1. Will the ACA’s Medicaid Changes Improve Outcomes for Schizophrenia? A New Jersey Case Study Tom Pyle MBA, MS (PsyR), CPRP

2. Presentation at the Recovery Workforce Summit of the Psychiatric Rehabilitation Association at Baltimore, MD Tom Pyle MBA, MS (PsyR), CPRP June 2014 2

3. Fee for service  managed care… Integration of PH and BH… Medicaid expansion… Health insurance exchanges… Evidence-based practices.. Community integration… Medical model  Recovery model… The biggest change in 50 years… How will our loved ones be affected? 3

6.  11 th most populous (8.9 million)  Highest density (1030 psm)  Most urban (90% in urban areas)  Strongest state executive  “Blue” State 6

7.  Taxes  Real estate taxes: Nation’s highest…  Income tax: 1% pays 50%…  Budget gap: $800 million!  Public workers vs. pensioners vs. bond holders  Bonds downgraded: A-  49 th of 50 states… 7

8.  Budget: $ 33 billion  Pension fund: $47 billion short!  Needs $5 billion p.a.! 8

9. The macro view from 30,000 feet… 9

10. 1. Reform  “Innovations” (ACOs)  “Benchmark” plans 2. Expansion  25% increase 3. Managed care  BH  ASO  Grant  FFS  Case  Capitated 10

11. 1. Public program changes (Medicaid) 2. Private insurance changes 3. Health insurance exchanges 4. Cost containment measures 5. Quality improvement measures 6. Funding measures (e.g., taxes) 11

12. 1. Beneficiaries 2. Providers 3. Agencies 4. Government 12

13.  Beneficiaries 1.Enrolled 2.To be enrolled 3.Not enrolled 13

14. 14 1. Access 2. Availability 3. Quality 4. Cost 5. Innovation

15. 1. Coverage: As much? 2. Providers: Enough? 3. Exchanges: Overlap? 4. Transitions: Churn? 5. “Woodwork Effect”? 6. Measures: Of What? 7. Outreach: Possible? 8. Implement: Complex? 9. Deadlines: Too Tight? 10. Agency $: Enough? 15

16. 16 EnrolledTo be enrolledNot enrolled Access Availability Quality Cost Innovation  

17.  Health insurance for all  Individual Mandate  Corporate Requirement  Help for those who need it  Medicaid  Subsidies for premiums and cost-sharing 17

18. 18

19.  An entitlement  Big funder of…  Health care for poor, disabled  Safety-net hospitals, LT care  Federal-state partnership  FMAP: 50% to 83% 19

20. Federal Medical Assistance Percentage: Federal matching funds to state Medicaid programs. 20

21. Federal Medical Assistance Percentage 21 NJ: 50%

23. Federal Medical Assistance Percentage: For “new eligibles”: 23

24. Federal Medical Assistance Percentage: For “new eligibles”: 24 Till 2017: 100%

25. Federal Medical Assistance Percentage: For “new eligibles”: 25 Till 2017: 100% By 2020: 90%

27. Eligibility Enrollment Coverage Cost Consumers Rates Autonomy Referrals Administration Compliance Providers “Rights” “Access” Administration Quality Cost Governments Administration Overheads Compliance Cash flow Agencies 27

28.  Health insurance coverage  31 mm children; 16 mm adults; 16 mm E&D  Long-term care assistance  1.6 mm institutionals; 2.8 mm community-based  Assistance to Medicare beneficiaries  9.4 mm E&D (20% of Medicare enrollees)  Safety net funding  16% national health funding; 35% safety net hospitals  Funding for state capacity  FMAP Health insurance coverage Assistance to Medicare beneficiaries Long-term care assistance Safety net & system funding Funding for state capacity 28

29. $404.1 billion 29

30. $404.1 billion 30 $33.0 billion

31. 31

32. 32

34. 34

38. $30,834 (CT) $15,893 (CA) $15,747 (PA) $22,595 (DE) $19,951 (NJ)

40.  Overtreatment  Failure of care coordination  Failure of care process (Tx)  Administration complexity  Failure of pricing  Fraud and abuse At least 20% of costs 40

41.  Counter-cyclical to economy  Largest source of federal revenue (  jobs)  Biggest target for state cost controls 41

42.  Medicaid  an entitlement  States can only...  Reduce provider payments  “Manage” utilization  Restrict eligibility 42

43. 43 NJ Medicaid, May 2014 20%? (~40,000?) NJ population 2010 8,900,000 x 1% ~ 90,000 50%? (~45,000?)

44.  3 Big Changes  5 Big Outcomes  FMAP: NJ = 50%  2.8% of GDP  15% of all health spending  W,F,A = 20%  18% beneficiaries  45% cost  5 Functions  4 Constituencies 44

45. 45

46. CategoryFinancialResource 46

47.  Children  Pregnant women  Parents of certain children  Seniors  Individuals with disabilities  NOT childless non-elderly adults 47 Mandatory (before ACA):

48. The Federal Poverty Level (HHS) 48 2014: Family of 1: $11,670 Family of 4: $23,850

49. 49

50. 50

51. 51

52. 2014 Federal Poverty Limit (FPL) 52

53. Family of 1: $11,670x 133% =$15,521 Family of 4: $23,850x 133% =$31,721 2014 Federal Poverty Limit (FPL) 53

55. 55

56. < + 56 (To keep SSI, net worth < $2000)

57.  Medicaid: < 138% FPL.  Exchanges: > 100% FPL. 57

58. 58

59. Before: 62 mm? (53 mm PYEs) 59 After: + 6 mm more?

60. 60

61.  Poor families with children  2/3 rd of enrollees  1/3 rd of spending  Elderly and disabled  1/3 rd of enrollees (70% in nursing homes)  2/3 rd of spending 61

62.  US average: only ~ 2/3rds !  Enrolled eligibles: Highly variable by state OK44% MA 80% NJ 53% 62

63. 63

65. 65

66.  Services, not programs  Discrete and individual, not comprehensive 66

67.  Doctor visits  Emergency care  Hospital care  Prescription drugs  Long-term care  Vaccinations  Hearing  Vision  Preventative care for children 67

68.  Inpatient hospital  Outpatient hospital  EPSDT  Nursing facility  Home health  Physician  Rural health clinic  Federally qualified health center (FQHC)  Laboratory and X-ray  Family planning  Nurse midwife  Certified pediatric and family nurse practitioner  Freestanding birth center (when licensed or otherwise recognized by the state)  Transportation to medical care  Tobacco cessation and tobacco cessation counseling for pregnant women and youth under 21 as part of EPSDT 68

69. 69

70. 70 “Benchmark” Essential Benefits coverage under ACA Excludable for newbies under ACA

71.  Service Setting  Type of Provider  Extent of Coverage 71

72.  “Habilitative” services: to develop skills never acquired (as among DD population)  Only through home/community-based waiver  “Rehabilitative” services: to restore lost functioning (as among PD population)  Not limited to clinical treatment 72

73. 73  Deductibles  Co-pays  (Opportunity costs)

74. 74  Classic Fee-for-Service  Managed care  Contractually-defined services…  For an enrolled population…  In a closed network…  Paid by capitation premiums

75. 1. Managed care organization (MCO) ▪ Capitation: Per person per month ▪ Risk: Who accepts it? State or vendor? 2. Primary care case management (PCCM) ▪ Case management fee 3. Pre-paid Health Plans (PHP) ▪ In-patient ▪ Ambulatory 75