the state of medicaid today & tomorrow...source: source: nabso state expenditure report,...

May 2018

The State of Medicaid Today & TomorrowSKYGEN USA SUMMIT 2018

Medicaid Today

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©2018 LEAVITT PARTNERS

EnrollmentMEDICAID

TODAY

Medicaid enrollment has increased substantially since implementation of the Affordable Care Act (ACA).

Source: CBO 2017, Baseline Projections for Health, Children's Health Insurance Program, Effects of the Affordable Care Act on Health Insurance Coverage, and Medicaid

0

10

20

30

40

50

60

70

80

90

100

2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027

Enro

llees

(Mill

ion

s)

Medicaid Enrollment and Growth Breakdown

Adults

Children

Blind and Disabled

Aged

Projected

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Traditional expansion (24 states & DC)

Alternative expansion

Traditional & Alternative Medicaid ExpansionMEDICAID

TODAY

Source: National Academy for State Health Policy “Where States Stand on Medicaid Expansion Decisions”

5


0 (5 states)

>0 – 50% (11 states)

51 – 65% (5 states)

66 – 80% (15 states, including DC)

81–100% (16 states, including PR)

U.S. Overall = 68.1%

Comprehensive Medicaid Managed Care PenetrationMEDICAID

TODAY

Source: Centers for Medicare & Medicaid Services Medicaid Managed Care Enrollment and Program Characteristics, Current as of 7/1/2016

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Medicaid Dental OverviewMEDICAID

TODAY

Source: Medicaid and CHIP Payment and Access Commission (MACPAC) Medicaid Coverage of Dental Benefits for Adults

Types of Adult Dental Services Covered for Non-Pregnant, Non-Disabled Adults under Medicaid, 2015

Type of Service Number of States Services Typically Included

Preventive 28Examinations, cleanings, and sometimes fluoride applications or sealants

Restorative 26 Fillings, crowns, endodontic (root canal) therapy

Periodontal 19Periodontal surgery, scaling, root planning (cleaning below the gum line)

Dentures 26 Full and partial dentures

Oral surgery 25 Non-emergency extractions, other oral surgical procedures

Orthodontia 2 Braces, headgear, retainers

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Dental Industry Trends

↗Medicaid proportion of industry reimbursement continues to increase

↗DSOs are spreading across the country and decreasing fragmentation

↗Capitation model is becoming increasingly prevalent

MEDICAID

TODAY

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Dental Industry Trends8

Near-Term 3 – 5 Years 5 – 10 Years

• Several states carve in dental into managed care

• Incorporation of quality metrics for dental

• Stand-alone dental plans seek “equal treatment” of their coverage inside and outside the exchange: required purchase on exchange

• Separate pricing by medical carrier

• More states carve in dental

• Outcome-driven measurements

• Greater data transparency• CMS and State Medicaid

Agencies will have more evidence to consider mandating programs

• Best practice models to emerge

• Greater likelihood of downside risk arrangements that include dental

• Potential emergence of capitated arrangements with built-in PMPM

MEDICAID

TODAY

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Dental under Medicaid Managed CareMEDICAID

TODAY

Coverage of Select Benefits under MCO Contracts, 2015

Children’s Dental

Adult Dental

Carved In Carved Out Carved In Carved Out

AZ, CO, DC, FL, GA, IL, KS, KY, MN, MS, MO, NV, NJ, NM, NY, OH, OR, PA, TN, TX, WV

CA, DE, HI, IA, LA, MD, MA, MI, NE, NH, RI, SC, UT, VA, WA

AZ, CO, DC, FL, IL, KY, MN, MS, MO, NJ, NM, NY, ND, OR, PA

CA, IA, KS, LA, MD, NE, RI, SC, UT, WA

VA, TX and GA: Not covered for adults

SOURCE: Kaiser Family Foundation, Medicaid Reforms to Expand Coverage, Control Costs and Improve Care: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016

http://files.kff.org/attachment/report-medicaid-reforms-to-expand-coverage-control-costs-and-improve-care-results-from-a-50-state-medicaid-budget-survey-for-state-fiscal-years-2015-and-2016

Key Influences

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Certainty & Uncertainty KEY

INFLUENCES

Unsustainable Growth in Health

Care Expenditure in the US

Vision and Strategy of President Trump’s

Administration

Medicaid

Long-Term Care

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State Flexibility

1115 Waivers

Eligibility Limitations

Program Design (alternative expansions, benefits)

Political and Ideological Priorities

Reduced Funding (Block Grants)

Rollback of regulatory and consumer protections

Policy & Politics

High Need Populations

LTSS

Prescription drug costs

SUD/Opioid Use

Social Determinants of Health

Legal Challenges

ACA

Eligibility Limitations

Consumer Protections

KEY INFLUENCES

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Political & Ideological Priorities – Federal KEY

INFLUENCES

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Political & Ideological Priorities – Federal KEY

INFLUENCES

Continued Transition to Value-based Models

Price Transparency

Consumer Involvement

New Provider Models

State Flexibility

Fiscal Stewardship

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State Flexibility in Trump EraKEY

INFLUENCES

Premiums (limited)

Some copays above federal limits

DSRIP/DSHP

Waiving retroactive coverage

Cost sharing below 100% FPL

Lock-out period

Partial expansion to 100% FPL with enhanced FMAP

HSA-like models

Healthy behavior incentives

IMD exclusion

Work requirement

Enrollment caps

Enrollment time limits

Closed formularies

?

X

?

?

?

X✓

✓

✓

✓ ✓

✓

✓

✓

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Unsustainable Growth in Health Care ExpenditureKEY

INFLUENCES

19.8%29.0%

21.0%

19.4%

10.4%

10.4%4.0%1.4%3.6%

3.0%9.1%8.1%

32.1% 28.7%

FY 1995 FY 2017

Comparison of State Spending, Fiscal 1995 vs 2017

Medicaid Elementary & Secondary Education

Higher Education Public Assitance

Corrections Transportation

All Other

Source: Source: NABSO State Expenditure Report, 2015–2017 (left); Kaiser Family Foundation, 2016 (right)

26%

21%

46%

3%

4%

Distribution of Medicaid Spending By Service

FFS Acute Care FFS Long-Term Care

Managed Care & Health Plans Payments to Medicare

DHS Payments

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Political & Ideological Priorities - StateKEY

INFLUENCES

Source: MACPAC, 2017, analysis of state expenditure reports from the National Association of State Budget Officers

Distribution of Medicaid, Education, and All Other Spending from State-Funded

State Budgets, SFY 2016

Medicaid’s Share of State Budgets Including and Excluding Federal Funds, SFYs 1990 – 2016

https://www.macpac.gov/subtopic/medicaids-share-of-state-budgets/

http://nasbo.org/mainsite/reports-data/state-expenditure-report/stateexpenditure-archives

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Political & Ideological Priorities - StateKEY

INFLUENCES

SOURCE: Kaiser Family Foundation (left); Medicaid State Resource Center (right)


By some estimates, social, economic and physical

determinants of health account for 50% of health

outcomes

In 2017, the CMS Innovation Center chose 32organizations to implement the Accountable

Health Communities model to address health-related social needs of Medicare and Medicaid individuals.

Of 39 states with managed care organizations (MCOs),

19 require MCOs to screen enrollees for social

needs as well as provide referrals.

Opioid Response

40 percent of the 1.9 million nonelderly adults with

opioid addiction are covered by Medicaid.

In 2016, those with Medicaid were 2 times as likely to

receive treatment for their addiction.

Several policy changes are allowing states to improve addiction treatment in response to opioid crisis. • 10 states have received 1115 waivers for IMD

exclusion have been received by 10 states• Limited eligibility expansion• Community based services expansion

https://www.kff.org/report-section/medicaid-moving-ahead-in-uncertain-times-managed-care-initiatives/

https://www.medicaid.gov/state-resource-center/downloads/mac-learning-collaboratives/justice-involved-populations.pdf

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Long-Term Services & SupportsKEY

INFLUENCES

Medicaid covers an estimated 62% of US spending on long-term services and supports (LTSS).

Total Medicaid LTSS expenditures were $158 billion in FY2015

The number of people needing LTSS is expected to increase from 12 million today to 27 million by 2050.

To address rising demand for LTSS, states are transforming their LTSS Medicaid delivery system.

More Medicaid LTSS spending is now in home and community based care than institutional care.

As of December 2017, 20 states have established MLTSS programs up from only 8 states in 2008

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States with Managed Long-Term Services and SupportsKEY

INFLUENCES

Current MLTSS Program

MLTSS under consideration

MLTSS in active development

Duals demonstration program only

Source: NASUAD Survey, CMS data

Medicaid Tomorrow

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Leavitt Partners Medicaid Belief StatementsMEDICAID

TOMORROW

• The new HHS secretary will shape agency priorities at a critical juncture in health care.

• Pressure will remain high to address the cost of Medicaid at both the federal and state levels.

• States will seek and HHS is likely to grant additional state Medicaid flexibility to address cost and ideological policy preferences

• States and the federal government will continue to seek new strategies to address high need populations.

• The growing importance of managed care in Medicaid is resulting in a greater focus on MCO contracts and strategies.

• There is unprecedented opportunity for new product vendors to enter the Medicaid technology space.

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Top of Mind Issues for Medicaid LeadersMEDICAID

TOMORROW

Multiple Reimbursement Models

Focused Population Strategies


Need for an Enabling Infrastructure

Rapidly Changing Program Priorities/Needs

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Move Toward ValueMEDICAID

TOMORROW

Evolutions in Delivery System Reform

Moving toward Value-based Payment Arrangements

Fee-for-Service

PCCM, PAHP, PIHP, & Risk-based

managed care

Managed long-term services and

supports

Managed care for dual eligible

Value-based and Alternative

Payment Models

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Provider StrategiesMEDICAID

TOMORROW

New delivery models require new approaches to provider management:

✓ Accurate directors to ensure access to care

✓ Measure and track performance for value-based contracts

✓ Identify high quality/low cost providers

✓ Track providers across delivery models

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Pregnant

Women

Foster

Children

Persons

with ID/DD CSHCNs

Persons

with

SMI/SED

Adults w/

Physical

Disabilities

Always mandatory 32 20 11 20 18 19

Always voluntary 2 8 4 3 3 4

Varies 4 8 16 14 16 11

Always excluded 1 3 8 2 2 5

Focused Population StrategiesMEDICAID

TOMORROW

SOURCE: Kaiser Family Foundation, Medicaid Moving Ahead in Uncertain Times Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2017 and 2018

MCO Enrollment of Populations with Special Needs, July 2017 (# of States)

http://files.kff.org/attachment/Report-Results-from-a-50-State-Medicaid-Budget-Survey-for-State-Fiscal-Years-2017-and-2018

Program Needs & Opportunities

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Advanced Data CapabilitiesNEEDS &

OPPORTUNITIES

✓ Better understand population and care needs

✓ Refine benefit packages & programs

✓ Address non-medical needs

✓ Track and measure outcomes to support risk-based contracting

✓ Reduce waste, fraud, and abuse

The ability to collect, analyze and share data across systems is critical

to states’ ability to better understand and manage the populations they serve.

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Modularity ChallengesNEEDS &

OPPORTUNITIES

✓ Procurement

✓ Legacy Systems

✓ Market Diversity

✓ Interoperability

✓ Lack of Standards

✓ Consumer Experience

✓ State Readiness

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New Contracting StrategiesNEEDS &

OPPORTUNITIES

✓ Shifting Managed Care from Controlling Utilization to Increasing Value

✓ Integrating care across services and systems• Medical care, dental, pharmacy, behavioral health, post-acute and long-term care, social

determinants of health

✓ Risk-based Contracting

✓ Direct Provider Contracting

✓ Multiple IT Module Vendors

Smart on Value

www.leavittpartners.com801-538-5082

Offices in Salt Lake City, Chicago, and Washington, D.C.

@LeavittPartners

the state of medicaid today & tomorrow...source: source: nabso state expenditure report,...

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