NJSpotlight: The Impact of Medicaid Expansion on New Jersey's Healthcare System - Chapter 2
Table of Contents
- Welcome to the NJ spotlight roundtable series in this program the impact of...
- Legislation currently that would expand the scope of practice for advanced...
- Enrolled who comes in there are federal laws called an there's an intolerable...
- Say nice things um no I think it's really education and really it's...
- And in the abuja the assumption is that there are many of these people are going...
- Of need for education this is one of those issues policymakers are going to...
00:02
welcome to the NJ spotlight roundtable
series in this program the impact of
Medicaid expansion on New Jersey's
health care system this program was
recorded in trenton new jersey on march
7 2013 this program is brought to you by
amerigroup real solutions in healthcare
the hospital alliance of new jersey and
the nicholson foundation panelists on
the program today are dr. poonam awake
00:34
former commissioner of the New Jersey
Department of Health and Senior Services
and a board member of the common sense
Institute of New Jersey raymond castro
senior policy analyst from New Jersey
policy perspective Susannah yani
president and CEO of the hospital
alliance of New Jersey incorporated John
CEO of amerigroup New Jersey
incorporated and state senator joseph
italie vice chair of the Health Human
Services and senior citizens committee
moderating the program is Andrew kitchen
01:04
man healthcare reporter from NJ
spotlight in this program chapter 2 the
panel continues its discussion of the
issue moderating the program is Andrew
kitchen man healthcare writer for NJ
spotlight and I want to follow up on
that big question hopefully with all of
the panelists to get their perspectives
on with the implementation what do you
see is the biggest challenges facing the
state and do you see the pieces that are
01:35
currently in place such as not knowing
exactly the amount of funding that the
navigators are going to receive the
navigators that are going to be funded
through the the exchange and then the
the mandates and penalties that are
going to be in place under the ACA do
you see those things that are in place
being enough to reach the state's goals
or do you think the additional steps
will be needed and if so what steps and
then senator vitality i think is already
somewhat touch done that through some of
the legislation he's talked about but
i'd be interested in your thoughts on
02:06
that senator well i think that for a
time we did really good work in outreach
and when the state was
providing their share of dollars to the
Department of through the Department
Human Services that was matched by
federal dollar so as a million state
million federal at least at one time we
were effective and we were able to reach
provide dollars for organizations and
others and that could do the enrollment
there was some of of advertisement there
were bus placards and they were you know
pencils and you know yard sticks but you
02:37
know we also did some real thorough sort
of advertising and marketing program
that we'd hire people to do of the state
hire people to do that actually made a
difference and we saw them we stopped
marketing the program was so a
significant decrease in those
individuals or understand the program
known that it existed actually enrolling
in the program so there was a real cause
and effect by not having those dollars
here because it for a quite a long time
and even today it's I think in some ways
it's the state's best kept secret at
03:07
Family Care Medicaid and even though
Medicaid is you know for you know a
childless adult you have to be you know
so poor and below twenty four percent of
poverty is unimaginable so I don't know
even how you can find someone who'll is
below twenty four percent of poverty
unless you check under the overpass so
you know it's it's a horrible way to
live and for those above twenty four
percent there is nothing and so what
this is I again why the exchanges so why
the expansion is important all that's
from 30,000 feet and very important I
think the other thing we should talk
about too is the is a provider network
03:37
and be may certainly being able to have
enough primary care providers or docs
and nurse practitioners you know in the
field on the ground doing this work we
know we have a primary care physician
shortage in New Jersey and it's going to
take a long time to correct that you
know long ago I spoke to a class at
Rutgers a medical school and about 40
students and I asked by way of a show of
hands how many we're going to go into
primary care or family medicine and to
04:08
raise their hands and the rest were
going to do some other things that's
great but to have just two is really
troubling and so to even if today we
adopted the best program with tuition
assistance and loan forgiveness
by the way we do have some of that it's
going to take years to cultivate and
graduate young men and women who will be
primary care providers for the residents
in the patience of the state I've
written laws and I've introduced
04:39
legislation currently that would expand
the scope of practice for advanced
practice nurses and anyone who thinks
that well anyone who thinks that that
isn't a viable solution and a thoughtful
solution to expand the capacity for
patients in the state is I think just
wrong nurses have the ability and the
training to do this work we change the
scope of practice a few years ago to
allow them to diagnose and prescribe and
now we're trying to move them a little
bit more away from this tether that they
05:11
have to physicians we're really doesn't
need to exist to let them work
independently to the limits of their
practice limits of their license and
they do great work we have the ability
to do much much better in our school
systems and to do outreach and to
actually put advanced practice nurses on
the ground in these facilities we've
done some pilot programs in my hometown
of Woodbridge and it's been very
effective reducing absenteeism and
increasing reducing absenteeism to
school but actually also have to reduce
absenteeism in the workplace when
05:42
parents that take off from work because
they have sick kids at home that aren't
getting better faster would they will if
they were treated sooner so there are a
number of ways in which we can address
the shortage issue it's not going to be
easy it's not going to happen overnight
but if we don't begin to work on this
somehow someway now I will never get
there you know I didn't think we Susanna
smart that to say that we should you
know manager expectations but it doesn't
mean that there aren't enough smart
people in this room and outside this
06:12
room that can actually make a difference
and make this work you know years ago we
didn't think that we could do any number
of things in this state and across the
country because it took too much work
nothing that's worth something that's as
valuable important as this doesn't
require that much work it does
Thanks thank you right what are you yeah
I mean I think there are no number of
things that we need to do I think that
the first thing is we need to and and
I'm working with the new jersey
healthcare coalition which as many of
you know has been very active in the
06:43
original federal legislation and very
involved in the implementation of the
Affordable Care Care Act and I think one
of the first thing we need to do is is a
detailed study of the population that
we're going to serve who are they and
where do they live and then we need to
develop a comprehensive outreach
strategy with specific enrollment goals
based on that population and we need to
have different strategies for each group
I mean obviously in terms of how we
reach someone who's h-60 who was an
07:15
engineer loss of job no hope of getting
another job so he has zero income that
person could be eligible for the
Medicaid expansion versus a college
graduate living with mom and dad who
doesn't have health care coverage so how
you deal with those populations are
going to be very very different than
materials that you prepare physically
how are you reach them is going to be
very very different this is a very very
diverse population and studies have
shown that seventy eight percent of
everyone who is eligible for the
Medicaid expansion is not aware of that
07:45
and part of the problem here is that
these charges are eligible for the first
time and we've never had this V before
so they don't know exactly what Medicaid
yes they certainly don't know how to
apply for it so and then once we've
developed that strategy we need to
figure out well how much funding do do
we need we need to identify that funding
and I mean unfortunately once we we do
that I'm sure we're going to be able to
be funny it's not going to be sufficient
we have a huge a man then the question
becomes how can we marshal other
resources I think we need to look at in
08:17
terms of encouraging the public to be
involved I know in the in Santa and San
family care they've been a focus group
which have shown that most people know
about this from their neighbors and
their relatives so we need to have a
message out to the public that reaching
out to these folks is really everyone's
responsibility and if we all only by
working together can we really improve
the
the health of our state and also I just
wanted to add that on the navigator
program the New Jersey for healthcare
08:47
coalition is coordinating some some some
of this I suggest that you if you want
to be a navigator I suggest and we have
folks from the coalition here that you
might want to contact that organization
if you want to be a navigator at some
point I can explain a little bit about
the navigator program as well but I can
do that later thanks right Suzanne yeah
just a couple of comments I think this
Medicaid expansion is going to be more
challenging than the family care
expansion in the past because as we all
know if parents you do a lot for your
kids that you don't do for yourself
09:18
right and also i think the point of
contact i think the lot was done through
the schools so you you hit the kids
there and you also hit the parents there
but now as ray said you could have a 60
year old person and you can have a
college graduate and that so the point
to touch those those people is its
varied so i think it's going to be a
little harder this time around to enroll
everyone now for the hospitals we are
the point of contact if someone comes
into the hospital but i just want to
give you a little perspective on why
it's challenging to get everyone
09:50
enrolled who comes in there are federal
laws called an there's an intolerable
that says you have to treat everyone who
comes in and you actually have to triage
them and treat them before you're
allowed to discuss anything having to do
with how they pay or if they have
insurance so for somebody who just comes
in and it is an emergency room kind of
treat and release patient the hospital
does its best to say and now you are
going into this room to discuss you know
what programs you may be eligible some
people don't go to that next room
because they've already been treated so
10:21
I just want to put that little layer of
reality there because you know we do
have the patient we are the point of
contact but it's a lot easier to get
them enrolled in Medicaid if afterwards
they are you know if they're admitted
you have them the bed the financial
Council goes to visit them but if their
emergency room treatment release the
patient can just walk without actually
you know hearing hearing the financial
counselor out so just a little dose of
reality there dr. Ali um I think the
10:52
rest of the house talked about some of
the key
shoes that are actually going to be very
critical in making sure that this is a
successful implementation because the
state can only put together a blueprint
but the implementation and really coming
up with the best practices is our
responsibility so when you come in
addition to the physician shortage issue
the important thing is how do we retain
our physicians because they're leaving
the state there only two percent of
physicians who finish their residency
actually practice in our state so those
11:23
are some of the shorter term solutions
we're going to have to look at whether
it's malpractice reform or whether it's
looking at loan redemption programs but
again expanding the scope of primary
care and getting other non-physician
providers involved as part of the team
is going to be critical in fact there's
a lot of literature out there that talks
about advanced practice nurses and nurse
practitioners who do a much better job
in primary care than even the physicians
because they spend the time they they do
go through the preventive screening
11:55
elements of care so those are going to
be some of the things we're going to
look at telehealth telemedicine EIC use
IEDs you know things like that that
we're going to be doing electronically
are going to be critical obviously we
talked about the enrollment and engaging
the community so that they do come on to
the exchanges because that's going to be
your central a single point of entry and
so how are you going to integrate that
with the new insurance subsidies but the
important thing at least for me that I
think is going to be critical stems from
12:25
a discussion I had with a physician just
last week and he was telling me about
this patient of his had no idea how sick
this patient was and as part of the
accountable care organization initiative
we're getting all kinds of data from CMS
right now so he pulls up the patient
supposed to be coming and seeing him
pulls up the data that in terms of the
utilization and realizes that over the
past year this patient has utilized a
health care costs of 220,000 dollars
12:58
with 20 admissions and he had no idea
that this was happening so he gets back
with the rest of the specialists who are
taking care of these
asians they come up with a plan they
come up with a home care a solution for
this patient put her into rehab CEO pad
had lung disease put her in an
appropriate rehab program and start
managing the patient and start talking
about palliative care so this is sort of
an an example of what we have to do if
the Medicaid program is going to be
successful we need transparency we need
13:31
data we need data at the point of care
to understand where the gaps in care are
how are we going to bridge it what is
the best solution well how fragmented is
this care and how are we going to bring
all this together and then to be
reporting on quality because it is how
it has to be competitive we have to be
looking at what is the best solution for
what population segments something that
we talked about earlier is what is this
population going to look like what are
how are we going to stratify them how
are we going to risk allocate them what
are those targeted interventions that
14:03
are going to take care of those specific
segments of our population for which
we're going to get the best possible
outcomes those are going to be key and
that's where we as a healthcare
community will have to come together and
make the seamless in addition to being
able to integrate behavioral and men and
physical health that's going to be
critical if we're going to be able to
succeed in Medicaid
senator vitality wanted to follow up
okay you don't want to cut me off
senator thank you I appreciate that I'll
14:34
say nice things um no I think it's
really education and really it's
education for three groups its members
which we've talked a lot about already
and I'm not just saying this because
senator vitality let me speak but you
know new juice is going to be a little
bit different than other states in the
fact that due to Center Vitale's
leadership single adults in our state
have had coverage previously so is that
going to make us a little bit different
maybe than other states and and as I
think about education for policyholders
you know there are a lot of new
variables out there that are going to
15:07
change the dynamics in the marketplace
one you've got the subsidies in the
commercial exchange to you've got other
states that even if New Jersey is in
advertising perhaps as much as we would
like New York is going to be we would
expect what's that going to do there's
some other you know the the consequence
of the federal tax penalty even though
none of these people will actually have
to pay it because the the cost is far
above the hardship level how is that
going to impact people in terms of their
15:38
enrollments so we're going to have to be
agile in terms of adjusting to what are
the effects of these policy changes that
we've made the other thing I would say
about provider education one of the
important steps of the ACA is primary
care doctors will get paid at a hundred
percent of Medicare now it's only for a
two year period frankly it's taken a lot
to get that off the ground but I feel
fairly certain a large number of
providers don't realize that is supposed
to happen some level they don't realize
16:10
because it isn't happening but once it
does and what does that do in terms of
PCP availability so on and so forth and
the last thing I would say obviously i
think senator vitality and i would
disagree in terms of the degree of PCP
shortage in our state but undoubtedly as
the senator points out scope of practice
here in New Jersey for nurses needs to
be expanded we're behind other states
those sort of common-sense changes
should be made regardless of sort of
where we
we stand in terms of supply they do a
16:41
great job why would you cut somebody
like that out from the market but for me
it's really education to those three
groups thank you John senator I just
want to follow up on two things one with
Suzanne said and John the first I think
you talk a little about accountability
does we have all these great ideas and
programs in place now and sometimes
there just is an accountability so Suzie
I'm talked a little bit earlier about
you know really tracking down that
patient who presents at the emergency
room you can't ask them out of the gate
if they have insurance although the
probably some can be creative with that
17:13
but it's about what happens afterward
but you know we have an opportunity to
gather that information and we do that
now and we're supposed to be doing that
in our schools so when when you know
parents send in that slip with all that
information on the contact information
there's now a check off that we did that
asks whether or not that parent has
insurance or whether the trial has
insurance and in this state is supposed
to follow up you know we could think
about doing that and some of our
hospitals or points of contact where
people leave without answering the
questions but their information and
17:43
others may have issues but we're not
asking for something that's that
dramatic is there not ensure that we can
that the state can follow up
electronically through the through the
hospitals and information they provide
to send those individuals applications
or information about the program but
there has to be has to be thoughtful has
to be thoughtfully designed then
produced then it has to be
accountability and I say that because
what's frustrating now and we have this
program now Family Care and you know we
18:12
we have told our schools that and asked
our school is that when you get that
slept that says your child is not
insured but that students not insured
that information is supposed to be
electronically communicated to the state
and the state then sends the information
to that parent cities like Newark and
Camden and others some of their biggest
cities with some of the most uninsured
children are not doing that at all and
it's just good one thing not doing that
at all and so we're going to I'm going
to begin to address that issue why isn't
18:45
it that they can send that information
that's on a database isn't about paper
and war
having to pay someone thousands of valve
to send this information even they had
to do that so what but to send that
information and what are they waiting
for us we've got thousands of kids who
don't have health insurance and they
could potentially have it or least some
of them if there's parents had the
information so all I'm saying is that
there has to be accountability in all of
this accountability for me who write
these crazy laws and then for those who
provide the information and provide the
19:15
services as well right yeah I just want
to follow up on that the internment and
I think to you know support this senator
here when Andrew was talking about the
hundred thousand about who are going to
go on the rolls those are the childless
adults only okay also there are there
are folks who are currently eligible
where we expect an increase in
enrollment which is sometimes called the
woodwork effect or thorn to the welcome
mat effete so as they hear about the
program more people are going to apply
19:47
and in the abuja the assumption is that
there are many of these people are going
to apply because of that also the we
have the individual mandate so in
addition to the 100 south south south
and we're going to be a hundred percent
federal matching funds there's going to
be a ask you about 60,000 parents are
also going to be at going to enroll
that's 160 thousand adults plus which
more children are expected I don't have
those numbers right here they expect a
substantial number of children and an
adult at the welfare level will be a
20:18
plot line as well so the total number
who are going to be going on in and
going into HMOs it's much much higher
than the hundred south-south thousand
and I know we've been talking a lot
about enrollment but we also need to
think about the the other side of this
which is what kind of benefits are they
going to get and here there's a great
deal of flexibility in the expansion
it's one of the most positive pieces of
the legislation I think it's in line
with what it has been said earlier that
we need to sort of transform Medicaid
and look at it in a new new new way the
20:49
way we've done benefits in the past it's
pretty much follow federal regulation
some things you have to do then you have
options that you may may or may not want
to do here we have very broad
flexibility and we have an opportunity
to actually have a benefit package that
is better than what
is in Medicaid now and we can target it
to this group's I mean we know a lot of
these adults have substance and mental
health problems so why not target those
services and there are other services as
well so so we should really look at this
in a different way rather than have a
flat benefit package let's look at the
21:21
needs of this particular population and
then provide the services to meet those
needs thank you everyone Oh John yeah if
I might follow up sue Devon on senator
Vitale's point I I think he's exactly
right in terms of the accountability but
also in terms of some there are some
very basic things we can do as a state
that will make some very real
differences and and one of them as the
senator is getting to is demographics
21:51
how do you reach these people what's the
contact information the state Medicaid
human services department has had a
long-standing effort to improve their
enrollment sista their demographic
system I'm optimistic that that will
make real differences a concern I have
is just if you think about changes in
the last 10-15 years about how we all
talk to each other it's a it's affecting
the Medicaid population as well they do
use cell phones but frequently they buy
22:22
the disposable type so the numbers
changing and one of the key you know a
very simple thing not necessarily simple
idea but may be difficult to execute as
if the state could store multiple phone
numbers because these phone numbers
change you know our ability to get in
touch with people is really vital to
educating them so i think the center is
exactly right there's some very basic
stuff that we got to do that can make a
big difference but we got it we got to
pay attention to it i wanted to return
22:52
to the point you made about the
increasing reimbursement for error
payments to medicaid
for doctors who treat Medicaid patients
now that my nursing is that that's
already gone into effect in a sense in
the any care that doctors have provided
since January first will receive that
elevated level but because of delays in
the federal regulations now there have
been delays in the state regulations so
doctors aren't really aware of some
23:24
doctors are aware of it but they're not
aware of how it will work or when that
will come in any thoughts from the panel
on whether this will be significant in
increasing the number of doctors who
will treat patients who who are in
Medicaid well let me say a couple things
first if I might one you're absolutely
right so doctors already provided the
services will get that payment
unfortunately you're also right and it's
true I think in all 50 states at this
point nobody's been able to implement it
23:54
at this point federal government's
demanding some real accountability in
terms of making sure that the feds are
paying for this increase entirely so
there are accountability issues and
states have to submit plans but to the
federal government before that gets
approved so there's unfortunately a lot
of gears in place that have to happen
before the the money gets out into the
doctors hands in terms of whether
whether it will work or not I'm
optimistic but as I said before in terms
24:25
of need for education this is one of
those issues policymakers are going to
have to follow and potentially adjust to
one of the the big frustrations in our
business is fifty percent of all doctors
in new jersey if you call them and you
say medicaid that ends the conversation
they don't want to have a discussion
with you about how much will pay you
that's it they don't want to talk about
it so hopefully this changes that
percentage in some way and there can be
24:56
better recruitment whether that's going
to work or not that's just one of those
unknowns and until that policies out
there in in place you don't know but i
do think it's vital to Senator Vitale's
point accountability we got to get this
done got to get this done sooner than
we've gotten it done so far so
not sure but hopefully it does have an
impact I i would agree i mean i think in
addition to accountability we really
look at this more broader planning
perspective i mean you know a lot of the
25:26
an affordable care act there are a lot
of opportunities but this is really a
partnership with with the state you know
i agree that if all over doing is simply
increasing the paycheck for fri frankly
a primary care physicians it's going to
have very little impact but we should
really and by the way this is going to
have we're talking I believe hundreds of
millions of dollars here so this is not
a small initiative because New Jersey
was either dead last was very close to
dead dead last in the country so it
25:58
would appear the reimbursement rates
going to be about doubly so so that's
very positive but we need it but what's
this happening we didn't need to have
sort of a strategy of how can we use
this as an opportunity to develop and
you know first of all assess where the
need is in terms of more primary care
physicians and then try try try to use
this as a way to encourage physicians to
participate in the program simply
mailing a check to them is not going to
do it the state has to do a lot and the
26:27
HMOs have to do a lot I think the
Medicaid a division needs to have some
some accountability standards we need to
have some goals so we need to address
the entire issue of reimbursement and
any shortage that might exist with
respect to primary care physicians so
again being a physician and having
talked to a few physicians about this
I've got mixed reactions so some of them
are excited because again to your point
26:59
where amongst the lowest when it comes
to our Medicaid fee schedule and some of
them a lot of them actually are saying
well this is just a two-year fixed so
what's going to happen after that now I
have a relationship with my patients I
can't abandon them so should I to even
go into that and my advice as I'm
talking about this issue is that this is
sort of the the roadmap to how things
are going to change and how we need to
be making
things like our Medicaid accountable
27:29
care organization successful so now as a
group of providers we start looking at
the care of the comprehensive care for
these patients and then at the end of it
if the projected savings is if there are
any projected savings then everybody
gets a piece of those projected savings
if the quality measures continue to rise
now the Medicare accountable care
organization is based on that premise
and I have to tell you that the third
party payers the commercial payers have
27:59
been really great at adopting what's
happening in terms of changing how we're
reimbursing for health care and there
have been the catalyst to what's going
to happen in the next few years when it
comes to making sure that we're paying
for good outcomes not purely for
utilization so so if we all we did was
increase the the fee schedule for two
years we've actually lost a huge
opportunity we have to do that in tandem
to getting these positions engaged
28:30
excited and looking at those
opportunities from the Affordable Care
Act and seeing how we can mobilize it
right here in our state and get the
right partners together to be able to
bring about successful results so I see
this the next two years as critical in
terms of shaping what our Medicaid
reimbursement strategy is going to be
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29:00
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