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
RAC SSI disabled SSI disabled Not receiving AFDC, but eligible (parents/ caregivers) Under 19, income <125% FPL Clinical condition Developmental disability Mental health: neuroses Pregnancy with complications Preventive/ Admin encounters Provider type Waiver services PNMI/Waiver services Physician/ Hospital Physician/ Hospital As illustrated in Table 13, Maine’s spending on developmental disability waiver services is above the national average and represents an area for potential cost savings through enhanced management strategies as discussed further in the Recommendations section. Table 13: Intellectual Disability & Development Disability HCBS Waiver Rank Average Expenditures per Waiver Recipient in FY 2009 (State and Federal Expenditures) 25th percentile $31,161 50th percentile $42,155 US average $42,896 75th percentile $51,199 90th percentile $68,478 Maine average $77,736 Current DHHS Management & Administrative Strategies & Options Current MaineCare management and administrative strategies were reviewed by the Task Force. These current initiatives were reviewed against nationwide trends for managing Medicaid populations. The Task Force examined multiple options for MaineCare’s long-term management strategies. Management options were considered based on the analysis of spending patterns in the MaineCare program, separated by eligibility group and clinical diagnoses to determine the appropriate management strategy by population. Recent MaineCare initiatives have centered on value based purchasing strategies. Under value based purchasing, payers reimburse for outcomes and quality versus volume-based reimbursement under traditional fee-for-service arrangements. Additionally, consumers have incentive to become active participants in their healthcare consumption and benefits are designed to provide appropriate intensity and levels of care. Under such strategies, the goal is for providers to better coordinate total care resulting in better outcomes at lower costs. MaineCare value based purchasing initiatives include an Accountable Communities Program, Patient Centered Medical Homes, and a Primary Care Provider Incentive Program. Additionally, MaineCare collaborates with ER departments to identify high utilizers and drivers of utilization and to encourage members to seek care in appropriate treatment settings.
The Accountable Care Organization (ACO) model was reviewed by the Task Force. ACOs are organizations under which there is shared responsibility among providers for enrollees’ care. In an ACO model providers have an opportunity to reap the benefits of shared savings. Medicaid ACOs are still in their infancy but a growing number of States are examining this model as a potential management strategy. Review of Initiatives Being Used in Other States’ Medicaid Programs Medicaid agencies around the country are experiencing significant budget constraints. Immediate savings have been realized through traditional strategies aimed at decreasing utilization and restricting reimbursement. Such strategies were reviewed by the Task Force in the context of long-term impact on access to care and cost shifting. Nationwide, longer-term strategies continue to be explored to transform the delivery of care to both improve quality outcomes and realize cost savings. Table 14 provides a summary of recent cost-cutting and quality initiatives being implemented by State Medicaid agencies. Table 14: Nationwide Cost-Containment Trends Strategy Nationwide Trends Recent MaineCare Initiatives Increased FY 2012: 14 states adopted N/A Benefit reductions & limitations FY 2012: 17 states imposed limits 7 states eliminated Use of Prior Authorization Concurrent review Targeting high cost imaging & radiology Common benefits targeted: Home health & personal care Dental Physical, Speech & Occupational Therapy Vision Eliminate - Smoking cessation products (except for pregnant women): 10/1/12 (pending) Eliminate - Ambulatory surgical center services: 9/1/12 (pending) Eliminate - STD screening clinic services Limit - Optometry visits for adults (1/3 years) Limit - Chiropractic visits (12/year) Limit - Added medical eligibility criteria for Case Management for homeless Limit - Physical therapy (2 hr./day) Limit - Occupational therapy (2 hr./day & 1 visit/year for palliative or maintenance care PA currently required for a multitude of services
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)
Conditions (HACs) Expand list to include all of those listed for the State of and Payment adjustments made annually based on HACs Section 45, HS $0.16M $0.66M $0.66M 3/1/13 Yes; Routine Technical Yes Yes No Yes No Yes Yes Readmissions Increase time span for which readmissions are not reimbursed Section 45, Ch. III, HS $0.38M $1.53M $1.53M 3/1/13 No Yes Yes No Yes No Yes Yes Leave Days Nursing Facility IMD ICF-MR Eliminate reimbursement for hospital leave & therapeutic leave days Eliminate - Nursing Facility: 10 hospital leave days & 36 therapeutic leave days Eliminate - ICFMR: 25 hospital leave days & 52 therapeutic leave days PNMI-Appendix C and F Section 67, NF; Section 45, HS; Section Section $0.16M $0.64M $0.64M 3/1/13 Section 45-Yes; Routine Technical Sections 67 (II and III), 50 (III) and 97 (II)-Major Yes Yes No Yes Yes Yes No Pharmacy Expand Medication Management Initiative/J Code PDL Section 80, RxS Section 90, PS $0.17M $0.64M $0.64M 4/1/13-J Code PDL Yes Yes Yes No Yes No Yes No Monitor use of in Children and Adults and Seniors PA required Section 80, RxS $0.3M $0.3M 3/1/13 No; Managed through PDL No Yes No Yes Yes Yes No Total savings for Short-term strategies $1.35M $5.38M $5.38M
Proposed Change: Mid-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 Pharmacy Competitive bid for specialty pharmacy Section 80, RxS - $0.39M $0.79M 1/1/14 Yes; Routine Technical Yes SPA and 1115 Waiver Yes No Yes Yes Yes No Increase generic dispensing rate by 1%, Reduce use of specialty drugs Section 80, RxS - $1.01M $1.35M 3/1/13 Yes; Routine Technical No Yes No Yes Yes Yes No Program Integrity Develop operational policy and procedure to handle day to day Medicaid discretionary functions and Internal review of data collected Utilize CMS’s best practice annual summary report Develop policy/procedure and mechanisms for reporting to the Medicaid and CHIP Payment and Access Commission - $1.83M $2.44M 10/1/13 No No No No No No Yes No Total savings for Mid-term strategies - $3.23M $4.58M Proposed Change : Additional Short-term Strategies 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 Increase benefits Restore smoking cessation benefits - 7/1/13
Allow dental benefits for individuals using the ER for dental services - 7/1/13 Total savings for Mid-term strategies with additional benefits - $0.9M Proposed Change : Long-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 TBD - $1.46M $1.95M 10/1/13 TBD TBD TBD TBD TBD TBD TBD TBD Value-based purchasing with Care Management Organization (CMO) Care Management Organization TBD - $0.51M $0.68M 10/1/13 TBD TBD TBD TBD TBD TBD TBD TBD Reduce neonates & increase normal births Healthy Babies Initiative/Also combines with Care Management Organization TBD - $0.7M $1.39M 10/1/13 TBD TBD TBD TBD TBD TBD TBD TBD 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