N ATIONAL H EALTH C ARE R EFORM : I MPACT I N T HE D ISTRICT OF C - - PowerPoint PPT Presentation

NATIONAL HEALTH CARE REFORM: IMPACT IN THE DISTRICT OF COLUMBIA

Wayne Turnage Department of Health Care Finance Washington DC August 2018 Presentation to Eastern Medical Pharmacy Administrators Association

(I have no actual or potential conflict of interest related to this presentation)

PRESENTATION OUTLINE



Broad Goals Of The Affordable Care Act (ACA)  ACA Impact In The District of Columbia (DC)

Performance of DC Health Exchange – DC Health Link Trends In Coverage Rates Across Income And Poverty Levels

 Medicaid-Specific Impact of ACA In The District of Columbia

Coverage Changes To DC Medicaid Eligibility Levels Post ACA Medicaid Enrollment and Cost Trends In DC

 The District’s Approach To Innovation

Payment Reform Establishing Health Homes

 Monitoring Efforts To Repeal Or Destabilize The ACA

2

THE AFFORDABLE CARE ACT (ACA) HAS THREE PRIMARY GOALS

1.Increase private coverage rates for persons who live above the poverty level by using an individual mandate, health insurance exchanges, and subsidies or premium tax credits to make health care more accessible and affordable 2.Expand the Medicaid program to cover all adults with incomes below a certain level of federal poverty 3.Support innovative medical delivery methods and payment reform policies that offer the promise of increased health care access at lower cost

3

THE DISTRICT OF COLUMBIA HAS FULLY EMBRACED THE GOALS OF ACA

Provision In ACA Law Purpose Did DC Implement

Individual mandate Requires most Americans to have a basic level

• f health insurance coverage or be subject to a
• penalty. Goal is to create healthy risk pools

that are large enough to cover the cost of the sick members in the pool

Yes

Health Insurance Exchange Health insurance marketplaces established by quasi-government organizations to facilitate the purchase of private or commercial health insurance

Yes

Medicaid Expansion Provide Medicaid eligibility for childless adults with incomes up to 138% of the federal poverty level to increase coverage of persons with low-income

Yes

Basic Health Plan (Early Medicaid Expansion in DC) Provide Medicaid eligibility for childless adults with incomes from 139% to 206% of federal poverty levels to increase coverage for persons with low income

Yes

Innovative programming Promote the use of a variety of health care service delivery models, strategies, and payment structures to improve health care access, quality, and outcomes

Yes

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PRESENTATION OUTLINE



Broad Goals Of The Affordable Care Act (ACA)  ACA Impact In The District of Columbia (DC)

Performance of DC Health Exchange – DC Health Link Trends In Coverage Rates Across Income And Poverty Levels

 Medicaid-Specific Impact of ACA In The District of Columbia

Coverage Changes To DC Medicaid Eligibility Levels Post ACA Medicaid Enrollment and Cost Trends In DC

 The District’s Approach To Innovation

Payment Reform Establishing Health Homes

 Monitoring Efforts To Repeal Or Destabilize The ACA

5

THE IMPACT OF THE DC HEALTH EXCHANGE ( DC HEALTH LINK) HAS BEEN SUBSTANTIAL

6

Key Performance Metrics

• More than 96% of DC

residents covered

• Uninsured rate cut in half
• DC in the top 3 states with

lowest uninsured rates

• DC has 2nd lowest individual

health insurance rates in the U.S. (CMS May 2018) DC Health Link enrollment:

• 17,000+ individual marketplace
• 77,000+ small business

marketplace (includes 11,000 Congressional staff & Members)

• ~5,000 small businesses

covered through SHOP

 800 brokers participate in DC Health Link 6

2018 HEALTH INSURANCE OPTIONS THROUGH DC HEALTH LINK

Plans:

• 151 Small Group Plans
• 26 Individual Plans (includes 2

catastrophic) Insurers:

• 3 United HealthCare Companies (group
• nly)
• 2 Aetna Companies (group only)
• CareFirst BlueCross BlueShield
• Kaiser Permanente

Also offer Dental (SHOP and Individual) and Vision (Individual) 7

ACA POLICY HAS HELPED THE DISTRICT CUT THE UNINSURED RATE ALMOST IN HALF

7.8% 7.1% 6.1% 6.7% 5.2% 3.9% 4.0% 2010 2011 2012 2013 2014 2015 2016 District of Columbia Unisured Rate

Source: “Selected Characteristics of Health Insurance Coverage in the United States” and “Health Insurance Coverage Status”, American Community Survey. United States Census Bureau, 2009-2016

8 DC Uninsured Rate

ACA POLICY HAS HELPED THE DISTRICT CUT THE RATE OF UNINSURED SIGNIFICANTLY FOR ALL INCOME GROUPS

7.8% 4.0% 11.8% 5.9% 12.0% 10.6% 9.1% 9.3% 6.8% 6.5% 4.9% 3.1% 2010 2011 2012 2013 2014 2015 2016

Note: Data on sub-group health coverage rates are not available for 2010. Source: “Selected Characteristics of Health Insurance Coverage in the United States” and “Health Insurance Coverage Status”, American Community Survey. United States Census Bureau, 2009-2016

9 DC Uninsured Rate

PRESENTATION OUTLINE



Broad Goals Of The Affordable Care Act (ACA)  ACA Impact In The District of Columbia

Performance of DC Health Exchange – DC Health Link Trends In Coverage Rates Across Income And Poverty Levels

 Medicaid-Specific Impact of ACA In The District of Columbia

Coverage Changes To DC Medicaid Eligibility Levels Post ACA Medicaid Enrollment and Cost Trends In DC

 The District’s Approach To Innovation

Payment Reform Establishing Health Homes

 Monitoring Efforts To Repeal Or Destabilize The ACA

10

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319% 319% 319% 319% 216% 74% 210% 133% 133% 133% 133% 74% 228% 205% 199% 213% 133% 129% 211% 187% 180% 198% 95% 86%

Children Ages 0-1 Children Ages 1-5 Children Ages 6-18 Pregnant Women Parents/ Caretaker Relatives* SSI Childless Adults*

DC Eligibility Level Federal Minimum* Avg Level for Expansion States National Average

In Combination With It’s Legacy Coverage Levels, The District’s Eligibility Thresholds Under ACA Significantly Exceed Federal Requirements And Statewide Averages

Source: Centers for Medicare and Medicaid Services State Medicaid and CHIP Income Eligibility Standards, updated June 2016.

11

Since ACA Implementation, Medicaid Enrollment Growth Is Now More Than Double Pre-ACA Levels

Medicaid Expansion

Notes: Excludes ineligible individuals (individuals who failed to recertify due to lack of follow-up, moving out of the District, excess income, or passed away), and those in the Alliance and Immigrant Children programs. Source: Data for 2000-2009 data was extracted by Xerox from tape back-ups in January, 2010. Data from 2010-present are from enrollment reports.

Medicaid Enrollment Trends, FY2003-2017 Medicaid Enrollment Trends, FY2003-2017

Post- Expansion

12

Other DC Residents

60%

Other DC Residents

60%

DC Residents

• n Medicaid or

Alliance

40%

DC Residents

• n Medicaid or

Alliance

40%

Source: District population estimate from 2017 United States Census Bureau. Medicaid and Alliance data reported from DHCF’s Medicaid Management Information System (MMIS). Note: These data excludes some District residents who are not United States Citizens and thus the percent of residents on publicly funded health care may be slightly overstated.. Source: District population estimate from 2017 United States Census Bureau. Medicaid and Alliance data reported from DHCF’s Medicaid Management Information System (MMIS). Note: These data excludes some District residents who are not United States Citizens and thus the percent of residents on publicly funded health care may be slightly overstated..

Now, Four In 10 District Residents Rely On Publicly- Funded Heath Care Services Now, Four In 10 District Residents Rely On Publicly- Funded Heath Care Services

*Total Residents 693,972

13

34% 40%

59% 57%

7% 3% 2009 2017

*693,972

*599,657

This Represents A 33 Percent Increase Since 2009 – The Year Before The District Pursued Medicaid Expansion Policies

14

*Total Residents

Source: District population estimate from 2009 and 2017 United States Census Bureau. Medicaid and Alliance data reported from DHCF’s Medicaid Management Information System (MMIS). Note: These data excludes some District residents who are not United States Citizens and thus the percent of residents on publicly funded health care may be slightly overstated. Source: District population estimate from 2009 and 2017 United States Census Bureau. Medicaid and Alliance data reported from DHCF’s Medicaid Management Information System (MMIS). Note: These data excludes some District residents who are not United States Citizens and thus the percent of residents on publicly funded health care may be slightly overstated.

Percent of DC Residents with Medicaid or Alliance Insurance Percent of DC Residents with Medicare, Individual or Group Commercial Insurance Percent of Uninsured DC Residents

Source: Spending totals extracted from Cognos by fiscal year (October, 1 through September, 30). Includes fee-for-service paid claims only, including adjustments to claims, and excludes claims with Alliance or Immigrant Children's group program code. Only includes claims adjudicated through MMIS; excludes expenditures paid

• utside
• f MMIS (e.g. pharmacy rebates, Medicare Premiums).

Medicaid Cost Trends Track ACA-Driven Enrollment Growth Trends

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PRESENTATION OUTLINE



Broad Goals Of The Affordable Care Act (ACA)  ACA Impact In The District of Columbia

Performance of DC Health Exchange – DC Health Link Trends In Coverage Rates Across Income And Poverty Levels

 Medicaid-Specific Impact of ACA In The District of Columbia

Coverage Changes To DC Medicaid Eligibility Levels Post ACA Medicaid Enrollment and Cost Trends In DC

 The District’s Approach To Innovation

Payment Reform Establishing Health Homes

 Monitoring Efforts To Repeal Or Destabilize The ACA

16

50,000 100,000 150,000 200,000 250,000 300,000 FY2009 FY2010 FY2011 FY2012 FY2013 FY2014 FY2015 FY2016 FY2017

Average Monthly Enrollment

Fee-For- Service Managed Care (Medicaid) Total Enrollment

63% 69% 67% 73% 73%

More Than Three-Fourths of DC Medicaid Enrollees Are In Full-Risk Managed Care Programs

70%

Source: DHCF staff analysis of data extracted from the agency’s Medicaid Management Information System

75% 76% 68%

DC Medicaid Enrollment by Coverage Type, FY2009-2017

17

 Given the thrust of the ACA, achieving high value in health care for Medicaid and Alliance beneficiaries is a preeminent goal of DHCF’s managed care program.  The District’s three managed care plans are expected to increase their members’ health care and improve outcomes per dollar spent through aggressive care coordination and health care management.  Following the passage of the ACA and after reviewing several years worth of data, DHCF decided to closely examine the following performance indicators for each of the District’s three health plans:

• Emergency room utilization for non-emergency conditions.
• Potentially preventable hospitalizations – admissions which could have been avoided

with access to quality primary and preventative care.

• Hospital readmissions for problems related to the diagnosis which prompted

a previous and recent – within 30 days – hospitalization.

18

The District Has Established Payment Incentives For Its $1 Billion Managed Care Program

19

AmeriHealth MedStar Trusted Total Low Acuity ER Avoidable Admissions Hospital Readmissions

$5.4M

Notes: Low acuity non-emergent visits are emergency room visits that could have been potentially avoided, identified using a list of diagnosis applied to outpatient data. Avoidable admissions are identified using a set of prevention quality measures that are applied to discharge data. Readmissions represent inpatient visits within 30 days of a qualifying initial inpatient admissions. Measurement of performance relies upon FY17 (October 2016 – September 2017) with payment runout through December 2017. The amounts listed as potentially avoidable would likely be offset by other costs if the MCOs improved their care management, such as increased outpatient costs due to increased use of outpatient facilities. Source: Enrollment and expense data are based on self-reported MCO Quarterly Financial Data for DCHFP submitted directly to DHCF.

$6.6M $12.9M $1.5M $4.7M $8.9M $1.2M $1.9M $3.1M $8.1M $13.2M $25.0M Managed Care Spending Attributed To Beneficiary Outcomes That Are Potentially Avoidable Through The Use Of Robust Care Coordination Programs

Data Analysis Revealed That The District’s Managed Care Plans Have Opportunities To Improve Beneficiary Outcomes Through Stronger Care Coordination Efforts

20

Notes: Low acuity non-emergent visits are emergency room visits that could have been potentially avoided, identified using a list of diagnosis applied to outpatient data. Avoidable admissions are identified using a set of prevention quality measures that are applied to discharge data. Readmissions represent inpatient visits within 30 days of a qualifying initial inpatient admissions. The amounts listed as potentially avoidable would likely be offset by other costs if the MCOs improved their care management, such as increased

• utpatient costs due to increased use of outpatient facilities.

Source: Mercer analysis of MCO Encounter data for DCHFP reported by the MCOs to DHCF for FY2017, with a December 2017 run out period.

Patient Metrics

2016 2017

$46M 16% 17% $53M Low-Acuity ER Use Avoidable Admissions Hospital Readmissions 54% 29% 57% 27%

Comparison Of MCO Potentially Avoidable Spending 2016 To 2017

Driven By Payment Incentives, The Health Plans Improved Performance On Two Of Three Patient Metrics, Avoiding $23 Million In Unnecessary Spending

22% 53% 78% 47%

$2,541,148,023

Fee-For-Service Beneficiaries Make Up Disproportionate Share of Medicaid Expenditures

Source: Data were extracted from DHCF MMIS system. *Only persons with 12 months of continuous eligibility in 2017 are included in this analysis.

21

Fee-For-Service Beneficiaries

Managed Care Beneficiaries

N = 246,374

*Medicaid Beneficiaries

Total

Total Medicaid Expenditures

Annual Per-Person Cost $24,838 $6,224

53% 22% 78% 47%

• Goals of Program -

 Increase health quality and outcomes  Reduce preventable utilization of 911 ambulance service,

avoidable hospital admissions and ER

• Key Design Elements -

 Robust care coordination for beneficiaries with 3+ chronic

conditions

 Monthly primary care provider payment to integrate and

coordinate all health-related services

 Includes pay-for-performance component to hold providers

accountable

 12 providers with interdisciplinary teams in 33 primary care settings 22

The District Has Also Launched A Health Homes Project -- My Health GPS -- Based On The Innovation Features Of ACA

1. Patient Care Snapshot 2. Population Health Analytics 3. Clinical Quality Measures Dashboard 4. Obstetrics/Prenatal Specialized Registry 5. Supporting Connectivity to HIE Tools and Technical Assistance

23

Health IT Tools Are Provided To Support Program Care Coordination Efforts

Characteristic (Based on Claims in FY2016) All Other Non-Waiver And Non-Institutional Medicaid Adults (n=83,377) My Health GPS Enrolled Population (n=3,500) Average Age 39 53 Per-Member Cost $7,090 $17,622 Average Hospital Admissions (at least one admission) 1.4 2.4 Average Emergency Room Visits 1.2 3.0 Mean Medications Per Person 3.2 14.9 Percent with substance use disorder (SUD) 1.7% 16.1% Percent living in Wards 7 or 8 38.4% 36.7%

Source: DHCF staff analysis of data extracted from the agency’s Medicaid Management Information System (MMIS). Utilization measure are based on claims with dates of service in FY2016. Other Medicaid Adults were defined as beneficiaries age 21 and over with 12 months of continuous eligibility in

• FY2016. Figures exclude data on persons in nursing homes, intermediate care facilities, and the community-based waiver programs, as well as those

determined eligible for My Health GPS.

Average Beneficiaries Enrolled in My Health GPS Are Older and Account for Higher Spending and Utilization

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PRESENTATION OUTLINE



Broad Goals Of The Affordable Care Act (ACA)  ACA Impact In The District of Columbia

Performance of DC Health Exchange – DC Health Link Trends In Coverage Rates Across Income And Poverty Levels

 Medicaid-Specific Impact of ACA In The District of Columbia

Coverage Changes To DC Medicaid Eligibility Levels Post ACA Medicaid Enrollment and Cost Trends In DC

 The District’s Approach To Innovation

Payment Reform Establishing Health Homes

 Monitoring Efforts To Repeal Or Destabilize The ACA

25

ACA risk pool stability depends on:

• Protecting entitlement feature of

Medicaid and coverage expansion

• New (and young/healthy) covered lives
• Avoiding market/risk pool

segmentation

• Stable regulatory and legislative

environments for carriers

The Key To The Long-Term Sustainability Of The ACA Sustaining Medicaid Expansion And Ensuring The Stability Of The Risk Pools 26 26

• Cut open enrollment period in half
• Cut navigator funding
• Allowing direct enrollment via web-based

enrollers

• Restricted Special Enrollment Periods
• $0 federal individual responsibility

requirement

• Pushed to attempt to repeal ACA and block

grant the Medicaid program

• Ended cost sharing reduction reimbursement

(CSR)

• Threatened to prohibit silver-loading
• Temporarily stopped risk adjustment payments
• Expanded association health plans (AHPs)

 DC estimate: increase premiums in individual market by $1,307/year $1,486/year per person small group

• Expanded short-term limited duration plans

 DC estimate: increased claims cost 21.4%; 6,100 people become uninsured (~35% of DC’s individual market

Federal Actions Have Destabilized The ACA By Segmenting Risk Pools And Creating Uncertainty In The Insurance Market

27

THE CONCEPT OF THE PER CAPITA CAP IS DESIGNED TO SHIFT SPENDING ABOVE THE ESTABLISHED THRESHOLD TO THE STATES OR FORCE PROGRAM CUTS AT THE STATE-LEVEL

2 4 6 8 10 12 14 12 13 14 15 16 17 18 Federal Medicaid Funding (in (billions) Total Medicaid Spending (billions)

28

Additional State Cost

Shared Federal-State Responsibility State-Only Responsibility

Under Existing Medicaid Law Under Senate And House Proposed Per-Capita Caps $

Simulated Cap = $14.4 Billion

Note: Scenario assumes a 60 percent federal share and constant enrollment as spending varies. Source: Recreated from Leonard D. Shaffer, Center for Policy and Health Economics, USC.

MEDICAID SPENDING GROWTH IN THE DISTRICT OUTPACES THE INFLATION FACTORS PROPOSED IN THE SENATE BILL

0% 2% 4% 6% 8% 10% 12% 14% 2012 2013 2014 2015 2016 Average Annual Growth Rate Medicaid Provider Payments CPI U- Medical Care +1% CPI U- Medical Care CPI U- All Items

Average: 3.0% Average: 4.0% Average: 1.3% Average: 5.8%

Sources: Federal Reserve Economic Data (https://fred.stlouisfed.org):

• CPI U- Medical Care: Consumer Price Index for All Urban Consumers: Medical Care, Percent Change from Year Ago, Annual, Not Seasonally

Adjusted

• CPI U- All Urban: Consumer Price Index for All Urban Consumers: All Items, Percent Change from Year Ago, Annual, Not Seasonally Adjusted
• Medicaid Provider Payments: CMS-64 reporting excluding prior period adjustments. Average growth for each inflation factor is calculated using CY2012-16 data.

Inflation factors in OCFO analysis differ primarily because the used data from CY2007-2016 to calculate average growth. Note: CPI U data represent average annual calendar year spending growth, while Medicaid Provider Payments represent average annual fiscal year spending.

Average Annual Spending Growth Rate Comparison, 2012-2016

District of Columbia Medicaid Provider Payment Growth Rate 29

Efforts to reverse adverse federal policies have included -

• Lobby: vigorously oppose federal efforts to block grant the Medicaid program
• Extended Open Enrollment Period: Nov 1 to Jan 31 for 2018 and 2019 plan

years

• Invested in outreach, marketing, and enrollment: navigators funding;

additional paid media

• Provided relief from burdensome federal requirements: SEPs
• Created more robust plan design: standard plans to ensure access to care pre-

deductible

• ACA working group: ~20 meetings; diverse members (DC Chamber,

advocates, health plans, a broker, hospitals, community health centers, individual & business enrollees); unanimous local policy recommendations

The District Has Countered Pernicious Federal Actions With Stabilizing Strategies

30 30

• Bill introduced by Mayor Bowser and unanimously passed by DC Council;

currently under Congressional review

• Applies to 2019 (when federal fine decreases to $0)
• Applies to any “applicable individual” (Similar to federal standards as of

12/15/2017--Person covered by DC HealthCare Alliance or Medicaid is not considered an “applicable individual”)

• Applies if go without coverage for ≥3 months (per federal standards

12/15/2017)

• Fine similar to federal (offset if federal is reinstated)

Responsibility fine: Whichever is greater: $695 per adult/$347.50 per child -- up to a cap of $2085 per family OR 2.5% of family income that is

• ver the filing threshold

Fine is capped at the average DC bronze level health plan

Most Significant Policy Was DC’s Passage Of Local Individual Responsibility Requirement

31 31

Questions Or Comments

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