%3.0%2.9%2.8%2.7%2.7%2.6%2.5%2.5%

2.5%2.4%2.3%2.2%2.2%2.1%

2.0%1.9%

1.6%1.5%

1.3%1.1%

0.7%

0.6%0.4%0.4%

-3.4%-3.4%

-4.3%-4.7%

-5.3%-10.7%

7.8%7.0%

6.7%6.0%

5.6%5.6%

4.3%

AlabamaSouth Carolina

LouisianaMississippi

New HampshireWest Virginia

UtahMissouriNevada

ColoradoTexas

KentuckyArkansas

TennesseeMontana

North CarolinaIdaho

GeorgiaOhio

IndianaOregon

MichiganConnecticut

IllinoisDistrict of Columbia

NebraskaFlorida

IowaSouth DakotaNorth Dakota

OklahomaNew Jersey

WyomingCalifornia

KansasWashington

MaineAlaska

VirginiaWisconsin

Rhode IslandMaryland

PennsylvaniaNew Mexico

MinnesotaMassachusetts

HawaiiVermont

DelawareNew YorkArizona

4.2%4.2%

4.0%4.0%4.0%

3.7%3.7%3.6%3.5%3.4%3.3%

3.1%3.1%3.1%3.0%2.9%2.8%2.7%2.7%2.6%2.5%2.5%

2.5%2.4%2.3%2.2%2.2%2.1%

2.0%1.9%

1.6%1.5%

1.3%1.1%

0.7%

0.6%0.4%0.4%

-3.4%-3.4%

-4.3%-4.7%

-5.3%-10.7%

Percent Change in State Medicaid Spending for 2014 through 2019 by State



Piecing together the information and solutions needed to move forward requires delving deeper into existing data, using analytics and predictive modeling to determine best estimates and impacts, and revamping programs to appropriately manage the rapid growth in the populations they will serve.

States should conduct analyses and model how new requirements will play out, leverage state data from related health and human services programs (currently siloed in most states), use the best analytic and predictive modeling tools available to better understand and manage their anticipated expanded enrollment and, most importantly, get started today.

“The circumstances of an expanded Medicaid program are going to force states to examine models of care delivery, program effectiveness and data resource utilization,” according to Dave Goetz, vice president for government solutions, OptumInsight™. “This crosses all of the traditional silos and barriers of health care and state government. Medicaid directors need to begin planning and devising strategies for how they are going to integrate and coordinate their health care processes and systems.”

Incoming: Understanding the new Medicaid populationEligibility changes under ACA will result in the movement of individuals both into and out of the state Medicaid program. This movement—who is going and who is coming—will directly affect access, cost, and quality of care.

Understanding how various program factors interrelate will help states get a handle on expansion planning, said Julie Pollard, senior solution executive, government solutions, OptumInsight. “Medicaid programs are like a balloon,” said Pollard, a former Medicaid director in Connecticut. “If you push on one side, the other side will bulge out. You can carefully expand and stretch the system, but you have to be aware that you can’t change ‘X’ without considering all of the other letters.

“For example, if a state lowers provider reimbursement rates to save money, it may affect access to care, which could end up costing the state more in the long run. So, while in theory you can change just about anything, you have to understand and plan for the ripple effects within this closed system.”

To get a better idea about what changes make sense in a given state’s “balloon,” each state already should be conducting impact analysis and modeling at the state and county level. The Lewin Group uses tested models to estimate the effects of reform under various assumptions and alternative economic scenarios that are specific to an individual state’s health systems and economies. Using economic projections developed by the Congressional Budget Office and other key assumptions, Lewin models can evaluate ACA’s impact on individual counties and metropolitan areas. Lewin has also used the models to evaluate options for managing the quality and cost of Medicaid programs.

“While some of the new enrollees may be similar to the population states already have been serving, a newly eligible group—childless adults under 65—will have different characteristics,” Kuhmerker said. “Any intelligence that states can use to get a good sense of what the population is going to look like will help state Medicaid directors plan more appropriately for service and program changes.”

For example, The Lewin Group recently examined health reform’s impacts on Los Angeles County. Among many findings, The Lewin Group was able to predict that the highest percent increase of Medicaid newly eligible adults in that county was in the 19–24 age group (37 percent). Learning more about that 37 percent will help Los Angeles County focus its attention and programs on the right demographic.5

“The circumstances of an expanded Medicaid program are going to force states to examine models of care delivery, program effectiveness, and data resource utilization.”

—Dave Goetz, Vice President of Government Solutions

OptumInsight



Case Study: How ACA translates in Wyoming

The Lewin Group recently modeled the impact of Affordable Care Act (ACA) provisions on Wyoming’s Medicaid program and estimated the projected increases in the number of individuals eligible for the program, as well as their related costs.

Using The Lewin Group’s Health Benefits Simulation Model and state data, Lewin experts also identified major activities that the state needed to address to meet the requirements of ACA, including making modifications to its Medicaid eligibility system to meet the streamlined eligibility determination process called for in ACA. A simple chart (below) highlights how several ACA provisions apply in the context of Wyoming’s program.

Source: The Lewin Group

Provision WY Context

Expands Medicaid to individuals with incomes up to 133% FPL in 2014

Medicaid maintenance of effort (MOE) for adults with incomes >133% FPL until 1/1/2014.

Medicaid MOE for children until 10/1/2019

Significant expansion expected to increase EqualityCare enrollment by 32,000

Substantial eligibility system, MMIS claiming, staff training and program documentation implications

Provides enhanced federal funding for new eligibles

100% for 2014-2016 phases down to 90% by 2020

Total EqualityCare spending will increase by nearly $1 billion over 10-year period; $61.4 million in state funds

In 2014, provides all newly eligible adults with a benchmark benefit package that meets the minimum essential health benefits available in the Exchanges

Appears that states can define the benchmark to provide full Medicaid benefits to new eligibles

Analysis required to design benchmark package for Wyoming

Kid Care CHIP benefit package may meet ACA benchmark standard

Substantial MMIS claiming and perhaps eligibility system implications.

Must use modified adjusted income (MAGI) to determine eligibility without income disregards

Significant change from existing EqualityCare methodology that is based on net income with disregards

Kid Care CHIP will also be impacted, but perhaps to a lesser degree

Major eligibility systems and staff training implications

Demographic findings and their implications for implementation and program operations will vary greatly from state to state,” Kuhmerker said. “There is not a one-size-fits-all solution here, because each state is unique.” Therefore each state must plan for its unique situation.

Understanding populations = understanding riskBecause Medicaid populations are complex, any data on existing beneficiaries and incoming enrollees’ specific medical conditions can help states build programs that provide adequate treatment of multiple, chronic, or disabling conditions or long-term care needs.

“Medicaid programs are financially restricted, but they still are expected to offer the services their beneficiaries need,” Goetz noted. “Being able to target limited resources in the right places will make a significant difference.” Program and expenditure analyses can help states recognize where their current programs are working (and where they are not) and allow them to predict trends for 2014 and beyond based on current data.

If states can better comprehend their current Medicaid population, they can make more accurate predictions using census data about what their incoming population will look like, including likely chronic conditions and the best ways to manage those conditions and their associated expenses.

With funding from the California HealthCare Foundation, The Lewin Group and OptumInsight prepared a snapshot for the public of California Medi-Cal’s (Medicaid’s) high-cost beneficiaries to show where California’s dollars are being spent. A summary of the Medi-Cal findings indicated that:

• Just 7 percent of Medi-Cal beneficiaries accounted for more than three-quarters of fee-for-service expenditures for fiscal year 2008



• Two-thirds of high-cost beneficiaries had multiple health conditions, with nearly half having three or more conditions

• Annual expenditures for the 1,000 most costly beneficiaries averaged more than $500,000 per person

• More than half of the 1,000 most costly beneficiaries were under the age of 21

Among numerous recommendations, The Lewin Group advised Medi-Cal to concentrate on high-cost beneficiaries with new approaches that better integrate physical health, mental health, and long-term care services. It also suggested that the state partner with health care providers and health plans to improve data sharing and early identification of complex cases, and to develop and support comprehensive patient-centered systems of care for high-cost beneficiaries.

These California findings parallel the experience of Medicaid programs across the United States. In 2008, 5 percent of beneficiaries nationally accounted for more than half of all Medicaid spending, and 1 percent of beneficiaries accounted for 25 percent of all expenditures. Reducing the average cost of care by just 10 percent for the 5 percent of beneficiaries who use the most care could save $15.7 billion in total Medicaid spending and improve care.6

Findings such as these can be extrapolated so states can fine-tune or redirect resources to beef up necessary programs for Medicaid expansion. “Each state needs to mobilize its vision for the federal requirements by using its own data and modeling the data to create a state-specific analytic framework—an empirical Petri dish—for strategizing and planning,” Pollard said.

“Making use of existing data with analytics and using modeling to better understand the ‘what ifs’ in your world is priceless,” she continued. “In addition,

Case study: Showing the “Show-Me” state its program gaps and needs

The state of Missouri worked with The Lewin Group in 2010 to conduct both a comprehensive review of its Medicaid program as well as a more detailed look at the state’s high-cost beneficiaries. The comprehensive review—based on multiple interviews with Missouri officials, documentation review, and intensive data analysis—yielded a prioritized list of short-term cost-containment opportunities and a more detailed assessment of the overall Missouri Medicaid program and its potential opportunities for organizational improvement. This review produced compelling findings:

• Siloed structure inhibits coordination

• Low staffing levels in certain areas limit effectiveness

• Program reliance on contractors necessitates stronger coordination and oversight

• In-house reporting capacity is limited

• Limited use of performance measures

• Existing care management/service coordination approaches are not optimized

For each finding, The Lewin Group also presented multiple concrete recommendations for fixing problems. For example, to help remediate reporting issues, The Lewin Group suggested several ways of improving in-house reporting, such as using software products and policy analysts to produce ad hoc reports.

The Lewin Group also recommended using metrics to track expenditures, enrollment, program integrity, long-term care, care management, contractor performance, and special projects.

In its more detailed assessment, The Lewin Group examined high-cost individuals whose claims history demonstrated either 1) unusually high use of certain services, such as pharmacy, inpatient hospital, and emergency room services, or 2) unusually high overall spending levels. The Lewin Group recommended an intervention model designed to create a Missouri-specific, evidence-based outreach approach to persons with multiple inpatient admissions, persons with a high number of emergency room visits, and persons with seemingly high prescription drug usage.

The Lewin Group also assessed the “top 1,000 costliest beneficiaries” in the Missouri Medicaid program and noted that 57 percent of the top 1,000 most expensive beneficiaries were male, 66 percent were ages 19–64, and 24 percent were dually eligible for Medicare.

The Lewin Group can use its vast data resources and sophisticated analytics to show states where health reform requirements squeeze their current system and, in turn, where reform efforts should be aimed. Results of the recommendation are not yet available.


Unique client identifier (UCI) contributes to millions saved in Michigan through human services programs integration

The Michigan Department of Technology, Management & Budget (MDTMB) and the Michigan Department of Community Health (MDCH), in partnership with OptumInsight, integrated data from 15 separate health-related program areas—41 different data sources—into a single, unified business intelligence environment. With OptumInsight support, the MDCH worked with the MDTMB to apply advanced analytics to assess care and costs across multiple state programs and examine statewide health issues.

With the business intelligence/data warehouse as its backbone, Michigan can now, among other functions, provide better health care services, measure the effectiveness of programs and the performance of health plans, and predict the state’s health care needs and priorities in the years to come.

Using these health management solutions from OptumInsight, the MDCH estimates that it saves more than $200 million annually by increasing preventive programs, targeting at-risk communities, and improving overall program efficiencies. One of these efficiencies is the unique client identifier (UCI) that Ingenix, now OptumInsight, developed to help the MDCH track many of the 1.4 million clients who are enrolled in multiple programs supported by the department.

UCIs, in tandem with master client indexes, could help other states learn more about their existing and future enrollees, Dunn explained, because UCIs can provide states with information gleaned from electronic health records and state health information exchanges (HIEs).


comparing and contrasting the situation in your state with states that have similar characteristics can help. By leveraging the experience of others to inform local thinking, states can trim time and bring cost efficiency their expansion plans.” For example, if modeling for a particular state shows that more than one-third of new Medicaid beneficiaries are 19- to 24-year-old adults without high-cost health needs, that state can focus more on expanding primary care and less on contracting with additional specialists or developing greater capacity in chronic care or disease management programs.

Maximizing data requires program coordination, data analytics right nowTo envision a more complete picture of new Medicaid enrollees, states also need to start taking full advantage of the data they currently own today. “States already have multiple data sets that can be used to obtain a more holistic view of potential enrollees, such as data from community health centers, the Woman, Infant and Children (WIC) nutritional program, the Supplemental Nutrition Assistance Program, cancer registries, etc.,” explained Scott Dunn, director, health and human services programs, OptumInsight.

If states can integrate these data, they can acquire a more comprehensive view of new enrollees, identify service needs, and create a health information technology system that will enable improved coordination of care and case management for Medicaid populations, according to Dunn. “Non-Medicaid health and human service data can help states enrich their Medicaid data as well as help them catch folks who may fall through the cracks of the Medicaid system.”

For example, enrollment in the WIC program has a direct effect on reducing Medicaid claims for pregnancies resulting in low birthweight and very low birthweight babies. If the WIC and Medicaid databases are linked, states can identify women who are eligible but not receiving WIC benefits, then conduct outreach to get those women enrolled in the program, which will improve health outcomes and reduce Medicaid costs.

Alternatively, an individual newly eligible for Medicaid may first appear at another health and human services agency. A pregnant woman may sign up for WIC but not yet be enrolled in Medicaid. A business intelligence system that pulls data directly out of an enterprise database system would allow the WIC staff to direct the woman to the Medicaid program for enrollment and prenatal examination if there are no other processes in place.

OptumInsight helps states integrate program-specific data in a business intelligence data warehouse through which it can be analyzed. Medicaid programs can benefit from the various data sources at their disposal, but they may need assistance in turning those data into actionable business intelligence.

To move forward with Medicaid expansion, HIE, and other reform initiatives, states will have to make electronic platforms their focus. Accordingly, states need to assess their current levels of data sharing, explore data sharing agreements, and build in privacy protections if they do not already exist. “Currently most state systems are dated, legacy systems and are not anywhere close to interoperable,” Goetz asserted. “They need to be electronic as much as possible and as soon as possible to enable interactivity. States should consider which types of systems would integrate well with other systems, such as community health, corrections systems and other human service programs, and state-level HIE initiatives.”



Predictive analytics help states plan and create targeted programs for 2014States have an abundance of data. Even as they work on connecting systems, a variety of data exists today in Medicaid systems and related health and human services. Predictive analytics can be an important strategy in planning for 2014 populations. Predictive modeling uses data-driven decision-support tools to estimate an individual’s future potential health care costs7 and is viewed as a viable tool to help states make educated estimates about future enrollment needs.

Clearly, states can benefit from a system that uses rules-based analytics to create “markers of risk” or predictive markers that provide clinical insights into why an individual may be considered high risk. OptumInsight’s health management and population analytics applications use administrative data—medical and pharmacy claims, as well as recipient and provider demographics—to identify and characterize health risk and forecast future needs for medical resources.

The primary goal of this solution is to take the substantial, objective content and health care and related data that states possess and conduct analytics modeling, such as assessing an individual’s future potential health care costs and need for care management, as well as the identifying candidates who are most likely to benefit from care management and intervention programs. Although states need the initial data to make predictive modeling work for their new beneficiaries, having this tool in place allows them to better manage their existing populations and hit the ground running as soon as the first pieces of data emerge regarding new enrollees.

“We then can use that objective, empirical intelligence to help inform a state’s strategic plan,” said Pollard. “If you can identify segments or subsets of the population that need special programs, you can proactively get your arms around them sooner rather than supply ‘rescue care’ later,” she indicated.

Predictive modeling and analytics provide state Medicaid administrators with the information necessary to:

Gain perspective on health care quality, utility, and cost

Plan strategies to effectively allocate health care resources

Implement programs to create improvements in care and outcomes

Monitor population-, recipient-, and provider-specific trends

Accurately measure the impact of policies and programs

OptumInsight has found compelling evidence for incorporating pharmacy profile information and predictive risk modeling into Medicaid expansion strategies because it gives states the ability to gather pharmacy information and run predictive analytics in real time. Pollard pointed out that applying analytics to pharmacy data—which is the first data states are likely to receive on new enrollees—provides the capability to predict potential health risks early. She added that OptumInsight uses pharmacy risk groupers for this population to understand health risks that might lead to a need for expensive emergency care or inpatient hospital utilization.

“When you add pharmacy data to other data, you can better predict utilization, gaps in care and costs,” Pollard explained. “That doesn’t mean the transition to accommodating new enrollees will be easy or that there will not be any surprises, but it does give states the ability to be strategic and proactive.”

Predictive modeling boosts care management in Wisconsin

WEA Trust, a not-for-profit insurance company serving Wisconsin public school employees and their families, recently was looking to increase efficiency while enhancing the care management services it provides. Accordingly, the organization was seeking a system that could help it identify at-risk populations, offer up-to-date information and reports, provide a central source of information for all health data, and offer transparency down to the patient level.

One of the reasons WEA Trust chose Impact Pro™ from OptumInsight amid several other vendors was Impact Pro’s robust predictive modeling tool. This tool was used to identify opportunities for improved care based on evidence-based care profiles, to find those populations predicted to incur the greatest cost, and to identify population health programs for these individuals.

As a result, Impact Pro has helped WEA Trust provide better care with better outcomes at lower costs. The projected, cumulative five-year net benefit from the system is $1,149,165, due to an increase in the efficiency of care managers, a reduction in analysis costs, and the elimination of homegrown systems and outside consultants.

The deployment has a payback period of 18 months and a return on investment of 68 percent. The new system has also streamlined the process of identifying members for outreach and made the process more efficient. It also reduced the number of false positives by 50 percent, helping care managers to reach out to the right members at the right time and help members better manage complex conditions and improving their quality of life.

Care managers’ increased productivity and ability to handle larger case loads is expected to result in $2 million in benefits over five years for the WEA Trust, since the organization will not have to hire more care managers to handle the case load. Moreover, time spent analyzing member data will be faster by an estimated 200 percent, freeing up staff to be redeployed to activities with more impact—for a projected savings of $600,000 over five years.



States must embrace new approaches today States may be overwhelmed by the number of items on their Medicaid expansion “to do” list, but there is one item that cannot be allowed to slide to the bottom of that roster: a simplified Medicaid eligibility system that matches up with the new eligibility requirements under health care reform.

Many states may be waiting for CMS to simplify these eligibility requirements, but they cannot wait to address the eligibility system overhaul, which in numerous cases involves extricating Medicaid data from county welfare departments.

According to an article in State Health Policy Briefing, “Dramatic simplification of eligibility is the only way to achieve the promise of near-universal coverage embodied in the federal law. To put it bluntly, 36 million Americans cannot be enrolled in Medicaid or the new exchange by relying upon, what in most states is a county-based eligibility platform designed around the cumbersome and intrusive processes of the welfare eligibility systems.”8

ACA specifies that by Jan. 1, 2014, states must establish a state-run website to streamline the enrollment process and enable individuals to apply for, enroll in, or renew Medicaid/health exchange coverage. “There is no question that states have to simplify enrollment and retention activities to make it easy for individuals to get on and stay on Medicaid and coordinate with other health care coverage, especially subsidized coverage,” The Lewin Group’s Kuhmerker said.

Recognizing that cash-strapped states need help to establish this new, more nimble system, federal guidelines authorize 90 percent funding for states that install eligibility systems through 2015, with 75 percent ongoing funding for maintenance and operations.

“It’s crucial that states take advantage of this enhanced federal funding, which has an expiration date,” Kuhmerker said. “However, to do so, state Medicaid directors need to get started today by establishing who within their organizations will be responsible for this task and by figuring out how to integrate exchanges into the eligibility system and how systems can be integrated,” she advised.

States may struggle with the accountability, especially if they currently use Medicaid eligibility systems that interface capabilities and are unable to distinguish between currently eligible and newly eligible individuals. This distinction is vital for the Medicaid expansion because federal funds will cover only the newly eligible, and states have to have a clear and reasonable system that supports eligibility classifications.

Further, state eligibility systems must be designed to ensure that status changes—due to falling and rising incomes—are taken into account.

Filling the provider gapAfter eligibility strategies are in place and states have a better idea of who will be enrolling in expanded programs, they would be wise to begin intense planning to determine how they will meet the newly eligible enrollees’ needs for health care providers and specialists, Goetz said. “Demand for services will increase as the number of individuals in the system increases, so states will have to examine their roster of providers and determine where they have gaps or shortages,” he said.

For example, if a high number of new enrollees are childless adults with mental health issues, the state may not have sufficient behavioral health specialists under contract to serve those individuals. Further, if a subset of those individuals also has diabetes and their untreated depression has a negative impact on medication adherence, it is likely that acute care costs will increase and these individuals’ health will suffer.

States cannot wait to address the eligibility system overhaul, which in numerous cases involves extricating Medicaid data form county welfare departments.



Alternatively, in states where fewer specialists are needed but more primary care providers will be required, Medicaid directors need to start getting creative about boosting primary care access. To that end, states should determine how they can provide care through other means, such as “physician extenders,” within the boundaries of their state regulations. These “physician extenders”—such as nurse practitioners and physician assistants—will help Medicaid programs expand the system to meet the needs of an increased constituency.

States also should consider innovative care delivery approaches, such as providing prescription assistance to help keep enrollees’ medical conditions under control with medication and diverting people from costly emergency room treatment to care at federally qualified health centers and clinics.

“For a smoother transition, states need to think creatively about how to provide care, as well as how to engage providers who haven’t undergone eight years of medical training in order to be deployed,” said Goetz. “Without alternative models for care, the system will soon become overloaded or paralyzed,” said Goetz.

Start managing the Medicaid surge ASAP The mission before state Medicaid directors is daunting, but having a clearer understanding of what tools they will need to develop strategic objectives is half the battle. The other half is taking those objectives and making them a reality. To do that, Medicaid agencies need to start heading down the road toward 2014 today.

OptumInsight and The Lewin Group have the data resources, technology tools, and in-depth Medicaid and health and human services expertise to help state Medicaid directors truly understand the challenges before them. These partners work with states to anticipate changes to their Medicaid populations, streamline current operations, identify the characteristics and needs of newly eligible enrollees, and transform all of that knowledge into business intelligence. That analytics insight will empower states as they determine how to modify their programs, all while taking into account program costs, opportunities for program savings, and new care delivery models to improve health outcomes.

“Together, our goal is to help states understand what they need today and make the extensive preparations needed for what they must have in place tomorrow,” Kuhmerker remarked. Experts at both of OptumInsight and The Lewin Group, Goetz explained, have a great deal of hands-on experience working in or supporting state Medicaid programs, so “we understand—from the inside out—how to effectively organize and use information to make state health care programs more efficient and effective.”

In other words, OptumInsight and The Lewin Group can help states determine who is coming to partake in expanded Medicaid and how to build an appropriately expanded Medicaid program that satisfies federal requirements, meets patient needs, makes financial sense, and improves the health outcomes of individuals while making health care system work better. “The time for states to get started has arrived—that time is now,” Goetz said.

This article was prepared for general information purposes only to permit you to learn more about OptumInsight and The Lewin Group and its services. It is not intended as a basis for decisions in specific situations, and is subject to change without notice, nor is it intended to be legal or professional advice.

OptumInsight and The Lewin Group have the data resources, technology tools, and in-depth Medicaid and health and human services expertise to help state Medicaid directors truly understand the challenges before them.



Contributors

Kathy KuhmerkerVice President, The Lewin Group

Kathy Kuhmerker plays a key role in The Lewin Group’s state health consulting work. As director of New York’s $46 billion Medicaid program, Kuhmerker developed innovations that helped reduce fraud, waste, and abuse; began a formulation to rebalance New York’s long-term care system; oversaw the multi-year design and installation of the new Medicaid claims payment and management information system; managed the program’s response to the 9/11 World Trade Center attack; and saw the successful implementation of the Family Health Plus program for low-income adults. She had previously managed health, housing, transportation, debt management, and bonding projects for the New York State Division of the Budget. Most recently, Kuhmerker was a vice president at Affiliated Computer Services, where she combined her health care expertise with information technology to develop and enhance programs to improve health care delivery, quality, and management.

Julie PollardSenior Solution Executive, Government Solutions, OptumInsight

Julie Pollard, RPT, has more than 30 years of health care experience within the public sector. She specializes in creating unique business process improvement opportunities and service delivery enhancements supporting health and human services organizations. She previously served as the director of Medical Care Administration for the State of Connecticut, managing a comprehensive health care system. Her expertise ranges from state Medicaid program administration to MMIS operation and development to health care service delivery for special needs populations. As former S-TAG chair, she led national MMIS reform efforts. Additionally, she was a founding member of the New England States Consortium Systems Organization (NESCSO).

Dave GoetzVice President, Government Solutions, OptumInsight

Dave Goetz’s areas of expertise include state policy; state legislative processes; state finance/budget; the impact of health care programs on state financing; and budgets, overall governance, and government program needs. Prior to joining Ingenix, now OptumInsight, he was the commissioner of finance and administration for the governor of Tennessee and oversaw the state’s $30 billion budget, with direct responsibility for providing health coverage for 1.7 million individuals. He also managed the development and deployment of the state’s health information technology plans. He serves on the Health Information Exchange Workgroup for the HIT Policy Committee, a federal advisory committee to the Office of National Coordinator.

Scott DunnDirector, Health and Human Services Programs, OptumInsight

Scott Dunn has been involved with federal, state, and local government health and human services programs and systems for more than 30 years. He currently provides domain expertise and policy guidance in the health and human services practice to OptumInsight’s health care analytics and business intelligence initiatives. He develops enterprise-wide solutions and service offerings based on customer specifications involving HHS business intelligence, predictive analytics, and decision support systems. Prior to joining Ingenix, now OptumInsight, he held senior executive-level positions at the U.S. Department of Agriculture and served as a professional staff member with the U.S. Senate Committee on Budget. He also worked at the state and county levels of government in California.

References

1 The Patient Protection and Affordable Care Act (consolidated), Sec. 2001.

2 All stats are found on Kaiser State Health Facts, http://statehealthfacts.org, under Medicaid & CHIP statistics 2007 to 2009, the most current dates available.

3 Weil, Alan; State Policymakers’ Priorities for Successful Implementation of Health Reform, State Health Policy Briefing (May 2010).

4 Buettgens, Matthew; Holahan, John; Carroll, Caitlin; Health Reform Across the States: Increased Insurance Coverage and Federal Spending on the Exchanges and Medicaid – Timely Analysis of Immediate Health Policy Issues, (March 2011)

5 Page 12, “Market Impacts of Health Reform: A Case Study of Los Angeles County,” issued January 5, 2011

6 Centers for Medicare & Medicaid analysis of FY 2008 CMS MSIS data.

7 Knutson, Dave; Bella, Melanie; Predictive Modeling: A Guide for State Medicaid Purchasers, Center for Health Care Strategies Inc. (August 2009).

8 Weil, Alan; State Policymakers’ Priorities for Successful Implementation of Health Reform,” State Health Policy Briefing (May 2010).

OptumInsight™ | www.optum.com

From North America, call 866.306.1317 • [email protected] For a list of OptumInsight global office locations, please refer to our website www.optum.com. Corporate Headquarters | 12125 Technology Drive, Eden Prairie, MN 55344 Because we are continuously improving our products and services, OptumInsight reserves the right to change specifications without prior notice. OptumInsight is an equal opportunity employer. © 2011 OptumInsight | 11-26463 | 06/11 Page 11


About OptumInsightOptumInsight specializes in improving the performance of the health system by providing analytics, technology, and consulting services that enable better decisions and results. We integrate workflow solutions that deliver data in real-time and create actionable insights—processing health information that relates directly to and affects one in four patients in the U.S., one in every three Medicaid dollars, and one in every five emergency room visits.

About The Lewin GroupThe Lewin Group is a premier national health care and human services consulting firm. We understand the industry and provide our clients with high-quality products and insightful support. The Lewin Group operates with editorial independence and provides its clients with the very best expert and impartial health care and human services policy research and consulting services. The Lewin Group is an OptumInsight Company. OptumInsight is part of Optum—a leading health services business. For more information, visit www.lewin.com.

The information in this document is subject to change without notice.

This documentation contains proprietary information, which is protected by U.S. and international copyright. All rights are reserved. No part of this document may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying and recording, without the express written permission of Ingenix, Inc. Copyright 2011 OptumInsight, Inc.

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