Mark Trail, Managing Principal Trends and Transitions Future for Long Term Care National Association of State Human Services Finance Officers Louisville, KY July 28, 2014 Mark Trail, Managing Principal

The Number of People Will Demand Change Source: Administration on Aging; HHS; July 2014

The Cost of Care Will Demand Change Medicaid LTC Cost increased about 25% in 5 years From $113 Billion in 2007 to $140 Billion in 2012 The population > 65 is expected to double in the next 20 years Medicaid Cost very well could double Medicaid covers > 60%of all NH residents, and pays 40% of the nation's total costs for LTCS NH cost 246% of household median income; Home Care only 84% Factors such as Obesity, Physical Activity, and Health Status will affect need for LTC About ½ of all Medicaid LTC expenses were for people < 65 years old

Location of Care Will Demand Change 90% of Seniors prefer to stay at home according to AARP report 15 years after Olmstead Decision States have increased the % of LTC expenditures on HCBS National average increased from 32% in 2002 to 45.5% in 2012 DOJ enforcing very specific changes Increasing emphasis on preventing institutional admission in the first place

Recent Initiatives/Incentives No Wrong Door/Single Point of Entry Balancing Incentive Program Money Follows the Person First Choice (1915i) Self-Direction Employment

Care Management Best Practices Provided face-to-face contact between patients and care managers Integrated care management within primary care practices Targeted patient selection Stratified services based on patient needs Focused on transitions of care from the hospital to other settings Coached patients in self-management techniques Used electronic medical records Source: “Best Practices in Care Management for Senior Populations”; CHRT; April 2014

Workforce Development Nurse delegation Flexibility in funding Other Strategies Care Giver Support Patient Centered Care Workforce Development Nurse delegation Most states don’t permit Flexibility in funding Capitation or Bundled payment strategies

Payment Factors Treatment of assets LTC Insurance GAO report 14-473 - Medicaid 58% had assets > $2,501 Questioned how states are enforcing LTC Insurance Dropped from ACA Most states have incentive; only 10% > 50 years old have coverage 46% of older adult households has less than $10K in ‘non-housing assets’.

Cost Management Strategies Care Management Strategies (like PCCM) Showed some improvement in quality of care Produced little cost savings, especially for folks > 85 years old Early CMS demos showed 6% had costs go up, and 91% showed no significant change Program of All-inclusive Care for the Elderly (PACE ) Full risk program - showed savings Have high start up cost and limited inclusion Source: “Best Practices in Care Management for Senior Populations”; CHRT; April 2014

Cost Management Strategies Full Risk Managed Care (MCO) MLTC Full risk, typically all services carved in Over half the states now use some form of MLTC Current Market Share of Members 44% Private for Profit 32% Private non-profit 24% Public or Quasi-Public Source: “The Growth of Managed Long-Term Services and Supports (MLTSS) Programs: A 2012 Update”; CMS; July 2012

LTCC Report to Congress Rebalancing Incentivize care to enable living in the most integrated setting based on a person-centered process that is informed by an objective assessment of need Care Integration Establish a single point of contact for LTSS care team Align incentives to improve the integration of LTSS with health care services Use technology to mobilize/integrate resources & information Uniform Assessments Consumer Access/Assistance No Wrong Door; & information/before transitions Quality Focus quality improvement efforts on HCBS Payment Reform Pay for post-acute & long-term services/supports based on service rather than setting

LTCC Report to Congress Workforce Include family caregivers Consider career paths for direct line workers Finance Strengthen LTSS financing through private options Strengthen LTSS Financing through Social Insurance Comprehensive or Basic Medicare Benefit For LTSS Medicaid Improvement Demonstration project to provide workers with disability coverage for the LTSS they need to remain employed Greater uniformity of eligibility & benefits in Buy-In programs Medicare Improvement Eliminate the 3-day hospital stay requirement for SNF coverage Reconsider the “homebound” requirement for receiving home health services