Forecasting and Trends Related to Aging, Long Term Care and Managed Care Neil Heyman Southern NY Association NY Health Care Alliance Image from: http://www.freeimages.co.uk/galleries/space/

Population Growth SOURCES: Centers for Disease Control and Prevention, National Center for Health Statistics, Health, United States, 2007, Figure 1, updated using population growth projections from U.S. Census Bureau Current Population Report P25-1138, May 2010.

Demographic Changes NYS 65 + In 2006, the NY 65+ population represented 13.1% of the total population. In 2014, estimates indicated that the 65+ represented 14.7% of the total. In 2020, the NYS 65+ projected population will represent 15.8% of the total population. Source: The chart was developed from data from the US Census Bureau, 2006, 2014, and 2020 projections.

Average Life Expectancy Through History Using the scientific method (i: Strengths) (i: of the Scientific Method) can (i: Avoids…) avoid many (i: overgeneralization) of the common (i: inaccurate observation) pitfalls of errors (i: ego-involvement) in human inquiry. It is based on (i: open mind) keeping an open mind. Knowledge is viewed as tentative and subject to refutation. The scientific method promotes research (i: empirical evidence) that relies on empirical evidence, is (i: systematic…) systematic and comprehensive, and (i: minimizes bias) minimizes bias. Source: Figures for 2010-2050 are from U.S. Census Bureau. (2008). Projected Life Expectancy at Birth by Sex, Race, and Hispanic Origin for the United States: 2010 to 2050 (NP2008-T10), Table 10. Other figures are from United Nations, 100 Plus.

Residential Health Care Facility (RHCF) Beds in New York State Geographic Region 2014 Current Beds (Based on NYS Report) 2016 Former NYS DoH Estimated Bed Need * New York City 41,368 51,071 Other NYS 67,260 70,278 Total NYS 108,628 121,349 Using the scientific method (i: Strengths) (i: of the Scientific Method) can (i: Avoids…) avoid many (i: overgeneralization) of the common (i: inaccurate observation) pitfalls of errors (i: ego-involvement) in human inquiry. It is based on (i: open mind) keeping an open mind. Knowledge is viewed as tentative and subject to refutation. The scientific method promotes research (i: empirical evidence) that relies on empirical evidence, is (i: systematic…) systematic and comprehensive, and (i: minimizes bias) minimizes bias. NYS Department of Health plans to adjust RHCF Bed Need Methodology in the near future. Source: This table was created from data from the NYS Department of Health estimates of RHCF Bed Need by County. Accessed at https://www.health.ny.gov/facilities/nursing/rhcf_bed_need_by_county.htm. tps://www.health.ny.gov/facilities/nursing/rhcf_bed_need_by_county.htm 2010

Adult Day Health Care Slots Need Estimates - NYS Total Resources 2015 Projected Need Unmet New York City Only 1,771 2,068 297 Nassau/Suffolk Only 1,314 1,365 51 All Other New York State 1,640 2,860 1,220 New York State Total 4,725 6,293 1,568 Using the scientific method (i: Strengths) (i: of the Scientific Method) can (i: Avoids…) avoid many (i: overgeneralization) of the common (i: inaccurate observation) pitfalls of errors (i: ego-involvement) in human inquiry. It is based on (i: open mind) keeping an open mind. Knowledge is viewed as tentative and subject to refutation. The scientific method promotes research (i: empirical evidence) that relies on empirical evidence, is (i: systematic…) systematic and comprehensive, and (i: minimizes bias) minimizes bias. Source: New York State Department of Health, Reinstatement of the Certificate of Need (CON) Application Process for Adult Day Health Care (ADHC) Applications, https://www.health.ny.gov/facilities/cons/more_ information/2010-06-25_reinstatement_of_con_application.htm#adult

RHCF Beds by Auspice Source: Figure was developed from data contained in the New York State Department of Health Report (2016). Recommendations for Revision of the Residential Health care Facility Bed Need Methodology.

Recent CBO Projections of Medicare Outlays Billions of current dollars Source: Congressional Budget Office; CEA calculations CBO’s August 2016 report An Update to the Budget and Economic Outlook: 2016 to 2026 contains tables detailing the agency’s budget projections for fiscal years 2016 to 20126.fiscal years 2016 to 2026. Those tables are reproduced in Excel at www.cbo.gov/publication/51908

Medicare 30-Day, All-Conditions Hospital Readmission Rate Percent of patients Note: Data through July 2013. Recent months are based on preliminary data. Dotted lines depict the range in which the final estimates are likely to fall. Source: Centers for Medicare & Medicaid Services (Office of Information Products and Data Analytics).

Medicare Advantage Enrollment on the Rise Source: US Department of Health and Human Services (2016). HHS FY2015 Budget in Brief https://www.hhs.gov/about/budget/fy2015/budget-in-brief/cms/medicare/index.html

Future Future forecasting is this presenter’s opinions.

Trends in Health Care Increase in Multi-Hospital Multi-Nursing Home System One of the key components of the scientific method is that “everything is open to question.” (i: words “Everything is Open to Question” appears) Another related concept is that all knowledge is conditional and subject to revision as we acquire new empirical evidence. One of the essential components of the scientific method is to keep an open mind. This approach allows us to be receptive to new information and letting go of previously held beliefs when those are shown to be wrong. In this way we are able to avoid preconceived ideas when there is no evidence that they are correct. Some social workers may continue to do things according to traditions in their practice setting. However, keeping an open mind allows us to question what is accepted as fact. This also allows us to consider whether there are different or more effective ways to practice than a traditional method. This ability to question and learn is a critical ingredient for professional growth and competence. Decrease in Individually Owned/Operated Facilities

Shifts in RHCFs Auspice Propriety RHCFs will increase. Voluntary RHCFs will continue to decline. Public RHCFs will significantly decline. Proprietary Voluntary Public One of the key components of the scientific method is that “everything is open to question.” (i: words “Everything is Open to Question” appears) Another related concept is that all knowledge is conditional and subject to revision as we acquire new empirical evidence. One of the essential components of the scientific method is to keep an open mind. This approach allows us to be receptive to new information and letting go of previously held beliefs when those are shown to be wrong. In this way we are able to avoid preconceived ideas when there is no evidence that they are correct. Some social workers may continue to do things according to traditions in their practice setting. However, keeping an open mind allows us to question what is accepted as fact. This also allows us to consider whether there are different or more effective ways to practice than a traditional method. This ability to question and learn is a critical ingredient for professional growth and competence. 13

Shifts in Financing There will be a decline in Medicaid. Medicare combined with Medicare Advantage will increase. Private pay will remain relatively stable Medicare Medicaid Private One of the key components of the scientific method is that “everything is open to question.” (i: words “Everything is Open to Question” appears) Another related concept is that all knowledge is conditional and subject to revision as we acquire new empirical evidence. One of the essential components of the scientific method is to keep an open mind. This approach allows us to be receptive to new information and letting go of previously held beliefs when those are shown to be wrong. In this way we are able to avoid preconceived ideas when there is no evidence that they are correct. Some social workers may continue to do things according to traditions in their practice setting. However, keeping an open mind allows us to question what is accepted as fact. This also allows us to consider whether there are different or more effective ways to practice than a traditional method. This ability to question and learn is a critical ingredient for professional growth and competence. 14

Trends in new Programs Move more sub-acute patients into nursing homes to reduce costs. Adult day programs will increase in number. Behavioral health programs will increase. One of the key components of the scientific method is that “everything is open to question.” (i: words “Everything is Open to Question” appears) Another related concept is that all knowledge is conditional and subject to revision as we acquire new empirical evidence. One of the essential components of the scientific method is to keep an open mind. This approach allows us to be receptive to new information and letting go of previously held beliefs when those are shown to be wrong. In this way we are able to avoid preconceived ideas when there is no evidence that they are correct. Some social workers may continue to do things according to traditions in their practice setting. However, keeping an open mind allows us to question what is accepted as fact. This also allows us to consider whether there are different or more effective ways to practice than a traditional method. This ability to question and learn is a critical ingredient for professional growth and competence. 15

Model Predictions PACE and ISNPs will Continue to Thrive Risk Models will Prevail Incentive Models will be Developed FIDA?

Technology Focus on Larger IT Systems and Databases Confidentiality and Cyber Security More Federal and State Audits/Oversight

Collaborations Increase of nursing home and hospital collaborations (e.g. bundling) More collaborations among LTC associations. Increased collaboration between MLTC associations and LTC associations. Increased collaboration with the NYS Department of Health and CMS.

Other Considerations Block Granting Medicaid funding RHCF Star Ratings Federal and State Legislative Composition Emergency Planning Union Contracts 19

Conclusions Changing demographics will impact the delivery system. Hospital readmissions will continue to decline. Four and five star RHCFs will be more successful. The MLTC will survive if there is a significant infusion of dollars into the long term care Medicaid system. If the federal government moves to reimburse Medicaid through block grants, future funding will likely decrease. Using the scientific method (i: Strengths) (i: of the Scientific Method) can (i: Avoids…) avoid many (i: overgeneralization) of the common (i: inaccurate observation) pitfalls of errors (i: ego-involvement) in human inquiry. It is based on (i: open mind) keeping an open mind. Knowledge is viewed as tentative and subject to refutation. The scientific method promotes research (i: empirical evidence) that relies on empirical evidence, is (i: systematic…) systematic and comprehensive, and (i: minimizes bias) minimizes bias.

Conclusions (continued) The auspice of facilities will move rapidly toward a proprietary system. There will be an increase in number of older adults in PACE program and ISNP. The FIDA will likely be phased out when the demonstration program ends in 2018. There will be an increase in collaborations with hospitals, as well as with other long term care organizations. Medicare privatization will be implemented but probably not for several years.