1. Health Care Reform IT’S COMPLEX! Jeffery Thompson, MD MPH Chief Medical Officer Washington State Medicaid

3. Medicaid Expenditures by Service, 2007 Total = $319.7 billion (WA State Medicaid ~$4 billion) NOTE: Total may not add to 100% due to rounding. Excludes administrative spending, adjustments and payments to the territories. SOURCE: Urban Institute estimates based on data from CMS (Form 64), prepared for the Kaiser Commission on Medicaid and the Uninsured. Inpatient 15.0% Physician/ Lab/ X-ray 3.7% Outpatient/Clinic 7.4% Drugs 4.7% Other Acute 6.7% Payments to MCOs 19.0% Nursing Facilities 14.8% ICF/MR 3.9% Mental Health 1.5% Home Health and Personal Care 15.0% Payments to Medicare 3.5% DSH Payments 5.0% Acute Care 59.9% Long-Term Care 35.1% Why are costs going up: PRIVATE SECTOR CUTS MEDICAL COSTS ELDERLY DISABILITIES

4. WA State Programs Categorically Needy (70%) Categorically Medical (spend down 70%) SCHIP/Apple Care (300%) General Assistance Unemployable (38%) Basic Health Plan (200%) Aid to Drug and Alcohol (38%) Long Term Care (75%) Family Planning (75%) Maternal Support (185%) Foster Care (wards of the state) NOTE: Medicaid income eligibility for most elderly and individuals with disabilities is based on the income threshold of Supplemental Security Income (SSI). SOURCE: Based on a national survey conducted by the Center on Budget and Policy Priorities for KCMU, 2009. Median Medicaid/SCHIP Income Eligibility Thresholds, 2009 Federal Poverty Line ( For a family of four is $21,200 per year in 2008)

5. Medicaid and Health Care Reform Cost Estimates. The Congressional Budget Office (CBO) estimates that the House bill will increase Medicaid/CHIP coverage by 15 million at a cost of $425 billion (2010 to 2019) and an estimated increase in state spending of $34 billion. Medicaid Coverage and Financing. Expands Medicaid to everyone under 133% of FPL with increased Federal funds for this population; Children’s and Adult Health Insurance Program. Current eligibility levels, procedures and methodologies are frozen until 12/31/2013 for adults and 9/30/2019 for children (including CHIP) Benefits and Access. Expands Medicaid to any individual under 26 who aged out of Child Welfare; Creates State-plan option for family planning services –Establishes the CLASS Act: a national long term care insurance program funded by payroll deductions, Creates new options for community care and FMAP increases Duals and Long-Term Care. The House bill provides payment of Part B deductibles and cost sharing under Medicaid for Medicare beneficiaries under age 65 with incomes below 150% of poverty, subject to regular Medicaid matching rate. Mandatory Providers Increases. Provider rates Medicaid pays for primary care services (100% Federal funds).

6. State Options for Coordination of Care Eligible individuals with chronic conditions’ means an individual who— is eligible for medical assistance under the State plan or under a waiver of such plan: has at least 2 chronic conditions; 1 chronic condition and is at risk of having a second chronic condition; or 1 serious and persistent mental health condition. The term ‘health home services’ means comprehensive and timely high- quality services comprehensive care managed care coordination and health promotion; comprehensive transitional care, including appropriate follow-up, from inpatient to other settings; patient and family support (including author­ized representatives); referral to community and social support serv­ices, if relevant; and use of health information technology to link services, as feasible and appropriate. This will cause us to rethink how care is delivered and accessed

7. How do you spend less and get better care? Benefit Reform Pay for what works (EBM, HTA) Reduce utilization of what doesn’t Better Informed Decision (PDA) Payment Reform Pay for Outcomes not services (ACO, Integration) Radiology and Advantaged Imaging “Generics First” Integrate Primary Care and Mental Health/Substance Abuse Pay for team based care Administrative Simplification Reward those that do it better with less overhead

8. Let me conclude on a good note: WA is a good state and with King Counties Help it is becoming a Great State Washington State: What happens when we work together? In 2007, ~ 265,000 eligible youth ages 0 – 18 19,228 (6.5) prescribed a psychotropic –Average Number Agents 1.6 (range 1 – 8) Quality Thresholds #% users –AAP used in a child less than 5151 (3%) –2 or more Antipsychotic Agents 807 (17 %) –Doses exceeding 2 times recommendations 31 ( 0.6%) –5 or more Psychotropics 567 (3%) –Gap In Antipsychotic RX > 20 days 1512( 38 %)

9. Working Together the Variation is Less? % of Eligible with 5 or More Mental Health Drugs in Children Comparing 2004 and 2008 Children >= 5 MHD 0.6% 0.3% 0% 2008 2004