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

2

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?

3

Aging is a complicated story here in New Hampshire

44

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

66

Growth in the Frail Elderly

7

The Geography of Elderly Poverty

8

The Aging Bubble will end …

9

Aging Changes the Way We will Spend

10

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)

11

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)

1212

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%

1313

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

14

Workforce Issues will become more acute.

15

What do you mean when you say managed care?

16

Acute Medical

ChronicMedical

Community Based LTC

Assisted Living

NursingHome

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

1717

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

1818

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

1919

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 ?

21

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

22

What Can We Learn from Phase 1 about Phase 2?

23

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?

24

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

25

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

26

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)

27

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)

28

Insurance Companies Offering Long Term Care Managed Care (in Florida)

• American Elder Care

• Ameri-group

• Coventry

• Humana

• Molina

• Sunshine

• United

29

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

30

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

31

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?

32

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