1. Aging and Long-Term Health Policy Mark R. Meiners Ph. D. Long-Term Care Educational Foundation National Capital Healthcare Executives January 14, 2014

2. Economics of Aging and Long-Term Care Can we create a new way to pay for long-term care? Can we integrate acute and long-term care? Can we encourage informal care? Can we give people with disabilities maximum control over the services they receive? Partnership for Long-Term care Medicare/Medicaid Integration Program Service Credit Banking in MCOs Consumer Direction: Cash and Counseling

3. 3 Coping with Chronic Conditions is Now the Norm in Health and Health Care Coping with Chronic Conditions is Now the Norm in Health and Health Care 1 in 4 Americans have a chronic illness1 in 4 Americans have a chronic illness 54 million Americans have some level of disability54 million Americans have some level of disability 50% of Adults 65 years old+ report limitations of activity50% of Adults 65 years old+ report limitations of activity For adults 80 years old+For adults 80 years old+ - 25% are in chronic care facilities - 40% need assistance with Activities of Daily Living

4. Chronic Care Challenges The health care system is increasingly complicated and difficult to use;The health care system is increasingly complicated and difficult to use; The emergence of chronic illness is the major reason for medical encounters rather than acute care;The emergence of chronic illness is the major reason for medical encounters rather than acute care; Care coordination support is neededCare coordination support is needed Transitions among providers can be improvementTransitions among providers can be improvement Patient Center Medical/Health Homes must become the normPatient Center Medical/Health Homes must become the norm Community based LTSS key part of quality improvementCommunity based LTSS key part of quality improvement

5. Why is LTC such a Challenge? Assistance with ADL’sAssistance with ADL’s Monitoring & SupportMonitoring & Support Care vs. CureCare vs. Cure Physical and/or CognitivePhysical and/or Cognitive Greater than 90 daysGreater than 90 days

6. What is in a Name? Acute vs. Chronic illnesssAcute vs. Chronic illnesss Chronic Illness vs. LTC vs. LTSSChronic Illness vs. LTC vs. LTSS Medical vs. Health vs. Social ServicesMedical vs. Health vs. Social Services Disability vs. Frailty vs. Co-morbidityDisability vs. Frailty vs. Co-morbidity Seniors vs. Adult Disabled vs. DD vs. IDSeniors vs. Adult Disabled vs. DD vs. ID HCBS vs. Institutional Care vs. Assisted Living vs. HospiceHCBS vs. Institutional Care vs. Assisted Living vs. Hospice

7. Incorporating LTC in Health Reform Chronic Care Improvement: Care Coordination, Medical Home, House-call Primary Care, ACOsChronic Care Improvement: Care Coordination, Medical Home, House-call Primary Care, ACOs Investment in Safety Net: HCBS alternatives to Institutional Care, Dual Eligible Integrated Care, Workforce DevelopmentInvestment in Safety Net: HCBS alternatives to Institutional Care, Dual Eligible Integrated Care, Workforce Development LTC Financing: Public Insurance, Private Insurance, Medicare and Medicaid System ReformLTC Financing: Public Insurance, Private Insurance, Medicare and Medicaid System Reform

8. Why the Interest in LTC? Multi-disciplinary focus - health, welfare, housing, transportation, etc.Multi-disciplinary focus - health, welfare, housing, transportation, etc. Dramatic aging of the population suggests major structural changes in demand and supply of care.Dramatic aging of the population suggests major structural changes in demand and supply of care. Last big ticket item for which there is little insurance - a major cause of catastrophic costs leading to MedicaidLast big ticket item for which there is little insurance - a major cause of catastrophic costs leading to Medicaid

9. Source: Health Care Financing Administration, 2004 statistics 17% Medicare (Home Care and Nursing Home) 39% Medicaid 30% Out-of-pocket 7% Private Insurance 2% VA 5% Other 9 Who Pays for Long Term Care?

10. What Does Medicare Say? Taken from an actual Social Security Statement 10

11. Long Term Care Financing Reform Options—Overview Social Insurance—e.g., Medicare expansion. Social Insurance—e.g., Medicare expansion. Means tested—e.g., Medicaid improvements. Means tested—e.g., Medicaid improvements. Public-private partnership—e.g., private financing options linked with public program reforms. Public-private partnership—e.g., private financing options linked with public program reforms.

12. Economics of Aging and Long-Term Care Can we create a new way to pay for long-term care? Can we integrate acute and long-term care? Can we encourage informal care? Can we give people with disabilities maximum control over the services they receive? Partnership for Long- Term care Medicare/Medicaid Integration Program Service Credit Banking in MCOs Consumer Direction: Cash and Counseling

13. Early 80's: research based awakeningEarly 80's: research based awakening Mid 80's: LTC insurance became real/so much so that it promoted a debate about the relative worth of social vs. private insuranceMid 80's: LTC insurance became real/so much so that it promoted a debate about the relative worth of social vs. private insurance Mid 90’s: Medicare catastrophic, Pepper Commission, Clinton Plan, Contract with America, Partnership for LTCMid 90’s: Medicare catastrophic, Pepper Commission, Clinton Plan, Contract with America, Partnership for LTC Mid 00’s: 2005 DRA Partnerships, CLASSMid 00’s: 2005 DRA Partnerships, CLASS History of LTC Insurance

14. Economics of Aging and Long-Term Care Can we create a new way to pay for long-term care? Can we integrate acute and long-term care? Can we encourage informal care? Can we give people with disabilities maximum control over the services they receive? Partnership for Long-Term care Medicare/Medicaid Integration Program Service Credit Banking in MCOs Consumer Direction: Cash and Counseling

15. Why the Interest in Acute and LTC Integration? Important public financing considerations Important public financing considerations Cost shifting in both directions Cost shifting in both directions Unintended consumer consequences Unintended consumer consequences An opportunity to do better with limited resources An opportunity to do better with limited resources Managed care implications Managed care implications Aging of the population/Chronic Care Imperative Aging of the population/Chronic Care Imperative

16. 16 Picture the Problem: Medical and Social Service System Silos

17. Economics of Aging and Long-Term Care Can we create a new way to pay for long-term care? Can we integrate acute and long-term care? Can we encourage informal care? Can we give people with disabilities maximum control over the services they receive? Partnership for Long-Term care Medicare/Medicaid Integration Program Service Credit Banking in MCOs Consumer Direction: Cash and Counseling

18. Village Research Goals –Increase awareness of the importance of medical and social service coordination; chronic care needs –Encourage teamwork between health and social service providers; –Teach the value of patient empowerment; –Teach providers and their patients how to identify and use available techniques, tools, and resources to better serve their patient care needs; –Support care coordination among community providers.

19. Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Chronic Care Model Improved Outcomes Figure 1 from Wagner, E.H. Chronic Disease Management: What Will It Take to Improve Care for Chronic Illness? Effective Clinical Practice, 1998; 1:2-4 19

20. Medication self-managementMedication self-management Personal Health RecordPersonal Health Record Transition Tracking and Follow-UpTransition Tracking and Follow-Up Knowledge of “Red Flags”Knowledge of “Red Flags” Source: Tools booklet developed by Dr. Eric Coleman: MD, MPH; Care Transitions Program; Denver, Colorado 20 Evidence Based Decision Support Strategies

21. TEAM SAN DIEGO Goals –Increase awareness of the needs of chronically ill elderly and disabled patients; –Encourage teamwork between health and social service providers; –Support care coordination among community providers; –Teach the value of patient empowerment; –Teach providers how to identify and use available techniques, tools, and resources to better serve their patients needs.

22. Economics of Aging and Long-Term Care Can we create a new way to pay for long-term care? Can we integrate acute and long-term care? Can we encourage informal care? Can we give people with disabilities maximum control over the services they receive? Partnership for Long- Term care Medicare/Medicaid Integration Program Service Credit Banking in MCOs Consumer Direction: Cash and Counseling

24. 24 Medical Home 3.0 Medical Home 3.0 Fully E-Health Capable Advanced Care Management Capable Community Practice Translational Research Site Connected to Community Resource Databases Patient E-Learning Center Psycho/Social Evaluation And Intervention Community Health Surveillance Interfaces Horizontally Integrated With Interoperable HIT Remote Bio-metric Monitoring Capable

25. 25 Medical Home 1.0 Medical Home 1.0 E- Prescribing Individual Patient Care Plans Care Coordination Capable Electronic Medical Record

26. Questions & Answers 26