medicaid reform: the opportunities for home and community … · 2013-03-12 · • evolution of...

Independent Living Systems, LLC5201 Blue Lagoon Drive, Suite 270Miami, Florida 33126Tel: 305 262 1292

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Medicaid Reform: The Opportunities for Home and Community Based Providers



ILS Background & Experience

• Care Management Company founded in 2001

• Focuses on Duals, Medicaid ABD and Managing Medicaid Long‐term Care Costs

• Clients are principally MCOs

• Currently serving almost 2 million Medicaid and/or Medicare Members in about 40 states



Our Services

Care Transition & Post‐Discharge

Services

Managed Long Term Care Services

Back office, administrative and

coordination services for MLTC plans

Nutrition Services & Home Delivered

Meals

Nutrition care management,

education & meals services

Comprehensive Case Management & Coordination

Population risk stratification,

assessment, care plans and case management

Patient‐centered care transition, post

discharge coordination and coaching



The Challenge

• Aging of Population and related costs of chronic diseases and Long‐term Care

• Difficult to manage costs of disabled person (acute and LTC)• Increase in Medicaid Eligibles• Limited State Budgets and competition for resources at

State Level



Proportion of Medicaid LTSS Spendingfor HCBS Among Aged/Disabled

1 Avalere analysis of the 2008 CMS National Health Expenditures data; the National Investment Center for the Seniors Housing and Care Industry MAP Data and Analysis Service data; and data from Burwell, B., Sredl, K., and Eiken, S. “Medicaid expenditures for LTC services, 1996‐2008.”

$264 Billion1



HCBS Spending as a Percent of Medicaid Long‐Term Care Spending By State, 20091

AK

HI

CA

AZ

NV

OR

MT

MN

NE

SD

ND

ID

WY

OK

KSCOUT

TX

NMSC

FL

GAALMS

LA

AR

MO

IA

VA

NCTN

IN

KY

IL

MIWI

PA

NY

WV

VT

ME

RICT

DEMD

NJ

MANH

WA

OH

D.C.

<30%

50%+40% to 49.9%30% to 39.9%

1 HCBS spending includes HCBS expenditures authorized under Sections 1915(c) and 1915(j) of the Social Security Act including MR/DD; the home health benefit; theoptional personal care benefit; the Program of All Inclusive Care for the Elderly; and select HCBS expenditures authorized under Section 1115 of the Social SecurityAct. It does not include HCBS spending under Section 1915(i) of the Social Security Act, spending through managed care programs, or spending authorized underSection 1115 that was not clearly allocated to community‐based long‐term care. Reliable fee‐for‐service data do not exist for Arizona and Vermont.

Source: Analysis of data from the CMS Form 64 performed by Eiken, S., Sredl, K., Burwell, B., Gold, L. “Medicaid Long‐Term Care Expenditures, FY 2009.” HCBS Clearing House, August 2010. http://hcbs.org/moreInfo.php/nb/doc/3325/Medicaid_Long_Term_Care_Expenditures_FY_2009

http://hcbs.org/moreInfo.php/nb/doc/3325/Medicaid_Long_Term_Care_Expenditures_FY_2009



Medicaid Costs for Dual Eligibles

TENNESSEE– Inpatient 1.35 %– Outpatient 2.06 %– Physician 5.62 %– LTC 86.91 %– Home Health 2.12 %– Hospice 1.94 %TOTAL 100.00 %



Profile of Medicaid Costs

• Duals account for more than 40% of costs, but represent less than 20% of Eligibles

• LTC is more than 80% of Duals Medicaid costs• LTC costs are 60% aged, 40% disabled• Costly ABD population, Duals and LTC remain in uncoordinated FFS systems



State Approaches

• Capitation to include costs of acute and long‐term Care

• Development of integrated Medicare/Medicaid programs

• Evolution of Managed Fee for Service models‐ Enhanced PCCM models‐ ACOs and Medical Homes



• The only way to reduce or contain the cost of Long‐term Care is to rebalance; i.e. shift proportion of institutional care toward community

• Capitation moves responsibility for rebalancing from State to MCOs

Re‐Balancing



Features of Capitated Programs ‐MLTC

• State Pays MCO a Risk Adjusted Capitation Rate 75/25

• Blended rate reductions lag rebalancing progress

• Claims may be paid by MCO or fiscal intermediary

• If MCO pays claims, MCO can establish provider reimbursement

• Capitated Programs are moving from voluntary to mandatory

Community Facility BlendDuals 1500 4500 3750Medicaid Only 2200 5500 4675



Florida’s Medicaid Reform

• Currently have 20,000 in principally community based Nursing Home Diversion Program

• Beginning in late 2012 all Medicaid will move to mandatory capitated programs for both acute and LTC, community and nursing home residents

• Enrollment in capitated LTC will grow from 20,000 to 80,000+

• $ will grow from $350 million to more than $3 billion• HCBS $ will grow $30 million for each 1% rebalancing



Integrated Medicare/Medicaid programs

• PACE Programs• Medicare Dual Eligible (“DE”) Special Needs Plans with a crossover Medicaid Contract

• Medicaid Plans expanding by creating DE SNPs• State initiated Dual Integrated Care Demonstrations



New Opportunity for States

• CMS announced in its July 8th letter to States (SMDL #11‐008)financial models to promote integration. CMS will give States Medicare monies to manage if they create integrated Health Systems– Medicare and Medicaid– Acute and LTC– MCO Capitated or Coordinated FFS Model– Want fast track implementation– Must file letter of intent by October 1, 2011



Enhanced Fee For Service Models

• Patient Centered Care Management• Medical Homes• Accountable Care Organizations• Provider Service Networks• States can implement with current fiscal intermediary, providers



Medicare SNPs

ABD Pop.California

MedicalHomes

AccountableCare Org.

Individual Assessments

Risk Stratification

Individual Care Plans

Interdisciplinary Care Team

Case Manager

Care Transition Program

Patient Centered Care Management



– Intel’s expertise in technology + GE’s deep healthcare experience

– History of innovating to solve hard problems– Industry leadership and advocacy– Proven world‐class quality

We collaborate with you to create human‐centered solutions that improve lives.



New Funding Sources for HCBS

• Rebalancing produces significant additional funding for HCBS.– Need to expand provider capacity and choice– Need to create new provider options, for example:

• Housing/group homes • Adult Daycare• Morphing of facility providers to provide community based care

– Need for provider contracting/credentialing and oversight– Increased need for care coordination and case management

• Integrated programs and Medicare Special Needs Plans can fund HCBS Services with Medicare

• Capitated programs can fund services that are not cost effective in uncontrolled FFS environment

• Significant potential for private pay products / cost sharing



Aging Network and HCBS Provider Strategies

• Be partners with and advisors to MCOs• Establish Provider networks• Move up the food chain• Establish MCOs, BUT do not be exclusive• Mobilize multiple funding sources• Develop capabilities to provide Care Transition Services



Aging Network and Care Transition Services

• Care Transition Can Foster Nursing Home Diversion– NH Access to Hospitals Promoted Institutional LTC– Similar Access Makes HCBS an Alternative

• CMS Committed to Care Transition and Aging Network Role – CCTP Is Just the Beginning— Real Goal Is All Medicare

• Private‐Pay Programs for Medicare Patients Should Accompany Care Transition Support

• Medicaid Savings Also Possible with Care Transition



Can the Aging & Disability Networks position themselves to take advantage of historic Federal and State opportunities?



• ILS enterprise systems and experience support rapid implementations with MCO’s

• ILS core competencies enable seamless integration with Medicare MCO’s

• Medicare Savings would produce significant new Medicaid Funding

• Program would contain LTC costs

• CMS permits direct negotiation with health plans

ILS Enterprise Solutions



Independent Living Systems, LLC

Nestor Plana, President & CEOE‐mail: [email protected]

Ray Noonan, Executive Vice President, FinanceE‐mail: [email protected]

Josefina Carbonell, Senior Vice President, Long‐Term Care and NutritionE‐mail: [email protected]

Frank Burns, former HHS Deputy Assistant Secretary for Program OperationsE‐mail: [email protected]

1

OPPORTUNITIES…

for Home and Community Based

Providers

National HCBS ConferenceSeptember 13, 2011

2

MLTC = OPPORTUNITIES for HCBS

MLTC = Win/Win…Win

MLTC = Results (for the “engaged” only)

3

Why? …because we have a common mission

RESULTS: changed lives & compelling numbers

How? …ENGAGE

4

Hospice

Hospital

HomeAmbulatory Care Clinic

Skilled NursingFacility

SNF

Rehabilitation Facility Hospice

WHY?

5

WHY?

Nursing Home Care

Acute Health

CONSUMER/FAMILY

Medicare

Behavioral Health

HCBS Waiver Services

6

RESULTS

Community Choices Act of 2008 (CHOICES)

Legislation restructured LTC

Integrated Services

SPOE

Expanded Access

Care Coordination

7

RESULTS: CHOICES

In HomeCapability

Risk

StratificationHRA

ACUTE

MEDICARE

NURSING

HOME

CONSUMER

DIRECTION

ADVISORY

MONITORING

HCBS

8

MostRestrictive

LeastRestrictive

Assisted Living/Residential Care

Adult FosterCare Home

Adult CareHome

Home orApartment

Specialty Unit within a

Nursing Facility

NursingFacility

Right Service, Right Time, Right Setting

CHOICES for consumers

Money Follows the Person

9

RESULTS: CHANGED LIVES

James: "It's the best thing that ever happened to me, and I'm excited to be

home with my wife and grandkids.”

Priscilla:“This program gave me my independence back.”

10

RESULTS: HCBS Perspective

“The program is the right thing to do.”

“This is the wave of the future.”

“The program is highly successful for consumers.”

“Billing is much smoother, quicker, better cash flow.”

11

RESULTS: BALANCE

12

RESULTS: Population Shift

13

HCBS OPPORTUNITY

14

HOW? ENGAGE

Recognize common missions/goals

Leverage strengths of ALL stakeholders

Use lessons learned

Define roles/responsibilities

15

Interim State Population Projections FileSource: U.S. Census Bureau, Population Division, Interim State Population Projections, 2005

Percentage of Medicaid LTC Expenditures in Nursing Home A/D Population (2007)

medicaid reform: the opportunities for home and community … · 2013-03-12 · • evolution of...

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