11 …to raise new ideas and improve policy debates through quality information and analysis on issues shaping New Hampshires future. Aging and the Health.

11

“…to raise new ideas and improve policy debates through quality information and analysis on issues shaping New Hampshire’s future.”

Aging and the Health 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

New Hampshire House Long-Term-Care Commission

March 18, 2014

Major Areas of Consideration

• Aging

• Service Demand

• Service Supply

• Financing

• Responsibility and Authority for Policy

• Flexible Systems (Peak Load)

Critical Questions• 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 these answers affect the state’s implementation of managed care for

long term care services? • 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?

4

Are we old? Not yet, but getting there …

Population Projections For those Over the Age of 65

191,403245,952

311,144

383,087437,194

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

450,000

500,000

2010 2015 2020 2025 2030

~120,000

~126,000

5Geography Matters

6

The new 60? Significant growth of 75-79 population

Change In Population over the Age of 65 2010-2030

58,646

78,415

61,173

34,277

13,280

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

65-69 70-74 75-79 80-84 85+

Age

7

The Geography of Elderly Poverty

Predicting the Future in Spending

Private Pay – Tremendous growth in 45-64 y.o. range

Spending 2010 and Age Only Simulated 2030

$1,033,472,506

$1,678,406,996

$228,623,473

$574,702,735

$34,141,154

$220,738,941

$523,595,054

$84,023,769

$0.00

$200,000,000.00

$400,000,000.00

$600,000,000.00

$800,000,000.00

$1,000,000,000.00

$1,200,000,000.00

$1,400,000,000.00

$1,600,000,000.00

$1,800,000,000.00

0-19 20-44 45-64 65+

2010 All2030 All

Aging has

real impacts on Medicare …. Impact of Aging on Total Spending in Medicare

Estimated 2010 Spending and Aging Impacts on 2030 only

$144

$956$881

$296$135

$2,709

$2,409

$513

$0

$500

$1,000

$1,500

$2,000

$2,500

$3,000

19-64 65-74 75-84 85+

In M

illi

on

s $

Spending 2010Spending 2030

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)

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)

14

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%

15

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

16

Can the current system support such demand for institutional and

non-institutional services?

Large Growth in Spending

The Impact of Aging Only

$992

$1,871

$2,277

$1,496

$2,507

$5,766

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

Medicaid Private Medicare

2010 2030

Medicare will play a growing role in driving the

healthcare system

2010Millions of $

Medicaid, $992, 19%

Private, $1,871, 36%

Medicare, $2,277, 45%

2030 Millions of $

Medicare, $5,766, 59%

Medicaid, $1,496, 15%

Private, $2,507, 26%

Workforce Issues will become more acute.

The Workforce Is Aging As Well!

Distribution of Family Practitioners by Age (2004)

11%

31%

40%

1%

18%

5%2%

4%

13% 15%

31%29%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

FP < 35 FP 35 - 44 FP 45 - 54 FP 55 - 64 FP 65 to 74 FP 75 +

Age Group

Per

cetn

of T

otal

New Hampshire

United States

Capacity Questions

• Home Health• Home and Community Based Care slots• Geriatric hospital services• Assisted Living Facilities• Alzheimer's Support (Hospital, Nursing

Homes)• Prisons• Inpatient versus Outpatient services

What does a comprehensive

assessment of the system of LTC supports look like?

Acute Medical

ChronicMedical

Community Based LTC

Assisted Living

NursingHome

What does a Long-Term-Care Accountable Care Organization Look Like?

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Support and Information

• Service Link (ADRC)

• Legal Services

• 211 Calls

• Other ?

25

Financial Assistance (2012)

• 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

• Property Tax Exemptions?– 96% of cities and towns provide mandated base

elderly exemption (94% provide additional value)– In 2006, 11,753 individuals received an exemption,

average $1,727 for a total of $20.3 million across the entire state.

• Local welfare expenditures?

26

Nutrition (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

• Local food kitchens

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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

28

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

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

The National Long Term Care Commission

• The Commission identified the following problems with the current LTSS system:

• Currently, family caregivers are providing most of the care, but their responsibilities can be very overwhelming. Their availability will decline as more of the population ages.

• Many Americans approaching retirement are unaware of how costly paid LTSS are and are not prepared for these expenses.

• There are training and retention problems within the direct care workforce that will affect the quality and accessibility of practiced employees in the future.

• Paid LTSS are fragmented and difficult to access. They often lack the focus and efficiency that would result in the best outcomes, all the while remaining a financial burden.

Critical Questions• 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 these answers affect the state’s implementation of managed care for

long term care services? • 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?

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