Impact of Medicaid and Medicaid Managed Care Presented to: - PowerPoint PPT Presentation

Impact of Medicaid and Medicaid Managed Care Presented to: Mississippi Senate Medicaid Committee February 19, 2020

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Economic Impact of Mississippi Hospitals • Mississippi hospitals employ over 61,000 individuals • Mississippi hospitals help create over 119,000 jobs • Mississippi hospitals provide direct salaries and wages of over $8 billion • Mississippi hospitals directly and indirectly provide total salaries and wages of over $15 billion 3

Mississippi Hospitals and Extended Hospitals • In addition to the specialized services provided at our larger trauma hospitals such as UMC, North MS, Forrest General and Memorial Gulfport, out ‐ of ‐ state hospitals also serve Medicaid patients • Regional One Health in Memphis, Univ. of South Alabama in Mobile and Ochsner in New Orleans are significant providers of hospital services. • Methodist Le Bonheur – almost half of the babies in the NICU were from Mississippi. 4

Holding the Line on Expenses • Mississippi non ‐ profit hospitals have the lowest national inpatient per diem expenses ‐ $1,365/day. • Mississippi state and local government hospitals have the 8 th lowest national inpatient per diem expenses ‐ $1,239/day. • Mississippi for profit hospitals have the 12 th lowest national inpatient per diem expenses ‐ $1,762/day. 5

Community Benefits • Alzheimer’s Walk (Memorial Hospital at Gulfport) • Community Lunch and Learn (Gilmore Memorial Hospital) • Heart Health & Wellness Awareness (Bolivar Medical Center) • Relay for Life (North MS Health Services) • Free Pain Management Clinic (Covington County Hospital) 6

Community Benefits • Free Skin Cancer Screening, MS Support Group (Anderson Regional Medical Center) • Student Ambassador Leadership Program (Forrest General Hospital) • Children’s Health & Safety Fair (Greenwood Leflore Hospital) • Diabetes Management Classes and Relay for Life (Lawrence County Hospital) 7

Community Benefits • National Alliance on Mental Health (Anderson Regional Medical Center) • Distinguished Young Woman Scholarship Pageant (Lackey Memorial Hospital) • My Preemie & Me Event (Delta Regional Medical Center) • American Legion Post #200’s Salute to Veterans (Greenwood Leflore Hospital) • Community Health Fair (Covington County Hospital) 8

Fiscal Challenges for Mississippi Hospitals • Reductions in Medicare Inpatient and Outpatient Marketbasket Increases through 2027 ‐ $3 Billion • Medicare DSH and Sequestration and Other Cuts Projected Through 2027 ‐ $1.7 Billion • Since 2010, 6 hospital closures – Belzoni, Kilmichael, Natchez, Newton, Marks, Senatobia • Since 2010, 6 hospital bankruptcies – Natchez, Clarksdale, Batesville, Aberdeen, Amory, Magee 9

Important Events • Medicaid Adopts DSH and UPL programs, 1990s • Hospital Provider Tax Codified, 2009 • Outpatient MississippiCAN (Managed Care), 2011 • Mississippi Medicaid DRGs and APCs, 2012 • Inpatient MississippiCAN (Managed Care) and FFS UPL program eliminated, 2015 10

Mississippi Hospitals ‐ Payer Mix Q1 ‐ 3, 2019 Medicare Advantage ‐ Blue Cross Blue Shield 5.92% ‐ 15.49% Medicare ‐ 31.63% Other ‐ 3.73% Commercial Insurance ‐ 13.06% Medicaid FFS ‐ 5.04% Magnolia Health ‐ 7.19% Self Pay ‐ 10.10% Molina Healthcare ‐ United Healthcare ‐ 11 2.14% 5.71%

Provider Taxes By Mississippi Hospitals • For SFY 2020, Mississippi hospitals will pay the entire state share for hospital access payments, $122,190,418 to receive $527,364,770. • For SFY 2020, Mississippi hospitals will pay the entire state share for Disproportionate Share Hospital Payments, $53,328,509 to receive $231,661,637. • For SFY 2020, Mississippi hospitals will pay an additional $100,878,125 to support the state share used for hospital payments. 12

Hospitals – Medicaid Inpatient SFY 2013 ‐ 18 680,000,000 671,151,312 658,486,490 660,000,000 648,729,141 640,000,000 620,000,000 600,662,599 600,000,000 580,915,145 580,000,000 576,019,642 560,000,000 540,000,000 520,000,000 2013 2014 2015 2016 2017 2018 13

Medicaid Inpatient Visits • Normal Newborn • Prematurity • Psychoses • Bronchitis / Asthma • Delivery w/o Comp. Diagnosis • Red Blood Cell Disorder • Neonate with Sig. Problems • Septicemia • C ‐ section • Behavioral Disorders 14

Hospitals – Medicaid Outpatient SFY 2013 ‐ 18 450,000,000 419,523,868 407,653,121 400,000,000 366,734,630 350,000,000 327,527,599 300,000,000 278,613,836 274,754,394 250,000,000 200,000,000 150,000,000 100,000,000 50,000,000 ‐ 2013 2014 2015 2016 2017 2018 15

Medicaid Outpatient Visits • Respiratory Infections • Back Pain • Pharyngitis • Viral Infection • Fever • Hypertension • Abdominal Pain • Chest Pain • Headaches • Dental Caries 16

Hospitals – Medicaid Total Claims SFY 13 ‐ 18 1,040,000,000 1,020,186,467 1,020,000,000 1,000,000,000 986,014,089 983,672,763 980,000,000 960,000,000 945,905,706 947,649,775 940,000,000 927,342,977 920,000,000 900,000,000 880,000,000 2013 2014 2015 2016 2017 2018 17

Medicaid and Medicaid Managed Care • Admin. Costs for MCOs exceed $1.3B since 2011 • SFY 2019 total program admin approx. $400M • $750M for SFY 2011 direct state appropriation June 2011 enrollment: Total – 707,450; MCO < 200,000 • $931M for SFY 2020 direct state appropriation December 2019 enrollment: Total ‐ 715,815; MCO ‐ 438,029 18

Hospital Issues with Medicaid Managed Care • Claims rejected b/c providers were not loaded into payer’s system; after providers correctly loaded, claims were resubmitted and were denied as untimely • Claims denials as a result of failure to properly load new CPT codes – took 5 months to resolve in 2017 and 4 months to resolve same issue in 2018 • Implemented an ER level reduction policy in July 2019; but, tried to recoup claims dating back to 2018. Recoupment was significantly reduced after appeal. 19

Hospital Issues with Medicaid Managed Care • Ongoing challenges enrolling mothers and babies in the same MCO • MCO incorrectly configured certain surgical codes causing codes to underpay • MCO system configuration issue caused claims to deny as non covered services – issues resolved after 10 months 20

Hospital Issues with Medicaid Managed Care • Revenue Code 204 behavioral health claims were incorrectly routed by MCO to its medical claims payer from behavioral health sub and claims denied – 28 mo. • MCO incorrectly loaded wrong NPI number which caused claims to process as out of network. MCO then tried to recoup the correctly paid claims which required an appeal. • MCO credentialing issues and delays in physician and provider credentialing 21

HEDIS Measures for Mississippi MCOs Magnolia – Consumer Satisfaction – Overall 4.5 Prevention – Overall 2.0 Children and Adolescent Well Care – Overall 1.5 Dental Visits – 5.0 Childhood Imm. Combo 10 by age 2 – 1.0 Adolescent Imm. Combo 2 by age 13 – 1.0 BMI Percentile Assessment ages 3 ‐ 17 – 2.0 Women’s Reproductive Health – Overall 3.0 Prenatal Checkups – 3.0 Postpartum Care – 2.0 22

HEDIS Measures for Mississippi MCOs United – Consumer Satisfaction – Overall 3.0 Prevention – Overall 2.0 Children and Adolescent Well Care – Overall 2.0 Dental Visits – 5.0 Childhood Imm. Combo 10 by age 2 – 2.0 Adolescent Imm. Combo 2 by age 13 – 1.0 BMI Percentile Assessment ages 3 ‐ 17 – 1.0 Women’s Reproductive Health – Overall 3.5 Prenatal Checkups – 4.0 Postpartum Care – 3.0 23

HEDIS Measures for Mississippi MCOs Magnolia ‐ Treatment – Overall 2.0 Asthma – Overall 3.0 Asthma Control – 5.0 Asthma Drug Management – 1.0 Diabetes – Overall 2.0 Blood Pressure Control – 2.0 Eye Exams – 3.0 Glucose Control – 2.0 Patients received statin therapy – 1.0 Patients statin adherence – 1.0 24

HEDIS Measures for Mississippi MCOs United ‐ Treatment – Overall 2.0 Asthma – Overall 2.5 Asthma Control – 4.0 Asthma Drug Management – 1.0 Diabetes – Overall 2.0 Blood Pressure Control – 2.0 Eye Exams – 4.0 Glucose Control – 2.0 Patients received statin therapy – 2.0 Patients statin adherence – 1.0 25

HEDIS Measures for Mississippi MCOs Magnolia – Mental and Behavioral Health – Overall 2.5 Depression: Adhering to medication 6 mo. – 1.0 Follow up after hospitalization – 3.0 Follow up after ED visit – 2.0 Follow up after ED for alcohol / drug abuse ‐ 1.0 Alcohol or drug abuse treatment engaged – 2.0 Continued follow up after ADHD diagnosis – 5.0 Diabetes screening for schizophrenia / bipolar – 1.0 Adherence to antipsychotic meds for schizophrenia – 2.0 Cholesterol/sugar testing for youth on antipsych meds ‐ 2.0 26

HEDIS Measures for Mississippi MCOs United – Mental and Behavioral Health – Overall 2.0 Depression: Adhering to medication 6 mo. – 1.0 Follow up after hospitalization – 3.0 Follow up after ED visit – 2.0 Follow up after ED for alcohol / drug abuse ‐ 2.0 Alcohol or drug abuse treatment engaged – 2.0 Continued follow up after ADHD diagnosis – 4.0 Diabetes screening for schizophrenia / bipolar – 1.0 Adherence to antipsychotic meds for schizophrenia – 2.0 Cholesterol/sugar testing for youth on antipsych meds ‐ 1.0 27