Aging, Managed Care and the Long Term Care System
description
Transcript of Aging, Managed Care and the Long Term Care System
111
“…to raise new ideas and improve policy debates through quality information and analysis on issues shaping New Hampshire’s future.”
Aging, Managed Care and the Long Term
Care System
Board of DirectorsWilliam H. Dunlap, Chair
David Alukonis
Eric Herr
Dianne Mercier
James Putnam
Todd I. Selig
Michael Whitney
Daniel Wolf
Martin L. Gross, Chair Emeritus
Directors Emeritus Sheila T. Francoeur
Stuart V. Smith, Jr.
Donna Sytek
Brian F. Walsh
Kimon S. Zachos
Managed Care Commission
May 1, 2014
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Topics to Consider
• NH Ages • Shifts in Medicaid Spending• Managing the care of an elderly
person with complex needs is … complex.
• What can we learn from phase 1 implementation?
• What kind of program do you want? • What about the counties?
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Aging is a complicated story here in New Hampshire
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Are we old? Not yet, but getting there …
The Largest Impact of Aging will occur after 2020
53,14760,414
69,643 75,360 81,50688,494
106,086
138,484
175,419
216,153
247,740
0
50,000
100,000
150,000
200,000
250,000
300,000
1990 1995 2000 2005 2010 2015 2020 2025 2030 2035 2040
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
Population Age 75+
% NH's Total Pop. That is Age75+
55Geography Matters
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Growth in the Frail Elderly
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The Geography of Elderly Poverty
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The Aging Bubble will end …
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Aging Changes the Way We will Spend
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Currently, much of the Medicaid spending is for those under the
age of 65 (2009)
Medicaid Spending 2009 by Age and Sex
$0
$50,000,000
$100,000,000
$150,000,000
$200,000,000
$250,000,000
$300,000,000
0-19 20-44 45-64 65-74 75 - 84 85 +
2010 (Women)2010 (Men)
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A very different picture in 2030
2030 Aged 2009 Medicaid Spending by Age and Sex
$0
$50,000,000
$100,000,000
$150,000,000
$200,000,000
$250,000,000
$300,000,000
$350,000,000
$400,000,000
0-19 20-44 45-64 65-74 75 - 84 85 +
2030 (Women)2030 (Men)
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Shifts in Medicaid Spending
2009 Medicaid Spending by Age
0-1929%
20-4424%
45-6422%
65-746%
75 - 848%
85 +11%
2030 Aged (2010) Spending
0-1919%
20-4417%
45-6412%65-74
10%
75 - 8419%
85 +23%
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Driven by Age and Shifts in Demand for Services
2009
All Other7%
66 HOME&COMM BASED CARE-CI &
ELD6%
78 PRIV NON-MED INST FOR CHILDREN
2%
65 HOME&COMM BASED CARE - DI
16%
45 DENTAL SERVICE2%
43 PHYSICIANS SERVICES
4%
32 FURNISHED MED SUP OR DME
1% 30 DISPENSE
PRESCRIBED DRUGS7%
25 CLINIC SERVICES3%
17 MENTAL HEALTH CENTER
8%
15 SNF NURSING HOME ATYPICAL
CARE0%
16 ICF NURSING HOME ATYPICAL
CARE0%
12 INTERMED CARE FAC NURSE HOME
31%
11 SKILL NURSING FAC NURSING HOME
1%
7 OUTPATIENT HOSPITAL, GENERAL
6%
1 INPATIENT HOSPITAL, GENERAL
6%
2030
32 FURNISHED MED SUP OR DME
1%
43 PHYSICIANS SERVICES
3%
17 MENTAL HEALTH CENTER
6%
30 DISPENSE PRESCRIBED DRUGS
5%
25 CLINIC SERVICES2%
15 SNF NURSING HOME ATYPICAL
CARE0%
16 ICF NURSING HOME ATYPICAL
CARE1%
45 DENTAL SERVICE1%
65 HOME&COMM BASED CARE - DI
13%
66 HOME&COMM BASED CARE-CI &
ELD8%
78 PRIV NON-MED INST FOR CHILDREN
1% All Other6%
11 SKILL NURSING FAC NURSING HOME
2%
7 OUTPATIENT HOSPITAL, GENERAL
5%
1 INPATIENT HOSPITAL, GENERAL
4%
12 INTERMED CARE FAC NURSE HOME
42%
Nursing Home Care
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Workforce Issues will become more acute.
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What do you mean when you say managed care?
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Acute Medical
ChronicMedical
Community Based LTC
Assisted Living
NursingHome
What does a Long-Term-Care Accountable Care Organization Look Like?
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Nutrition and Financial support (2012)
• Food-stamps– Maximum grant is about $5.80 per day per person.
Of a total 56,887 cases in July (2012), 5,944 or 5.1% are over age 65. Of these, 1,215 have a cash grant
• Meals Programs (Title III)– 11,454 individuals received home delivered meals. – 17,192 received congregate meals
• TANF Grants for Lower Income Elderly– Household size of one must be under $712 per month
and aged 65 or older; Average grant is $164.13 in July 2012
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Other
• Housing– Section 8 housing?– Other efforts
• Transportation– Title III – provided almost 19 visits per person over
the age of 65 living in poverty in NH.– Medicaid provides transportation services
• Acute Healthcare– Medicaid– Local Welfare
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State (or county based) Long Term Care Supports
• Public Health (support for falls, chronic conditions for those 55 to 64)
• Medicaid Nursing Home• Home and Community Based Care • Title III
– Adult Day Care – 654 individuals received support– Homemaker – 645 individuals received support– Personal Care Services – 523 received support
2020
Support and Information
• Service Link (ADRC)• Legal Services• 211 Calls• Managed care prior
authorization and care coordination?
• Other ?
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What about the impact of the budgetary changes
from 2010 – 2013?12345678910111213141516171819212223
A B E F G H
SFY10 SFY11 SFY12 SFY13
BEAS Rate Reduction-Contracted Services ($808) ($1,397)BEAS MQIP 100% (State Retains 25%) ($8,438) ($8,606)BEAS Redefine/clarify Rule for Personal Care Services & Homemaker Services ($839) ($1,520)BEAS Raise county cap by 2% in line with inflation $0 ($2,000)BEAS Require Single Dose Medication for H.H.RN Visits ($853) ($879)BEAS Freeze funding Congregrate Housing Supports ($751) ($766)BEAS Discontinue Case Management to Mid-Level Care ($514) ($575)BEAS Freeze funding ADRD & Caregiver Program ($324) ($330)BEAS Funding from Money Follows The Person ($259) ($259)BEAS Eliminate Catastrophic Illness Program ($250) ($260)BEAS Reduce general funds for SSBG programs ($1,303) ($2,253) ($166) ($166)BEAS Freeze State Funding of Service Link Program ($105) ($119)BEAS Volunteer -Sr. Companion-Foster Grandparent ($12) ($184) ($130) ($130)BEAS HCBC-ECI - Rebalancing Similar Services ($400) ($400)BEAS Adjust county cap for nursing services $0 ($500)BEAS Reduced class 512 transportation of clients ($134) ($134)
Department of Health and Human ServicesAdjustments to BEAS Budget Requests
General Funds Rounded to $000
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What Can We Learn from Phase 1 about Phase 2?
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NEW HAMPSHIRE DEPARTMENT OF HEALTH AND HUMAN SERVICESBEAS PROVIDER PAYMENTSFOR THE FIRST TWELVE MONTHS OF STATE FISCAL YEARS 2010, 2011 AND 2012
Total Expenditures by Category of Service Total Expenditures Total
Recipients
Average Cost per Recipient
Service Count
Average Cost per Service
ADULT MEDICAL DAY CARE 386,695.68$ 138 2,802.14$ 20,706 18.68$ ADVANCE REG NURSE PRACT 5,011.62 166 30.19 615 8.15 AMBULANCE SERVICE 220,814.72 2,407 91.74 14,385 15.35 AUDIOLOGY SERVICES 3,882.60 72 53.93 259 14.99 CHIROPRACTIC - 0 - 0 - CLINIC SERVICES 31,201.35 219 142.47 2,338 13.35 DENTAL SERVICE 58,266.00 164 355.28 858 67.91 FAMILY PLANNING SERVICES 181.39 2 90.70 6 30.23 FURNISHED MED SUP OR DME 2,099,084.90 2,546 824.46 46,925 44.73 HOME HEALTH SERVICES 620,515.23 451 1,375.87 16,876 36.77 HOME&COMM BASED CARE-CI & ELD - 3 - 0 - I/P HOSPITAL SWING BEDS, ICF 48,862.49 24 2,035.94 1,308 37.36 I/P HOSPITAL SWING BEDS, SNF 256,706.23 110 2,333.69 8,004 32.07 ICF SERVICES FOR MR 148,300.74 2 74,150.37 378 392.33 INPAT PSYCH FAC SRVS-UNDER 22 6,792.00 1 6,792.00 81 83.85 INPATIENT HOSPITAL, GENERAL 3,412,973.88 1,739 1,962.61 575,247 5.93 LABORATORY (PATHOLOGY) 17,663.12 156 113.23 2,468 7.16 MEDICAL SERVICES CLINIC 3,096.33 4 774.08 308 10.05 OCCUPATIONAL THERAPY 542.77 12 45.23 151 3.59 OPTOMETRIC SERVICES EYEGLASSES 93,222.65 1,634 57.05 6,238 14.94 OUTPATIENT HOSPITAL, MENTAL - 1 - 9 - PERSONAL CARE 5,176,748.24 149 34,743.28 7,010 738.48 PHYSICAL THERAPY 12,100.09 66 183.33 1,399 8.65 PHYSICIANS SERVICES 1,556,569.94 6,204 250.90 137,709 11.30 PODIATRIST SERVICES 34,661.63 1,361 25.47 4,133 8.39 PRIVATE DUTY NURSING 597,156.20 7 85,308.03 12,048 49.56 PSYCHOLOGY 27,794.36 150 185.30 1,242 22.38 RURAL HEALTH CLINIC 245,107.85 957 256.12 7,583 32.32 SKILL NURSING FAC NURSING HOME 5,348,053.07 2,946 1,815.36 216,018 24.76 SNF NURSING HOME ATYPICAL CARE 7,465,435.75 70 106,649.08 15,362 485.97 SPEECH THERAPY 275.70 2 137.85 21 13.13 WHEELCHAIR VAN 2,070,659.30 2,394 864.94 119,105 17.39 X-RAY SERVICES 24,831.64 1,515 16.39 7,675 3.24
Subtotal Category of Service 29,973,207.47 25,672
NUMBER OF INDIVIDUALS SERVED 7,842
Claims Paid First Four Quarters SFY 2012
05-01-08-04-01 6173-101
What services did the
Department pay for before?
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Prior Authorization
• Each Health Plan will have their own approach to service authorization/prior authorization. If there is a particular service you are curious about, the Health Plan’s customer service line (members) or provider relations (providers) can assist. The DHHS is preparing a tool called the Quick Reference Guide for providers, which will include information on what services require a PA and how to obtain one.
http://www.dhhs.nh.gov/ombp/caremgt/documents/provider-qa.pdf
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Relative to care in a nursing home ….
What services are not included in the per diem and, therefore, are the responsibility of the Health Plans? The Health Plans are responsible for all services not included in the per diem (see Services Associated with the Nursing Facility Per Diem). Services not included in the per diem, include:
• Physician services and/or consultations • Non-emergent or emergency transportation by ambulance • Transportation by any vehicle not owned by the facility • DME – for example, a specialized, customized wheelchair • Prosthetics and orthotics • Elective admission • TPN/all infusion services • Lab services – all lab services provided by a provider other than the facility • Outpatient facility services • Pharmacy • All hospital services
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Supporting the Transition to Managed Care for Frail Elderly with Complex
Needs• Care Coordinators - Providing or arranging for care coordinators to
support the primary care practices is a prominent feature across the programs.
• Technical Assistance and Practice Support - Most programs dedicate considerable resources to direct practice support by helping them reorganize workflow and systems and by providing tools to enhance practice capacity to assure continuous access and care coordination.
• Health IT to Identify and Monitor At-Risk Patients - In addition to requiring that practices use EHRs, some programs require the practices to use an EHR system that feeds information to the program sponsor as a term of participation.
• Quality Improvement Activities - All of the programs emphasize quality improvement, supported by the use of the EHR and data capabilities described above.
Source: Organizing Care for Complex Patients in the Patient-Centered Medical Home (http://annfammed.org/content/10/1/60.full.pdf+html)
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What kind of system do you want?
• New York – Medicaid Choice– MLTC – Medicaid Services – Medicaid Advantage – Coordinating
Medicare and Medicaid services. – PACE – Program for All Inclusive Care for
the Elderly.
• Florida – All traditional long term care services
(including nursing home and community based care)
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Insurance Companies Offering Long Term Care Managed Care (in Florida)
• American Elder Care
• Ameri-group
• Coventry
• Humana
• Molina
• Sunshine
• United
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And the counties?
County Expenditures Per Capita by Function
$65.51
$97.92
$151.23
$165.60
$183.91
$203.43
$185.29
$245.76
$343.45
$598.99
$0 $100 $200 $300 $400 $500 $600 $700 $800 $900
Hillsborough
Rockingham
Grafton
Strafford
Belknap
Merrimack
Cheshire
Carroll
Sullivan
Coos
Cou
nty
Annual Expenditure per Capita (2011-2013 average)
Nursing Human Services
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Nursing home expenditures are an increasing burden on the counties.
Cumulative Surplus (Deficit) of Nursing Home Revenuein Comparison to Expenditures, 1996-2004
$0.9
$(0.4) $(1.9)$(4.7)
$(11.1)
$(24.0)
$(41.3)
$(68.9)
$(92.1)-$100
-$80
-$60
-$40
-$20
$0
$20
1996 1997 1998 1999 2000 2001 2002 2003 2004
Cum
ulat
ive
Sur
plus
(D
efic
it) in
$ m
illio
ns
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Critical Questions• What impact do other supports and services (and budgetary changes) have
on a successful managed care product? • How will demand for different services change as a result of aging and new
disease burden (e.g. dementia)? • Is the system of supports for aging sufficient to meet this growing demand
(caretakers, institutions)? • Is a state solution the right answer? How do regional differences impact the
questions being asked?• Does the growth of Medicare enrollment and changes in Medicaid
(expansions to 55-64-year-old adults) provide opportunities? • What does a long-term-care accountable care organization look like? • How do national policy changes (Affordable Care Act) and potential
recommendations out of the long term care commission impact New Hampshire?
• What role will the counties play in providing the services needed across the spectrum of long-term-care supports and services (Meals on Wheels to institutional care)?
• Long-term-care expenditures are projected to grow more quickly then revenues. How will the state and counties finance these changes?
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New Hampshire Center for New Hampshire Center for Public Policy StudiesPublic Policy Studies
Want to learn more?• Online: nhpolicy.org• Facebook: facebook.com/nhpolicy• Twitter: @nhpublicpolicy• Our blog: policyblognh.org• (603) 226-2500
“…to raise new ideas and improve policy debates through quality information and analysis on issues shaping New Hampshire’s future.”
Board of DirectorsWilliam H. Dunlap, Chair
David Alukonis
Eric Herr
Dianne Mercier
James Putnam
Todd I. Selig
Michael Whitney
Daniel Wolf
Martin L. Gross, Chair Emeritus
Directors Emeritus Sheila T. Francoeur
Stuart V. Smith, Jr.
Donna Sytek
Brian F. Walsh
Kimon S. Zachos