Two Decades of Progress in Delivering Long- Term Services and Supports in Ohio: But What’s Next? Bob Applebaum Western Reserve Area Agency Annual Meeting.

Two Decades of Progress in Delivering Long-Term Services and Supports in Ohio:

But What’s Next?

Bob Applebaum

Western Reserve Area Agency Annual Meeting

National Long-Term Care Numbers

• 6 million older people with disability– will more than double by 2040

• Long-term care about one-third of Medicaid expenditures (Ohio 36%)

• Medicaid about 22% of state budgets (Ohio 24%)• 63% of Medicaid LTC funds to nursing homes– varies by

state• Two-thirds of residents now on Medicaid

Population 60 plus by County

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Population 60 plus by County

7

8

9

An Aging America: Are You Aging?

• Gravity more powerful than kryptonite• You are starting to look like your parents• You can’t stay awake for Sat Night Live• You have given up hope of being a professional

athlete (mostly men)• You have given up hope of finding a sensitive

partner (Exclusively women)

The Ohio LTC Context

Large state-- 7th highest population 65 and olderHigh supply of NF beds per pop. 75+ (ranks 6th)High number of NF beds 93,000 (ranks 7th) Traditionally high reimbursement rates for NF--changing One of two states with NF formula in state statute42nd state to get assisted living waiverNo state level home care programNo personal care option under MedicaidRestrictive Medicaid program (209B state)1.6 mill 65 plus– 85 plus grown by 75k in last 10 yrsLast state in the nation to ban leisure suits

Ohio Context Continued

Large expansion of home care waiver to more than 30,000 each day

AL waiver 4100 participants in 2013NH reimbursement flat for last 8 years72 of Ohio’s 88 counties now have home care property

tax levies-- $165 million in 2011State efforts to balance culminating in Unified Budget

Workgroup-- sets financing and balancing targets2010 Legislature passes Diversion and Transition

Initiative2012 Legislature passes Integrated Care Demonstration

and includes AAA care management involvement

Proportion of Ohio's Population with Physical/Cognitive Disability Receiving Care in Different Settings, 2011

Nursing Facility Private9%

Nursing Facility Medicaid

29%

Residential Care Facili-ties5%Aging Waivers

20%

Ohio Home Care5%

Aging Levies6%

Prisons1%

Privately purchased LTC17%

Informal Care Only9%

NF Admissions by Payment Sources (1992-2011)

• 1992 1997 2001 2007 2009 2011

• Total Admissions (in thousands)• 71 130 150 201 197

216

• Medicare Admissions (in thousands)• 30 80 91 127 109

149

• Medicaid Admissions (in thousands)• 18 19 24 25 27

29

Proportion of Total & Medicaid Nursing Home Residents Still Living in a Facility

13.1

19.6

33.4

40.1

46.7

53.3

5.7

9.0

16.1

20.7

32.5

43.1

0%

10%

20%

30%

40%

50%

60%

0-3 Months At 6 Months At 9 Months At 12 Months At 24 Months At 36 Months

Medicaid

Total

Nursing Facility Capacity and Occupancy, Over Time

1992 1997 1999 2001 2005 2007 2009 2011

Number of Facilities 1,261 1,232 945 1,000 950 973 972 966

Avg. Beds/FacilityNA 81 99 88 96 98 98 98

Number of Beds Available for Service 91,531 99,302 95,701 94,231 91,274 92,443 93,209 94,710

N of Beds/1,000 65+ Population 64.1 67.2 63.5 62.0 58.3 58.2 58.3 56.9

Average Daily Census 84,117 84,643 79,216 78,427 78,805 81,108 80,008 78,790

Overall Occupancy 91.9 87.7 83.5 83.2 86.4 87.7 84.7 83.6

Medicaid Occupancy 67.4 61.8 55.4 58.5 58.8 56.9 55.4 54.4

Nursing Home Resident Characteristics

• Age 59 and under Today 12.7% 1994 4%• Age 65 and under 19.1% 7%

• Medicaid 59 and under 16.7%• Medicaid 65 and under 24.2%

• Today’s nursing home-- Higher proportion of men, minorities, married

Characteristics of Medicaid LTCSS Consumers, 2012

PASSPORT Choices Assisted Living

PACE Transitions Carve-Out

Medicaid Residents of

NF

Avg. Age 75.6 76.1 80.4 71.6 64.6 76.0

% Female 75.9 82.0 80.4 74.1 72.7 68.4

% White 70.4 84.2 89.0 35.2 66.0 81.8

Avg. ADL 3.0 3.6 2.6 2.6 3.7 4.5

Needs for Supervision 20.8 38.3 47.6 16.3 6.6 NA

LTCSS Exp. (PMPM) $1,460 $2,165 $1,688 $2,851 $3,300 $4,340

N of Residents/Consum

ers 34,173 585 4,102 897 2,375 51,865

Average Number of People Age 60 and Older Receiving LTCSS, Paid by Medicaid, 1997-2011

1997 1999 2001 2003 2005 2007 2009 20110

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

47,652 46,393 44,872 47,119 45,000 43,370 42,379 42,840

14,168 15,860 18,361

23,302 24,163 26,153 30,427

35,64161,820 62,253 63,233

70,420 69,162 69,523 72,80678,480

Average Daily NF Census

Average Monthly Waivers Enrollment

Use of Nursing Facilities Compared to Home and Community-Based Services by People with Physical and/or Cognitive Disability, Paid by Medicaid

2005 2006 2007 2008 2009 2010 2011

63% 61% 60% 58% 57% 56% 54%

37% 39% 40% 42% 43% 44% 46%

NF HCBS

Number of People Age 60 and Older Residing in Nursing Facilities or Enrolled in a Waiver Per 1,000 Persons in Population

1997 1999 2001 2003 2005 2007 2009 2011

24.5 23.722.5 22.9

21.219.8

18.8 18.5

7.3 8.19.2

11.3 11.4 11.913.5

15.4

Avg Daily NF Census Avg Monthly Waiver Enrollment

Total Medicaid Expenditures on LTCSS for People Age 60 and Older : 1997 - 2011 at 2011 PMPM Rates (in Thousands of Dollars)

1997 2009 2011

$248,290

$583,125$689,982

$2,438,834

$2,168,962

$2,192,530

$2,687,124$2,752,087

$2,882,512

Waivers + PACE Expenditures NF Expenditures Total

Changes But Future Challenges

• Decreased over 60 use of nursing homes by 11% in last 15 years

• Increased under 60 use by 26%• Decreased overall use, but decreased

private pay share of nursing home funding• Very small proportion of U.S. population

with Long-term care insurance- Insurers getting out of business

One problem Addressed– New One Gets Added to the List

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• Acute and long-term care systems don’t live in the same world– provider fragmentation

• Medicare and Medicaid as funders don’t work together and in fact cost shifting has been the norm

• The lack of integration is bad for consumers --- bad for quality, bad for costs

• Overall system unsustainable

Who Are the Medicaid Consumers in Ohio and How Much of the Resources each Group Use?

Families, Women & Children78%

Aged Blind & Disabled22%

70% 30%

Source: Health Policy Institute of Ohio. Ohio Medicaid basics 2009

Integrated Care Demonstration

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• DOM working on efforts to implement ICDS demonstration – MY CareOhio

• OMA and CMS have agreed to a demonstration with evaluation to start on May of 2014

• All Medicaid/Medicare NF residents must enroll in ICDS

• Many unanswered questions both about the final intervention and outcomes

MyCare Ohio Regions27

Region Plan

Northwest Aetna, BuckeyeSouthwest Aetna, MolinaWest Central Buckeye, MolinaCentral Aetna, MolinaEast Central CareSource, UnitedNortheast Central CareSource, UnitedNortheast Buckeye, CareSource

United

Type of Facility or ProgramAcute care /Total cost

LTCSS as % of Total PMPMUnder 65

Total Medicaid PMPMUnder 65

LTCSS as % of Total PMPM65 +

Total Medicaid PMPM65 +

Nursing Facility 72.6% $6,555 92.5% $4,430

PASSPORT 41.4% $2,368 69.5% $1,550

Ohio Home Care 46.6% $4574 __ __

Assisted Living 62.8% $2,680 86.3% $1,730

Aging Carve-Out 53.9% $4,173 65.4% $3,814

PACE __ $3,083* __ $2,437*

Choices 60.5% $2,775 79.8% $1,857

LTCSS as Proportion of Total Medicaid Per-Member,

Per-Month Exp. For Ohio’s Population Using LTCSS by

Age Group, 2010

Integration of LTCSS and Health Care System Issues

State to bring all Medicaid long-term services recipients into Managed Care and hope is that dual eligible individuals will leave Medicare fee for service for combined managed care

Evidence on dual integration – cost savings, quality?

Could it have unintended side effect of expanding Medicaid participation?

Will this approach negatively impact the strong aging network in the state? How impact NF rates?

Ohio’s Challenges: Today Ohio has 305,000 individuals of all ages with severe

disability and 122,000 (40%) receive LTC services through Medicaid

Today 24% of state budget is Medicaid– 36% goes to LTC

By 2020, 348,000 with severe disability and 138,000 projected to receive Medicaid LTC services

By 2020, 30-35% of state budget could be Medicaid, with 40-45% going to LTC

By 2040, 600,000 with severe disability and 237,000 projected to receive Medicaid LTC services

By 2040 more than 50% of state budget could be Medicaid with more than 60% going to LTC

System Unsustainable: Now What?

• Supports for family and other caregivers to assist older person to stay in community

• Support for communities to become more aging friendly

• Too many nursing home beds as a nation—varies dramatically– Industry transformation to right size

• Integration of Medicaid and Medicare– does not really address these issues

System Unsustainable: Now What?

• Serious prevention – lower prevalence of disability– Good news is disability rates dropping slightly for older people– Bad news increasing for under 60 population

• Use of technology to promote more independence, even when disability occurs (low tech to high tech)

• Support for individuals with moderate level of disability and moderate income- Now pretty good system for very poor, very disabled.

• 8% of 65 plus on Medicaid in community, 66% on Medicaid in nursing homes

Policy and the Future

• Even with changes the current system is simply not sustainable

• Short-term window where “boomer growth” remains small, before the major increase

• The current system was never designed– • Meaningful change is very slow• We often have policy changes with unplanned

consequences. Hospital reform --new nursing home• LTC system must be innovative and efficient-- • Heavy pressure driven by Medicaid budget concerns–

Contact info34

Bob Applebaum [email protected] Scrippsaging.org (Scripps web site)