1 11 “…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 Directors William 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

4 4 Are we old? Not yet, but getting there …

5 5 Geography Matters

6 6 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)

11 A very different picture in 2030

12 Shifts in Medicaid Spending

13 Driven by Age and Shifts in Demand for Services Nursing Home Care

14 Workforce Issues will become more acute.

15 What do you mean when you say managed care?

16 Acute Medical Chronic Medical Community Based LTC Assisted Living Nursing Home What does a Long-Term-Care Accountable Care Organization Look Like?

17 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 $ in July 2012

18 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

19 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

20 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?

22 What Can We Learn from Phase 1 about Phase 2?

23 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.

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 (

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?

30 Nursing home expenditures are an increasing burden on the counties.

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 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 Public Policy Studies Want to learn more? Online: nhpolicy.org Facebook: facebook.com/nhpolicy Our blog: policyblognh.org (603) “…to raise new ideas and improve policy debates through quality information and analysis on issues shaping New Hampshire’s future.” Board of Directors William 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