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 2

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

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 MADISO N PERRY PIKE MARIES HOWARD PETTIS MORGA N COLE MONITEA U MILLER CAMDEN MONTGOMERY LINN BOLLINGER PHELPS STODDARD DEKALB LAFAYETTE ST CLAIR ST FRANCOIS ST CHARLES4 LINCOLN CARROLL CAPE GIRARDEA U 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 LIVINGSTO N CALDWELL RAY CLAY CLINTON HOLT ANDRE W GENTRY WORTH HARRISON ADAIR LEWIS CLARK SCHUYLER KNO X MACON HOWELL TEXAS PULASKI RANDOLPH MONROE RALLS AUDRAIN OSAGE WASHINGTON STE GENEVIEVE IRON REYNOLDS SHANNON WAYNE RIPLEY BUTLER SCOTT MISSISSIPPI NEW MADRID DUNKLI N PEMISCOT OZARK WRIGHT ATCHISON NODAWAY DAVIESS SALINE COOPER BATES HENRY VERNON DADE LAWRENCE MCDONAL D BARRY STONE TANEY WEBSTER WARREN FRANKLIN ST LOUIS COUNTY JEFFERSON <<< ST LOUIS CITY CASS JACKSON JOHNSON PLATTE BUCHANAN GASCONADE Missouri Managed Care Regions 6

Medicaid Managed Care Trends Source: CMS as of 06/09; DSS Monthly Management Reports, Table 23 % Total Eligibles Enrolled in Managed Care 7

Is Managed Care Good for Patients? Defined Access Standards Required Adequate Provider Network Defined Appointment Standards Yearly Member Satisfaction Surveys 8

Quality Provisions Performance Standards - Well-child visits, including Adolescent Access - Case Management of High Needs Individuals Behavioral Health High Risk Pregnancy Special 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 10

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 11

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 Critical 12

Missouris Medicaid Program 13