briefing on medicaid managed care alliance for health reform october 28, 2011 missouri medicaid and...

Briefing on Medicaid Managed Care Alliance for Health Reform

October 28, 2011

Missouri Medicaid and Managed Care:What Are We Buying?

Ian McCaslin, M.D., M.P.H.Director, MO HealthNet

Missouri Dept. of Social Services

• OUR EMPHASIS is to increase the health status of Missourians through better:–Coverage for health care services–Access to those services–Quality of those services–Accountability to taxpayers

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Items Funded with General Revenue:

– MO HealthNet ($1.2 billion)– Elementary and Second. Education ($2.75 billion)

– Higher Education ($834.1 million)– Non-Medicaid Social Services ($350.3 million)

– Corrections ($595.3 million)– Mental Health ($563.5 million)– Judiciary ($170.1 million)

TAFP After Veto FY 2012 3

Source: DSS Annual Table 23

Managed Care Eligibility

Not Allowed by Statute Statewide:- Permanently and Totally Disabled- The Elderly

Mandated in 54 Counties: - Children- Pregnant Women- Very Low Income Parents and Caretakers- Certain Exceptions 5

Number of Counties

Central Region (28 )

Eastern Region (13 )

Western Region (13 )

CEDAR

MADISON

PERRY

PIKE

MARIES

HOWARD

PETTIS

MORGAN

COLE

MONITEAU

MILLER

CAMDEN

MO

NTG

OM

ERY

LINN

BOLL

ING

ER

PHELPS

STODDARD

DEKALB

LAFAYETTE

ST CLAIR

STFRANCOIS

ST CHARLES4

LINCOLN

CARROLL

CAPEGIRARDEAU

CRAWFORD

DENT

CARTER

GREENE

CHRISTIAN DOUGLAS

OREGON

NEWTON

JASPER

BARTON

BENTON

HICKORY

POLK

DALLAS

LACLEDE

CALLAWAY

BOONE

CHARITON

MARION

SHELBY

SCOTLAND

SULLIVAN

PUTNAM MERCER

GRUNDY

LIVINGSTON

CALDWELL

RAYCLAY

CLINTON

HOLT ANDRE

W

GENTRY

WORTH

HARRISON

ADAIR LEWIS

CLARK

SCHUYLER

KNOX

MACON

HOWELL

TEXAS

PULASKI

RANDOLPH

MONROE

RALLS

AUDRAIN

OSAGE

WASHINGTON

STEGENEVIEVE

IRON

REYNOLDS

SHANNON

WAYNE

RIPLEY

BUTLER

SCOTT

MISSISSIPPI

NEW MADRID

DUNKLIN

PEMISCOT

OZARK

WRIGHT

ATCHISON

NODAWAY

DAVIESS

SALINE

COOPER

BATES

HENRY

VERNON

DADE

LAWRENCE

MCDONALD

BARRY

STONE

TANEY

WEBSTER

WARREN

FRANKLIN

ST LOUIS

COUNTY

JEFFERSON

<<< ST LOUIS

CITY

CASS

JACKSON

JOHNSON

PLATTE

BUCHANAN

GAS

CON

ADE

MissouriManaged Care

Regions

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Medicaid Managed Care Trends

Source: CMS as of 06/09;DSS Monthly Management Reports, Table 23

% Total Eligibles

Enrolled in Managed

Care

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Is Managed Care Good for Patients? Defined Access Standards

Required Adequate Provider Network

Defined Appointment Standards

Yearly Member Satisfaction Surveys

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Quality Provisions

Performance Standards - Well-child visits, including Adolescent Access

- Case Management of High Needs IndividualsBehavioral HealthHigh Risk PregnancySpecial Needs Children

- Healthcare Effectiveness Measures (HEDIS) 9

Costs Monthly Capitation Payments based on Certified

Actuarially Sound Rates

Overall Managed care cost FY-2011 $1.04b

CMS Requires Cost Effectiveness over Two Year Period

External Evaluation of FY-2009 Managed Care vs FFS Demonstrated Savings of 2.7%, or $38 million, compared with a FFS Structure

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Concerns with Managed Care Health Plans Vary in their Performance

Doctors, Clinics, Hospitals Dislike the Administrative and Contracting Burden

Evidence Exists that the “Value-added” Services of Managed Care are not Always Delivered Adequately

State Staff Contract Compliance of Health Plan Performance Requires a Lot of Resources to Do Well

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Missouri Medicaid and Managed Care:What Are We Buying?

Accountability for Access to Care and Quality of Care

Predictability of Budgeting

A Cost-effective Delivery System

State Enhanced Focus on Value is Paying Off

Effective Compliance Monitoring is Critical12

Missouri’s Medicaid Program

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