1. Essential Elements of a State Rebalancing Effort Susan Reinhard, RN, PhD Senior Vice President AARP Public Policy Institute Rhode Island, May 28, 2009

2. 2 Objectives Identify essential elements of a successful state rebalancing effort, based on research and experience with states National View Rhode Island Stimulate discussion

3. 3 National View AARP Public Policy Institute Balancing Act and Across the States 2009 reports Across the States 2009 – AARP Public Policy Institute’s LTC state data reference Current recession in perspective

4. 4 A Balancing Act 2008 Publication “A Balancing Act” took a new look at the balance of Medicaid LTC system between HCBS and nursing homes Analysis for the nation and for each state Federal and state policy barriers

5. 5 A Balancing Act Reports on Medicaid LTC spending and participation for older people and adults with physical disabilities for the 1 st time When the data for all populations are combined, it’s impossible to get an accurate understanding of how well we are “balancing” for older people and adults with physical disabilities

6. 6 Consumer Perspective Want greater Access to HCBS Most people age 50+ want to “age in place” (84%) People with disabilities want to live in their own homes (87%)

7. 7 Sources: AARP Public Policy Institute calculations based on: Burwell, B., Sredl, K., and Eiken, S. (2008) Medicaid Long- Term Care Expenditures in FY 2007. Cambridge, MA: Thomson Reuters Bad News: Almost Three- Fourths of Medicaid LTC $$ Go to Nursing Homes

8. 8 Medicaid Institutional Bias Nursing home an entitlement HCBS primarily through 1915 (c) waivers –State plan option under the DRA Establishing financial eligibility more difficult in the community Medicaid covers housing costs in an institution

9. 9 Good News: HCBS Going Up Sources: AARP Public Policy Institute calculations based on: Burwell, B., Sredl, K., and Eiken, S. (2008) Medicaid Long- Term Care Expenditures in FY 2007. Cambridge, MA: Thomson Reuters; Burwell, B. (2002) Medicaid HCBS Waiver Expenditures, FY1995–2001. Cambridge, MA: Thomson Reuters.

10. 10 HCBS Can Be Cost- Effective On average, Medicaid dollars can support nearly 3 older people or adults with physical disabilities in HCBS for every person in a nursing home Sources: HCBS from Ng, T., Harrington, C., and O’Malley, M. (2008). Medicaid Home and Community-Based Service Programs: Data Update. Kaiser Commission on Medicaid and the Uninsured; Nursing Homes from Center for Medicare & Medicaid Services (CMS), Medicare & Medicaid Statistical Supplement, 2008 edition.

11. 11 Good News for Some States, Bad News for Other States Source: AARP Public Policy Institute calculations based on: Burwell, B., Sredl, K., and Eiken, S. (2008). Medicaid Long-Term Care Expenditures in FY 2007. Cambridge, MA: Thomson Reuters. NOTE: This does not take into account state-funded HCBS programs, which are significant in some states.

12. 12 We Can Do A Lot Better Nearly half of all states spend less than 1 in 5 Medicaid LTSS dollars for older people and adults with physical disabilities on HCBS. Only 8 states spend more than 2 in 5 Medicaid dollars. Sources: AARP Public Policy Institute calculations based on: Burwell, B., Sredl, K., and Eiken, S. (2008) Medicaid Long- Term Care Expenditures in FY 2007. Cambridge, MA: Thomson Reuters

13. 13 Balancing is Achievable MR/DD Success Sources: AARP Public Policy Institute calculations based on: Burwell, B., Sredl, K., and Eiken, S. (2008) Medicaid Long- Term Care Expenditures in FY 2007. Cambridge, MA: Thomson Reuters

14. 14 Pace of Change Matters Sources: AARP Public Policy Institute calculations based on: Burwell, B., Sredl, K., and Eiken, S. (2008) Medicaid Long-Term Care Expenditures in FY 2007. Cambridge, MA: Thomson Reuters (historical); AARP Public Policy Institute (projections). Current trends in balancing = 50/50 spending balance achieved in 2019

15. 15 Current Economic Climate How will the current economic downturn affect the pace of change? As a percentage of total Medicaid spending, LTC declined 12% between 1998 and 2007 LTC is not the major driver of increased Medicaid spending during a recession.

16. 16 Current Economic Climate States that invest in HCBS programs experience slower expenditure growth than states with low HCBS spending Budget decisions that increase Medicaid’s institutional bias should be avoided

17. 17 Rhode Island Medicaid LTC Spending in is Unbalanced, 2007

18. 18 Change in Rhode Island Medicaid LTC Spending, 2002-2007

19. 19 Medicaid LTC Spending in Washington is Balanced, 2007

20. 20 Medicaid LTC Spending in Texas is Making Progress, 2007

21. 21 Medicaid LTC Spending in Vermont is Making Progress, 2007

22. 22 Vermont: Community Choices For Care Goals  Provide choice and equal access  Serve more people  Manage long term care costs  Improve the system  Create a balanced system  Prevention Patrick Flood, VT DAIL

23. 23 Nursing Facility HCBS Waiver Enhanced Residential Care Waiver Below Nursing Home Level of Care Acuity Previous eligibility threshold Eligibility – Old System

24. 24 Choices for Care Eligibility Highest Need Extensive/total assist 1 ADL, limited with 1 other ADL Severe impairment with decision making or moderate plus behavior Condition requiring daily nursing assessment Moderate Need Group Acuity NF, HCBS threshold Entitlement Group High Need Group

25. 25 Vermont Choices for Care Participants, 2005–2008 Source: J. Senecal, Commissioner, Vermont Department of Disabilities, Aging and Independent Living, presentation at the 2009 Money Follows the Person conference

26. 26 Rationale for Medicaid Managed LTC Burgeoning cost of Medicaid services. State officials can achieve budget stability over time through capitation. Minimize financial risk by passing part or all of it on to contractors. States can hold one entity accountable for both controlling service use and providing quality care.

27. 27 Rationale for Medicaid Managed LTC (con’t) Officials are also interested in MMLTC ability to address the following: –Waiting lists for LTC services –Families unaware of services or how to get them because of multiple agencies. –Lack of accountability –Avoidable hospital admissions, unnecessary use of nursing home care, & medication mismanagement resulting from multiple parallel systems of care.

28. 28 3 Types of Medicaid Managed LTC Models 1. Medicaid Long-Term Care Only 2. All Medicaid3. Medicaid- MedicareContractor at risk for HCBS Medicaid Long- Term Care Nursing Home Medicaid Primary Medicaid Acute Medicaid Rx Medicaid Primary Medicaid Acute Medicaid Rx Medicaid Primary and Acute Care Medicare AcuteMedicare HCBS = home and community-based servicesMedicare Rx

29. 29 State Examples Model I - Wisconsin Family Care - New York Managed Long-Term Care Model II - Florida Frail Elder Option Program - Arizona Long Term Care System - Texas Star Program - Florida Diversion

30. 30 State Examples (con’t) Model III -Program for All-inclusive Care for the Elderly (PACE) -Wisconsin Partnership Program -Minnesota Senior Health Options (MSHO) -Massachusetts Senior Care Options (SCO)

31. 31 Medicaid Managed LTC: Pros Pros: Less consumer cost sharing than fee- for-service. Enhanced benefits. Greater emphasis on home and community-based services.

32. 32 Medicaid Managed LTC: Potential Issues Cons: Limit number of providers members can see? Is the network adequate? Providers concerned about accepting a price that may be less than fee-for-service rates. Network adequacy… In a few areas, MMLTC is the only option for consumers who need Medicaid-funded LTC…choice?

33. 33 AARP Policies on Medicaid Managed LTC Choice: Consumers have choice to enroll and can disenroll from managed care “for cause” Enrollment: States conduct enrollment directly or contract with third-party enrollment brokers Plan Standards: Plans need to meet comprehensive set of standards that apply to other health plans –Full range of consumer protections –Fair, rapid appeals process

34. 34 Questions: Medicaid Managed LTC Enrollment: Is enrollment in managed care optional, or do beneficiaries have the right to opt-out? Capitated benefits: What benefits should be included in the capitation? Should contractors be at risk only for long-term care, Medicaid long-term care, and acute care, or for the comprehensive range of Medicaid and Medicare benefits?

35. 35 Questions (con’t) Contractors: Does the managed care organization have an adequate network of home and community- based service providers? Services: Will self-direction of services be allowed? What is the role for family caregivers? Can they be paid as service providers?

36. 36 Questions Consumer Info: Will consumer information be available for people with visual impairments, limited reading proficiency, and in languages other than English? Geographic area: What areas are viable? Quality: How should the quality of care be measured?

37. 37 Comprehensive System – Selected Features Philosophy, leadership Consolidate functions or figure out how to overcome turf –Policy, eligibility, licensing, oversight, program management Comprehensive entry points/one stop/coordinated entry: uniform assessment, options counseling

38. 38 Comprehensive System (con’t) Financing that supports access and choice –Unified budgets, flexible funding, consumer choice –Managed long-term care Full array of services Nursing home case management and relocation assistance Streamlined access

39. 39 Impact of a Comprehensive System Reduces Medicaid growth trend line NF reliance Broad array Time $$