Medical Education and the State Budget Kathy Eckstein Director of - - PowerPoint PPT Presentation

Medicaid, Graduate Medical Education and the State Budget

Kathy Eckstein Director of Public Policy Children’s Hospital Association of Texas (CHAT)

The Significance of Medicaid

• 14% of the Texas population was covered

by Medicaid in 2011, and more than three- fourths of these recipients were children.

• In 2011, the State of Texas spent $29.4

billion (State General Revenue (GR) plus Federal) on Medicaid, accounting for 26%

• f the state’s budget.

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Medicaid History and Oversight

• Established by Title XIX of the Social Security

Act in 1965

• A joint state-federal entitlement program
• Administered by the Centers for Medicare

and Medicaid Services (CMS), part of the US Department of Health and Human Services

• In Texas, the Health and Human Services

Commission (HHSC) is the “single state agency” for Medicaid.

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What Does Medicaid Provide?

• Health insurance coverage to low-income

– Children (all medically necessary services) – Pregnant Women – Very Low Income Parents – Persons with Disabilities

• Assistance to low-income Medicare beneficiaries
• Long-term care services for the elderly and

persons with disabilities

• Support for the health care safety net

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Income Caps for Texas Medicaid and CHIP, 2012

0% 50% 100% 150% 200% 250%

Pregnant Women Newborns Age 1-5 Age 6-18 TANF parent of 2, no income Working Parent of 2 SSI (aged

• r

disabled) Long Term Care CHIP

Mandatory Optional

$25,390 $35,317 $35,317

185% 185% 133%

$19,090

100%

$2,256 $3,696

12% 19% 75%

$8,376

225%

$25,128 $38,180

200%

indicates Texas choices to go ABOVE federal minimum Income Limit as Percentage of Federal Poverty Income Annual Income is for a family of 3, except individual incomes shown for SSI and Long Term Care

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2012 Federal Poverty Levels

Family Size 12% 75% 100% 133% 185% 200% 1 $1,340 $8,378 $11,170 $14,856 $20,665 $22,340 2 $1,816 $11,348 $15,130 $20,123 $27,991 $30,260 3 $2,291 $14,318 $19,090 $25,390 $35,317 $38,180 4 $2,766 $17,288 $23,050 $30,657 $42,643 $46,100 5 $3,241 $20,258 $27,010 $35,923 $49,969 $54,020 6 $3,716 $23,228 $30,970 $41,190 $57,295 $61,940 7 $4,192 $26,198 $34,930 $46,457 $64,621 $69,860 8 $4,667 $29,168 $38,890 $51,724 $71,947 $77,780

Citizenship Requirements

• Medicaid does not provide health

coverage to undocumented persons.

• Medicaid reimbursement for

undocumented persons is limited to emergency medical services.

• Legal immigrant adults are not covered by

Texas Medicaid.

• Legal immigrant children are covered by

Medicaid.

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Texas Medicaid/CHIP: Who is Helped Today

Medicaid Children, 2,540,312 Maternity 93,531 TANF Parent, 82,660 Poor Parents, 143,406 Elderly, 320,467 Disabled, 418,368 CHIP, 583,151

August 2012, HHSC data

Total enrolled 8/1/2012: 3.6 million Medicaid; 583,000 CHIP 1 in 7 Texans, but 42% of Texas kids

25.6 million Texans 7.4 million under 19

2,027,082 2,105,663 2,118,841 2,276,341 2,519,915 2,728,628 2,769,173 298,776 307,700 452,402 500,461 535,776 534,943 581,687 2,325,858 2,413,363 2,571,243 2,776,802 3,055,691 3,263,571 3,350,860 500,000 1,000,000 1,500,000 2,000,000 2,500,000 3,000,000 3,500,000 4,000,000

2006 2007 2008 2009 2010 2011 2012

Number Enrolled

Total Children Enrolled Children <19 Enrolled in Medicaid CHIP

Children Under 19 Enrolled in Medicaid & CHIP Texas, 2006-2012

Note: Counts are for May of each year. CHIP counts include the CHIP Perinatal Program. Source: Final Count – Medicaid Enrollment by Month at www.hhsc.state.tx.us/research.MedicaidEnrollment/ME-Monthly.asp. CHIP Enrollment, Renewal and Disenrollment by Month at www.hhsc.state.tx.us/research/CHIP/Disenrollment-Rate.asp. CHIP Perinatal Coverage Enrollment by Month at www.hhsc.state.tx.us/research/CHIP/perinatal.shtml.

Children's Hospital Association of Texas

Texas Medicaid & CHIP Eligibles by Age May 2012

Sources: Medicaid Eligibles: HHSC 8th Month Medicaid Eligibility File (final eligibility count); CHIP Eligibles: Maximus A010 CHIP Enrollment file. Prepared by Data Quality and Dissemination, SDS, HHSC.

Children's Hospital Association of Texas

Number and Percent* of Texas Children Enrolled in Public Insurance (Medicaid or CHIP) by Age Group May 2012

=100,000 Texas Children Enrolled in Public Insurance All Others Infants and Toddlers 0-1 Years – 800,000 Children Preschool 2-4 Years – 1,200,000 Children Elementary School 5-11 Years 2,800,000 Children

Public Insurance - 500,000 (63%) Public Insurance - 600,000 (50%) Public Insurance - 1,300,000 (46%)

Junior High School 12-14 Years – 1,200,000 Children High School 15-18 Years 1,500,000 Children

Public Insurance - 500,000 (42%)

*Numbers rounded to nearest 100,000; percentages based on rounded numbers. Sources: Medicaid 8th Month Eligibility File (final eligibility count) & Maximus A010 CHIP Enrollment File; Data Quality & Dissemination; Strategic Decision Support; HHSC. 2012 Population Projections by Age: 2010-2050, Texas State Data Center, Texas Population Estimates & Projections Program; University of Texas at San Antonio, November 2012.

Public Insurance - 500,000 (33%)

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Services and Providers

Medicaid Services: Mandatory and Optional

Federal Law Requires

• Inpatient/outpatient hospital
• Physician services
• Lab and x-ray
• EPSDT (Texas Health Steps)
• Ambulance
• Home health
• Rural Health Clinics/FQHCs
• Nursing facilities
• Immunizations/comprehensive

care for children

• Family planning
• Nurse Midwife, Nurse

Practitioner

• Medical and surgical services

provided by a dentist Federal Law Allows

• Prescription drugs
• Institutional care for

developmentally disabled

• Community care for elders or

people with disabilities

• Rehabilitation and other therapies
• Care by physician extenders and

mental health providers

• Dental care, Eyeglasses, Hearing

aids

• Private duty nursing
• Maternity service clinics
• Case management
• Podiatry
• Chiropractic
• Hospice services

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94.1 (2.3 Million Discharges) 303.5 (789,700 Discharges) 105.2 (634,800 Discharges) 78.7 (758,700 Discharges) 22.6 (146,400 Discharges)

50 100 150 200 250 300 350 Total** 65+ Years 45-64 Years 18-44 Years 1-17 Years 2010 Discharges Per 1,000 Population

*Discharges were reported by 375 acute care hospitals. Excludes state-owned and licensed psychiatric hospitals, rehab hospitals, acute long term care hospitals, approximately 65 additional rural hospitals and other hospitals specifically exempted from reporting discharge data in 2010. **Excludes discharges under 365 days of age. Source: Texas Hospital Inpatient Discharge Public Use Data File, 2010; State Center for Health Statistics, DSHS.

Children's Hospital Association of Texas

Teen Obstetrics = 0.4% (47,400 days) Normal Newborns = 4.4% (546,600 days) Neonatal = 7.1% (890,100 days) Pediatric 0-17 Yrs = 6.0% (749,700 days) Adults 18+ Yrs = 82.1% (10.3 million days)

Texas Hospital Industry Serves an Adult Population Predominantly

Total Inpatient Days in 375 Texas Acute Care Hospitals* = 12.5 Million

*Includes acute care hospitals only: CHAT - 7; Other Urban - 285; Rural - 83. Excludes state-owned and licensed psychiatric hospitals, rehab hospitals, acute long term care hospitals, approximately 65 additional rural hospitals and other hospitals specificially not required to report discharge data in 2010. Pediatric days include inpatient data for pediatric cases age 0 -17, excluding normal newborns and teen obstetrical care. Source: Texas Hospital Inpatient Discharge Public Use Data File, 2010; State Center for Health Statistics; DSHS.

Children's Hospital Association of Texas

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Payment Models

• As of July 2012, 82% of Medicaid clients were

provided care through contracts with Managed Care Organizations that receive monthly premiums for each enrolled client.

• Dental services for children on Medicaid are

provided through contracts with Dental Maintenance Organizations.

• Payment for Medicaid clients who are newly

enrolled and most children receiving SSI (who are now voluntary for managed care) is made through fee-for-service claims. Proposed legislation mandating that children on SSI move into managed care is likely to pass.

Medicaid Managed Care Programs

• The STAR program serves low-income

families, non-disabled children and pregnant women.

• The STAR+PLUS program integrates

acute and long-term care services for clients who are disabled or elderly.

• The STAR Health program provides care

to children in foster care.

• NorthSTAR is a behavioral health

delivery system in the Dallas area.

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Provider Payment Rates

• HHSC develops rates for fee-for-service claims.
• Medicaid provider rates are generally below

rates for comparable services in Medicare and the commercial insurance marketplace.

• Managed care payments must be actuarially

sound; plans negotiate rates with providers to build an adequate network.

• Increases occur for certain Medicaid services

by primary care providers to Medicare rates (calendar years 2013 and 2014), per ACA.

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A Look at Medicaid Spending

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FMAP: Federal Medical Assistance Percentage

• FMAP is an annual calculation based on a

state’s per capita income, relative to the nation.

• As Texas’ per capita income has improved, the

FMAP has declined about 5 points the past 20 years, contributing to the cost of Medicaid.

• Although differences seem small, given the

volume of spending the fiscal impact is significant.

• The FMAP in 2013 is 59.3%.

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Outpatient and Professional Services are Important for Children

T exas Medicaid Expenditures, SFY 2009

* Aged, Blind & Disabled, and Non-Disabled Children

Aged, Blind & Disabled

$11.5 billion

Non-Disabled Children

‡ $5.0 billion Inpatient 8% Outpatient 9% Physician and Professional Services 18% Other 11% Vendor Drugs 8% Long T erm Care 45% Inpatient 29% Outpatient 14% Physician and Professional Services 40% Vendor Drugs 17% Long T erm Care 0.2%

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Source: Medicaid Management Information System (MMIS), Office of Strategic Decision Support, Financial Services, Texas Health and Human Services Commission, June 2010. Note: Costs for non-disabled children do not include TANF level children.

Children are Relatively Inexpensive

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Source: HHS Financial Services, HHS System Forecasting. 2011 Medicaid Expenditures, including Acute Care, Vendor Drug, and Long- term Services and Supports. Costs and caseload for all Medicaid payments for all beneficiaries (Emergency Services for Non-citizens, Medicare payments) are included. Children include all Poverty-level Children, including TANF. Disability-related Children are not in the Children group.

Texas Medicaid Beneficiaries and Expenditures, FY 2011

Legislature’s Perspective

• n Medicaid
• The prevailing sentiment of the Legislature is

that Medicaid “is broken” (e.g., runaway costs, fraudulent activity, complex administration, etc.)

• Resentment exists over the growing portion of

the state budget that must be devoted to Medicaid expenses.

• Of the total request for additional funding for

health and human services, Medicaid accounted for almost 80%.

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Medicaid Shortfall for 2014-15

• Neither the House or Senate appropriations bill

restores rate reductions made last session, provides cost growth in 2014-15, and addresses caseload growth related to the Affordable Care Act (ACA).

• HHSC projects Medicaid needs $1.6 billion GR

for cost growth in 2014.

• Both bills also assume further cost

containment initiatives will be implemented, totaling $840 million in the House bill and $963 million in the Senate bill (GR + Federal).

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Medicaid Shortfall (continued)

• HHSC requests $760 million additional

GR for Medicaid services related to the ACA.

• About half of the $760 million is for

children who are currently eligible but not enrolled in Medicaid (the “welcome mat” effect).

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Big Budget Picture: Available Revenue

• The Comptroller estimates $101.4 billion

in state GR is available for 2013 and the 2014-15 biennium.

• This represents a 12.4% increase from

the amount available for 2012-13.

• Absent any appropriation, the Rainy Day

Fund is projected to reach $11.8 billion by the end of August 2015.

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Supplemental Appropriations: 2013

• HB 10, signed by the Governor March

13th, provides $6.6 billion GR to close out 2013 funding obligations.

• $4.4 billion GR funds 2013 Medicaid

expenditures.

• $2 billion GR reverses a deferral made

last session to push August 2013 payments to schools into fiscal year 2014.

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Spending Limit

• The Texas Constitution limits growth in the

appropriation of non-dedicated state revenue to the estimated growth in personal income.

• The LBB adopted the Comptroller’s estimate
• f 10.7%.
• Funding requests for Medicaid compete with
• ther funding needs and are unlikely to be

accommodated within the Spending Limit.

• A majority vote can lift the cap, but members

appear firm on abiding by the limit.

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GRADUATE MEDICAL EDUCATION

Children's Hospital Association of Texas

Year Ratio** No. 2000 39.2 2,435 2001 39.2 2,461 2002 41.1 2,605 2003 42.7 2,735 2004 43.0 2,788 2005 43.9 2,884 2006 44.3 2,943 2007 44.0 2,959 2008 43.8 2,982 2009 44.0 3,028 2010 46.4 3,226 2011 47.7 3,321 **Ratio per 100,000 Children 0-18

Sources: Texas Medical Board & HPRC-DSHS (physicians) Texas State Data Center (population) * Diplomates Ever Certified. Sources: American Board of Pediatric (physicians) Texas State Data Center and Census Bureau (population)

Texas Trends

General Pediatricians in Texas

Children's Hospital Association of Texas

Texas Ratio as a Percent of the Subspecialty Texas U.S. U.S. Ratio* Rheumatology 12 264 49.0% Adolescent Medicine 26 496 56.5% Developmental-Behavioral Pediatrics 31 551 60.6% Endocrinology 66 1,054 67.4% Child Abuse 16 237 72.7% Emergency Medicine 114 1,648 74.5% Nephrology 32 451 76.4% Gastroenterology 78 1,089 77.1% Pulmonology 60 825 78.3% Cardiology 122 1,677 78.4% Infectious Disease 79 1,067 79.7% Critical Care 133 1,687 84.9% Hematology-Oncology 149 1,750 91.7% Neonatal-Perinatal Medicine 329 3,852 92.0%

*(No. of ABP Diplomates per 100,000 Children <18 in Texas) divided by (No. of ABP Diplomates per 100,000 Children <18 in the U.S.) Source: American Board of Pediatrics (ABP) 2011-2012 Workforce Data https://www.abp.org/abpwebsite/stats/wrkfrc/workforce10.pdf

• No. of Physicians

2011

Limited Availability of Pediatric Subspecialists in Texas

Children's Hospital Association of Texas

7,442,755 7,779,305 8,345,673 8,958,154

Projected increase between 2012 and 2015: 336,550 Projected increase between 2015 and 2020: 566,368 Projected increase between 2020 and 2025: 612,511 5,000,000 6,000,000 7,000,000 8,000,000 9,000,000 10,000,000 2012 2015 2020 2025 Number of Children

Projected Growth in the Number of Children Under 19 Years of Age Texas 2015, 2020 and 2025

Source: Projections of the Population of Texas and Counties in Texas by Age, Sex and Race/Ethnicity for 2010-2050 (based on 2000-2010 Migration (1.0) Scenario); Population Estimates and Projections Program, Texas State Data Center, Office of the State Demographer, Institute for Demographic and Socioeconomic Research, The University of Texas at San Antonio, November 2012.

Children's Hospital Association of Texas

More Students than Residency Slots

• Texas increased its medical school enrollments 31% from fall 2002

to fall 2011, from 1,342 to 1,762.

• Texas currently provides instruction and operation formula funding

to support its medical students at $42,000 annually, or a total of $168,000 per student.

• Without increases in the number of first-year residency positions,

beginning in 2014, at least 63 graduates of Texas medical schools will not have an opportunity to enter a Texas residency program.

• By 2016, at least 180 medical school graduates will have to leave

the state for their first year of residency training due to a lack of residency positions. The state’s investment in their education of $168,000 per graduate, or $30.2 million annually will not benefit the state.

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Appropriated Appropriated 2012-13 Appropriated 2014-15 2010-11 2012-13

• 2010-11

2014-15

• 2012-13

GRADUATE MEDICAL EDUCATION (GME) UT Southwestern Center at Dallas $17.0 $12.9

• $4.1

$14.6 $1.7 UT Medical Branch at Galveston $9.0 $4.3

• $4.7

$4.9 $0.6 UT Health Science Center at Houston $10.5 $7.5

• $3.0

$8.1 $0.6 UT Health Science Center at San Antonio $9.3 $6.3

• $3.0

$6.7 $0.4 UT MD Anderson Cancer Center $1.7 $1.1

• $0.6

$1.2 $0.1 UT Health Science Center at Tyler $0.3 $0.2

• $0.1

$0.4 $0.2 Texas A&M Univ System Health Science Center $6.7 $4.8

• $1.9

$5.4 $0.6 North Texas Health Science Center at Fort Worth $2.1 $1.6

• $0.5

$2.1 $0.5 Texas Tech University Health Sciences Center $7.1 $4.9

• $2.2

$5.6 $0.7 Total Graduate Medical Education $63.7 $43.6

• $20.1

$49.0 $5.4 HIGHER EDUCATION COORDINATING BOARD (SELECTED PROGRAMS) Family Practice Residency Program $21.2 $5.6

• $15.6

$5.6 $0.0 Primary Care Residency Program $5.0 $0.0

• $5.0

$0.0 $0.0 Joint Admission Medical Program $10.6 $7.0

• $3.6

$7.0 $0.0 Physician Education Loan Repayment Program $25.4 $5.6

• $19.8

$33.8 $28.2 Professional Nursing Shortage Reduction Program $49.7 $30.0

• $19.7

$30.0 $0.0 Baylor College of Medicine - Undergraduate GME $83.3 $75.9

• $7.4

$77.3 $1.4 Baylor College of Medicine - GME $15.3 $10.4

• $4.9

$10.4 $0.0 Total Selected HECB Programs $210.5 $139.0

• $71.5

$164.1 $25.1 Prepared by Children's Hospital Association of Texas, February 26, 2013 FUNDING FOR HEALTH-RELATED INSTITUTIONS OF HIGHER EDUCATION Introduced Bills 2014-15 (in millions)

Increasing GME Slots

• The Chairmen of House Appropriations

(Pitts) and Senate Finance (Williams), as well as key members (e.g., Rep. Zerwas,

• Rep. Otto, Sen. Duncan and Sen. Nelson)

support this as a priority.

• Increased funding is expected to expand

positions in existing residency programs, provide planning grants for hospitals without residency programs, and maximize funding through Medicaid.

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