Estimated Savings from Early · PDF file Estimated Savings from Early Intervention . September 10, 2013 . Lisa Alecxih, Senior Vice President

Estimated Savings from Early Intervention

September 10, 2013

Lisa Alecxih, Senior Vice President

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ACL Commissioned Study • National and state-specific estimates of costs and benefits of a

Return to Community type program implemented across the U.S.

• Steve Kaye, UCSF Institute for Health & Aging and The Lewin Group

• Initial estimates based on published and secondary data sources – Pre-MFP (prior to 90th day in a nursing facility) Medicare post-acute

target group

• Refined estimates based on Medicare and Medicaid claims, plus MDS assessments available in CMS Chronic Condition Warehouse (CCW) – Various target group explored

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Intervention Costs: Key Assumptions Intervention Costs

– Screening costs will be included in administrative costs and based on Minnesota’s electronic screening tool and secure referral system

– Assessment costs assume 2 hours staff time and overhead at $108 per assessment, based on Minnesota experience

– Care Planning, Activation and Short-Term Intensive Follow-Up, assumes 20 hrs staff time and overhead at $1,080/participant, based on Minnesota experience

Participation – 30% of individuals screened will be identified as being at high-risk of a long-term SNF

stay and having the potential to transitioned, and will be assessed to confirm their possible transition, based on S. Kaye analysis of 2004 NNHS.

– 20% of those assessed will be transitioned, based on the Kansas 5-year tracking study (R. Chapin, 2002).

Preliminary Estimates

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Intervention Savings: Key Assumptions

Service Costs – Total per participant annual service costs will be $15,000, based on ¾ of Money

Follows the Person costs; on average, $10,000 of the costs will be covered out-of- pocket by participants, with the demo covering $5,000, based on S. Kaye analysis of 2004 NNHS

Medicaid Savings – 50% of the transitions will be “successful” (i.e., the participant will remain in or die in

the community) and most of these individuals will not spend down to Medicaid; based on the Kansas 5-year tracking study (R. Chapin, 2002) and Minnesota’s 3- year experience.

– Medicaid will save $40,100 annually for every successful transition, which is the average annual cost to Medicaid for all Medicare-only beneficiaries who enter nursing facilities on the Post-Acute SNF benefit and experience a length of stay longer than 60 days

Medicare Savings - TBD

Preliminary Estimates

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Projected National Annual Targets

Assess 499,400 of Beneficiaries Screened

(30% of total screened)

Serve 99,880 Beneficiaries at High Risk of Long-Term SNF

Stays (20% of total assessed)

Divert 49,940 Beneficiaries from Long-Term SNF Stays

(10 % of those identified at-risk)

49,940 Beneficiaries not served due to

NH readmission, and not included in Savings Estimates

Preliminary Estimates

Serve Assess Outcomes

•Includes only FFS Medicare beneficiaries. Sources: Medicare and Medicaid Research Review/2011 & 2012 Statistical Supplements; MEDPAC, Report to Congress: Medicare Payment Policy, March 2012; Jencks (2009); and, 2004 National Nursing Home Survey. All numbers are preliminary; further refinements and precision in identifying target population will be developed in the coming weeks with data from the CMS Data Warehouse.

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Intervention Savings Applied Nationally Projected Savings to Medicaid ($31.9B)

** National First and 10 Year estimates include a 1% cost for national administration, and 10 Year costs are inflated by 2.5% annually.

Preliminary Estimates

Costs/Savings Over 10 Years**

Building Pre-MFP Nursing Home Transition Programs into “High

Performing” ADRC/NWD Systems

John Wren Deputy Administrator for Disability and Aging Policy

U.S. Administration for Community Living HCBS Conference, September 10, 2013

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A Niche Transition Population

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Hospital

Home/Community

Skilled Nursing

Facility

Medicaid Eligible Residents Post 90 Days

The Pre-MFP Nursing Home Population

Money Follows the Person Demonstration

CCTP, QIO 10th Scope, HENs Care Transitions

Demo to Reduce Avoidable Hospitalizations for Dual Eligible Long-Term SNF Stay Residents

Nursing Home

Long-Stay Residents

(22% of post-acute

admissions)

Private Home 26%

Nursing Home, Rehab Facility

8%

Hospital or Hospital SNF

58%

Assisted Living, Group Home

6%

Other 2%

Home 67%

Elsewhere 33%

The Transition from Hospital to SNFs is the Main Pathway to Long-

Term Stays in Nursing Homes for Medicare Beneficiaries

Data source: 2004 National Nursing Home Survey 3

Nearly Two-Thirds of Long-Stay Nursing Home Residents Admitted Under Medicare End Up on Medicaid within 1 Year

4 * Private resources that could be used for community services

*

*

Length of stay at time of interview

Data source: 2004 National Nursing Home Survey

Nearly Two-Thirds of Long-Term SNF Residents Admitted Under Medicare End Up on Medicaid within 1 Year

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*

* Private resources that could be used for community services

Length of stay at time of interview

Data source: 2004 National Nursing Home Survey

Experience Transitioning People Out of Nursing Homes CMS Money Follows the Person Demonstration

 Enacted in 2007, targets Medicaid beneficiaries in Nursing Homes longer than 3 months (originally longer than 6 months).

 Over the first 5 years, 31 states have transitioned over 26,000 people out of NHs, and have gained experience developing the infrastructure, tools, techniques and service strategies needed to help NH residents return to and live in the community.

 The program has served large numbers of elderly, younger people with physical disabilities, and people with intellectual disabilities, and has documented the transition and services costs for these different groups; annual average cost for elderly = $23,725.

 Most MFP transitions to date have had moderate to high impairment levels, and involved people who have been in the Nursing Home more than 1 year.

 Performance varies by state: from 2010 – 2011, 6 states increased new MFP transitions by 50% and another 13 states by 20% or more, with the remaining states showing modest gains or declines.

Source: Money Follows the Person 2011 Annual Evaluation Report, Oct. 2012, Mathematica Policy Research; Institutional Level of Care Among MFP Participants, Oct. 2012, Mathematica Policy Research; Post-Institutional Services of MFP Participants: Use and Costs of Community Services and Supports, Feb 2012, Mathematica Policy Research

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Experience Diverting People from Nursing Homes Kansas Client Assessment Referral and Evaluation Program

Program Design - State requires all individuals applying for NH placement to have their needs

assessed and be counseled about community alternatives Key Outcomes from 5-Year Tracking Study - Of 2,882 individuals applying for NH placement in 1999-2000, 20% (599 )

were successfully diverted, and after 5 years, 57 % of those diverted were still in the community or had died in the community

- Service use was most intensive in the first month, then sporadic, often following acute episodes; with average monthly state cost of services being $367 in 2003

Source: Residential Outcomes for Nursing Facility Applicants Who have Been Diverted: Where Are They 5 Years Later?, R. Chapin, et al, The Gerontologist

2009, and unpublished reports.

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The Vast Majority of Kansas Diversions Who Stayed in the Community Did Not Enroll in Medicaid

Funding Source for Services for People Still Living in the Community by Length of Time in the Community

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16.8% 13.9%

Source: The Community Tenure Study: Community Tenure Status of CARE Assessment Customers 60 Months After Diversion, R. Chapin, et al, University of Kansas, 2007.

Experience Transitioning “Pre-MFP” Population from Nursing Homes

The MN Return to Community Program

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Nationwide Infrastructure for Scaling A Pre-MFP Transition Program

 ACL/CMS have been funding Aging and Disability Resource Center (ADRC) Programs since 2003, and the CMS Balancing Incentive Program now requires states to develop No Wrong Door Systems to receive the enhanced match.

 ADRC/NWD programs are managed by states help consumers and their families understand their options and navigate the LTSS system.

 Currently, 50 state ADRC programs cover over 70% of the U.S. population

 42 state ADRC programs have counselors doing MFP transitions, and have also been designated by their state Medicaid agency to serve as a Local Contact Agency for SNF residents who have expressed a desire during the MDS assessme