Developing Performance Metrics for Marketplace and Medicaid Systems under Healthcare Reform

Transcription

1 Developing Performance Metrics for Marketplace and Medicaid Systems under Healthcare Reform Jay Himmelstein, MD, MPH Professor and Chief Health Policy Strategist Co-Authors Scott Keays, MPH, and Natasha Dolgin, MD/PhD Candidate UMass Medical School, Center for Health Policy and Research Medicaid Enterprise Systems Conference Charleston, SC., September 10, 2013

2 Agenda Overview of Massachusetts Health Reform and Role of Massachusetts Health Connector Measuring Massachusetts Health Reform: Goals, Metrics and Lessons Learned Measuring National Health Reform Initial CMS Health Benefit Marketplace Outcomes Metrics and Medicaid Performance Indicators Using Multiple Data Sources to Measure Implementation and Outcomes at State and National Level Implications/Discussion 2

3 Chapter 58 of the Acts of Signed Into Law - April 12,

4 2006 Framework for Massachusetts Health Reform Similarities with ACA Medicaid Expansion to 133% FPL Subsidized private insurance coverage for lowincome ( % FPL) adults Requirement to obtain and maintain health insurance or face a tax penalty the so-called individual mandate Requirement for employers to contribute to employees health insurance or make a fair share contribution to the state the employer mandate Insurance market reforms, including establishment of a state health insurance exchange The Health Connector 4

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14 Referred to Paper Process 14

15 Agenda Overview of Massachusetts Health Reform and Role of Massachusetts Health Connector Measuring Massachusetts Health Reform: Goals, Metrics and Lessons Learned Measuring National Health Reform Initial CMS Health Benefit Marketplace Outcomes Metrics and Medicaid Performance Indicators Using Multiple Data Sources to Measure Implementation and Outcomes at State and National Level Implications/Discussion 15

16 Measuring Massachusetts Health Reform: Goals and Metrics 1. Expand Coverage/Decrease Number of Uninsured 2. Promote Competition and Price Transparency in the Health Insurance Market 3. Provide Consumers with Enhanced Choice Among Health Insurance Products and a Modern Shopping Experience 16

17 Coverage Metrics: Insured and Uninsured Rates Data Sources: Massachusetts Household Survey (yearly) Outcomes: Over 411,000 residents gained coverage in the first 5 years after reforms ( ) Overall insurance coverage rose from 93% to 97-98% Primary growth in coverage came from Medicaid (MassHealth) 193,000 (47%) Subsidized purchase through the Connector (Commonwealth Care) 159,000 (39%) Individual Purchase (including non-subsidized purchase through the Connector) 55,000 (13%) 17

18 Coverage Metrics: Health Connector Contribution Data Source: Department of Revenue and Health Connector Outcomes: Subsidized Private Coverage: ~180,000 Massachusetts residents purchased subsidized coverage through the Connector s Commonwealth Care programs Un-subsidized Individual Coverage: ~50% of all newly covered plans were purchased through the Health Connector during its first year of operations SOURCES: Massachusetts Health Connector and Department of Revenue, Data on the Individual Mandate, June 2012 Massachusetts Health Connector, Report to the Massachusetts Legislature Implementation of the Health Care Reform Law, Chapter , Oct

19 Coverage Metrics: Impact on Employer Sponsored Insurance (ESI) Data Source: Massachusetts Household and Employer Insurance Survey Outcomes: Employers offering insurance increased from 70% pre-reform in 2005 to 76% by 2011 Though the employer offer rate of insurance increased over time, the percentage of Massachusetts residents enrolled in ESI fell from 67% to 62% between 2009 and 2011 as the result of the recession SOURCE: Center for Health Information and Analysis, Massachusetts Household and Employer Insurance Surveys: Results from 2011, Jan

20 Employers Offering Health Insurance: Massachusetts Compared to the Nation SOURCE: Center for Health Information and Analysis, Massachusetts Household and Employer Insurance Surveys: Results from 2011, Jan

21 Trends in Type of Health Insurance Coverage for All Massachusetts Residents SOURCE: Center for Health Information and Analysis, Massachusetts Household and Employer Insurance Surveys: Results from 2011, Jan

22 Health Connector Business Analytics Activities monitored on a regular basis include: Customer Service Grievances and Appeals Enrollment and Membership Financial Performance Carrier Management Routine procedures in place for reviewing performance metrics and enforcing contractual requirements with vendors through penalties or incentive payments where appropriate 22

23 Example: Customer Service Metrics Data Source: Annual Commonwealth Care Member Survey Outcomes: High member satisfaction 77% of respondents extremely satisfied or satisfied Primary drivers of member satisfaction: Choice of plans Helpfulness of benefit materials Knowledge about plan benefits SOURCE: Massachusetts Health Connector, Report to the Massachusetts Legislature, Dec

24 Example: Enrollment and Membership Metrics Data Source: Monthly Health Connector Summary Report Outcomes: Commonwealth Care (subsidized) Total # of members # of members added and terminated Enrollment by plan type (i.e., enrollment by income level) Commonwealth Choice - unsubsidized Total # of paid members # of members added and terminated Enrollment by benefit level (i.e., Gold, Silver, Bronze, YAP) Enrollment by Product type (i.e., non-group vs. group) SOURCE: Massachusetts Health Connector, Commonwealth Care Member Survey & Contract Renewals (VOTE), April

25 Lessons Learned from Measuring MA Health Reforms Evaluation of reform impacts depends on data from multiple sources State specific data and surveys are essential to measuring health reform impact Challenges include measuring the impact of multiple changes over time Results will take time to stabilize, and early data should be interpreted with caution Policy makers will be interested in measuring the specific contributions of marketplaces and other factors to health reform outcomes 25

26 Agenda Overview of Massachusetts Health Reform and Role of Massachusetts Health Connector Measuring Massachusetts Health Reform: Goals, Metrics and Lessons Learned Measuring National Health Reform Initial CMS Health Benefit Marketplace Outcomes Metrics and Medicaid Performance Indicators Using Multiple Data Sources to Measure Implementation and Outcomes at State and National Level Implications/Discussion 26

27 Review: Role of Health Benefit Marketplaces (HBMs) under the Affordable Care Act (ACA) The Massachusetts Health Connector was the working model for State-based Health Benefit Marketplaces under the ACA HBMs State and Federal - are the key mechanism for implementation of ACA coverage expansions and health insurance market reforms Determining eligibility for affordable health programs including Medicaid and subsidized private coverage HBMs will have significant responsibilities in both the private and public insurance markets E.g. Identifying qualified health plans to be offered 27

28 ACA High Level Vision: Simplified Eligibility & Enrollment Process User Seeks health care coverage HIX/IES Web Portal Initial Eligibility Screener Questionnaire User may browse for health plans before completing an application Applicant browses for health plans without subsidy No Applicant appears eligible for subsidized coverage Yes Single Streamlined Application Yes Verification Rule-based Eligibility Engine Unsubsidized QHP MassHealth (Medicaid, CHIP) QHP (with APTC) Health Plan Enrollment Federal Data Hub SSA, IRS, DHS etc. 28

29 CMS/CCIIO Reporting Requirements Federal agencies will require data collection and reporting from state Marketplace and Medicaid/CHIP programs aimed at: Ensuring consistent, timely and reliable information for program monitoring Tracking and measuring the effectiveness of Marketplace and Medicaid/CHIP eligibility and enrollment processes CMS recently (August 28) released reporting template for Medicaid and CHIP Performance Indicators SOURCE: CMS, Medicaid and CHIP Draft Eligibility and Enrollment Performance Indicators, Aug

30 Proposed CCIIO State Based Marketplace Outcomes Metrics CCIIO will be collecting data from State Marketplaces in the initial years of operations in order to track implementation progress Will include the reporting of well over 600 data elements on a quarterly basis. Aggregate data on individuals and families will include elements such as: Federal Poverty Level; 6 discrete categories Household Structure: as related to insurance application Health coverage at time of application 30

31 Proposed CCIIO Outcome Metrics Include Domain Current Health Coverage: individuals determined eligible QHP Application: Eligibility & Enrollment Metrics Health insurance coverage of individuals found eligible for financial assistance with QHP coverage (i.e., APTC/CSR) at the time that application is submitted. Number of individuals at various stages in application, eligibility, and enrollment in a QHP as of the last day in the reference period. Transfers APTC QHP eligible-assist Number of transfers between SBM and Medicaid/CHIP. Amount of Advanced Premium Tax Credit (APTC) that enrollees were deemed eligible to receive and the percentage selected. QHP eligibles by type of assistance SHOP Appeals Employer and employee SHOP activity Status of appeals and report median time to resolve appeals. 31

32 Medicaid & CHIP Eligibility & Enrollment Performance Indicators Domain Call Centers Call Vol Wait Time Abandon Rate Apps-Week Apps-Month Transfers Renewals Enrollment Eligible Indivs. Ineligible Indivs. Pending Process Time Metrics Description of State Call Centers Total Call Volume Call Center Wait Time Abandonment Rate Number of Applications Received in Previous Week Number of Applications Received in Previous Month Number of Electronic Accounts Transferred Number of Renewals Total Enrollment Total Number of Individuals Determined Eligible Total Number of Individuals Determined Ineligible Pending Applications/Redeterminations Processing Time for Determinations 32

33 Medicaid Eligibility and Enrollment Indicators and Reporting Frequency 33

34 Initial Observations on Reporting Requirements Initial CMS/CCIIO reporting requirements for State Based Marketplaces appear to be primarily focused on establishing baselines, tracking the E&E process, and informing program integrity efforts Standardization of reporting requirements at the federal level will facilitate comparison across states and aggregation of information at the national level Given reporting load, States should aim to develop systems to automate reporting in an efficient and accurate manner. 34

35 Marketplace Data Architecture for Reporting and Analytics Data Sources Data Flow Results HIX/ IES Data Validation Federal Reports Call Center Data Cleaning Data Transforming Data Warehouse Data Marts State Reports Academic Research Legacy Systems Data Aggregating Data Loading Data Mining MMIS 35

36 Going Forward: Measuring ACA Implementation and Outcomes There will be a need and opportunities for states to establish additional infrastructure to collect and analyze data from multiple sources to understand the impact of the ACA on insurance markets, access to care, and ultimate impact on population health States have the opportunity to leverage investment in new systems and data sources to better understand ACA implementation 36

37 Potential Areas of Analysis Include Analytic Area 1 Producing Required State & Federal Reports: supporting Reporting and Program Integrity efforts 2 Operations Research: Supporting Medicaid and State- Based Marketplaces management and improvement 3 Consumer Decision Research: Support consumer decision-making 4 Applied Health Reform Research: Support for policy makers in understanding impact of health reform implementation and informing future policy decisions 37

38 Providing Access to Insurance is Necessary but not Sufficient Individuals Seeking Insurance Coverage Marketplace Shopping Health Plan Enrollment SBM Process Health Plan Content & process Access to Health Care Providers Clinical Services and Coordinated Care Health Care Delivery System Quality Consumer Experience: Health and Social Outcomes Individual and Population Based Outcomes Barriers to Access Facilitators of Access Access to Health Insurance Access to Health Care and Coordinated Services Examples: Plan Design, Adequacy of Provider Networks, Level of Deductibles (Especially for Low Income) SOURCE: Adapted from Lawthers and Himmelstein

39 Health Reform Analytic Opportunities CER studies; supplement HIE with APCD transactions; etc. Population Health APCD Rate review; MLR review; Medicaid product /benefit design; quality improvement and demonstrations, etc. Link clinical w/ financial Shared Services* Send claims, eligibility, nonclaim fiscal transactions HIE HIX Relationship studies between benefits, care delivery; and outcomes, quality rankings for HBE/HIX; etc. Link benefits w/ care delivery * Future shared services opportunities might include master provider or patient indexes or other services. Adapted from APCD Counsel, NAHDO, UNH 39

40 Agenda Overview of Massachusetts Health Reform and Role of Massachusetts Health Connector Measuring Massachusetts Health Reform: Goals, Metrics and Lessons Learned Measuring National Health Reform Initial CMS Health Benefit Marketplace Outcomes Metrics and Medicaid Performance Indicators Measuring Mid- and Longer Term Implementation and Outcomes at State and National Level Implications/Discussion 40

41 Implications: Measuring the Impact of the ACA and Health System Change The Affordable Care Act (ACA) will have far-reaching impacts on health insurance coverage, health care financing, and health care delivery in the United States Understanding state-level impacts and outcomes of the ACA through process and outcomes measures aimed at HBM and Medicaid programs will help inform ongoing improvement processes within states and across state lines Evaluators and policymakers will need to consider and integrate multiple data sources over time to truly understand and learn from the impact of the ACA. 41

42 Thank you! Jay Himmelstein, MD, MPH Professor and Chief Health Policy Strategist Office of Health Policy and Technology University of Massachusetts Medical School 42

43 References Center for Health Information and Analysis, Massachusetts Household and Employer Insurance Surveys: Results from 2011, Jan CMS, Medicaid and CHIP Draft Eligibility and Enrollment Performance Indicators, Aug (Available on CALT) Massachusetts Division of Health Care Finance and Policy, Health Care in Massachusetts: Key Indicators, May Massachusetts Health Connector and Department of Revenue, Data on the Individual Mandate, June 2012 Massachusetts Health Connector, Report to the Massachusetts Legislature Implementation of the Health Care Reform Law, Chapter , Oct Massachusetts Health Connector, Report to the Massachusetts Legislature, Dec Massachusetts Health Connector, Commonwealth Care Member Survey & Contract Renewals (VOTE), April 2013 SHADAC, A Framework for Tracking the Impacts of the Affordable Care Act in California, June