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“…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?
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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
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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)
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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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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 ?
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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?
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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
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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
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