Methodology and Assumptions supporting Private Option Cost Estimates

Transcription

1 Memrandum T: Frm: Optumas Date: Subject: Arkansas Divisin f Medical Services Methdlgy and Assumptins supprting Private Optin Cst Estimates Optumas was cntracted by the Arkansas Divisin f Medical Services (DMS) t assist with actuarial analyses and prjectins related t the implementatin f the Private Optin. The Private Optin uses an 1115 Waiver frm the Centers fr Medicare and Medicaid Services (CMS) t purchase cmmercial insurance plans fr lw-incme, Medicaid-eligible individuals. During the engagement between Optumas and DMS, there were tw primary cst estimates created by Optumas. The first was an estimate f Private Optin csts utilizing Medicaid data. This estimate was referenced during legislative discussins in March f The secnd estimate was a Budget Neutrality calculatin, which is a standard cmpnent f an 1115 Waiver. The Budget Neutrality amunt represents a spending threshld beynd which CMS and the federal gvernment n lnger retain financial respnsibility. Budget Neutrality calculatins are typically presented in terms f a per-member, per-mnth (PMPM) cst, and states are nt held liable fr enrllment vlume r mix. These PMPM Budget Neutrality amunts can be revisited and adjusted fr differences between actual and prjected enrllment. In Arkansas, current premium spending, n a PMPM basis, t date is higher than Budget Neutrality prjectins, but when experience is adjusted fr differences in the assumed age, the State is spending less than prjected in the Budget Neutrality calculatins. Each f these cst estimates fllwed a unique methdlgy, and each relied n certain assumptins. The methdlgy and assumptins fr each cst estimate are discussed separately belw. March 2013 Legislative Cst Estimate This cst estimate used available Medicaid infrmatin t prject the PMPM cst f ptential Private Optin enrllees. This was cmpleted thrugh a multi-step prcess designed t cnvert Medicaid ppulatin data in t a prjectin fr the Qualified Health Plan (QHP) premium csts that wuld be incurred under the Private Optin. The analysis cnsisted f the fllwing steps: Optumas received service-level Medicaid claims data fr all Medicaid-cvered services incurred during Fiscal Years (FYs) 2010, 2011, and 2012, spanning July 1, 2009 thrugh June 30, Optumas als received summary-level infrmatin fr supplemental payments made utside f the claims system. Optumas reviewed, analyzed, and summarized service-level data t validate the reasnableness f the claims data, but did nt perfrm a full audit f the Medicaid data. Schramm Health Partners, LLC 7400 East McDnald Dr, Suite 101 Scttsdale, AZ

2 Page 2 Optumas als received an eligibility file cntaining the enrllment histry and demgraphic infrmatin fr any individuals enrlled in Medicaid during the same July 1, 2009 thrugh June 30, 2012 timeframe. Optumas identified individuals cnsidered actuarially similar t the ptential enrllees under Private Optin by using eligibility data in cnjunctin with medical service claims. This is a significant step in the cst prjectin, and is necessary due t the relatinship between incme and health status and due t the eligibility criteria f Arkansas pre- Private Optin Medicaid prgram. Prir t Private Optin, Arkansas Medicaid prgram predminantly served children, disabled adults, and pregnant wmen. The ppulatin newly eligible fr Medicaid due t the prgram s expansin int cmmercial insurance is significantly different, cnsisting f individuals 19 t 64 year lds between 17% and 138% f the Federal Pverty Level (FPL). Additinally, these individuals will likely nt have a significant disabling cnditin, therwise they wuld have been eligible fr Medicaid prir t the cmmercial insurance expansin, r wuld be captured by the Medically Frail screener and transitined t fee-fr-service (FFS) Medicaid. In rder t accunt fr this significant difference between pre-expansin Medicaid enrllees and the expansin-eligible ppulatin, Optumas identified sub-ppulatins within the Medicaid prgram that wuld mst clsely represent the expansin cmmercial insurance ppulatin. The ppulatins cnsidered fr the prjectin f Private Optin csts cnsisted f eligibility cdes 20, 21, 22, 25, 51, 52, 61, 62, 63, 65, 91, 92 i. Medicaid recipients in thse ppulatins where further limited t include nly individuals ver the age f 18. Optumas discussed these ppulatins with DMS t ensure prper interpretatin and understanding f Medicaid eligibility categries. Additinally, Optumas reviewed the data fr these ppulatins, including inherent utilizatin and cst patterns, t verify that the individuals were cmparable t expectatins f cmmercial insurance expansin enrllees. Medical service data fr these ppulatins was aggregated at a Categry f Service (COS) level. Cst data frm Calendar Years (CYs) 2010 and 2011 were used t serve as the basis fr rate prjectin. These tw years were chsen ut f the 36 mnths f data pssessed by Optumas because they represented the ideal cmbinatin f recent infrmatin and data with a sufficient amunt f claims payment run-ut. Tw years were chsen instead f ne t allw fr a mre rbust base, which was necessary particularly when cnsidering the relatively small prtin f Arkansas Medicaid enrllees cnsidered cmparable t the pst-expansin enrllees. Supplemental payments made utside f the Arkansas claims system, such as recnciliatin payments t hspitals and Federally Qualified Health Centers (FQHCs) were added in t the claims data summaries based n reprts cmpiled by DMS.

3 Page 3 After the base data was summarized, it was prjected frward t 2014 using utilizatin trend and medical cst inflatin. The trend factrs used were 0.5% annual utilizatin trend and 0.25% annual unit cst trends. These trend factrs were established by reviewing the data fr histrical trends, researching service-specific trend rates natinally, and discussing trend and cst grwth rates with Arkansas DMS. The natinal view fr trend estimates is necessary t ensure data anmalies that ccurred in the past are nt having an undue influence n prjected trend rates, and t cnfirm that Arkansas trend figures are cmparable t apprpriate reginal and natinal benchmarks. Once services were prjected frward t the apprpriate time perid, Optumas underwent the prcess f adjusting reimbursement levels t reflect cmmercial-level payments. This cnversin was dne in tw steps first by cnverting Medicaid reimbursement t Medicare reimbursement, and then by cnverting Medicare reimbursement t cmmercial reimbursement. The tw-step apprach was necessary t accurately represent cmmercial reimbursement and allw fr Arkansas cmmercial carriers t prvide input in t the prjectin prcess. T cnvert Medicaid reimbursement t Medicare reimbursement, Medicaid-t- Medicare cst indices were researched using infrmatin published by the Kaiser Family Fundatin. Medicare-t-Cmmercial cst adjustments were derived by researching cmmercial reimbursement in Arkansas, use f prprietary pricing tls, and discussins with cmmercial carriers. The discussins with cmmercial carriers helped Optumas ascertain what carriers felt was a reasnable reimbursement rate as a percent f Medicare reimbursement. This further illustrates a challenge in cnverting reimbursement t cmmercial levels mst cmmercial carriers cnsider their reimbursement levels prprietary and an integral part f their cmpetitive business plan. Fr this reasn, carriers were understandably reluctant t divulge infrmatin n their reimbursement amunts in the frm f actual dllar amunts, and Optumas felt that questins pertaining t reimbursement rates wuld nt be apprpriate. Rather, Optumas was able t discuss reimbursement as a percent f Medicare, allwing cmmercial carriers t prvide valuable insight withut divulging anything they cnsidered t be trade secrets. Balancing the need t prtect prprietary cmmercial plan infrmatin and the desire t prject cmmercial csts as accurately as pssible demnstrates bth the need fr the tw-step prjectin and the challenges assciated with accurately cnverting Medicaid reimbursement t cmmercial reimbursement. The remaining steps in the rate develpment prcess invlved prjecting changes t the cmmercial cst structure and mdeling the impact f cmmercial plan invlvement n cst levels.

4 Page 4 The first step f this was reducing the prjected service csts fr the cst sharing that wuld be paid by members. At this pint in the Private Optin develpment and wavier negtiatins, member cst sharing respnsibilities were still uncertain. Optumas used an assumed value f 2.5% t estimate the prtin f ttal medical expenses that wuld be paid by members. Managed Care Savings is anther critical cmpnent f cmmercial plan invlvement. Using the input f ur staff clinician cmbined with experience in transitining FFS reimbursement t Medicaid Managed Care, Optumas derived a 12% reductin fr medical cst savings generated by active care management frm cmmercial health plans. A third significant difference frm the Medicaid FFS structure t the prpsed Private Optin structure is the administrative and prfit margins. Health plans require administrative expenses and prfit t functin, and neither f thse cmpnents were built in t the FFS data used as a base fr rate setting. Based n experience develping Managed Care rates, Optumas built in a 10% lad fr administrative expenses and a 1% lad fr prfit. Nn-Emergent Medical Transprtatin (NEMT) was treated separate frm the prcess described previusly. It was prpsed that transprtatin be handled via FFS Medicaid, utside f the QHP delivery system. Fr this reasn it is unnecessary and inapprpriate t apply adjustments fr managed care savings, service payment level changes, r administrative lading fr these service csts. Instead, transprtatin csts were identified using Medicaid data and trended frward t the CY14 analysis perid. N ther adjustments were made t transprtatin csts. The Medicaid-t-Cmmercial prgram adjustments represent the final step in the Private Optin cst prjectin. The result was a PMPM cst estimate f $ fr the prvisin f medical services t the Private Optin expansin ppulatin via a private cmmercial insurance QHP delivery system. This PMPM includes the estimated csts fr transprtatin services administered via FFS Medicaid. Waiver Budget Neutrality Cst Estimate The majr distinctin between the March Legislative cst estimate and the Waiver Budget Neutrality cst estimate is the availability f cmmercial data and the underlying medical cst assumptins. As discussed abve, when cmpiling the March Legislative cst estimate, Optumas reviewed Medicaid data t identify ppulatins cnsidered actuarially similar t the Private Optin enrllees and adjusted reimbursement t be cnsistent with the expected cmmercial reimbursement levels. When creating the Waiver Budget Neutrality cst estimate, the estimated PMPM premium rates ii develped by and ffered by each issuer were available. Prjecting and estimating the cst f cmmercial carriers prviding the cvered medical services was n lnger necessary, and actual cst amunts culd be used. The Waiver Budget Neutrality cst estimate required much mre detailed analyses t determine the expected demgraphic make-up f the Private Optin enrllees.

5 Page 5 Cmmercial carrier premiums (using an analgus prcess based n the carrier s wn estimated ppulatin mix, service utilizatin, and unit cst assumptins) varied by age and regin, requiring Optumas t analyze the demgraphic makeup f the individuals likely t enrll in the Private Optin. Multiple surces were researched t determine the likely age and gegraphic distributin f Private Optin enrllees. Optumas utilized data frm the Current Ppulatin Survey (CPS), the Small Area Health Insurance Estimate (SAHIE), and the American Cmmunity Survey (ACS). When reviewing this data Optumas cnsidered the lw incme ppulatin nt already enrlled in Medicaid, with a particular fcus n the uninsured lw incme individuals. These tw grups f individuals represent thse mst likely t drp their current insurance t jin Medicaid r t n lnger be uninsured and take up Medicaid cverage, respectively. By analyzing and aggregating data available frm these surces Optumas was able t develp a picture f ptential Private Optin enrllees. The data review indicated that the average enrllee wuld likely be apprximately 37 years ld, and enrllment wuld be cncentrated in regins 1, 2, and 3, with thse three representing abut tw-thirds f the ttal statewide enrllment. Additinally, prgram design cnstraints were taken in t cnsideratin. This affected the distributin f members acrss varius plan designs and carriers. The aut-assignment algrithm s rules and prcesses were used t mdel the allcatin members int plans. Since members are given the ability t chse their plan prir t being aut-assigned, Optumas als cnsidered current market share in the Arkansas individual market t help mdel the allcatin f members int carriers. If a carrier ffered multiple plans, the assumptin was made that enrllment wuld be split equally between the tw plans. Fr example, if Arkansas Blue Crss ffers tw silver plans and previus mdeling indicates Arkansas Blue Crss will btain 40% market share, then the cst mdeling gives 20% market share t silver plan #1 and 20% market share t silver plan #2. The methdlgy as described resulted in Arkansas Blue Crss receiving a 47% assumed market share, Blue Crss & Blue Shield receiving a 23% market share, QCA receiving 18% market share, and Ambetter/Centene receiving 12% market share. These figures are smewhat skewed since nt every carrier perates statewide, resulting in sme carriers having drastically lwer market share since they are nt able t receive enrllees in each regin. The member s cst sharing respnsibility was als recnsidered fr the Waiver Budget Neutrality cst estimate. While researching demgraphic traits as described previusly, Optumas als researched the pverty level distributin f expected Private Optin enrllees. This research, cmbined with further develpment and clarificatin regarding the level f cst sharing applicable t Private Optin subppulatins, led t a revisin f the previus cst

6 Page 6 sharing estimate. Accunting fr the percentage f the ppulatin expected t be belw 100% f FPL and the additinal infrmatin regarding cst sharing design, Optumas prjected that the average Private Optin enrllee wuld pay fr 1.4% f ttal csts, rather than the previus estimate f 2.5% f ttal csts. This figure was arrived at by quantifying the cst sharing expected under the prgram design fr the ppulatin ver 100% FPL using cmmercial data, cntinuance tables, and the Actuarial Value f the prpsed High Value Silver Plan design. Since cst sharing was nt allwed fr the ppulatin under 100% FPL, the allwed cst sharing fr thse ver 100% was reduced t reflect the prtin f Private Optin enrllees expected t be ver 100% FPL. The remval f 1.4% f ttal csts t reflect member cst sharing results in a final QHP services estimate f $ PMPM. This des nt include the cst f nn-qhp services Medicaid will prvide via FFS delivery. Fr the Private Optin ppulatin, this cnsists f NEMT and Early and Peridic Screening, Diagnsis, and Treatment (EPSDT). These services were estimated t cst $8.58 PMPM, bringing the Waiver Budget Neutrality cst estimate t $ Differences between March Estimate and Budget Neutrality Estimate As utlined abve, the March Legislative cst estimate and the Waiver Budget Neutrality cst estimate fllwed different prcesses, with different levels f infrmatin available at the time. Bth estimates are intended t answer the same questin hw much will Medicaid expansin cst under the Private Optin. The difference in available infrmatin explains the difference in the estimates resulting frm each analysis. The March Legislative cst estimate cntained the significant assumptins regarding adjusting Medicaid reimbursement t cmmercial reimbursement, the typical healthcare utilizatin f the expansin ppulatin, and the assumed nn-medical lad (administrative csts and prfit). These assumptins were n lnger necessary fr the Waiver Budget Neutrality cst estimate, as Optumas used premium amunts submitted by cmmercial carriers. The increase in the PMPM estimate frm the $ Legislative estimate t the $ Budget Neutral amunt is largely attributable t differences in these prjectin factrs between Optumas and the carriers. Cmmercial prjectins f these csts ended up being higher than Optumas prjectins, which caused the PMPM cst estimate f the Private Optin t grw frm the riginal Optumas estimate t the higher private cmmercial carrier estimates. Differences between Budget Neutrality and Actual Premium Spend t Date The difference between the Waiver Budget Neutrality cst estimate and actual premium spend t date is due primary t the difference between assumed demgraphic characteristics and actual ppulatin presentatin. Differences can be bserved in plan selectin patterns and cverage f nn-ehb services, hwever the mst impactful differences are in the ppulatin age. The cst estimates, based n the afrementined data review, assumed an average age just under 37. The Private Optin enrllment experience, thrugh fur mnths, indicates an average age arund 39. This 2+ year difference is wrth

7 Page 7 apprximately $24 PMPM, which is larger than the difference between the Waiver Budget Neutrality cap and the year-t-date Private Optin experience. Apart frm these differences in the assumed age, the State is spending less than prjected in the Budget Neutrality calculatins. i Crsswalk f eligibility cdes t descriptins: Eligibility Cde Descriptin 20, 21, 22, 25 Transitinal Emplyment Assistance/Aid t Families with Dependent Children 51, 52, 63 Under 18 61, 62, 65 Pregnant Wmen 91, 92 Fster Care Nte that all ppulatins were additinally limited t individuals ver 18 years f age ii Each carrier independently cnducted their wn actuarial analysis, included prjectins f ppulatin mix, estimated utilizatin, and expenditures t determined their prjected PMPM premium csts