June 2017 Report to Congress on Medicaid and CHIP
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Report to Congress on Medicaid and CHIP JUNE 2017 Medicaid and CHIP Payment and Access Commission About MACPAC The Medicaid and CHIP Payment and Access Commission (MACPAC) is a non-partisan legislative branch agency that provides policy and data analysis and makes recommendations to Congress, the Secretary of the U.S. Department of Health and Human Services, and the states on a wide array of issues affecting Medicaid and the State Children’s Health Insurance Program (CHIP). The U.S. Comptroller General appoints MACPAC’s 17 commissioners, who come from diverse regions across the United States and bring broad expertise and a wide range of perspectives on Medicaid and CHIP. MACPAC serves as an independent source of information on Medicaid and CHIP, publishing issue briefs and data reports throughout the year to support policy analysis and program accountability. The Commission’s authorizing statute, 42 U.S.C. 1396, outlines a number of areas for analysis, including: • payment; • eligibility; • enrollment and retention; • coverage; • access to care; • quality of care; and • the programs’ interaction with Medicare and the health care system generally. MACPAC’s authorizing statute also requires the Commission to submit reports to Congress by March 15 and June 15 of each year. In carrying out its work, the Commission holds public meetings and regularly consults with state officials, congressional and executive branch staff, beneficiaries, health care providers, researchers, and policy experts. Report to Congress on Medicaid and CHIP JUNE 2017 Medicaid and CHIP Payment and Access Commission Advising Congress on Medicaid and CHIP Policy Commissioners June 15, 2017 Penny Thompson, MPA, Chair The Honorable Mike Pence The Honorable Paul Ryan Marsha Gold, ScD, Vice Chair President of the Senate Speaker of the House Brian Burwell S-212 The Capitol H-232 The Capitol Martha Carter, DHSc, MBA, Washington, DC 20510 Washington, DC 20515 APRN, CNM Frederick Cerise, MD, MPH Dear Mr. Vice President and Mr. Speaker: Gustavo Cruz, DMD, MPH Kisha Davis, MD, MPH On behalf of the Medicaid and CHIP Payment and Access Commission Toby Douglas, MPP, MPH (MACPAC), I am pleased to submit the June 2017 Report to Congress on Leanna George Medicaid and CHIP. This report examines three present-day responsibilities Darin Gordon Christopher Gorton, MD, MHSA of the partnership between the states and the federal government: Stacey Lampkin, FSA, MAAA, spending on Medicaid’s mandatory and optional populations and services, MPA the program’s response to the opioid epidemic, and federal and state Charles Milligan, JD, MPH activities to ensure program integrity in Medicaid managed care. Sheldon Retchin, MD, MSPH William Scanlon, PhD Chapter 1 responds to a request from the chairmen of the Senate Peter Szilagyi, MD, MPH Committee on Finance, the House Energy and Commerce Committee, Alan Weil, JD, MPP and the Energy and Commerce subcommittees on Health and Oversight and Investigations for an in-depth look at Medicaid coverage of optional Anne L. Schwartz, PhD, eligibility groups and benefits and the resources associated with them. Executive Director The Commission found that in fiscal year 2013—the most recent year for which data are available—almost half of Medicaid benefit spending was on mandatory populations receiving mandatory services; less than one-third of enrollees across the country were eligible on an optional basis and less than one-third of spending was on services for them. This analysis describes the decisions states have made within the parameters available to them. In the Commission’s view, however, mandatory and optional designations are not synonymous with necessary or unnecessary, or important and less important. As noted in the committees’ request letter, prescription drug coverage is optional but all states cover it because it is integral to the delivery of medical care. Similarly, home and community-based services, though optional, may help avoid or delay the need for and cost of institutional care, which is a mandatory service. Other optional services, such as behavioral therapy for substance use disorder, can reduce the need for mandatory inpatient care. Medicaid plays a singular role in covering vulnerable populations, such as adults with physical and intellectual disabilities, people with severe mental illness and addictions, children with special health care needs, and frail elderly. These populations are covered through a mix of mandatory and optional eligibility pathways. People with disabilities account for the largest 1800 M Street NW www.macpac.gov Medicaid and CHIP Payment Suite 650 South 202-350-2000 and Access Commission Washington, DC 20036 202-273-2452 share of optional Medicaid spending for long-term services and supports—services that other payers (including Medicare) rarely cover. Chapter 2 describes state Medicaid programs’ responses to the opioid epidemic, which disproportionately affects Medicaid beneficiaries. Adults with Medicaid coverage are prescribed pain relievers at higher rates than those with other sources of insurance. They have a higher rate of opioid use disorder than privately insured individuals and a higher risk of overdose and other negative outcomes, from both prescription opioids and illegal opioids such as heroin and illicitly manufactured fentanyl. State Medicaid programs are responding to the opioid crisis by innovating in the delivery of care and covering many components of medication-assisted treatment, the recommended treatment for opioid use disorders under current evidence-based guidelines. But because many of these services are optional, there is considerable variation in available services across states and many Medicaid enrollees with an opioid use disorder are still not receiving treatment. States are also working with other state agencies to prevent misuse of prescription opioids. The chapter concludes by describing barriers to care. Chapter 3 presents our in-depth examination of program integrity activities in Medicaid managed care, an important issue now that managed care is Medicaid’s primary delivery system, accounting for nearly half of program spending and about 60 percent of beneficiaries in 2015. Our analysis draws on interviews with 10 states, 3 managed care organizations, and relevant federal agencies. This inquiry found that while many program integrity practices are perceived to be effective, there are few mechanisms for measuring return on investment or for sharing best practices. We also note the need for greater coordination between managed care and program integrity functions, as well as better data on managed care encounters. Many stakeholders we interviewed believe the 2016 update to federal managed care regulations will strengthen managed care program integrity and lead to greater consistency across states. However, given that the states are still implementing major portions of the rule, it is too early to assess its ultimate effect. MACPAC is committed to providing in-depth, non-partisan analyses of Medicaid and CHIP policy, and we hope this report will prove useful to Congress as it considers future policy development affecting these programs. This document fulfills our statutory mandate to report each year by June 15. Sincerely, Penny Thompson, MPA Chair Medicaid and CHIP Payment and Access Commission www.macpac.gov Commission Members and Terms Commission Members and Terms Penny Thompson, MPA, Chair Marsha Gold, ScD, Vice Chair Ellicott City, MD Washington, DC Term Expires April 2018 Gustavo Cruz, DMD, MPH Charles Milligan, JD, MPH Health Equity Initiative UnitedHealthcare Community Plan of New Mexico New York, NY Albuquerque, NM Leanna George Sheldon Retchin, MD, MSPH Beneficiary Representative The Ohio State University Wexner Medical Center Benson, NC Columbus, OH Marsha Gold, ScD Peter Szilagyi, MD, MPH Independent Consultant University of California, Los Angeles Washington, DC Los Angeles, CA Term Expires April 2019 Brian Burwell Stacey Lampkin, FSA, MAAA, MPA Truven Health Analytics Mercer Government Human Services Consulting Cambridge, MA Tallahassee, FL Toby Douglas, MPP, MPH Penny Thompson, MPA Centene Corporation Penny Thompson Consulting, LLC Davis, CA Ellicott City, MD Christopher Gorton, MD, MHSA Alan Weil, JD, MPP Tufts Health Plan Health Affairs Watertown, MA Bethesda, MD Term Expires April 2020 Martha Carter, DHSc, MBA, APRN, CNM Darin Gordon FamilyCare Health Centers Gordon & Associates Scott Depot, WV Nashville, TN Frederick Cerise, MD, MPH William Scanlon, PhD Parkland Health and Hospital System West Health Institute Dallas, TX Oak Hill, VA Kisha Davis, MD, MPH Casey Health Institute Gaithersburg, MD Report to Congress on Medicaid and CHIP vii Commission Staff Commission Staff Anne L. Schwartz, PhD, Executive Director Office of the Executive Director Annie Andrianasolo, MBA Angelica Hill, MA Executive Assistant to the Executive Director Communications and Graphic Design Specialist Kathryn Ceja Director of Communications Policy Director Moira Forbes, MBA Principal Analysts Kirstin Blom, MIPA Jessica Morris, MPA Martha Heberlein, MA Chris Park, MS Joanne Jee, MPH Kristal Vardaman, MSPH Principal Analyst and Congressional Liaison Senior Analysts Benjamin Finder, MPH Robert Nelb, MPH Nevena Minor, MPP Analysts Kacey Buderi, MPA Kayla Holgash, MPH Research Assistant Madeline Britvec Operations and Finance Ricardo Villeta, MBA, Deputy Director of Operations, Ken Pezzella, CGFM, Chief Financial Officer Finance, and Management Brian Robinson, Financial Analyst