session 1.02 improving access to and quality of medicaid for pennsylvanians presented by: stefani...
TRANSCRIPT
Session 1.02Improving Access to and Quality of Medicaid for Pennsylvanians
Presented by:Stefani Pashman
Pennsylvania Department of Public Welfare
Medicaid Congress
June 5, 2008
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Agenda
I. Background on Pennsylvania State Medical Assistance (Medicaid) Program
II. Pennsylvania Medical Assistance Priorities
III. Cost Containment Efforts Lead to Improved Access
IV. Initiatives Focused on Quality and Value
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I. Background on Pennsylvania State Medical Assistance (Medicaid) Program
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Medical Assistance in Pennsylvania: At a Glance
Serves 1.9 million low-income individuals • 2/3 in mandatory managed care (based on geography) with
behavioral health carve out
• 1/3 in AccessPlus primary care case management program for physical health, behavioral health carve out
Generous optional benefit package
Diverse geography with significant urban and rural populations
Conservative legislature creates budget challenges
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Medical Assistance Makes Up 19% of Commonwealth Budget
Higher Education
7%
Debt Service3%
Other DPW Human Service
Programs
17%
Medical Assistance State Share
19%
Pre K-12 Education
34%
All Other
14%
Corrections
6%
FY 07-08
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FY 07-08 Medical Assistance Budget
(by Service Program)
Other
$1.3 Billion Behavioral Health Services $2.9
billion
Physical Health Services $6.6
billion
Long Term Living $3.8 billion
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Ongoing Budget Challenges We Face…
Loss of federal funding
Eligibility growth
Increase in elderly & disabled
Uncertain national economic outlook
Growth in national health care costs
Federal Government Continues to Cut State Funding in 2007-08
2007-08 Federal Changes 2002-03 through 2006-07
2007-08 Additional
Impact
Reductions in Program Funding ($ 57.7) ($ 17.9)
Unfunded/Under-funded Mandates ($335.5) ($525.4)
Federal “Clawback” ($338.5)
Other Losses/Revenue Reductions ($1,295.0) ($174.4)
Total ($2,026.7) ($717.7)
In 2007-08, Pennsylvania will have to absorb an additional $717.7 million in additional federal cuts
(Dollars in millions)
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Medical Assistance Eligibility Trend
800,000
1,000,000
1,200,000
1,400,000
1,600,000
1,800,000
2,000,000
2,200,000
*Projected
Average Monthly Enrollment
+10
.5% +
7.0% +4.
3% +4.
9%
-0.2
%
-3.6
%
-8.2
%
-1.7
% +2.
8% +4.
5%
+4.
8%
+7.
8%
+3.
9% +3.
4%
Source: DPW Budget Office
-2.9
%
+1.
4%
+4.
9%
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PA Medical Assistance Growth Areas are Elderly and Disabled
Eligibility Category Dec-06 Dec-07 % Change
Chronically Ill Adults 99,897 101,127 1.23
Elderly/Healthy Horizons 257,063 264,661 2.95
Disabled 383,769 396,503 3.31
Adults/Parents 292,925 293,464 .18
Children 837,910 837,642 (.03)
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Seniors and Persons with Disabilities use more Medical Assistance resources
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%102,168
5%
Chronically Ill Adults
$1,090,9698%
266,93914%
Elderly $4,219,22032%
395,39120%
$4,420,85733%
Disabled261,534
13%
$995,0737%
943,73848%
$2,649,88320%
Adults
Children
CostsPersons
FY 07-08 Estimated
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II. Pennsylvania Medical Assistance Priorities
Despite Budget Climate, Governor Committed to Core Principles Since 2005
CORE PRINCIPLE #2
Children will not experience any reduction in services
CORE PRINCIPLE #1
No one currently receiving services will lose eligibility
CORE PRINCIPLE #3
Pennsylvania will provide coverage for the growing number of vulnerable individuals and families that need
our assistance
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What has PA done to address funding challenges?
• Focus on quality and value
• Cut administrative spending
• Work smarter
• Build on existing cost containment initiatives
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III. Cost Containment Efforts Lead to Improved Access
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Governor Rendell has Reduced Statewide Administrative Spending
Dol
lars
in m
illi
ons
$1,953$1,914
$1,500
$2,000
2002-03 Actual 2007-08 Budget
State Administrative Spending
$40 million lower despite
5 years of inflation
and costincreases
Despite inflationary increases in health benefit costs, fuel costs and numerous other costs, administrative spending is still 2 percent lower in 2007-08 than in 2002-03
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Medicaid Program has Similarly Reigned in Administrative
Spending
Over the last four years, achieved $374.2 million in savings
Planning to save over $150 million next year
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Changes Made to FFS Pharmacy Program in Last 3 Years
• Established Pharmacy Division
• Implemented Payment Rate Changes
• Implemented Dynamic Pricing
• Established Preferred Drug List (PDL)
• Introduced Quantity Limits
• Implemented Clinical Prior Authorizations
FFS Pharmacy Non-Dual Eligible PMPM Trends(Federal and Supplemental Rebates are not excluded)
$0.00
$20.00
$40.00
$60.00
$80.00
$100.00
$120.00
3Q04
4Q04
1Q05
2Q05
3Q05
4Q05
1Q06
2Q06
3Q06
4Q06
1Q07
2Q07
3Q07
Paid Quarter
Spe
nd P
MP
M
Pharmacy PMPM
Linear (Pharmacy PMPM)
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Cost Containment Also Improved Program Operations
• Maximizing Recoveries and Minimizing Payments in Error• $140.7 million in Third Party Liability (TPL) cost recoveries in
2007• $24.9 million in recoveries for fraudulent and erroneous
payments in 2007
• Negotiating Better Contracts $29.1 million in negotiated contract savings in 2007
• $42.2 million in negotiated savings over the life of these contracts
• Reorganized Mental Health and Substance Abuse operations to improve integration and significantly reduced administrative expenses
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Under ACCESS Plus We Now Have a Managed FFS Program
AccessPlus takes managed care concepts and applies them to the fee-for-service program, in rural areas.
• Over 290,000 recipients enrolled in ACCESS Plus
• Medical home established for both children and adults
• Significant improvement in clinical quality for recipient with chronic disease
• Over 34,000 recipients involved in disease management (DM) managed by contractor
• 50% of Disease management recipients in the highest severity of illness (level 3) improved to a level 1 or 2
• Complex case management unit is actively involved with over 550 recipients per month
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New Initiatives to Improve Access to Medical
AssistancePrescription drug coverage
• Today 43,000 low income adults qualify for MA but are not eligible for prescription drug benefits
• New initiative would fill that gap in conjunction with the implementation of Cover All Pennsylvanians
Selected fee increases • Skilled nursing care and home health services• Dental and primary care providers
Goal is to ensure access for children and families
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IV. Initiatives Focused on Quality and Value
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Quality and Value Drive Budget Initiatives
Focusing on Credentialing Implemented
Family Planning Waiver
Implementing Predictive Modeling
QUALITY
&
VALUE
ER Diversion
Implemented Preventable
Serious Adverse Events Policy
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Quality and Value Drive Budget Initiatives
Updating Specialty
Pharmacy
Adopting TelemedicineAddressing
Disparities
Address Childhood
Obesity and Weight
ManagementQUALITY
&
VALUE
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Pay for Performance incentives leads to better health outcomes
Managed Care Organizations can earn
up to a 2.5% performance bonus (up from 0.5% two
years ago) based on specific measures
Hospitals 1) Can apply for competitive
grants for quality improvement projects
2) Access additional funds based on quality efforts
ACCESS Plus providers are eligible for similar
incentive payments
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Rebalancing the Long-Term Living System Enhances Efficiency and
QualityGOAL: 50/50 split between home & community based and institutional care
WHY? Better quality, better efficiency, consistent with consumer preference
HOW?• Established cross-department office• Expanding Adult day care to help seniors stay at home longer while giving their
families the support they need • Tenant based rental assistance pilot broadened to include 10 more counties• Funding for services for 1,170 additional persons with disabilities and 2,100
additional older persons • Building the systems to license, certify and inspect Assisted Living residences
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Take-Aways
• Having a mandate from the Governor helps stabilize the Medicaid program
• Cost containment initiatives pay off, but are labor-intensive to operationalize (there’s no more “low hanging fruit”)
• Investments in quality and pay for performance are long-run
• Each year only gets more difficult
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Stefani Pashman, Special Assistant to the Secretary
Pennsylvania Department of Public Welfare
Email: [email protected]
Questions?
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Appendix
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PA Medicaid Optional ServicesBenefits for Adults Over 21 Years*
• Ambulatory Surgical Center• Case Management (Targeted)• Dental**, including orthodontics• Home and Community-Based Waiver• Inpatient Hospital and Nursing Facility Service
for 65+ in an Institution for Mental Disease (IMD)
• Intermediate Care Facilities/Other Related Conditions (ICF/ORC)
• Medical Supplies and Equipment**• Pharmacy**• Prosthetic Devices**• Rehab Services• TB Related• Therapy (Occupational, Physical and Speech
for Adults Limited to Those Provided by Hospital, Outpatient Clinic or Home Health Provider)
• Birthing Center Services• Chiropractic• Drug & Alcohol Outpatient Clinic• Hospice• Intermediate Care Facilities for Persons with
Mental Retardation (ICF/MR)• Independent Medical Clinic/Surgical Center• Optometry• Primary Care Case Management (PCCM)
Services• Podiatrist• Psychiatric Clinic• Renal Dialysis• Transportation
*These Normally Optional Services are Redefined as Mandatory when Medically Necessary for Eligibles Under Age 21
**Adults eligible under the Medically Needy Only (MNO) category are not eligible for these services with some exceptions.
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Hospital P4P
• Hospital Quality Incentive• Incentives funded through incremental increase in DSH
and Med Ed payments for DSH qualifying hospitals
• Rate of payment increases for DSH hospitals tied to performance measures focused on:
• Re-admission rates for chronic disease
• Clinical indicators
• Commitment to EMR, pharmacy error reduction and quality reporting
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Hospital P4P
• Hospital Quality Grant Program
• $2.2 million (total) set aside in FY07-08
• Provide grants up to $100,000 to acute care DSH hospitals who have made investments in the following:
• Pharmacy error reduction• Single medical record• Programs that have a positive impact on the hospitals
treatment and management of asthma, diabetes, CHF or COPD• Programs that assist hospitals to improve LVF and community
acquired pneumonia quality results
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Other New P4P
• ACCESS Plus P4P• Expand physician P4P to encourage physicians to actively engage in care
management programs
• HealthChoices Provider P4P• Implement P4P program to incentivize providers. All monies will go directly
to the provider for activities which improve quality of care
• Increased MCO Contract Incentive Payments• Opportunity to earn up to 2.5% of capitation rate in incentive payments• Contract incentives focus on improving health status of members, not
utilization controls, e.g. :• Controlling high blood pressure• Improving prenatal care in 1st trimester• Improving adolescent well-care visit rates
http://www.dpw.state.pa.us