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Medicaid Redesign

Mike Scribner / Beth Spoto

National Medicaid FindingsAs states search for delivery models which decrease cost and provide more benefit, they are focused on efforts to

control Medicaid spending for the highest-cost populations. In 2011:

Elderly: 8% of the enrollees20% of the cost

Disabled: 15% of the enrollees44% of the cost

Adults: 27% of the enrollees14% of the cost

Children: 50% of the enrollees22% of the cost

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Georgia is one of the lowest in per capita spending

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States Aged Disabled Adults Children Unknown Total

US Average

$12,938 $14,840 $2,668 $2,164 $975 $5,337

Georgia $8,919 $9,573 $4,046 $1,809 $0 $4,074

Florida $8,456 $11,628 $2,841 $1,785 $0 $4,573

Alabama $8,110 $6,702 $1,845 $2,169 $0 $3,928

SC $10,706 $11,277 $2,847 $2,086 $0 $4,652

NC $10,046 $15,004 $3,599 $2,531 $0 $5,706

Navigant Options

Analyzed nine (9) delivery models; Recommend 3:

•Option 1: Georgia Families Plus•Option 2: Georgia Families Plus – Transitioning to “Commercial Style” Managed Care •Option 3: Georgia Families Plus – Transitioning to “Commercial Style” Managed Care Program that requires use of PCMHs and ACOs

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Georgia Families Plus (expansion of current CMO Program)

• Includes all Medicaid populations• Enrollment of Low-Income Medically Needy Adults & potential

Medicaid expansion population.• Includes all State Plan Service, including behavioral health• Value Based Purchasing• Medical Home Use – Encourage use of patient centered medical

home (PCMH) model• Reduced administrative complexities• Wellness Programs

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Recommended Services to Carve In

•Behavioral health•LTC Services•Home and community based waiver services•Dental services•Transportation services•Pharmacy services

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Option # 2 Commercial Style Managed Care

• Expands Option #1 by potentially adding the following:• Use phased approach to enroll patients in

“Commercial Style” plans.• Employs all levers/innovations that are used in

commercial marketplace, such as deductibles and co-pays.

• Utilizes copays, deductibles, HRAs, incentive payments, prizes, etc. to encourage healthy behaviors.

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Option #3

Georgia Families Plus “Commercial Style” Managed Care Program with use of ACOs and PCMHs.

CMO Feedback• Little support for carving in long term care.

• ABD is a done deal.

• ACO/PCMH concepts valid; Meeting federal definition is not.

• Use of commercial style patient payment is ineffective and only lowers provider payment.

• Use of health rewards has been shown to be effective.

• 3 – 5 CMOs will be approved. All statewide.

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What are CMO’s looking for?

• Willingness to move toward gainsharing mechanisms.

• Quick network development to support RFP response.

• Complete statewide network.

• Ability to address overutilization/high costs.

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Key Strategic Thoughts:

• More leverage prior to RFP award.

• More $’s in gainsharing than in FFS negotiations.

• What’s in it for you to help a prospect?

• Do you need to contract with all CMOs?

• Given current history, be smart about language / administrative items as well.

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Redesign Timeline:I. Assessment

August – December 2011. Completed.

II. Recommendation

January 2012. Posting of the Strategy Report.

January – April 2012. Review and analysis of the Strategy Report.

April - Summer 2012. Finalization of the Redesign Model.

III. Procurement

April – July/August 2012. Procurement planning/workgroups ongoing

September/October 2012. Procurement documents posted. (RFP issued)

1st quarter 2013. Contract award to successful vendors.

IV. Implementation

January 2014. Implementation begins.

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Next Steps?

• Finalization of redesign model.

• Ongoing discussions with CMOs

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