Increase Benefits Restore Smoking Cessation Benefits - ($0.53M) ($0.53M) Allow dental benefits for individuals using the ER for dental services - ($3.15M) ($3.15M) Total savings for Mid-term strategies with additional benefits - ($0.45M) $0.9M Value-Based Purchasing Increase promotion of targeted initiatives ED Maternal & child health Care Coordination to assist transition Provider incentive program - $1.46M $1.95M Value-Based Purchasing with CMO Care Management Organization - $0.51M $0.68M Reduce Neonates Healthy Babies Initiative - $0.7M $1.39M Targeted Care Management Targeted Care Management for top 20% - - $8.61M Total Savings for Long-Term Strategies - $2.67M $12.63M Overview The MaineCare Redesign Task Force was established in 2012 by legislative mandate to “provide detailed information that will maintain high-quality, cost-effective services to populations in need of health care coverage, comply with the requirements of the federal Patient Protection and Affordable Care Act of 2010 for state Medicaid programs and realize General Fund savings in fiscal year 2012-13 of $5,250,000” (Public Law, Chapter 657, LD 1746, 125th Maine State Legislature). This report provides an overview of the Task Force findings and recommendations for MaineCare reform and cost containment strategies. Background Task Force membership was established pursuant to PL 2011, Chapter 657, Part T. Mary Mayhew, the Commissioner of Health & Human Services, served as the chair of the Task Force. Eight additional members were appointed to represent MaineCare members and providers and to provide expertise in public health, financing, state fiscal and economic policy. The Task Force convened nine times between
Table 10: Cost Distribution – Next 15% (Non-Dual) State & Federal Expenditures – SFY 2010 Expenditures in Millions Adult/Child Disabled Other Hospital $144.3 $31.2 $4.6 Mental health $55.6 $23.0 $1.7 LTSS/Other $26.4 $19.9 $3.8 Physician $32.2 $8.7 $1.2 Pharmacy $40.0 $26.8 $1.6 All other $11.2 $3.8 $0.3 TOTAL $309.8 $113.4 $13.2 Table 11: Cost Distribution for Low 80% State & Federal Expenditures – SFY 2010 Expenditures in Millions Adult/Child Disabled Other Hospital $88.9 $7.7 $2.6 Mental health $30.6 $10.9 $1.5 LTSS/Other $29.8 $7.7 $9.1 Physician $51.9 $8.5 $9.3 Pharmacy $38.8 $9.2 $1.8 All other $22.3 $3.9 $1.1 TOTAL $262.4 $47.9 $25.3 Lives 191,916 28,857 37,390 Table 12: Consumer Characteristics Top 5% 2nd 5% 80-89% <80% Age group 18-44 18-44 18-44 Under age 18
Rate reductions FY 2012: 9 States reduced primary care reimbursement 14 States reduced specialist reimbursement 13 states reduced dental reimbursement Support services for adults with intellectual disabilities: 2010 Nursing facilities: 7/1/10 Rehab & community support services for children with cognitive impairments/physical limitations: 6/1/11 retro to 9/1/10 Developmental & behavioral clinic services: 7/1/10 Behavioral health services: 7/1/10 Transportation: 8/1/10 Occupational & physical therapy: 4/1/12 (pending) Podiatrist: 4/1/12 Private non-medical services: 10/1/10 Family planning: 7/1/11 Community support services: 7/1/10 Behavioral Health (Methadone): 4/1/12, 1/1/13 (pending) Group homes: 7/1/12 Pharmacy targeted reforms PDLs & PA MAC Rates – Blood Factor pricing Supplemental rebates Changes to ingredient cost & dispending fee reimbursement Increased use of generics & mail-order Enhanced management for high cost & overprescribed drugs HIT to encourage appropriate prescribing Cost sharing incentives 340b payment at cost Specialty drug vendors Monitoring use of Pharmacy TPL – cost avoidance Rebates for crossover claims Supplemental rebate agreements Restrictions on narcotics use to begin 1/1/2013 PAs for more costly drugs to begin 1/1/2013 Tried & failed requirements Additional step therapy Restrictions on scripts to begin 1/1/2013 Suboxone 2 year limit to begin 1/1/2013 Average Wholesale Price – 16%: 4/1/12 (pending) Mandatory generic substitution (pending) Smoking cessation 50% reduction (pending) Medication Management Initiative No coverage for: Anorexic or certain weight loss drugs Most vitamins and herbal products Hexachlorophene (for nursing facility patients) Products listed as part of the per diem rate of reimbursement for Nursing Facility Services Discontinued or recalled drugs Less than Effective Drugs (defined by FDA) TB drugs OTC drugs (unless designated otherwise) Fertility drugs Etc. (listed in MaineCare manual)
Eligibility Changes Review of eligibility categories to determine potential duplication with eligibility for tax credits beginning in 2014 Increased asset tests Reduced eligibility periods for spend-down SPA to reduce income eligibility for Medicare Savings Program to federal minimum SPA to eliminate coverage for 19 & 20 year olds SPA to reduce eligibility for parents from 200% to 100% FPL Program integrity initiatives Oversight through audit, data review, survey & certification Increased claims level analysis Contracts with program integrity vendors Utilization of Recovery Audit Contractors Centralized provider enrollment process Centralized program integrity training across all pertinent agencies Annual audit review by external agency or contractor Ongoing review of Medicaid policy and procedure Federal partnership best practice implementation (except CMS best practice annual summary report) Review of repayments due upon TPL payment Reimbursement reforms Expansion of list of hospital acquired conditions (HAC) for which reimbursement is barred beyond CMS required minimum Not reimbursing for potentially preventable readmissions No reimbursement for elective C-Section before 39 weeks Provider taxes Bundled payments Implements federal minimum requirement for HAC MaineCare does not reimburse for readmits within 72 hours Value-Based Purchasing Measuring and reporting comparative performance Paying providers differentially based on performance Designing health benefit strategies & incentives to encourage individuals to select high value services and providers and better managed their health care Patient Centered Medical Homes Accountable Communities Primary Care Provider Incentive Program Purchasing Strategies Managed Care Health Homes ACOs PCCM HIT Electronic health records Health information exchanges Current MaineCare initiative Managing Duals Special Needs Plans (SNPs) Program of All-Inclusive Care of the Elderly (PACE)
Presentation by Seema Verma and Rob Damler cont. information regarding Maine program Short-term: Changes to Optional Benefits Self-Directed personal assistance services – what might the consultants recommend Inpatient psychiatric services for individuals under 21 – require periodic re-authorization Out-of-state services – provide any information on Medicaid services Maine pays for any out-of-state services. Rehab Services (BH $ Substance Abuse) – Med Management, further define “up to 1 hr.” Is it annual? Weekly? More detail needed on Maine trends versus other states Dental – research studies regarding cost avoidance and provide list of states that contract services out Chiropractic – further limiting or elimination Private duty nursing – budget number by age group Personal care – budget numbers Case Management – provide list of groups eliminated Services for Individuals Age 65 or Older in an Institution for Mental Disease (IMD) Mid-Term Strategy: Eligibility Changes Review spend down eligibility and current medical expenses considered for eligibility. Increased use of generics – need to explore Rebates - cross over pharmacy claims and specialty pharmacy costs in Maine compared to other states HIT – explore restricted card program Mid-Term Strategy: Program Integrity
Appendix 4 - Matrix Proposed Change : Short-term Strategy Policy Section State Savings SFY 2013 State Savings SFY 2014 State Savings SFY 2015 Implementation Date Rule: Required; Type SPA/ Waiver Required Systems Changes Needed Legislative Approval Required Tribal Member Provider Public Notice Prior Authorization Implement concurrent review for psychiatric services for individuals under 21 in all settings Section 46, PH $0.02M $0.05M $0.05M 3/1/13 No No No No No No Yes No Elective surgeries Section 90, PS $0.07M $0.3M $0.3M 3/1/13 No PA criteria would have to be listed on the portal. No Yes No Yes Yes Yes No High cost imaging & Radiology Excluding Emergent Use Section 101, MI $0.23M $0.94M $0.94M 3/1/13 No PA criteria would have to be listed on the portal No Yes No Yes Yes Yes No Elective Inductions Prior to 39 weeks Section 90, PS; Section 14, APRN $0.08M $0.32M $0.32M 3/1/13 No PA criteria would have to be listed on the portal Yes No Yes Yes Yes No Proposed Change : Short-term Strategy Policy Section State Savings SFY 2013 State Savings SFY 2014 State Savings SFY 2015 Implementation Date Rule: Required; Type SPA/ Waiver Required Systems Changes Needed Legislative Approval Required Tribal Member Provider Public Notice
Value-based purchasing Increase promotion of targeted initiatives ED Maternal & child health Care Coordination to assist transition Provider incentive program Various - $1.46M $1.95M 10/1/13 Yes Yes Yes No Yes for changes to PCPIP No Yes for PCPIP changes Yes Value-based purchasing with Care Management Organization (CMO) Care Management Organization N/A - $0.51M $0.68M 10/1/13 No No No No No No No No Reduce neonates & increase normal births Healthy Babies Initiative/Also combines with Care Management Organization N/A - $0.7M $1.39M 10/1/13 No No No No No No No No Proposed Change : Long-term Strategy Policy Section State Savings SFY 13 State Savings SFY 14 State Savings SFY 15 Implementation Date Rule: Required; Type Required Systems Changes Needed Legislative Approval Required Tribal Member Provider Public Notice
Targeted care management for top 20% Aggressive case & disease management Home & community-based care Continually & periodically re-evaluate clients to assure appropriate level of care Carve outs Reduce waitlist Risk adjustment Performance bonus for meeting quality incentives Withhold to assure that process measures achieved Section 21-CW; Section 29-SW; Section Section 22-DW; Section 32-CW; Section 20-ORC - - $8.61M 7/1/14 Yes; Routine Technical and Major Substantive Yes; Waiver Yes Yes; Major Substantive Rule Yes Yes Yes Yes Total savings for Long-term strategies - $2.67M Savings Initiatives State Fiscal Year 13 State Fiscal Year 14 State Fiscal Year 15 Short-Term Savings $1.35M $5.38M $5.38M Mid-Term Savings (without additional benefits) - $3.23M $4.58M Long-Term Savings - $2.67M $12.63M Grand Total $1.35M $11.28M $22.59M Abbreviation Meaning CS Chiropractic Services HS Hospital Services MI Medical Imaging NF Nursing Facility PH Psychiatric Hospital