Congressional Budget Office November 2, 2017 Exploring the Growth of Medicaid Managed Care Association for Public Policy Analysis & Management Fall Research Conference Alice Burns, Ben Layton, Noelia Duchovny, and Lyle Nelson Health, Retirement, and Long-Term Analysis Division The information in this presentation is preliminary and is being circulated to stimulate discussion and critical comment as developmental work for analysis for the Congress.
Medicaid is a federal–state program that provides health benefits to over 70 million low-income individuals and accounted for $348 billion of federal spending and $205 billion in state spending in fiscal year 2015. 1 CONGRESSIONAL BUDGET OFFICE
States typically use two payment systems: fee-for-service (FFS) and Medicaid managed care (MMC) . States may adopt MMC to: Increase predictability of spending or Improve coordination of care, which may reduce costs or improve outcomes. 2 CONGRESSIONAL BUDGET OFFICE
This project aims to improve our understanding of: Whether MMC is “the predominant delivery system in Medicaid” and How and why MMC has grown over time. The project will therefore inform expectations for future growth. 3 CONGRESSIONAL BUDGET OFFICE
Key to understanding the growth in MMC is understanding the difference between the percentage of Medicaid enrollment in MMC and the percentage of Medicaid spending that is attributed to payments for MMC . 4 CONGRESSIONAL BUDGET OFFICE
Percentage of Total Medicaid Enrollment and Spending Accounted for by MMC 100% Enrollment 80% 60% 40% Spending 20% 0% 1999 2001 2003 2005 2007 2009 2011 5 CONGRESSIONAL BUDGET OFFICE
A major challenge to understanding the growth of MMC is the variation in state programs and the lack of systematic data. We constructed and plan to disseminate a new dataset to support comparisons of states’ MMC programs. 6 CONGRESSIONAL BUDGET OFFICE
Beneficiaries’ Enrollment in and Spending on Medicaid Managed Care 7 CONGRESSIONAL BUDGET OFFICE
CBO used Medicaid Analytic eXtract data on beneficiaries’ spending and enrollment from 1999 to 2012 (the most recent period for which the data were available). Analyses included beneficiaries who were eligible for full Medicaid benefits . 8 CONGRESSIONAL BUDGET OFFICE
Types of Managed Care Organizations (MCOs) Comprehensive MCOs General Comprehensive Long-Term Services The Program of All-inclusive Care for the Elderly (PACE) Noncomprehensive MCOs Behavioral Dental Case Management “Other” 9 CONGRESSIONAL BUDGET OFFICE
Enrollment in Medicaid Payment Systems, 2012 Millions of Beneficiaries 15.0 11.8 10.2 6.5 6.3 6.3 1 Comprehensive Comprehensive MCO, Comprehensive 1 Comprehensive Noncomprehensive FFS only MCO only multiple MCOs MCOs, multiple MCO and FFS MCO(s) and FFS MCOs, and FFS 10 CONGRESSIONAL BUDGET OFFICE
Average Monthly Spending on Payments for MMC and FFS, 2012 $1,329 $1,329 $553 $27 $439 $321 Payments for MMC $526 Payments for FFS $118 Medicaid Comprehensive Noncomprehensive MMC FFS Only MMC 11 CONGRESSIONAL BUDGET OFFICE
Enrollment by Medicaid Eligibility Group, 2012 Millions of Beneficiaries 31 22 12 7 Comprehensive MMC 6 8 2 8 Noncomprehensive 3 3 MMC 2 2 3 2 1 1 FFS Only Nonelderly Adults Children Elderly and Disabled Dual-Eligible Beneficiaries Beneficiaries 12 CONGRESSIONAL BUDGET OFFICE
Average Monthly Spending on Payments for MMC and FFS, 2012 $1,602 $1,402 $534 $233 $1,169 $1,068 $416 $242 Payments for MMC $241 $125 Payments for FFS $175 Medicaid $117 Nonelderly Adults Children Elderly and Disabled Dual-Eligible Beneficiaries Beneficiaries 13 CONGRESSIONAL BUDGET OFFICE
Percentage of Total Medicaid Enrollment Accounted for by Comprehensive MMC and of Total Spending Accounted for by MMC Nonelderly Adults Children Percentage Percentage 75% 75% Enrollment Enrollment Spending 50% 50% Spending 25% 25% 0% 0% 1999 2001 2003 2005 2007 2009 2011 1999 2001 2003 2005 2007 2009 2011 14 CONGRESSIONAL BUDGET OFFICE
Percentage of Total Medicaid Enrollment Accounted for by Comprehensive MMC and of Total Spending Accounted for by MMC Elderly and Disabled Dual-Eligible Percentage Percentage 75% 75% Enrollment 50% 50% Enrollment 25% 25% Spending Spending 0% 0% 1999 2001 2003 2005 2007 2009 2011 1999 2001 2003 2005 2007 2009 2011 15 CONGRESSIONAL BUDGET OFFICE
Annual Per-Beneficiary FFS Medicaid Spending Among Nonelderly Adults and Children in Comprehensive MMC, 2012 $84 $81 Total Spending per Beneficiary $2,783 Payments for MMC $2,408 Payments on FFS Medicaid $374 $53 $49 $35 $34 Mental/ Prescription Clinic/ Nonemergency Other Acute Care Inpatient Substance Use Drugs Outpatient Dental Hospital 16 CONGRESSIONAL BUDGET OFFICE
Annual Per-Beneficiary FFS Medicaid Spending Among Elderly and Disabled and Dual-Eligible Beneficiaries in Comprehensive MMC, 2012 Total Spending per Beneficiary $14,912 $1,002 Payments for MMC $11,509 Payments on FFS Medicaid $3,403 $450 $440 $429 $385 $261 Home/ Mental/ Other Acute Care Prescription Institutional Care Inpatient Community Substance Use Drugs Hospital Services 17 CONGRESSIONAL BUDGET OFFICE
Changes in States’ MMC Programs Between 1999 and 2014 18 CONGRESSIONAL BUDGET OFFICE
Difference in Percentage of Spending Attributed to Payments for MMC 19 CONGRESSIONAL BUDGET OFFICE
Number of States With Any Type of MMC by Program Type 45 1999 41 2014 29 27 21 16 16 12 8 7 7 4 2 2 1 0 General PACE Long-Term Behavioral Dental Transportation Case Other Comprehensive Services Management Comprehensive Noncomprehensive 20 CONGRESSIONAL BUDGET OFFICE
Of States With General Comprehensive MMC, Percentage With Programs That Were Statewide or Regional 83% 1999 2014 62% 47% 32% Statewide Programs Regional Programs 21 CONGRESSIONAL BUDGET OFFICE
Of States With General Comprehensive MMC, Percentage That Mandated Enrollment by Eligibility Group 1999 93% 2014 88% 76% 76% 73% 44% 41% 18% Nonelderly Adults Children Elderly and Disabled Dual-Eligible Beneficiaries Beneficiaries 22 CONGRESSIONAL BUDGET OFFICE
Of States With General Comprehensive MMC, Percentage That Covered Various Types of Services 1999 100% 98% 95% 2014 90% 78% 78% 76% 73% 71% 68% 66% 58% 11% 4% Hospital and Acute Postacute care Prescription Drugs Mental/Substance Nonemergency Nonemergency Institutional Care Home/Community Care Use Transportation Dental Services 23 CONGRESSIONAL BUDGET OFFICE
Key Takeaways 24 CONGRESSIONAL BUDGET OFFICE
By integrating quantitative and qualitative data , CBO developed a more in-depth perspective on the growth of MMC and created a dataset to support future empirical research . 25 CONGRESSIONAL BUDGET OFFICE
Measurement matters : MMC growth may be defined in terms of spending or enrollment . Comprehensive MMC has different levels of comprehensiveness . Such considerations have significant implications for developing policy analysis and expectations for future growth . 26 CONGRESSIONAL BUDGET OFFICE
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