Medicaid Advisory Committee September 23, 2015 General Services - - PowerPoint PPT Presentation

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Medicaid Advisory Committee September 23, 2015 General Services - - PowerPoint PPT Presentation

Oct 14, 2022 337 likes •801 views

Medicaid Advisory Committee September 23, 2015 General Services Building Salem, Oregon Time Item Presenter 9:00 Opening Remarks Co-Chairs Oregon Health Plan (OHP) and Coordinated Care Organizations OHA update Rhonda Busek, Janna Starr, 9:05

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Medicaid Advisory Committee

September 23, 2015

General Services Building Salem, Oregon

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Time Item Presenter 9:00 Opening Remarks Co-Chairs 9:05 Oregon Health Plan (OHP) and Coordinated Care Organizations – OHA update  OHP enrollment and determination dashboard  OHP quarterly report; 2nd quarter 2015 Rhonda Busek, Janna Starr, OHA 9:25 Oral Health and OHP – OHA Dental Director  Oral health and OHP  2015 legislative priorities and OHA initiatives on oral health

  • Dr. Austin, OHA

9:55 InterCommunity Health Network CCO Community Advisory Council (CAC)

  • IHN’s CAC membership and community engagement

activities

  • Council priority areas and implementation activities outlined

in the CHIP Rebekah Fowler, CAC Coordinator 10:25 Break 10:30 Medicaid 12 Month Continuous Eligibility

  • Review draft recommendations; finalize.

Co-Chairs; staff 11:20 Health Evidence Review Commission (HERC) Darren Coffman, Jason Gingerich, OHA 11:50 Closing comments Co-Chairs

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OHA Update: Oregon Health Plan (OHP) and CCOs

Rhonda Busek and Janna Starr Health Systems Division, OHA

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Oral Health and OHP

Bruce Austin, OHA Dental Director

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Community Advisory Council

Rebekah Fowler, PhD

CAC Coordinator

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Presentation Overview

1. Describe CAC structure & representation 2. Provide overview of CHIP and its impact 3. Discuss current CAC CHIP work 4. Give 3 CHIP activity examples 5. Discuss community engagement activities 6. Provide my contact information 7. Answer questions

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Community Representation

 Regional CAC Structure

  • 12 IHN-CCO members (63%)
  • 3 county staff
  • 3 community members
  • 1 Chair

 Three Local Advisory Committees

  • 6 CAC Representatives plus county &

community partners

  • Provide broader, deeper level of community

involvement

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CHIP: Community Health Improvement Plan

CHIP Focus Areas

  • Access to healthcare
  • Behavioral health
  • Chronic disease
  • Maternal & Child health

Strategic Planning

  • The CHIP focus areas are used to prioritize

transformation pilot projects

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Current CHIP Work in Progress

The CCO will use Outcomes and Indicators to further prioritize pilot project proposals

  • Outcome example: IHN-CCO members will

receive appropriate care at the appropriate time and place

  • Indicators are measures of progress toward

achieving outcomes such as length of time to receive an appointment or Emergency Department use.

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Sample Initiatives

Health Disparities Workgroup will:

  • Identify areas of health disparities
  • Identify root causes of disparities
  • Develop strategic plan to create equity

Traditional Health Workers (THW)

  • Inventoried region’s use of THWs
  • Developed learning collaborative for THW

alternative payment method pilot projects

  • Embedded THWs into patient centered primary

care homes and schools

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Community Engagement:

A Work in Progress

 Community Conversations  Pros & Cons comments outreach  Strategic Planning Retreat will focus

  • n identifying 2-5 questions the CAC

wants to ask of the community

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Challenges

 Data availability  Community engagement – lessons learned  Differences in work styles  While the CAC has always maintained an IHN-CCO member majority, more members are needed.

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Contact Information

Rebekah Fowler, PhD CAC Coordinator rfowlerconsulting@gmail.com (541)768-7699

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BREAK

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12-Month Continuous Eligibility for OHP Adults

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12-Month Continuous Eligibility

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Problem: Low and moderate-income parents and childless adults experience substantial income volatility throughout the year, which affects eligibility and can cause churning on and off Medicaid – Option for children since 1997; 32 states have adopted policy in their Medicaid or CHIP programs; 23 states have in both programs – Federal policy has been an option for Medicaid adults since 2013

  • To date, only New York state had has implemented the policy

for their adult populations, likely due to financing barriers Impact: Promotes coverage continuity for eligible individuals, despite fluctuations in income or other eligibility criteria, but also creates additional costs for a state Policy: 12-Month Continuous Eligibility Allows beneficiaries to maintain coverage for up to one full year, even if individuals/families experience a change in income or family status

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Method for Determining Costs of 12-Month Continuous Eligibility for OHP Adults, 2017-19 Biennium

Forecast OHP enrollment for 17-19 biennium Develop continuity

  • f coverage

ratios Estimate annual program expenditures for 17-19 biennium Calculate federal/state program costs for current and new eligibility policy Estimate budget impact for 12- month continuous eligibility for income-eligible OHP adults

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Continuity Ratio

  • Used similar approach to the Medicaid “continuity ratio” developed by

researchers at George Washington University (GWU) in 2009

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Eligibility Categories Current Policy (%) New Policy (%) Difference Medicaid Expansion Adults 68.2 78.7 +10.5 Aid to the Blind and Aid to the Disabled (AB/AD) 83.8 87.3 +3.5 Parent/Caretaker Relative 61.9 77.7 +15.8

Sources: George Washington’s analysis of Medicaid Statistical Information System Datamart for FY 2006-11; DHS/OHA Integrated Client Services data warehouse, 2008-2012

Table 2. Continuity Ratios, 2017-19 Biennium 100% Continuity Ratio = Everyone Was Enrolled for the Entire Year _______Average Member Months________ Total # of Unduplicated Enrollees that Year = Continuity Ratio

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Federal Financial Participation

  • Federal funding for the AB/AD and Parent/Caretaker Relative adult

groups for the 2017-19 biennium is estimated at 62.47%

  • Federal funding for the Medicaid expansion population gradually

decreases from 100% in 2016 to 90% in years 2020 and beyond

– 2014 CMS guidance indicated that states would not receive the full-enhanced match rate for their Medicaid expansion population under 12-month continuous eligibility

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SFY Year Estimated ACA Enhanced FMAP 12-Month CE FMAP for Adults FMAP Reduction 17-19 Biennium 2018 94.50% 93.68%

  • 0.82%

2019 93.50% 92.68% Table 4. Federal Participation for Oregon’s Medicaid Expansion Population with New Policy (i.e. 12-Month Continuous Eligibility), 2017-19 Biennium

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Results

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Current Policy New Policy Change 17-19 Biennium Total Member Months of Coverage 11.8 million 13.5 million 1.7 million PMPM Cost $770 $759 N/A Federal Share FMAP $7.64 billion 83.81% $8.66 billion 83.58% $1.01 billion

  • 0.22%

State Share $1.47 billion $1.7 billion $223 million Total Program Cost 2017-19 Biennium† $9.1 billion $10.3 billion $1.2 billion

†The change in combined program expenditure from “current policy” to “new policy” reflects a change in the ratio of clients due to changes in the continuity ratio for the respective adult populations resulting from the implementation of 12-month continuous eligibility. Because each eligibility group has a different program expenditure (PMPM), the combined weighted average PMPM is different when the ratio of member months changes.

Table 8. Combined Estimated Cost for OHP Adult Populations, 2017-19 Biennium

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Summary of Results

If a 12-month continuous eligibility policy were implemented for OHP adults for the 17-19 biennium:

  • Coverage Continuity: estimated to increase total member months
  • f coverage by nearly 15% over the biennium, resulting in 1,734,346

additional member months of coverage.

– Continuity ratios are estimated to increase on average by nearly 10 percent for the three OHP adult populations.

  • Program Costs: estimated to increase total program spending by

$1.23 billion

  • Additional federal revenue of $1.01 billion
  • Additional state spending of $223 million
  • $58 million due to decrease in ACA Expansion FMAP

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Recommendations

Committee’s Task:

  • Prepare and submit recommendations to OHA regarding the

feasibility of 12-month continuous eligibility for adults in OHP in the 2017-19 biennium.

  • Outline the potential fiscal impact on the state budget in the

next biennium. Potential Recommendations:

  • Recommend to OHA to request the Legislature to fund 12-

month continuous eligibility for 17-19 biennium

  • Don’t recommend 12-month continuous eligibility
  • Alternative options/considerations: see draft memo
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Preliminary Recommendations (July 2015)

Request policy as part of Oregon’s 1115 Waiver renewal: Propose to the Centers for Medicare and Medicaid Services (CMS) that 12-month continuous eligibility for OHP income-eligible adults be incorporated into Oregon’s 1115 waiver in 2017, including waiving the reduction in FMAP for this policy, reducing the overall state investment to $165 million. Monitor OHP program performance: Implement data collection procedures to monitor changes in the fiscal, quality and health outcomes that result from churn in OHP:  Adopt transparent OHP eligibility, enrollment and redetermination performance indicators.  Complete annual assessment of administrative costs that result from churn and potential savings to the Medicaid program, CCOs, and health providers if this policy were adopted. Conduct longitudinal cost-benefit study: estimate potential financial benefits that could result from changes in health care utilization associated with increases in coverage continuity (i.e. stable Medicaid coverage).

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Public Comment or Testimony

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Health Evidence Review Commission Overview

September 23, 2015

Darren Coffman, Director Jason Gingerich, Policy Analyst Health Evidence Review Commission

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Assumptions of the List

  • Every person is entitled to a diagnosis

– Diagnostic office visit(s) – Imaging/lab/biopsies

  • Each covered condition includes

– Prescription drugs – DME and supplies – Other ancillary services

  • Services Recommended for Non-Coverage do not

appear on list (formerly excluded services)

– Excluded in DMAP administrative rules – Cosmetic services – Experimental treatments – Not effective for any condition

  • Flexible services are not on the List
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Current methodology: Categories of Care

1) Maternity/Newborn Care (100) 2) Primary & Secondary Prevention (95) 3) Chronic Disease Management (75) 4) Reproductive Services (70) 5) Comfort Care (65) 6) Fatal Conditions – Disease Modification/Cure (40) 7) Nonfatal Conditions – Disease Mod./Cure (20) 8) Self-limited Conditions (5) 9) Inconsequential Care (1)

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Methodology: Individual/Population Impact Measures

  • Impact on Healthy Life (+ 0 to 10)
  • Impact on Suffering (+ 0 to 5)
  • Population Effects (+ 0 to 5)
  • Vulnerability of Population Affected (+ 0 to 5)
  • Tertiary Prevention (+ 0 to 5)
  • Effectiveness (x 0 to 5)
  • Need for Medical Services (x 0 to 100%)
  • Net Cost (0 to 5)
  • Details available at http://www.oregon.gov/oha/herc/Pages/Prioritization-Methodology.aspx
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Example of Scoring: Type 2 Diabetes Mellitus

  • Impact on Healthy Life: 7
  • Impact on Suffering: 2
  • Effects on Population: 0
  • Vulnerability of Population Affected: 2
  • Effectiveness: 4
  • Need for Service: 1
  • Net Cost: 4
  • Category 3 Weight: 75

Total Score: 3300  Line: 33

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Sample Prioritized List Line

Line number (funding line is 476 for this list)

If the diagnosis and the procedure appear on the same line, the service is covered said to “Pair” (though it may be subject to a guideline note or coding specification). If the line number where it “pairs” is above the funding line, it’s covered.

Condition/treatment descriptions (plain English approximations) Reference to guideline notes

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Examples of Rankings in 2015

Funded Lines:

26 Schizophrenia 51 Appendicitis 143 Glaucoma 195 Breast cancer 288 COPD 347 Dental caries (Fillings) 358 Closed fracture of extremities 370 Strep throat 414 Migraine headaches

Unfunded Lines:

481 Chronic otitis media 519 Esophagitis and GERD (long- term medical therapy) 530 Uncomplicated hernia 545 Back pain* 567 Transplant for liver cancer 579 Uncomplicated lymphedema* 609 Sleep disorders w/o apnea 617 Common cold *Changes are scheduled for January, 2016

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Updating the List

Biennial review

– Effective January 1st of even numbered years – Significant changes

  • Line movement
  • Line merging/splitting
  • Changes involving significant fiscal impact

Interim modifications

– Effective every January 1st and October 1st – Technical changes

  • Incorporation of new diagnosis/procedure codes
  • Add appropriate pairings/delete inappropriate pairings
  • Guideline note additions/revisions
  • Fix errors
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‘Unfunded’ services can sometimes be covered

Comorbidity rule

– Nasal allergies unfunded

  • But treating them may help in treatment of asthma

CCO flexibility

– CCOs have flexibility to cover services at their discretion, but the rates they receive assume only funded services

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Evidence-based Process

  • In 1990s, decisions initially based on expert opinion.

Evidence-based medicine has shifted coverage decisions to rely on quality trials where possible.

  • Use research performed by recognized sources
  • Supporting evidence needed to place new services on

list

  • Evidence of harm or ineffectiveness can be used to

removed existing services from list

  • Cost-effectiveness considered where available when
  • utcomes are similar between treatments
  • Incorporate recommendations of coverage guidances
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The Prioritized List and the ACA

  • Medicaid expansion to 138% FPL. Changed the choice

between expanding eligibility vs. benefits. But budget constraints remain.

  • Essential Health Benefits

– Changes to Guideline Note 12 (Cancer treatment with little or no benefit) – Removal of age limits and other language that might be considered discriminatory

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The future of the list

  • Funding line is frozen (relatively)
  • Frequent state bills attempting to carve out

services from the List

  • Challenge for List to address systems issues

(systems of care, coordination, quality, metrics)

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Coverage Guidances

  • Evidence-based recommendations for any payer

who wishes to use them

  • Prioritized list usually follows suit
  • Each recommendation is strong or weak

depending on the confidence of the committee

  • Uses GRADE-informed methodology to make

recommendations

  • More explicitly incorporation of values and

preferences with evidence-based medicine

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HERC subcommittee structure

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HERC VbBS

Value-based Benefits Subcommittee

EbGS

Evidence-based guidelines subcommittee

HTAS

Health Technology Assessment Subcommittee

Coverage Guidance Coverage Guidance

Coverage Guidance Prioritized List Changes

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Topic Selection Report Development Review and Approval Monitoring

Coverage Guidance process overview

Topic Identification

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Coverage Guidances

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Coverage guidance recent/upcoming topics

  • Planned out-of-hospital birth
  • Nitrous oxide for labor pain
  • Skin substitutes for skin ulcers
  • Coronary bypass vs. stenting for chronic angina
  • Bariatric surgery
  • Attention Deficit/Hyperactivity Disorder in

children

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GRADE-informed framework (DRAFT)

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Get involved

  • http://www.oregon.gov/oha/herc/Pages/Get-

Involved.aspx

– eGov Delivery notice – Public meeting information – Written and verbal comment guidelines

  • Topic nomination survey

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Contact Information

Jason Gingerich, Policy Analyst Health Evidence Review Commission (503) 373-1771 Jason.D.Gingerich@state.or.us

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Remaining 2015 Schedule

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  • October 28th – Salem (Ferry St.)
  • December 9th – Salem (Ferry St.)

Looking Ahead: 2016

  • Starting in 2016, the MAC will meet at the Oregon State

Library.