Transcript Pennsylvania`s Medicaid Program

Session 1.02
Improving Access to and Quality
of Medicaid for Pennsylvanians
Medicaid Congress
June 5, 2008
Presented by:
Stefani Pashman
Pennsylvania Department of Public Welfare
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
2
I.
Background on Pennsylvania State
Medical Assistance (Medicaid) Program
3
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
4
Medical Assistance Makes Up 19%
of Commonwealth Budget
All Other
14%
Debt Service
3%
Corrections
6%
Pre K-12
Education
34%
Higher
Education
7%
Other DPW
Human Service
Programs
Medical
Assistance
State Share
19%
17%
FY 07-08
5
FY 07-08 Medical Assistance Budget
(by Service Program)
Long Term Living
$3.8 billion
Physical Health
Services $6.6
billion
Other
$1.3 Billion
Behavioral
Health Services
$2.9 billion
6
Ongoing Budget Challenges We
Face…
Uncertain national
economic outlook
Growth in national health
care costs
Eligibility growth
Increase in elderly & disabled
Loss of federal
funding
7
Federal Government Continues to
Cut State Funding in 2007-08
In 2007-08, Pennsylvania will have to absorb an
additional $717.7 million in additional federal cuts
2007-08 Federal Changes
2002-03 through
2006-07
2007-08
Additional
Impact
Reductions in Program Funding
($ 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)
(Dollars in millions)
10
19
90
-9
1
19
91
-9
2
19
92
-9
3
19
93
-9
4
19
94
-9
5
19
95
-9
6
19
96
-9
7
19
97
-9
8
19
98
-9
9
19
99
-0
0
20
00
-0
1
20
01
-0
2
20
02
-0
3
20
03
-0
4
20
04
-0
5
20
05
-0
6
20
06
-0
7
20
07
-0
8*
Average Monthly Enrollment
2,200,000
Source: DPW Budget Office
+3.4%
+3.9%
+4.9%
+7.8%
+4.8%
+4.5%
+2.8%
+1.4%
-0.2%
-3.6%
-8.2%
-2.9%
1,600,000
+4.9%
+4.3%
2,000,000
-1.7%
1,800,000
+7.0%
Medical Assistance Eligibility Trend
1,400,000
1,200,000
1,000,000
800,000
*Projected
11
PA Medical Assistance Growth Areas are
Elderly and Disabled
Eligibility Category
Chronically Ill Adults
Dec-06
Dec-07
% Change
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)
10
Seniors and Persons with Disabilities use
more Medical Assistance resources
102,168
5%
100%
266,939
14%
90%
Chronically Ill
Adults
$1,090,969
8%
80%
395,391
20%
70%
Elderly
Disabled
60%
261,534
13%
50%
Adults
40%
30%
943,738
48%
20%
$4,420,857
33%
$995,073
7%
Children
$2,649,883
20%
10%
0%
$4,219,220
32%
Persons
Costs
FY 07-08 Estimated
11
II. Pennsylvania Medical Assistance
Priorities
12
Despite Budget Climate, Governor
Committed to Core Principles Since 2005
CORE PRINCIPLE #1
No one currently receiving services will lose eligibility
CORE PRINCIPLE #2
Children will not experience any reduction in services
CORE PRINCIPLE #3
Pennsylvania will provide coverage for the growing number
of vulnerable individuals and families that need our
assistance
What has PA done to address
funding challenges?
•
•
•
•
Focus on quality and value
Cut administrative spending
Work smarter
Build on existing cost containment
initiatives
14
III.
Cost Containment Efforts Lead to
Improved Access
15
Governor Rendell has Reduced
Statewide Administrative Spending
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
State Administrative Spending
$2,000
$1,953
Dollars in millions
$1,914
$40 million
lower despite
5 years
of inflation
and cost
increases
$1,500
2002-03 Actual
2007-08 Budget
16
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
17
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
18
FFS Pharmacy Non-Dual Eligible PMPM Trends
(Federal and Supplemental Rebates are not excluded)
Pharmacy PMPM
Linear (Pharmacy PMPM)
$120.00
$80.00
$60.00
$40.00
$20.00
3Q07
2Q07
1Q07
4Q06
3Q06
2Q06
1Q06
4Q05
3Q05
2Q05
1Q05
4Q04
$0.00
3Q04
Spend PMPM
$100.00
Paid Quarter
20
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
20
Under ACCESS Plus We Now Have a
Managed FFS Program
AccessPlus takes managed care concepts and applies them to the fee-forservice 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
21
New Initiatives to
Improve Access to Medical
Assistance
Prescription 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
22
IV. Initiatives Focused on Quality and Value
23
Quality and Value Drive
Budget Initiatives
Implemented
Preventable
Serious Adverse
Events Policy
Implementing
Predictive
Modeling
QUALITY
&
Focusing on
Credentialing
VALUE
Implemented
Family Planning
Waiver
ER Diversion
24
Quality and Value Drive
Budget Initiatives
Address
Childhood
Obesity and
Weight
Management
Updating
Specialty
Pharmacy
QUALITY
&
VALUE
Addressing
Disparities
Adopting
Telemedicine
25
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
ACCESS Plus providers
are eligible for similar
incentive payments
Hospitals
1) Can apply for competitive
grants for quality
improvement projects
2) Access additional funds
based on quality efforts
26
Rebalancing the Long-Term Living
System Enhances Efficiency and
Quality
GOAL: 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
27
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
28
Questions?
Stefani Pashman, Special Assistant to the Secretary
Pennsylvania Department of Public Welfare
Email: [email protected]
29
Appendix
30
PA Medicaid Optional Services
Benefits 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.
31
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
32
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
33
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
34
http://www.dpw.state.pa.us