1. health and fitness

Office of Administration
Division of Budget and Planning
1
Temporary MO HealthNet during Pregnancy (TEMP)
 Presumptive eligibility program for pregnant women- Better to apply




for ongoing coverage through the Family Support Division
Determinations by qualified providers with staff trained to
complete the determinations
Eligibility is based on patient attestation of:
 Pregnancy
 Income under 196% of the Federal Poverty Level
Eligible patients receives a Medicaid card at the time of the
determination
 Only covers ambulatory prenatal care.
 Will not cover delivery, inpatient medical care, non-pregnancy
related medical services, or care for the newborn.
TEMP coverage
 begins on the date of the determination and continues through:
 Date regular MHN coverage, or
 Last day of the month following the month of the TEMP
determination.
 Since January, 2014 only one episode per pregnancy allowed
2
Emergency MO HealthNet Care for Ineligible
Aliens (EMCIA)
 EMCIA provides coverage for emergency medical care of
non-citizens who meet all eligibility requirements for a
federally funded MO HealthNet program except:
 Ineligible alien status, and
 Emergency medical condition.
 Ineligible alien status includes
 non-citizens lawfully admitted who have not met the five-year
period of ineligibility, lawfully admitted for a temporary
period,
 lawfully admitted but whose period of admission is expired,
 non-citizens not otherwise qualified, and
 undocumented non-citizens.
3
Emergency MO HealthNet Care for Ineligible
Aliens (EMCIA)
 Ineligible non-citizens are eligible only for the dates of
the emergency medical care.
 An emergency medical condition must exist or have
existed in the month of application, or in one of the
prior three months.
 The individual does not have to enter the hospital or
medical facility via an emergency room to qualify.
4
Emergency MO HealthNet Care for Ineligible
Aliens (EMCIA)
 Emergency Medical conditions could reasonably be expected to
result in:
 Placing the patient's health in serious jeopardy;
 Serious impairments to bodily functions; or
 Serious dysfunction of any bodily organ or part.
 All labor and delivery is considered emergency labor and delivery.
 Standard labor and delivery covered by EMCIA is defined as:
 One day prior to delivery and 2 days after for normal delivery, or
 One day prior to delivery and 4 days after for Caesarean-section.
 Labor and delivery excludes pre- and post-partum care.
 No Medical Review Team (MRT) required for standard labor and
delivery.
5
Early Elective Delivery (EED)
Elective delivery 37 to < 39 weeks gestation(26.3%)
 9.8% born by Early Elective C-Section
 16.5% by Early Elective Vaginal delivery after induction.
 American College of Obstetricians and Gynecologists advises
against non-medically indicated deliveries prior to 39 weeks
 EED identified as key quality indicator for obstetric hospital
care – National Goal is 5%
 The Joint Commission
 National Quality Forum
 Leapfrog Group
 March of Dimes
EED Maternal and Infant Consequences
• Increase in obstetrical procedures and maternal
•
•
•
•
•
•
•
•
complications
Increased NICU admissions
Increased transient tachypnea of the newborn (TTN)
Increased respiratory distress syndrome (RDS)
Increased ventilator support
Increased suspected or proven sepsis
Increased risk of death in the first year of life
Problems with brain development, including long-term
psychological, behavioral, and emotional morbidity
Increased newborn feeding problem
MHD EED Initiative
• Convened clinicians and other stakeholders to
discuss and develop policy
• Reviewed MHD EED data and came to consensus
• Developed an evidenced-based, best practice
regulation
– “Early elective deliveries, or deliveries before thirty-nine
(39) weeks gestation without a medical indication, shall
not be reimbursed by the MO HealthNet Division (MHD).
– Has been implemented in other states – New York, Texas,
New Mexico, and South Carolina
– Regulation filed and open
March, 2014
Today…
It’s not just
Missouri
Status of our
Nation
Healthcare
delivery and
payment “change”
strategies
Four key elements of the Affordable Care Act
2010
 Prohibits lifetime benefit limits
 Dependent coverage up to age 26 is mandated
 Cost-sharing obligations for preventive services
are prohibited
 Cancellation of individual policies (Recessions)
are prohibited
 Pre-existing condition exclusions for dependent
children (under 19 years of age) are prohibited
 Coverage for emergency services at in-network
cost-sharing level with no prior-authorization is
mandated
Duncan
 24 Years Old
 Works full time
 Minimum Wage
 Pays all his housing,
and personal
expenses
 Insured on parents
employer based
policy
13
More 2010
 Require coverage of tobacco cessation programs for pregnant women
under Medicaid free of cost-sharing
 Begin Community Health Centers and National Health Service
Corps Fund expanded funding to total $11 billion over five years
 Begin Medicaid global payments demonstrations to fund large,
safety-net hospitals in five states to alter payment from fee-forservice to a capitated, global payment structure.
 Establish Patient-Centered Outcomes Research Institute. Create a
private, nonprofit Patient-Centered Outcomes Research Institute to
set a national research agenda and conduct comparative clinical
effectiveness research.
2011
 85% MLR for large group (with refund) is mandated
 80% MLR for individual and small group (with
refund) is mandated
 Primary care physicians and General surgeons in
shortage areas begin 10 percent Medicare payment
bonus for next 5 years
 Medicare adds annual wellness visit with no
copayment or deductible and eliminates cost-sharing
for evidence-based preventive services
2012
 Medicaid starts option funding Health homes for
persons with chronic conditions
 Prohibit federal payments for Medicaid services
related to hospital-acquired conditions.
 Begin Medicaid Emergency Psychiatric Care
Demonstration Project. to expand the number of
emergency inpatient psychiatric care beds available.
2013
 Medicaid payment rates to primary care physicians for
furnishing primary care services raised no less than
100 percent of Medicare payment rates in 2013 and
2014.
 Medicaid coverage of preventive services approved by
the U.S. Preventive Services Task Force with no costsharing will receive an increased federal funds
2014
 Health insurance exchanges established
 Guarantee issue is required
 Community rating required limits use of age and
illness as a rating factor
 All annual and lifetime limits prohibited
 Essential Benefit established and required to cover
MH and SA at Parity
 Individual Mandate Starts
Emily
 Pediatric myopathic





pseudo-obstruction
TPN Dependent with
permanent Central
Line
Averages 4-8 hospital
admissions per year
Full Time College
Sophomore
Uninsurable outside of
large groups pre-ACA
Now able to get
affordable coverage
19
Insurance Exchanges
 To Date:
 16 states have selected a state-based model,
 7 are partnering with the federal government and
 26 states have chosen federally-run exchanges.
 Current enrollment deadline is March 31, 2014
 In non- expansion states low-income individuals may
experience more difficulty finding affordable coverage
because they are not Medicaid-eligible and do not
qualify for federal subsidies in the exchange.
Kathy
 58 y.o., Single, Self-Employed
 Before ACA had a high
deductible Health Savings
Account Policy
 Now has a Comprehensive
Policy
 Lower premium
 Much lower deductible
 Lower annual out of pocket
maximum
 No more Lifetime limit
21
Kathy’s Insurance Before and After ACA
Pre-ACA
Post -ACA
Coventry Silver QHP
Policy Type
Golden Rule
Health Savings
Account
Premium
$223
$454
Insurer
Comprehensive
Premium Subsidy $0
$311
Net Premium Cost $223
$143
Deductible
$5000
$2500
Max Out of Pocket $8000
$6350
22
2014 Medicaid Expansion
 Enrollment system went live in ALL STATES on
October 1, 2013. Insurance will became effective on
January 1, 2014. Scope is all uninsured adults above 133
percent of poverty (plus discounted 5 percent of
income).
 To date, 26 states are planning to expand coverage in 2014
 Some include non-traditional models such as Medicaid
premium support.
 Decisions to expand Medicaid or discontinue Medicaid
expansion in 2015 will impact bids that insurers submit in
the spring of 2014 for the 2015 enrollment period.
Delayed Changes
 Employer mandate delayed from 2014 to 2015
 First reduction of Disproportionate Share Hospital
(DSH) funds delayed from 2014 to 2016
 Compliance of small business Existing Plans with new
Rules
 CMS has delayed until September 2015
 15 States will permit renewal of non-compliant plans
 18 States will not
 17 States are undecided
2015 - 2017
 Innovation Waivers
 Beginning 2015, states may consider developing
proposals to waive portions of the ACA beginning in
2017.
 “Innovation Waivers” must cover at least as many people
as under the ACA and provide coverage that is at least as
comprehensive and affordable, at no extra cost to the
federal government.
 States that receive waivers may finance their reforms
with federal funding that otherwise would have been
provided for premium tax credits, cost-sharing
reduction and small business tax credits
2015 House Budget
 Continuing enhanced PCP rates
 Restore Dental coverage for adults
 Restore coverage of Therapies
 Physical Therapy
 Occupational Therapy
 Speech Therapy
 Asthma Education and Home Environment
Assessments
27
MEDICAID EXPANSION AND REFORM
BACKGROUND
 Key points
 Eligibility for Medicaid
 Cost for expansion
 Savings to the state budget
 Additional revenue
 Summary of budget impact
28
KEY POINTS
 Provide access to affordable health insurance to
313,000 Missourians.
 Save state general revenue to invest in other
priorities.
 Net positive impact, even with full cost of expansion
built in.
 Positive impact on the economy from additional
health care.
29
CURRENT ELIGIBILITY
FY 2013 ACTUAL MEDICAID CASELOAD (879,000)
 Children – 535,000
 Person with Disabilities – 163,000
 Parents – 79,000
 Seniors – 75,000
 Pregnant Women – 27,000
30
EXPANDED ELIGIBILITY
 Missourians with incomes up to 138% of the federal
poverty level ($32,913 for a family of four; $16,105
for an individual)
 Non-elderly and not Medicare eligible
 Two eligibility categories
- Medically frail
(provided with necessary wrap around services)
( for cost estimate, grouped by frail, ADA, and CPS)
- Healthy adults
31
DONUT HOLE
 Without expansion, Missourians with income from 19% to
100% of the federal poverty limit face a “donut hole.”
 For a family of four, annual income from $4,532 to
$23,850. For an individual, $2,217 to $11,670.
 They make too much money to qualify for the existing
Medicaid Program, but too little money to qualify for
subsidized health insurance through the Exchange.
 About 200,000 uninsured Missourians are in that donut
hole.
32
COST -- STATE SHARE
 No state cost for calendar years 2014, 2015 & 2016
 State share then phases up to 10%
-
January 2017 – 5% (half year for FY 2017)
January 2018 – 6%
January 2019 – 7%
January 2020 – 10%
33
COST SUMMARY
34
SAVINGS – TRANSFER POPULATIONS
 Current Medicaid Populations under 138% FPL
- Pregnant women (get coverage before pregnant)
- Ticket to Work
- Breast/cervical cancer
- Spend down
- People with disabilities (non-Medicare)
- CHIP (affordability)
- Women’s health services
- Increased Pharmacy Assessment
35
SAVINGS – TRANSFER POPULATIONS
 Current State Only Populations under 138% FPL
- Blind Pension
- Corrections
- Dept of Mental Health Clients
36
GENERAL REVENUE
SAVINGS SUMMARY
37
ADDITIONAL REVENUE
38
BUDGET SUMMARY
 State costs for new eligibles $0 until FY 2017
 Lose 100% federal match for every day we wait
 Full phase in of state share at 10% in FY 2021
 Savings for existing populations begin immediately
 Lose savings for every month that we wait
 Additional revenue estimate conservative – no multiplier
39
EXPANDING AND REFORMING MEDICAID
GENERAL REVENUE BUDGET SUMMARY
$s in Mils
FY 2015
FY 2016
FY 2017
New Cost
$0.0
$0.0
($35.3)
($78.9) ($164.0)
$90.8
$168.6
$200.9
$213.7
$222.0
($12.0)
($24.0)
($24.0)
($24.0)
($24.0)
Admin Cost
($1.5)
($0.8)
($0.8)
($0.8)
($0.8)
Net Savings
$77.3
$143.8
$140.8
$110.0
$33.2
New Revenue
$16.9
$42.1
$40.0
$36.4
$40.3
Net Positive Impact
$94.2
$185.9
$180.8
$146.4
$73.5
Savings
Access to Physicians
FY 2018
FY 2022
40
CONCLUSION
 Provide access to affordable health care insurance to
313,000 Missourians.
 Save state general revenue to invest in other
priorities.
 Net positive impact, with full cost of expansion built in.
 Other considerations - indirect budget implications:
- Improved access to care,
- Better health outcomes, and
- Improved job retention when healthy.
41
Per Member Per Month Costs
$1,600
$1,400
$1,200
$1,000
$800
No Mental Disorder
$600
Any Mental Disorder
$400
$200
$0
Private Sector
Medicare
Medicaid
Melek et al Milliman
Inc, 2013
MH/SU costs in NY State’s Medicaid Program
$30,000
$28,000
$26,000
$24,000
$22,000
$20,000
$18,000
$16,000
$14,000
$12,000
$10,000
Behavioral Health costs
Physical Helath costs
MH Disorder
SU Disorder
No MH/SU
Disorder
What is a Health Home?
 Not just a Medicaid Benefit
 Not just a Program or a
Team
 A System and
Organizational
Transformation
Health Care Home Strategy
 Case management coordination and facilitation of healthcare
 Primary Care Nurse Care Managers
 Disease management for persons with complex chronic medical
conditions, SMI, or both
 Behavioral Health management and behavior modification as
related to chronic disease management for persons with Medical
Illness
 Preventive healthcare screening and monitoring by MH providers
 Integrated Primary Care and Behavioral Healthcare
Health Home Strategy
 Health technology is utilized to support the service system.
 “Care Coordination” is best provided by a local community-
based provider.
 MH Community Support Workers who are most familiar
with the consumer provide care coordination at the local
level.
 Primary Care Nurse Care Managers working within each
Health Home provide system support.
 Behavioral Health Consultants in each Primary Care Health
Home
 Statewide coordination and training support the network of
Health Homes.
What is Different about Health Homes?
• Individual Practitioner
• Episodic Care
• Focus on Presenting Problem
• Referral to meet other Needs
• Managed Care
– Manages access to care
– Does not change clinical
practice
Treatment as Usual
• Integrated Primary/Behavioral Health
Care Team
• Continuous Care
• Comprehensive Care Management
– Coordinates care across the healthcare
system
– Data driven population management
– Transforms clinical practice
– Emphasizes healthy lifestyles and selfmanagement of chronic health
problems
Health Homes
Health Home
Target Populations
 Patients with Diabetes
 At risk for cardiovascular disease
and a BMI > 25
 Patients who have two of
the following
 COPD/Asthma
 Diabetes (also as single




condition)
Cardiovascular Disease
BMI>25
Developmental Disabilities
Use Tobacco
Primary Care Health Homes
 Individuals with a
serious mental illness; or
with other behavioral
health problems who also
have
Diabetes
COPD/Asthma
Cardiovascular Disease
BMI>25
Developmental Disabilities
Use Tobacco
CMHC Healthcare Homes
Missouri’s Health Homes
• Providers
– 18 FQHCs
•
67 Clinics
– 6 Hospitals
• 22 Clinics
• 14 Rural Health Clinics
• Enrollment
– 15,526 adults
– 428 children
– 15,954 total
Primary Care Health Homes
• Providers
– 28 CMHCs
•
120 Clinics/Outreach
Offices
• Enrollment
– 16,611 adults
– 2,387 children
– 18,998 total
CMHC Healthcare Homes
Health Home Team
 Nurse Care Managers (1FTE/250pts)
 Care Coordinators (1FTE/500pts)
 Health Home Director
 Behavioral Health Consultants (primary care)
 Primary Care Physician Consultant (behavioral
health)
 Learning Collaborative training
 Next day notification of Hospital Admissions
Principles
 One Team
 CMHC’s composed of pre-2012 CPRC staff plus NCM
and PC Consultant
 PCHH’s composed of new infrastructure and team
members
 One Treatment Plan for the Whole Person
 Rehab Goals
 Medical Goals
 Healthy Lifestyle Goals
 Some Goals and Outcomes reference Health Home
Performance Measures
 Wrap –Around approach to outside treating PCP,
mental health providers, community supports, etc
Six CMS Required Health Home Functions
 Care Management
 Care Coordination
 Managing Transitions of Care
 Health Promotion
 Individual and Family Support
 Referral to Community Services
Comprehensive Care Management
 Identification and targeting of high-risk
individuals
 Monitoring of health status and adherence
 Identification and targeting care gaps
 Individualized planning with the patient
Step 1 – Create Disease Registry
 Get Historic Diagnosis from Admin Claims
 Get Clinical Values from Metabolic Screening,
clinical evaluation and management, care plans
 Combine into EHR Disease Registry (Central Data
Registry, PROACT)
 Online Access available to all Providers
Step 2 – Identify Care Gaps and ACT!
 Compare Combined Disease Registry Data to accepted
Clinical Quality Indicators
 Identify Care Gaps
 Sort patients groups with care gaps into agency specific To-
Do lists
 Nurse care manager helps team decide who will act
 Set up indicated visits and pass on info with request to
treat
Care Coordination
 Coordinating with the patients, caregivers and
providers
 Implementing plan of care with treatment team
 Planning hospital discharge
 Scheduling
 Communicating with collaterals
Chronic Disease and At Risk
HCH Adults
July, 2013
50%
44%
45%
40%
38%
35%
35%
33%
30%
30%
26%
25%
24%
20%
20%
15%
15%
13%
8%
10%
7%
3%
5%
2%
0%
Asthma/COPD
Diabetes
Hypertension
HCH Adults
Obese
Extremely Obese
Gen. Adult Pop.
Dev. Disability
Substance Abuse
Improving Diabetes (HbA1c)
 7.2% Uncontrolled (too high)
 For 51% there are 2 results so we can find the trend
 The uncontrolled group average HbA1c decreased from
9.50% to 8.95% (-0.55%)
 1% point decrease in HbA1c yields:



21% decrease in Diabetes related deaths
14% decrease in Heart Attacks
37% decrease in micro-vascular complications
Improving Cholesterol (LDL)
 46.3% Uncontrolled (too high, greater than 100)
 For 58% there are 2 results so we can find the trend
 The uncontrolled group average LDL decreased from 122
to 115 (-7)
 A 10% Cholesterol Reduction yields a 30% reduction in
Coronary Heart Disease
Improving Hypertension (BP)
 23% Uncontrolled (too high, greater than 140/90)
 For 61% there are 2 results so we can find the trend
 The uncontrolled group average BP decreased from 142/90
to 137/86 (-5/4)
 A 6 point reduction yields:
 16% reduction in Coronary Heart Disease
 42% reduction in Stroke
Hypertension and
Cardiovascular Disease
370
3665
Disease Management
Diabetes
( 2822 Continuously Enrolled Adults)*
*29% of continuously enrolled adults
LDL Changes in PCHH
Patients with Initially High
Levels
132
HA1c Changes in PCHH
Patients with Initially High
Levels
131.19
10
130
9.89
9.8
128
9.6
126
9.4
124
121.12
122
p<.0001
p<.0001
9.17
9.2
120
9
118
8.8
116
Pre
Pre
Post
Diastolic Blood Pressure Changes
in PCHH Patients with Initially High
Values
Systolic Blood Pressure
Changes in PCHH Patients with
Initially High Values
89
152
150
88
149.75
Post
87.84
87
148
86
146
85
142.94
144
p<.0001
142
83
140
82
138
81
Pre
Post
83.85
84
Pre
Post
p<.0001
Outcomes
Medication Adherence
% Continuously enrolled CMHC Health Home Clients with an MPR >
.80 by Medication Type
85%
84%
83%
82%
2/1/2012
81%
1/1/2013
80%
79%
78%
77%
76%
Pscyhiatric
Cardiovascular
Asthma/COPD
CMHC Healthcare Homes
Hospital Follow Up
Jan. 2012 through May, 2013
80%
70%
60%
50%
40%
30%
20%
10%
0%
1
2
3
4
5
6 7 8 9 10 11 12 13 14 15 16 17
% Followed-up
% Med Rec.
Outcomes
Reducing Hospitalization
Primary Care Health Homes
CMHC Healthcare Homes
% Enrollees with
Chronic Health Conditions
100%
ER Events for PCHH Members
with at Least 8 Months of Service
and Who Were Initially Enrolled
during First Quarter 2012
69%
37%
34%
50%
56%
81%
3%
0%
1050
Number of ER Events By Month Since Enrollment
1000
950
900
850
800
750
700
PCHH ER Events
Linear (PCHH ER Events)
650
600
0
1
2
3
4
5
6
7
8
Months in Health Home (0=Admission Month)
9
10
11
12
Intial Estimated Cost Savings after 18
Months
 Health Homes
 43,385 persons total served (includes Dual Eligibles)
 Cost Decreased by $51.75 PMPM
 Total Cost Reduction $23.1M
 DM3700
 3560 persons total served (includes Dual Eligibles)
 Cost Decreased by $614.80 PMPM
 Total Cost Reduction $22.3M
ACA Section 2703 Health Home Activity
NH
VT
WA
AK
MT
MN
OR
ID
NY
WI
SD
MI
WY
IA
NE
NV
UT
CO
CA
AZ
IL
KS
OK
NM
MO
TX
OH
IN
WV VA
NC
TN
SC
AR
AL
GA
LA
FL
As of June 2013
Approved State Plan Amendment(s) (12)
Planning Grant (17)
PA
KY
MS
HI
Note: States with stripes have both
http://www.nashp.org/med-home-map
ME
★
ND
MA
RI ★
NJ CT
DE
MD
WebSites
 www.nasmhpd.org/medicaldirector.cfm
 www.dmh.mo.gov/about/chiefclinicalofficer
/healthcarehome.htm
Current Missouri Income Eligibility Levels
Compared to Federally-Mandated Levels
300%
300%
Current Missouri Level
300%
100%
Spenddown
200%
Missouri Level – Premium Required
185%
133%
133%
133%
Federal Minimum
85%
74%
0%
Pregnant
Women
(1)
Children
Infants
< 1 year
Elders &
Disabled(1)
19%
19%
Custodial
Parents
0%
Childless
Adults
Elders and the Disabled who are eligible except for income may spend down excess income to qualify
72