1. June 26, 2013 Jeff Bechtel, Senior Consultant Medicaid Capacity Access Analysis

2. Purpose Review of DOH Presentation and Follow-up Medicaid Capacity Analysis Discussion Presentation Outline 2

3. Demographic analysis shows anticipated decrease in working age population (20- 59) of 3,060 by 2030 Most counties are considered Primary Medical Care Health Professional Shortage Areas Lower density of primary care physicians (and other provider types) in more highly rural areas of state Average age of physicians increasing Primary Care Task Force convened to consider and make recommendations to ensure accessibility for all South Dakotans Summary – DOH Presentation 3

4. Question: How many licensed Physician Assistants (PAs) and Certified Nurse Practitioners are in SD? Answer: According to the Board of Nursing, there are 562 active Certified Nurse Practitioners licensed in SD. According to the Board of Medical and Osteopathic Examiners, there are 500 active Physician Assistants licensed in SD. DOH Follow-up 4

5. Question: Does the HPSA calculation formula take into account the distance from surrounding population centers outside the county borders? Answer: Yes. Designations of underserved are based on criteria established through federal regulation to identify geographic or population groups that are underserved in terms of access to health care services. The Health Professional Shortage Area (HPSA) designation criteria and procedures include creating a rational service area. Rational service areas are created by looking at whole counties, multiple counties, parts of adjacent counties and catchment areas (mental health). The HPSA designation process also looks at contiguous service areas to the rational service area to determine if health care services are nearby. DOH Follow-up (continued) 5

6. Data analysis was performed to support the States understanding of the potential impact of new Medicaid members on primary care and in-patient health care resources. Study examined the capacity of those same providers to deliver care to individuals who could become eligible for Medicaid under the optional ACA Expansion individuals who have income up to 138% of the Federal Poverty Level. Medicaid Capacity Data Analysis Project 6

7. Divided the state into five geographic regions. Identified the number of providers (by category) in each region, as well as the number of current Medicaid Low Income Family (LIF) Adult consumers receiving services, to calculate provider ratios (i.e. the ratio of members to providers). Identified the number of additional Medicaid consumers expected to be served by county and region if South Dakota chooses to expand Medicaid, to calculate future provider ratios. Calculated the percent change in provider ratios by county, region, and provider category if South Dakota moves forward with expansion. Lack of comparison data from other state Medicaid FFS programs. South Dakota Medicaid does not have private insurance, Medicare or other non- Medicaid claims data. As a result, the analysis does not provide a full picture of provider ratios throughout the state. Study Overview 7

8. Data: Eligibility and claims data from State fiscal year (SFY 2012) was reviewed to study the capacity for DSSs enrolled Medicaid providers to serve adults who are currently enrolled in Medicaid under the Low Income Families (LIF) category. Current LIF Adult Members: The population of beneficiaries who are eligible for South Dakota Medicaid under the LIF category was used as the baseline population due to its similarity in demographic and income characteristics to that of the potential Medicaid expansion population. There were approximately 14, 554 members that had at least one month of eligibility during State fiscal year (SFY) 2012 in the LIF category. Providers: Providers were grouped into five categories: hospital based services, physicians and clinics, pharmacies, dentists, and other (opticians and optometrists). There were 4,949 South Dakota Medicaid providers selected for this analysis that filed claims in SFY2012. The analysis excluded long-term care and home health providers who typically provide services for aged or disabled Medicaid beneficiaries. Key Terms/Assumptions 8

9. Geographic Regions RegionCounties West Region Butte, Custer, Fall River, Harding, Lawrence, Meade, Pennington and Perkins Counties American Indian Counties Bennett, Buffalo, Corson, Dewey, Jackson, Mellette, Shannon, Todd and Ziebach Counties Central Region Aurora, Brule, Campbell, Charles Mix, Douglas, Gregory, Haakon, Hand, Hughes, Hyde, Jerauld, Jones, Lyman, Potter, Stanley, Sully, Tripp, and Walworth Counties Northeast Region Beadle, Brookings, Brown, Clark, Codington, Day, Deuel, Edmunds, Faulk, Grant, Hamlin, Kingsbury, McPherson, Marshall, Roberts & Spink Southeast RegionBonn Homme, Clay, Davison, Hanson, Hutchinson Lake, Lincoln, McCook, Miner, Minnehaha, Moody, Sanborn, Turner, Union, Yankton 9

10. Analysis – LIF Adult Members/Provider Ratios by Region (Current Capacity) All Regions American Indian CentralNortheastSoutheastWest Member: Provider Ratio 2.9 : 146.4 : 13.3 : 11.9 : 11.7 : 12.6 : 1 10

11. Analysis – Current Capacity of Providers to Serve LIF Adult Members, by Specialty by Region RegionHospitalsPhysicians, Clinics, Independent Practitioners PharmaciesDentistsOther American Indian 284 : 181 : 1350 : 1505 : 11,137 : 1 Central 37 : 15 : 144 : 141 : 156 : 1 Northeast 32 : 13 : 135 : 127 : 1 Southeast 84 : 12 : 147 : 130 : 138 : 1 West 104 : 13 : 169 : 139 : 1 All Regions 81 : 14 : 166 : 146 : 154 : 1 11

12. If South Dakota were to expand financial eligibility to 138% FLP, there would be an additional 48,565 currently uninsured adults that would be provided care by South Dakotas Medicaid providers. When added to the current LIF membership, the future population equates to 63,118 members that would need to be served by South Dakota Medicaid providers. The number of providers (n=4,949) used in the analysis remained a constant. Analysis – Provider Capacity to Serve South Dakotas Future Medicaid Members 12

13. Analysis – Member/Provider Ratios by Region (Future Capacity) Provider Specialty/ Region All Regions American Indian CentralNortheastSoutheastWest Total Providers 4,950983768532,5511,071 Total LIF Adult plus Expansion Members 63,11813,4464,95312,10016,42016,179 Member: Provider Ratio 12.8 : 1137.4 : 113.2 : 114.2 : 16.4 : 115.1 : 1 13

14. Analysis – Member/Provider Ratios by Region (Future Capacity) Member: Provider Ratio – All Providers All Regions American Indian CentralNortheastSoutheastWest Current Capacity Member: Provider Ratio 2.9 : 146.4 : 13.3 : 11.9 : 11.7 : 12.6 : 1 Future Capacity Member: Provider Ratio 12.8 : 1137.4 : 113.2 : 114.2 : 16.4 : 115.1 : 1 Percent Change Current to Future -333.7%-196.0%-301.4%-628.5%-282.8%-473.5% 14

15. Map 1: LIF Adult Member: Provider Ratios by Region (Current Capacity) 15

16. Map 2: Member: Provider Ratios by Region (Future Capacity) 16

17. Map 3: Change in Capacity (Based on Member: Provider Ratios) by Region 17

18. The analysis demonstrates that for every one provider (primary care, Hospital- based services, dentist, pharmacist or vision provider), there are currently 2.9 income-eligible South Dakota Medicaid LIF adult members served. The greatest capacity for providers to serve members within the comparison population is in the Southeast region, where there is one provider for every 1.7 LIF Adult members. Conversely, the American Indian region has the fewest providers serving its LIF Adult Medicaid members (46.4 adult members served by one provider). The analysis of provider specialties across the state reveals that there is one primary care provider (physician, clinic or independent provider) for every four adult LIF Medicaid members, whereas one provider of hospital-based services serves 81 adult members. Findings/Observations 18

19. When considering the impact of additional individuals who would become eligible for Medicaid if the State were to expand income eligibility requirements to 138% of FPL, there would be a 333.7% change in capacity overall. The greatest change in capacity would be in the Northeast regionlikely a factor of 10,439 additional individuals that will become eligible for Medicaid within that region that will require services. This region is followed by West, Central, Southeast, and American Indian. The smaller drop in capacity in the American Indian region is likely due to an already high member: provider ratios in the region. This occurs regardless of provider group due to using the same volume of providers across comparison current to future populations. Findings/Observations (contd) 19

20. Ability and willingness of systems, provider groups to accept additional Medicaid consumers Additional steps, reforms that can be implemented to address access issues should South Dakota decide to move forward with Medicaid Expansion Moving forward – how to monitor access. Discussion Items 20

21. Discussion 21

22. Questions? Sellers Dorsey sellersdorsey.com Jeff Bechtel Senior Consultant Sellers Dorsey 717.695.4342 jbechtel@sellersdorsey.com 22