CMS Grant Programs: Improving Access & Quality for Medicaid Beneficiaries and the Uninsured Jessica Pollak Kahn, MPH Centers for Medicare & Medicaid Services.

CMS Grant Programs: Improving CMS Grant Programs: Improving Access & Quality for Medicaid Access & Quality for Medicaid

Beneficiaries and the UninsuredBeneficiaries and the Uninsured

Jessica Pollak Kahn, MPHJessica Pollak Kahn, MPH

Centers for Medicare & Medicaid Centers for Medicare & Medicaid ServicesServices

2008 Uninsured Congress2008 Uninsured Congress

Presentation ObjectivesPresentation Objectives

Medicaid Transformation Grants - $150mMedicaid Transformation Grants - $150m

High Risk Insurance Pool Grants - $49.1mHigh Risk Insurance Pool Grants - $49.1m

Emergency Room Diversion Grants- $50Emergency Room Diversion Grants- $50



Medicaid Transformation GrantsMedicaid Transformation Grants

Purpose: Section 6081 of the DRA adds a Purpose: Section 6081 of the DRA adds a new subsection to the Social Security Act new subsection to the Social Security Act which provides grant funds which provides grant funds for the for the adoption of innovative methods to adoption of innovative methods to improve the effectiveness and efficiency improve the effectiveness and efficiency in providing medical assistance under in providing medical assistance under MedicaidMedicaid


Allowable ProjectsAllowable Projects

Electronic health recordsElectronic health records, , electronic electronic clinical decision support toolsclinical decision support tools, & , & e-e-prescribingprescribing programs; programs;

Methods for Methods for improving rates of collectionimproving rates of collection from estates of amounts owed under from estates of amounts owed under Medicaid; Medicaid;

Methods for Methods for reducing waste, fraud, and reducing waste, fraud, and abuseabuse, ,

medication risk management medication risk management programsprograms


Allowable Projects ContinuedAllowable Projects Continued

Methods in reducing, in clinically appropriate Methods in reducing, in clinically appropriate ways, Medicaid expenditures for covered ways, Medicaid expenditures for covered outpatient drugs, by outpatient drugs, by increasing the increasing the utilization of generic drugs utilization of generic drugs through the through the use of education programs and other use of education programs and other incentives to promote greater use of generic incentives to promote greater use of generic drugsdrugs


Who and How Much$?Who and How Much$?

$150 million awarded to Medicaid agencies $150 million awarded to Medicaid agencies in 35 States, Puerto Rico and the District of in 35 States, Puerto Rico and the District of Columbia Columbia

2/3 of grants are focused on 2/3 of grants are focused on health health information technologyinformation technology– Electronic health recordsElectronic health records– E-prescribingE-prescribing– Health information exchangesHealth information exchanges– Predictive modeling systemsPredictive modeling systems


Intended Reforms from MT GrantsIntended Reforms from MT Grants

Improved care coordination through HIT/E Improved care coordination through HIT/E will result in:will result in:– Reduced duplicative testing and screeningReduced duplicative testing and screening– Fewer adverse drug eventsFewer adverse drug events– Fewer missed opportunities/improved Fewer missed opportunities/improved

adherence to treatment standardsadherence to treatment standards– Improved beneficiary satisfaction with care Improved beneficiary satisfaction with care


Other MT Grant Focus AreasOther MT Grant Focus Areas

Improved Neonatal OutcomesImproved Neonatal Outcomes Improved Fraud & Abuse DetectionImproved Fraud & Abuse Detection Improved Pharmacotherapy with Predictive Improved Pharmacotherapy with Predictive

ModelingModeling Improved Case Management with Predictive Improved Case Management with Predictive

ModelingModeling Streamlined Medicaid Eligibility and Citizenship Streamlined Medicaid Eligibility and Citizenship

DeterminationDetermination Automated Pharmacy and HCBS Pre-Automated Pharmacy and HCBS Pre-

Authorization SystemsAuthorization Systems


Example Medicaid Transformation Example Medicaid Transformation Grant: TexasGrant: Texas

Texas Health PassportTexas Health Passport– For children who are both Medicaid-eligible and in the For children who are both Medicaid-eligible and in the

TX foster care systemTX foster care system– Costs were Costs were 5x5x that of similar children in Medicaid but that of similar children in Medicaid but

not in foster carenot in foster care– Creates an online system that tracks their health Creates an online system that tracks their health

utilization, medications, lab results, behavioral health utilization, medications, lab results, behavioral health notes, etc for use by medical providers, foster care notes, etc for use by medical providers, foster care caseworkers and caregiverscaseworkers and caregivers

– Will streamline their care, reduce duplication of testing Will streamline their care, reduce duplication of testing and improve multi-disciplinary team coordinationand improve multi-disciplinary team coordination


Example Medicaid Transformation Example Medicaid Transformation Grant: AlabamaGrant: Alabama

Together for Quality:Together for Quality:– Transferring all of the Medicaid beneficiary records to Transferring all of the Medicaid beneficiary records to

electronic health recordselectronic health records– Creating an HIE between Medicaid providersCreating an HIE between Medicaid providers– Web-based, free EHR for providers that includes e-Web-based, free EHR for providers that includes e-

prescribing and clinical decision supportprescribing and clinical decision support– Also testing this approach with enhanced care Also testing this approach with enhanced care

management for persons with chronic diseasesmanagement for persons with chronic diseases– Using HEDIS measures for diabetes and asthma to Using HEDIS measures for diabetes and asthma to

track outcomestrack outcomes– Tremendous stakeholder involvementTremendous stakeholder involvement


Multi-State Collaborative for HIT and Multi-State Collaborative for HIT and MedicaidMedicaid

After the first of 2 solicitation rounds in 2007, After the first of 2 solicitation rounds in 2007, 14 states took the initiative to form a multi-14 states took the initiative to form a multi-state collaboration of MT Grantees, focusing state collaboration of MT Grantees, focusing primarily on HIT/EHR work. primarily on HIT/EHR work. – Sharing lessons learnedSharing lessons learned– Defining standardsDefining standards– Joint procurementJoint procurement– Open source codesOpen source codes– Peer to peer problem-solvingPeer to peer problem-solving


More Info on MTGMore Info on MTG

Final Evaluation Reports due 6 months after Final Evaluation Reports due 6 months after grants end grants end likely to be fall of 2010 likely to be fall of 2010

www.cms.hhs.gov/MedicaidTransGrantswww.cms.hhs.gov/MedicaidTransGrants//

http://www.cms.hhs.gov/MedicaidTransGrants/

http://www.cms.hhs.gov/MedicaidTransGrants/



High Risk Insurance PoolsHigh Risk Insurance Pools

Comprehensive health insurance programs Comprehensive health insurance programs targeting individuals who cannot obtain targeting individuals who cannot obtain health insurance in the private market health insurance in the private market because of pre-existing health conditions. because of pre-existing health conditions.

CMS grants since 2003CMS grants since 2003 Thirty-fiveThirty-five states have an active high risk states have an active high risk

pool grant from CMS. 31 are operational pool grant from CMS. 31 are operational high risk pools; 4 are seed grants.high risk pools; 4 are seed grants.


High Risk Pools GrantsHigh Risk Pools Grants

To be eligible for a CMS grant, they must To be eligible for a CMS grant, they must follow 1 of the 2 models in the NAIC Model follow 1 of the 2 models in the NAIC Model Health Plan for Uninsurable Individuals ActHealth Plan for Uninsurable Individuals Act

Most provide case management, disease Most provide case management, disease management & prevention screeningsmanagement & prevention screenings

Most offer either premium reduction Most offer either premium reduction programs for all members and/or low-programs for all members and/or low-income premium subsidies with federal income premium subsidies with federal grant funds.grant funds.


High Risk Pools & HIPAAHigh Risk Pools & HIPAA

Many States use the pools to comply with P.L. Many States use the pools to comply with P.L. 104-191 Health Insurance Portability and 104-191 Health Insurance Portability and Accountability Act of 1996 (HIPAA). Accountability Act of 1996 (HIPAA). – For eligible individuals moving from the group to the For eligible individuals moving from the group to the

non-group market, HIPAA requires state-licensed health non-group market, HIPAA requires state-licensed health insurers to make coverage available to such individuals, insurers to make coverage available to such individuals, and prohibits exclusion of coverage for pre-existing and prohibits exclusion of coverage for pre-existing conditions. conditions.

Approximately 29 of the pools are certified as a Approximately 29 of the pools are certified as a HIPAA alternative mechanism.HIPAA alternative mechanism.


High Risk Pool FundingHigh Risk Pool Funding

Federal fiscal year 2006: Federal fiscal year 2006: $90 million$90 million Federal fiscal year 2008: Federal fiscal year 2008: $50 million$50 million Funding is allocated by 3 factors:Funding is allocated by 3 factors:

1.1. Ranking by 3-year average number of Ranking by 3-year average number of uninsured per state (US Census)uninsured per state (US Census)

2.2. Ranking by number of persons enrolled in the Ranking by number of persons enrolled in the high risk pool in prior yearhigh risk pool in prior year

3.3. Divided equally among all eligible applicantsDivided equally among all eligible applicants


High Risk Pools: The StatsHigh Risk Pools: The Stats

The lowest average # of uninsured were: The lowest average # of uninsured were: MN, IA, WI.MN, IA, WI.

The highest average # of uninsured were: The highest average # of uninsured were: TX, NM, LA, MSTX, NM, LA, MS

The largest pools are:The largest pools are:– Minnesota (28,859 in 2007). Also oldest.Minnesota (28,859 in 2007). Also oldest.– Texas (27,733)Texas (27,733)– Oregon (18,656)Oregon (18,656)– Wisconsin (17,126)Wisconsin (17,126)


High Risk Pools: More DetailHigh Risk Pools: More Detail

Most high risk pools are funded in part Most high risk pools are funded in part through assessments levied against private through assessments levied against private insurers in their stateinsurers in their state

Most include representation from private Most include representation from private insurers on their Board membershipinsurers on their Board membership

Claims paid Claims paid alwaysalways exceed premiums exceed premiums collected, given the high morbidity of their collected, given the high morbidity of their membersmembers


What Role Do They Play in Assuring What Role Do They Play in Assuring Access to Health Care?Access to Health Care?

Two sides of the coin: Two sides of the coin: Heads:Heads:

–Serve as a safety net for those with pre-existing Serve as a safety net for those with pre-existing medical conditions who would not otherwise be able to medical conditions who would not otherwise be able to get coverage. get coverage. –While expensive, offers a comprehensive insurance While expensive, offers a comprehensive insurance package where none existedpackage where none existed–Broad provider networksBroad provider networks–Fashioned specifically for those with illnesses and/or Fashioned specifically for those with illnesses and/or chronic conditionschronic conditions


The Pros & Cons ContinuedThe Pros & Cons Continued

Tails:Tails: – Allows the private insurance market to “cherry-Allows the private insurance market to “cherry-

pick” who it will offer coverage based upon pick” who it will offer coverage based upon risk/cost avoidancerisk/cost avoidance

– Premiums are high and not affordable to allPremiums are high and not affordable to all– Benefits vary pool to poolBenefits vary pool to pool– Doesn’t exist in all statesDoesn’t exist in all states– Board representatives from private insurers Board representatives from private insurers

may have disincentives for pool expansion may have disincentives for pool expansion since that increases their assessmentssince that increases their assessments


Future of High Risk Pool Grant Future of High Risk Pool Grant FundingFunding

CMS requested funding in FY09 and FY10 CMS requested funding in FY09 and FY10 for support of state high risk insurance poolsfor support of state high risk insurance pools

After 2010, additional authorization is After 2010, additional authorization is needed from Congress to continue the grant needed from Congress to continue the grant programprogram


More Info on High Risk PoolsMore Info on High Risk Pools

www.cms.hhs.gov/highriskpools/www.cms.hhs.gov/highriskpools/ National Association of State National Association of State

Comprehensive Health Insurance Plans:Comprehensive Health Insurance Plans:– www.naschip.orgwww.naschip.org

http://www.cms.hhs.gov/highriskpools/



Alternate Non-Emergency Providers Alternate Non-Emergency Providers

The August 6, 2008 NHS Report states that The August 6, 2008 NHS Report states that in 2006, in 2006, 13.9% 13.9% of the Medicaid/SCHIP of the Medicaid/SCHIP emergency department visits were for non-emergency department visits were for non-urgent reasons. urgent reasons.

It is those preventable events targeted by It is those preventable events targeted by the new $50 million CMS grant program, the new $50 million CMS grant program, authorized by the DRA of 2005 to provide authorized by the DRA of 2005 to provide Federal grant funds to States to establish Federal grant funds to States to establish alternate non-emergency service providers.alternate non-emergency service providers.


Emergency Room Diversion GrantsEmergency Room Diversion Grants

Nearly 11% of all ambulatory medical care Nearly 11% of all ambulatory medical care visits in the US occur in hospital emergency visits in the US occur in hospital emergency departmentsdepartments

This coincides with decreasing numbers of This coincides with decreasing numbers of emergency departments and numbers of in-emergency departments and numbers of in-patient hospital beds.patient hospital beds.

The result? The result? OvercrowdingOvercrowding andand less than less than optimal careoptimal care


ER Diversion Grants: Who & How ER Diversion Grants: Who & How Much $?Much $?

20 State Medicaid agencies20 State Medicaid agencies were awarded were awarded $50 million$50 million in April 2008 for 29 separate in April 2008 for 29 separate projectsprojects– CO, CT, GA, IL, IN, LA, MA, MD, MI, MO, NJ, CO, CT, GA, IL, IN, LA, MA, MD, MI, MO, NJ,

NC, ND, OK, PA, RI, SD, TN, UT, WANC, ND, OK, PA, RI, SD, TN, UT, WA– Preference given to project in medically Preference given to project in medically

underserved areas & for partnering with local, underserved areas & for partnering with local, community hospitalscommunity hospitals


Variety of ApproachesVariety of Approaches

Identification of high-users ----- > outreachIdentification of high-users ----- > outreach HIT as part of the ER & medical home loopHIT as part of the ER & medical home loop Care coordinators co-located within the ERCare coordinators co-located within the ER Specialty coordination for substance abuse, Specialty coordination for substance abuse,

mental health and chronic medical conditionsmental health and chronic medical conditions New primary care access pointsNew primary care access points

– Expanded evening and weekend hoursExpanded evening and weekend hours– Mobile clinicsMobile clinics– TelemedicineTelemedicine– Urgent care clinicsUrgent care clinics– School-based primary care clinicsSchool-based primary care clinics


Expected ReformsExpected Reforms

Decreased use of participating hospital emergency Decreased use of participating hospital emergency departments by Medicaid beneficiaries for non-departments by Medicaid beneficiaries for non-emergent reasonsemergent reasons– Decreased cost to MedicaidDecreased cost to Medicaid– Increased beneficiary satisfactionIncreased beneficiary satisfaction– Improved ED efficiency as it contributes to a reduction in Improved ED efficiency as it contributes to a reduction in

over-crowdingover-crowding Increased utilization of “medical homes”Increased utilization of “medical homes”

– Improvements in chronic care management and Improvements in chronic care management and outcomesoutcomes

– Improvement in preventive careImprovement in preventive care


More Expected OutcomesMore Expected Outcomes

Improved care coordinationImproved care coordination– Predictive modeling to identify high-need Predictive modeling to identify high-need

individuals and provide targeted case individuals and provide targeted case managementmanagement

– Increased utilization of health information Increased utilization of health information technology and web-based scheduling toolstechnology and web-based scheduling tools


More Info on the ER Diversion More Info on the ER Diversion GrantsGrants

Final Evaluation Reports due by June 2010 Final Evaluation Reports due by June 2010 unless grants are extended (likely)unless grants are extended (likely)

http://www.cms.hhs.gov/http://www.cms.hhs.gov/GrantsAlternaNonEmergServ/GrantsAlternaNonEmergServ/

http://www.cdc.gov/nchs/fastats/ervisits.htmhttp://www.cdc.gov/nchs/fastats/ervisits.htm


Contact InformationContact Information

Jessica Pollak Kahn: Jessica Pollak Kahn:

410-786-9361 or [email protected] or [email protected]

CMS Grant Programs: Improving Access & Quality for Medicaid Beneficiaries and the Uninsured Jessica Pollak Kahn, MPH Centers for Medicare & Medicaid Services.

Documents

medicaid methods

medicaid eligibility

medicaid expenditures

medicaid purpose

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medicaid beneficiary