Health Policy Institute of Ohio Medicaid Enrollment and Impact Project

! !

Health Policy Institute of Ohio Medicaid Enrollment and Impact Project Submitted to: Amy Rohling McGee President Health Policy Institute of Ohio [email protected] (614) 224-4950 ext. 305 ! Prepared by: Sprout Insight, LLC Kathy Burklow, PhD [email protected]!

! !

Lisa Mills, PhD [email protected]! (513) 351-5555

November 3, 2014

1

Table of Contents Background Information Methodology Results Medicaid Expansion Coverage Group • Overall observed trends related to Medicaid expansion • Trends in usage • Segments who have gained coverage • Health status of patients seeking care • Access issues • Emergency Department use • Issues of cost and affordability • Non-use of coverage • Health insurance literacy and consumer education • Patient education efforts • Monitoring of changes Marketplace Coverage Group • Overall observed trends related to patients receiving coverage through the Marketplace • Trends in usage • Emergency Department use • Change in prescription drug coverage • Issues of cost and affordability • Coverage for those who cannot afford care • Non-use of coverage • Health insurance literacy and consumer education • Patient education efforts Future Challenges and Additional Considerations with Medicaid and Marketplace Insurances • Challenges facing the healthcare sector • Challenges facing the patient consumer sector • Additional considerations Conclusions

1 1 2 2 2 3 4 4 5 6 7 7 8 8 9 10 10 10 11 11 11 12 12 13 14 14 14 16 17 17

1

BACKGROUND INFORMATION The Health Policy Institute of Ohio (HPIO) contracted with Sprout Insight, LLC, an Ohio-based independent research organization, to explore the perspectives and experiences of key professional stakeholders who have been serving or representing Ohio residents receiving healthcare insurance through Medicaid expansion and commercial providers as a result of the Affordable Care Act. This project relates to HPIO’s strategic objective to ensure timely access to comprehensive, integrated and appropriate health services. HPIO will release the brief associated with this work in early December. METHODOLOGY HPIO staff distributed an email invitation to a contact list of 40 eligible stakeholders across Ohio that included hospital and health center representatives, physicians, Medicaid managed care organizations, and consumer advocates. Following distribution of this email invitation from HPIO, research staff members from Sprout Insight followed up via telephone calls and emails to ascertain interest in participating in the project. To ensure representation across a variety of healthcare sectors, stakeholders who agreed to be interviewed were recruited until targeted cell numbers per sector were satisfied, with a total goal of completing 25 interview for this project. For those willing to participate, Sprout Insight research staff scheduled 30-minute individual in-depth telephone interviews at a time convenient for stakeholders. Participants were asked to share their observations across the past 9 months with regard to the recent trends seen in overall usage and access of healthcare among patients eligible for or receiving Medicaid as a result expanded coverage. In addition, stakeholders were asked for their observations regarding issues of cost and affordability, levels of health insurance literacy, organizational monitoring, and challenges, opportunities and impact as a result of Medicaid expansion. Stakeholders were also asked to share their observations for these same coverage aspects for patients who had accessed commercial insurance through the marketplace in accordance with the Affordable Care Act during this same 9-month period. All interviews were conducted between October 6, 2014 and October 21, 2014. The total number of stakeholders interviewed for this project was 27. Sprout Insight research staff thematically analyzed the qualitative findings that emerged from all of the in-depth interviews. Results are presented separately below for the Medicaid expansion coverage group and the marketplace coverage group. To maintain the confidentiality of stakeholder respondent, only the health sector is identified following the supportive quote listed.

2

RESULTS A total of 27 key stakeholders from a variety of healthcare sectors provided input for this project. Table 1 below shows the distribution of the health sectors represented by the stakeholders who were interviewed. Table 1. Distribution of health sectors represented across participants Sector n= Hospital 6 Physician 2 Medicaid Managed Care 3 Consumer Advocates 3 Free Clinics 4 Community Health Centers 6 Pharmacist 1 Mental Health/Addiction Providers 2 Total 27 Medicaid Expansion Coverage Group •

Overall observed trends related to Medicaid expansion

In general, stakeholders reported observing a decline in the number of self-pay, or uninsured patients in their sector and a corresponding increase in Medicaid patients. This was a trend that they attributed to Medicaid expansion. We have had over a 50% drop in self-pay patients…There has been a corresponding increase in the number of Medicaid patients, or the number of people newly eligible for Medicaid.-Hospital We are seeing a trend of decline in self-pay patients. We were at 11% of self-pay patients and now we are below 5%. –Hospital We found that there was a decrease in uncompensated care. There have been upticks in the Medicaid book of business. – Hospital Over 50% of our patients have Medicaid. It used to be less, but has increased with the Medicaid expansion. The Medicaid expansion has been a financial benefit to health centers in addition to being beneficial for patients. –Community Health Center The community health centers are seeing a substantial decline in the number of uninsured patients. Some places went from having 50% of patients who are uninsured drop to 30%...some places have seen the number of uninsured patients they see drop in half. Most of these patients became insured through Medicaid.-Community Health Center

3 In the behavioral health population, for example, the Medicaid penetration rate preexpansion was about 59% and now it is about 74%...a pretty good shift. –Mental Health

•

Trends in usage

Stakeholders did not report consistent trends in healthcare usage as a result of Medicaid expansion. Some stakeholders reported that utilization of healthcare did not increase, whereas others reported that utilization had increased. We have seen an increase in new patients and a decline in returning patients.–Free Clinic Utilization is not up. –Consumer Advocate We have had a 20% increase in the number of patients we have seen. –Free Clinic In terms of volume of patients, we haven’t seen a change.-Hospital We haven’t really seen an increase in demand for care.-Community Health Center Some stakeholders explained that the increases in usage were reflective of pent-up demand for healthcare services from patients who had been delaying their care and were getting their healthcare needs addressed for the first time now that they had coverage. Similarly the types of services that patients were seeking not only included primary care issues, but were for specific needs such as dental, vision and behavioral health care, services that many individuals could otherwise regard as optional if they had to pay for these services on their own. In addition, healthcare providers could also take care of patient’s outstanding needs, such as lab work, without being as concerned with cost. With the Medicaid expansion population there is considerable pent up demand to healthcare needs…Plans are seeing these people accessing care to catch up and get their issues taken care of now. –Medicaid Managed Care There was considerable pent-up demand. We have seen a lot of growth in the areas of dental, vision, behavioral health and inpatient admissions in particular.-Consumer Advocate There has been an increase in demand for behavioral health in particular among Medicaid patients. –Community Health Center There has been an increase in demand for our therapy services as well as substance abuse services.-Community Health Center With more patients having Medicaid, doctors don’t have to worry as much about prescribing lab work.-Community Health Center Other stakeholders believed that the number of patients seen had not really changed, but only the method of payment had changed.

4

We haven’t had an influx of new patients. They just have moved from uninsured to being covered through the market place or Medicaid. There hasn’t been a change in number of patients, just how they pay.-Community Health Center Our script volume hasn’t changed. We haven’t really had an increase in the number of patients, just changes in what insurance their prescriptions are going through.-Pharmacist •

Segments who have gained coverage

Stakeholders consistently cited that patients who have most benefited from gaining coverage included older single and married adults, men, individuals with mental health issues, homeless individuals, and the working poor. Childless adults who generally have 1-2 jobs that still result in a poverty level income for single adults, or parents of children who have incomes just around the poverty line…We have seen adults and parents come onto the rolls.-Hospital People with mental health issues are gaining coverage. This is a tremendous plus for those needing mental health services and medicines.-Physician About 50% are over 40 years of age.-Medicaid Managed Care We are seeing a large group of single males and females without children gaining coverage. We expected a younger population. This group is older than expected—age 40 plus. –Medicaid Managed Care There were a lot of people in their 50s that work who weren’t covered. They weren’t eligible for Medicaid before. –Community Health Center Those people aged 45-60 who were maybe employed by a small employer or were unemployed didn’t have coverage and now with the Medicaid expansion, are covered.Community Health Center

Men, particularly young men from the ages of 18-30 with no family, no children. This group used to be left out.-Community Health Center Homeless folks are gaining coverage. Also working poor that have recently lost their job and end up in shelters—these people are newly homeless and gaining coverage.Community Health Center

•

Health status of patients seeking care

Several stakeholders shared the acute health status of patients who sought healthcare services as a result of Medicaid expansion. Stakeholders did not anticipate this poor state of health among patients.

5 Providers in the primary care area have shared that the new patients they are seeing that have Medicaid are complex and sick because they didn’t have good access to care before.-Hospital The overall health acuity of the members is higher than originally anticipated. The population is older than what was originally anticipated.-Consumer Advocate Since they are older, they are sicker than expected.-Medicaid Managed Care We are finding that the acuity [of overall health state] of people is worse than expected because people were not attending to their needs all along.-Medicaid Managed Care •

Access issues

Stakeholders who reported experiencing increases in patient healthcare usage often tended to represent specific healthcare sectors, such as free clinics. According to stakeholders from these sectors, patients appeared to be experiencing challenges with finding providers who accepted Medicaid. As a result, patients were opting to go to free clinics where they could have a shorter wait time for appointments. In a similar vein, stakeholders shared that patients seemed to be having the most difficulty with gaining access to care at doctor’s offices where capacity was limited due to small numbers of physicians who were accepting Medicaid. Stakeholders believed that access to care was at acceptable levels in major metropolitan areas, but not so much for individuals living in rural areas of the state where few providers offered appointments for Medicaid patients. There are new patients that have Medicaid, but can’t find a provider.-Free Clinic It has made access worse because more people are vying for fewer spots.-Hospital Capacity issues mainly are in the doctor’s offices. Medicaid has different plans with specific providers. Each doctor has to take a certain number of patients for each type of Medicaid plan. Once the slots are filled, they are filled and new patients have to find a doctor that has a slot open for them.-Free Clinic Doctors are stopping to donate their services [in free clinics] because they are taking so many Medicaid patients and they are full.-Free Clinic There has been growth in the number of patients needing care, but there is a shortage of physicians to provide care to these patients.-Community Health Center There are places where you can see a primary care provider in major metro areas. I don’t think there is an issue with lack of access no more than with the average person. I do think that individuals in rural communities may have more trouble accessing primary care providers and, in particular, specialists due to their location.-Medicaid Managed Care

6 To combat the increased service demand and help increase access, some stakeholders at Federally Qualified Health Centers reported that they have been able to hire new staff and expand services to fill the need. We have been hiring primary care providers like crazy. We have added two new sites as a result.-Community Health Center •

Emergency Department use

Stakeholders reported that Medicaid expansion did not seem to be having an impact on Emergency Department (i.e., Emergency Room) use. There have been no real dramatic changes—just normal organic growth. I don’t think Medicaid expansion has either encouraged or discouraged ER use.-Hospital We have not seen any really huge spike in the utilization of Emergency Departments in the state of Ohio, at least that is what we have been told.-Hospital There has not been more ER usage than expected because we expected there to be a lot of ER usage….This is where the expansion population used to access care prior to coverage.-Consumer Advocate I don’t think there has been a flood of people coming to the ER. I don’t think that has changed much.-Community Health Center Although stakeholders did not report significant increases in Emergency Room usage, they did express sensitivity to this topic and underscored the importance of needing to educate patients and engage them in a cultural shift to discourage them from using the Emergency Room for their primary care needs. These people are accustomed to going to the Emergency Room for care and getting good care. Why would they go elsewhere? We need education and a cultural shift to change this. Right now these people can go to one place (ED)… to get everything done that they need in one day and in one location.-Physician For Medicaid patients, there is high ER usage. This is a symptom of having a lot of ERs in Ohio. We need to deal with how we encourage ER use by having access to other options. We need primary care providers to be available during non-normal business hours, like nights and weekends.-Medicaid Managed Care We [community health clinic] have implemented walk-in hours to try to help deter people from using the ER. Before, we were not open late…but now we stay open later a few days per week.-Community Health Center

7 •

Issues of cost and affordability

Stakeholders unanimously agreed that there were no real issues related to affordability of healthcare for patients with Medicaid. The only exception to affordability in relation to Medicaid coverage was for individuals who received Modified Adjusted Gross Income (MAGI) Medicaid benefits and who faced large spend downs. For Medicaid, there is no out-of-pocket expense, except maybe for pharmaceutical.Medicaid Managed Care

For people on Medicaid, they don’t have to pay anything, so there are no affordability issues.-Consumer Advocate Medicaid seems to be affordable. There are almost no co-pays, except for people who have spend downs.-Community Health Center If a person is eligible for Medicaid, healthcare IS more affordable and they have access to coverage. The out-of-pocket expenses for a person on Medicaid is not so bad.Physician

Medicaid is the Cadillac of Insurance…this is the best coverage in the country. There are no co-pays. The only issue is wait times. A new Medicaid patient will have to wait 2-4 weeks to get in to see a primary care physician. For a specialist, the wait is typically 1-3 months.-Free Clinic •

Non-use of coverage

Stakeholders reported that many patients did not use the coverage that they had for healthcare services, primarily because they were not accustomed to engaging in preventive healthcare or they were experiencing barriers to getting an appointment. A lot of people don’t use their prevention services. It is about consumerism, not necessarily a Medicaid issue. For the working poor and the generationally poor, health prevention does not become a priority. –Medicaid Managed Care People can go to the ER…I have seen people going to the ER not using their insurance coverage, because they cannot get in to see a primary care physician.-Free Clinic Once in a while you will have people that say they have it if they need it but don’t ever use it. And then there are those that just don’t like to go to the doctor. –Community Health Center

Patients [who] now have Medicaid have chosen to go to another provider instead of continuing to be seen at our health centers. I would say this is primarily because of wait times to be seen...Probably about 20% of our patients have left our health centers for another provider.-Community Health Center

8 Several stakeholders also mentioned a subgroup of individuals who may be eligible for Medicaid but do not enroll because of mistrust of the government. [There are] those [who] are eligible for Medicaid but won’t complete the application process to become enrolled. Some people are reticent to enroll either because they have a distrust of the government and have their information “out there” or because they have an attitude that they don’t want anything free from the government.-Hospital There are some patients that have refused to sign up because they don’t want to be connected with the government. They don’t want to be in a government program. Mental Health

•

Health insurance literacy and consumer education

Stakeholders consistently and recurrently commented on the poor level of health insurance literacy among patient consumers. Stakeholders commented that patients with Medicaid have an easier time understanding the products. The greatest concerns with poor health insurance literacy related more to the commercial marketplace and the Affordable Care Act (to be discussed in greater detail in later sections). Nonetheless, stakeholders commented that Medicaid coverage was also confusing for some patients. People don’t know that they need to sign up for a HMO and a primary care doctor or otherwise they will be assigned to one if they have Medicaid. Patients don’t understand this. There are a few networks or patients to choose from and some networks are just not good.-Free Clinic Medicaid is still a little confusing as well. You have to understand in-network versus out of network and figure out how to and that you have to pick a managed care program.-Community Health Center •

Patient education efforts

Most stakeholders reported putting into place a variety of ways to help patients learn of their eligibility and enroll in Medicaid coverage as well as how to use their insurance. These efforts range from offering outreach educational presentations to hiring certified staff to work directly with patient enrollment. We hired about 200 people to do education and enrollment. These people have to be certified.-Hospital We are concentrating on educating patients on enrollment options. We actually have a vendor that helps people to enroll in Medicaid. These vendors counsel people in the Emergency Departments.-Hospital

9 The Medicaid managed care companies do phone calls and visits with their clients so the patient can be an active participant in the process of getting healthy.-Medicaid Managed Care

We have assigned a new navigator to new members; The navigator provides conciergelike services to new members. People have been doing trainings.-Medicaid Managed Care We developed a card that lays out the basic information on how insurance works.Consumer Advocate

We have a Vista worker that does community outreach.-Free Clinic For Medicaid folks, we are trying to educate people how to use their insurance correctly. For instance, letting patients know they don’t have to go to the ER for routine care.Community Health Center

•

Monitoring of changes

Stakeholders varied in their level of organizational monitoring or measurement of changes related to increased Medicaid enrollment. Some stakeholder organizations track payer mix and charges whereas others track staffing and patient clinical indicators. Other stakeholders are not currently tracking any data related to Medicaid enrollment. The stakeholders with the most sophisticated monitoring systems accessed beneficial digital tools, such as electronic medical records and software, to help with tracking. These tools may not be available to smaller organizations. We are tracking several things. We are tracking people that we do presumptive eligibility for—did they complete the Medicaid application? We are tracking the payer mix. We are tracking bad debt. We are tracking the number of days in accounts receivable. We are also tracking the other indicators for quality like readmission to the ER.-Hospital We are monitoring charges: uninsured gross charges, Medicaid charges and commercial charges. We have looked at inpatient data regarding discharges for uninsured, Medicaid, and commercially insured and on the outpatient side for visits.Hospital

We monitor to see whether or not members have received a health assessment and a face-to-face visit, if needed, based on their health risk. We measure a members’ satisfaction with the health plan as well as physicians and other specialists providing services to them.-Consumer Advocate We have an electronic health records system This allows us to run reports on people [who] haven’t come back to see us [who] should have. This way we can track them down and follow up with our patients. –Community Health Center

10 We track our patients to see if they have Medicaid to verify that they can continue with treatment. We use this information to figure out staffing needs.-Mental Health We look back on the health center report annually on 17-18 measures, such as controlled blood pressure, entry into prenatal care, patients with low birth weight babies, screening of BMI.-Community Health Center We don’t really have anything that we are following.-Physician Stakeholders reported using this gathered data and information to determine strategic direction and advocacy efforts. We use this information not only to determine strategic direction but for advocacy. We want to educate the legislators on the positives of Medicaid expansion.-Hospital It helps us with regard to advocacy efforts…[to show] the importance of expanding coverage and reducing the number of uninsured Ohioans in the marketplace. We also use it to track whether or not our hospitals maintain their economic sustainability over time…. [We know] that many hospitals in the state cannot sustain their operations with a payer mix made up wholly of public programs and the uninsured.-Hospital Marketplace Coverage Group •

Overall observed trends related to patients receiving coverage through the Marketplace

The following sections describe the trends that have been observed regarding patients who were eligible for or who are enrolled in Marketplace coverage in association with the Affordable Care Act. •

Trends in usage

Stakeholders did not report an increase in utilization of healthcare associated with patients who have received Marketplace coverage. Stakeholders largely attributed this lack of increase to affordability and the limited amount of coverage that they purchased. (This issue will be discussed in greater detail in the Issues of Cost and Affordability section below). There really hasn’t been an increase in demand for care for patients that received coverage in the Marketplace.-Community Health Center There hasn’t really been any additional demand for care from those who purchased insurance through the marketplace. …Most only got catastrophic insurance, so they still aren’t really covered for the day-to-day things that come up like getting sick with a cold. The result of this has been no increase in demand for healthcare for this population. – Community Health Center

11 •

Emergency Department use

Stakeholders reported that Marketplace insurance did not seem to be having an impact on Emergency Department use. Just because the expansion population has insurance doesn’t mean that they know how to use it. They have learned over time to go to the ER for all of their needs because they have no money and can still receive treatment at the ER.-Medicaid Managed Care

•

Change in prescription drug coverage

As with Medicaid plans, prescriptions, in most cases, do not cost the patient. For prescription drugs that are not covered, pharmacists must get approval before filling the prescription. With the marketplace exchanges, the pharmacist interviewed for this project reported greater restrictions. [Affordable Care Act] exchanges seem to be more restrictive. There seems to be more drugs on this plan that aren’t covered. However, a doctor can follow the same process of getting prior authorization to get the drug approved for the patient. -Pharmacist •

Issues of cost and affordability

Cost and affordability were the top two challenges that stakeholders spontaneously mentioned most consistently and recurrently when discussing patient experiences with Marketplace insurance obtained from the exchange. Stakeholders reported that the high deductibles, premiums and co-pays associated with the Marketplace insurance were prohibitive for patient consumers. Below is a selected list of comments from stakeholders on this issue. For the marketplace insurance, affordability is a huge concern. Even at the bronze level of coverage, consumers can’t afford the deductibles. People are paying for coverage that they can’t use when they need it. If they can’t use the coverage they are paying for, they can’t access primary care before they are really sick.-Consumer Advocate People have to choose between paying for healthcare and paying for a relatively safe and decent place to live.-Consumer Advocate These policies have high deductibles. About 28% of our patients have high deductible plans. The people enrolling in these policies off the exchange are low income and it is hard for them to pay [for the high deductibles].-Hospital People who purchased plans are not able to make the premium payments of the plan they chose and their policy lapses.-Community Health Center

12 With the plans going into the commercial market, those people who are working poor who don’t qualify for Medicaid. We are finding huge problems with the deductibles. They live hand-to-mouth, paycheck-to-paycheck, if that. Then they have a $5000 deductible. They aren’t coming in for care. We see a lot of people coming in with opiate addiction and they are still working and are making even $15 per hour, but $5000 is insurmountable for them. They can’t think about doing that.-Mental Health We have heard from FQHCs that patients still can’t pay for their primary care visits even though they have insurance. They struggle to pay for a visit.-Consumer Advocate

•

Coverage for those who cannot afford care

Stakeholders shared several different options for patients who could not afford to pay for their care. With the exception of care from free clinics, these options including instituting payment plans, offering sliding scales, and accessing indigent dollars. We do financial counseling with patients to work out a payment plan if they can’t pay.Hospital

If a patient can’t pay, we will allow them to spread out their payments over a 2 year period. But at some point, if they are still unable to pay, we will have to write it off.Hospital

We have a sliding fee scale.-Community Health Center We are trying to keep our indigent dollars available where we can. What we are seeing is that the dollars don’t go as far as they used to because costs have gone up and reimbursements have stayed flat or gone down actually. –Mental Health •

Non-use of coverage

Because of high costs associated with premiums and deductibles for Marketplace insurance, stakeholders stated that they see many patients in this insurance coverage group not using their coverage even if they have it or see patients stretching out visits with their physician to save costs. Patients don’t get lab work that is ordered for them because they can’t afford it. Doctors are trying to space out their patients’ lab work and appointments so that they can afford what they need to have done, cutting down on continuity of care.-Free Clinic

13 •

Health insurance literacy and consumer education

Although health insurance literacy was not reported to be at very high levels for the Medicaid or Marketplace coverage group, stakeholders repeatedly mentioned poor health insurance literacy as a greater challenge for the Marketplace group than Medicaid group due to the complexity of the exchange. Stakeholders stated that patients found the entire process--from selecting and signing up for coverage to understanding what services are covered and how to use the coverage—“confusing” and “overwhelming”. I think people have been seduced by plans where the premiums are the lowest. Then they don’t fully understand that the coverage may not be as comprehensive as they thought it was when they first bought it…which would explain part of the trend we are seeing in bad debt. -Hospital The level of literacy is low. We find that they don’t know how their insurance works or how to use their insurance. -Physician The learning curve is not as much for someone that has been employed before and has had insurance as it is for these people who have never had insurance before.-Medicaid Managed Care

A lot of these people haven’t ever had insurance before. This is all a foreign language to them.-Medicaid Managed Care People that haven’t had insurance really don’t understand all of this. There is coinsurance, co-pays, cost-sharing, premiums, etc. And the rules are so confusing…Shopping for plans is very complicated…There is such a variability in products that it is too complicated for the consumer.-Consumer Advocate I think that it is not understanding that the insurance is more of a catastrophic policy for them, not a policy they can use.-Mental Health The Marketplace insurance has not been only confusing to patients, but it also has been confusing to hospital intake professionals and physicians as well, preventing these professionals from helping patients to understand the exchange. Insurance on the exchange has been an issue for intake personnel at the hospitals. Some commercial insurance carriers have plans available on the exchange. It is not clearly stated on patients’ insurance card that they have a plan through the exchange…Plans that are available through the exchange may have different innetwork and out-of-network doctors, for instance, from their commercially available insurance plans. It is difficult and confusing for intake personnel to know what is covered and what is not…It is very confusing not only for the consumer but also for the provider.-Hospital

14 Patients are looking to their primary care physician’s office to help them understand all of this and sometimes the people in the physician’s office don’t even understand it. Physician

•

Patient education efforts

Efforts to educate patients around Marketplace insurance options were no different than efforts to educate patients around expanded Medicaid coverage as described previously. As mentioned above, these efforts included activities such as offering outreach educational presentations in the community, hiring certified staff to work directly with patients, and distributing informational materials. Future Challenges and Additional Considerations with Medicaid and Marketplace Insurances Stakeholders recognized several future challenges and opportunities facing the healthcare sector and consumers related to Medicaid expansion and Marketplace insurance. •

Challenges facing the healthcare sector

For Medicaid coverage, stakeholders shared concerns for the healthcare sector related to payment model of reimbursement and payment levels. Even with drawbacks, however, stakeholders believed that “Medicaid expansion has been a good thing.” As one stakeholder stated, “I think it would be an awful, horrible terrible tragedy if Medicaid expansion doesn’t continue past June.” Stakeholders underscored the importance of continuing Medicaid expansion in Ohio in the future. Healthcare sector future challenges with Medicaid expansion •

Payment model and reform

The Affordable Care Act is a good thing because it improves coverage. It is a poor thing because we need to change the payment model and the Affordable Care Act is not helping to do that. We currently have a fee-for-service model. This does not reward health, quality or efficiency. It rewards excessive surgeries. It doesn’t promote, for instance, taking charge of your health and losing weight or case management. The system and the payment model needs to reward quality of care and value.-Hospital We need to encourage patients to be informed and engaged. This requires payment reform as well. The doctor needs to be given time to answer the patient’s questions...If we have hands-on primary care, we can prevent a lot of hospitalization.-Consumer Advocate

•

Payment levels

Medicaid is paying at the Medicare level, so things are going okay for now. Physicians have been able to take Medicaid patients, but they can only take so many and be able to keep their doors open. If the increased pay rate goes away, there may be a

15 problem…physicians will probably have to decrease the number of Medicaid patients they can take. -Physician •

Continued support for Medicaid expansion

If the expansion isn’t continued, there will be an increase in self-pay patients again. Under ACA, primary care physicians receive an increased rate. Their Medicaid rate is paid out at and bumped up to the Medicare rate of pay. This helps patients have increased access to care. Because of this, physicians can expand the number of Medicaid patients they can take. If this pay rate increase goes away, patients won’t have access to physicians. The long-term effect of this is that hospitals will have to cut back on programs, staff and capital investments.-Hospital With regard to the Marketplace exchanges, stakeholders shared concerns with its future viability and associated costs. Healthcare sector future challenges with Marketplace coverage Pricing on these may change and rates could go up, especially if people taking advantage of these have chronic illnesses. The insurers will make changes. -Physician For both the Medicaid and Marketplace insurance coverage types, stakeholders believed that the future healthcare sector challenges were similar in terms of needing to engage in ongoing patient education and outreach activities and ensuring that there are enough healthcare providers available in the community. Healthcare sector future challenges for Medicaid expansion and Marketplace coverage •

Patient education

For both the Medicaid population and those in the marketplace, we need to teach these people the insurance terminology.-Medicaid Managed Care The biggest challenge is to be able to get people engaged in their healthcare and taking responsibility and accountability for what they need to do to manage their healthcare.Consumer Advocate

We found out that just telling them to sign up didn’t work—that we would have to do it with them or for them.-Mental Health [We need to] educate patients and ourselves to understand marketplace insurance.Community Health Center

•

Qualified providers

We need more providers. There is a lack of providers that take marketplace insurance or Medicaid.-Community Health Center [We need] recruitment and retention of qualified and passionate people to work in community health centers.-Community Health Center

16

•

Challenges facing the patient consumer sector

For Medicaid and Marketplace coverage, stakeholders shared future concerns for the patient consumer sector related to issues affordability, patient engagement, the application process, and potential changes in eligibility. Patient consumer sector future challenges for Medicaid expansion and Marketplace coverage •

Affordability

For those qualifying for Medicaid, affordability won’t be an issue. However, for those who fall outside of qualification for Medicaid and must take advantage of the exchanges, I see problems with them affording healthcare. This will cause a problem with respect to being preventive; these patients will wait longer to see a doctor.-Hospital •

Patient engagement

There is ‘churn’ where the consumers are on and off with the insurance. It is difficult to have quality of care if the consumer is with us for 1 month and then not with us for 6 months and then back again for 2 months.-Medicaid Managed Care •

Application process

It is hard to apply for Medicaid on the computer. These people don’t have access to a computer. The system needs to be more user friendly. For some people this is a literacy issue and they don’t want to be embarrassed that they can’t read. Some people feel more comfortable taking home a paper application and having someone at home help them with the application.-Free Clinic •

Eligibilty

People are starting to reduce their hours at work to become eligible for Medicaid so they don’t have to get insurance with the Affordable Care Act. Employers are also cutting back on hours they provide to their employees so they don’t have to provide insurance from the ACA marketplace…People can’t afford to work because they will lose their medical coverage.-Free Clinic It is important that we make sure that the General Assembly doesn’t add requirements to being eligible for Medicaid, such as cost-sharing and work requirements. There is this argument out there that people need some “skin in the game”. Their whole bodies are in it and it is not a game.-Consumer Advocate

17 •

Additional Considerations

Several stakeholders shared challenges and concerns related to the need for improved coverage for issues outside of primary care. In general, stakeholders cited the need for greater access to dental services and mental health and prescription coverage. Although FQHC settings provide dental services, providing such services were more the exception than the rule, leading many patients to go to the Emergency Room for acute dental care needs. In addition, mental and behavioral health continues to face coverage challenges. In our healthcare setting, we need to figure out how to turn on some of the Medicaid behavioral health codes. Medicaid has to be willing to turn these on in a primary care setting. In Ohio, these behavioral health codes are not turned on [for reimbursement coverage].-Community Health Center Issues related to prescription medications also related to affordability and cost. There is a new wave of high cost specialty drugs that have been made recently. These are expensive, effective medications…This will put a huge strain on taxpayers as well as the Medicaid and Medicare programs.-Consumer Advocate

CONCLUSIONS Healthcare sectors and patient consumers in the state of Ohio have experienced significant changes in availability of healthcare coverage within the past 9 months in the form of Medicaid expansion and the Marketplace exchange as a result of the Affordable Care Act. The current project was conducted to explore the perspectives and experiences of key professional stakeholders who have been serving or representing Ohio residents receiving healthcare insurance through these initiatives. Overall, stakeholder feedback was positive for Medicaid expansion, with many calling for renewal of the expansion next year. In contrast, stakeholder feedback related to the Marketplace exchange was not as positive, with issues of lack of affordability and low levels of health insurance literacy among patients interfering with the perceived success of the program. For both types of coverage, access to qualified healthcare providers remained a barrier to care. Stakeholders agreed, however, that these initiatives have resulted in Ohio now having fewer uninsured patients overall. Many of these individuals are older adults with significant health needs. Stakeholders regarded these initiatives as ultimately leading to greater access to quality care and improved levels of long-term health for Ohio residents. Several challenges, however, will need to continue to be addressed, including exploring models of payment reimbursement reform, ensuring adequate payment to healthcare providers, and increasing the number of primary care providers and organizations available to provide services to patient consumers in the community.