Fiscal Fitness: How States Cope: Massachusetts continues landmark health care reform
Fiscal Fitness: How States Cope
Massachusetts continues landmark health care reform
Like most states, Massachusetts has experienced a significant drop in tax revenues due to the economic downturn. In order to balance the budget, midyear reductions were needed in FY2009, and the legislature and governor needed to propose new revenue sources and significant reductions for FY2010.
"In the Medicaid program, our highest priority has been maintaining program eligibility and benefits," says Terry Dougherty, interim Medicaid director and assistant secretary for administration and finance in the Executive Office of Health and Human Services. "Our primary challenge is identifying effective strategies to continue to cover our existing Medicaid population at current benefit levels, and maintaining provider rates to ensure access to care for our members."
As required under the American Recovery and Reinvestment Act (ARRA), and as part of the state's commitment to maintaining near universal health insurance coverage, no changes have been made to Medicaid eligibility. "We have essentially held provider rates flat since fiscal year 2008. At this point, we have made no significant service or benefit cuts to the program," says Mr. Dougherty.
Near-universal coverage
Since the plan began in 2006, Massachusetts has covered 430,000 of its uninsured through Common- wealth Care, a state-subsidized insurance program for uninsured individuals up to 300% of the federal poverty level. "Even during these difficult economic times, we are committed to ensuring the long-term sustainability of health care reform," says Mr. Dougherty. "Moreover, in order to remain eligible for enhanced federal matching dollars under ARRA, we must not make any cuts to eligibility."
Due to the current fiscal situation, the legislature reduced funding for Commonwealth Care for approximately 31,000 special status legal immigrants who do not qualify for federal funding. "The governor worked with the legislature on a compromise program that will be funded at a significantly reduced amount," says Mr. Dougherty. "This new program provides a comprehensive and substantially similar benefit to Commonwealth Care for the remainder of fiscal year 2010, with slightly higher member cost sharing."
Mr. Dougherty says MassHealth, Massachusetts' Medicaid program, is leading the nation in finding savings in prescription drug utilization and implementing sensible clinical interventions.
"When compared to yearly spending growth prior to comprehensive clinical and programmatic interventions, the savings within the pharmacy program totals $1 billion over the last five years," says Mr. Dougherty.
Likewise, the MassHealth program has developed care management and benefit coordination efforts that focus on high-cost, medically complex populations. MassHealth has increased clinical reviews across many provider groups to ensure members receive the most appropriate level of care.
"Furthermore, MassHealth continues to lead in efforts to ensure Medicaid is the payer of last resort and all third-party liability opportunities are identified," says Mr. Dougherty. "More generally, controlling costs requires a combination of additional reforms."
These include insurance market reforms, health care provider payment incentives and payment reforms that reward quality of care, and reforms that will bring about patient-centered coordinated care. This will decrease avoidable hospitalizations, reduce medical errors, and improve care for people with chronic conditions. "Massachusetts is well on the way to examining the best ways to implement these next steps in reform," says Mr. Dougherty.
The Special Commission on the Health Care Payment System recently recommended that all payers in Massachusetts move away from a predominantly fee-for-service payment methodology.
"The governor and legislative leaders are working together to thoughtfully implement a strategy to reform the payment system," says Mr. Dougherty. "In addition, the state's Health Care Quality and Cost Council will soon release a road map to cost containment that will recommend other reforms and strategies to achieve them." The administration also has convened a panel representing all payers and primary care specialists, to develop and implement a plan to make all primary care practices patient-centered medical homes by 2015.
Mr. Dougherty says MassHealth is working closely with the congressional delegation to determine the impact of various proposals for health care reform. "Most of the proposals call for federal assistance to states to expand their Medicaid programs," says Mr. Dougherty. "We are advocating that states like Massachusetts that have already expanded their Medicaid programs should also receive federal assistance for those expansions."
Mr. Dougherty says he is glad to see that most proposals call for a state-run health insurance exchange. "This would allow our health insurance "connector" to continue to operate as is," he says. "We are also hopeful that federal health reform may provide flexibility that would allow states to develop innovative ways to serve dual-eligible individuals, as this is something we are looking at closely."
Express lane eligibility is new option for states
Nearly three-quarters of uninsured children eligible for Medicaid and the Children's Health Insurance Program (CHIP) are not enrolled. Now states have a new way to streamline enrollment of these children, due to the Express Lane Eligibility option in the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA).
"Studies show that children do not enroll into Medicaid and CHIP due to misunderstandings and confusion about eligibility, as well as the procedural difficulties their parents encounter in the application process," says Beth Morrow, staff attorney for The Children's Partnership's National Health Program in Washington, DC.
"While modest gains are possible through conventional outreach, covering the remaining millions of eligible children requires more than traditional strategies. Hence, Express Lane Eligibility," says Ms. Morrow.
Two obstacles gone
Ms. Morrow notes that most uninsured children already participate in other public need-based programs. "CHIPRA addressed two major obstacles that prevented states from making the most of cross-program enrollment coordination," she says.
The first obstacle is that each benefit program has its own technical rules for evaluating and counting income, as well as other eligibility criteria. Before the approval of Express Lane Eligibility, state Medicaid and CHIP agencies were forced to require families to complete new application forms and submit supporting documentation. This was done even after another program already had determined that a family was low-income and in need of assistance.
"Now, with CHIPRA, Medicaid/ CHIP can borrow another program's eligibility finding rather than gathering, archiving, and re-evaluating the data all over again," says Ms. Morrow.
The second obstacle is that in most states, Medicaid and CHIP computers cannot communicate with the computers housing eligibility data for other programs. "Employees often have to gather data from the nonhealth program by hand, convey it to the health program, evaluate the data, and enter it into health program files," says Ms. Morrow.
CHIPRA has facilitated the development of such data-supported eligibility findings by authorizing data-sharing with some additional sources, defining the process, and promoting linkages with the Social Security Administration database to enable an electronic citizenship/identity finding.
"It has also provided funds through outreach grants that are available to support such technology development, as well as through performance bonuses which reward states for streamlining the eligibility process through efforts like Express Lane Eligibility," says Ms. Morrow. "Furthermore, the Medicaid Information Technology Architecture is also pushing states in this direction, since it is pushing Medicaid programs to build systems linkages with other public agencies."
Ms. Morrow says, "Express Lane Eligibility allows states to develop long-term, systemic, cost-effective changes to benefit children. It cuts pointless red tape that now stops many families from enrolling."
Reduce inefficiency
One potential pitfall is that states will create an Express Lane Eligibility program that fails to significantly reduce administrative burdens or enhance efficiency. Ms. Morrow recommends that states do the following to create greater efficiencies for families, as well as Medicaid and CHIP agencies:
-Obtain eligibility information from other state databases wherever possible, instead of contacting the family to obtain that information.
-Implement automated processes that reduce the burdens placed on eligibility workers.
-Target efforts to reach eligible but uninsured individuals. "For instance, if a state does an Express Lane Eligibility effort through taxes, which will bring in large numbers of children, it needs to be able to identify the children who are already enrolled in Medicaid/CHIP in order to avoid wasting a lot of effort reaching out to those children," says Ms. Morrow. "This issue has dogged a number of efforts by states."
-Explore opportunities to use Express Lane Eligibility to accomplish renewal, which can be easy to administer and very helpful to families.
Virginia's Department of Medical Assistance Services is in the process of implementing the new Social Security data match simplification option available under CHIPRA. This process is expected to be in place January 2010. "This will allow the department to electronically verify citizenship for FAMIS and FAMIS Plus applicants. It will significantly ease the documentation burden on families," says Rebecca Mendoza, MA, director of the Division of Maternal and Child Health.
Virginia also was one of eight states to be awarded a Robert Wood Johnson Foundation "Maximizing Enrollment for Kids" grant. Through this grant, Virginia has recently completed a diagnostic assessment, will be receiving technical assistance from national experts, and is in the process of developing an improvement plan to increase enrollment and retention of eligible but currently uninsured children. An online application for Virginia's children's programs FAMIS and FAMIS Plus was launched in February 2005. "Pregnant women were added to the application later in the year, and a Spanish version was launched by the end of 2005," says Ms. Mendoza. "Approximately 50% of our new applications come through our web site."
Contact Ms. Mendoza at (804) 786-3206 or [email protected] and Ms. Morrow at (718) 832-6061 or [email protected].
Like most states, Massachusetts has experienced a significant drop in tax revenues due to the economic downturn. In order to balance the budget, midyear reductions were needed in FY2009, and the legislature and governor needed to propose new revenue sources and significant reductions for FY2010.Subscribe Now for Access
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