1. Medicaid Adult Quality Measures: Understanding the Target Population Lekisha Daniel-Robinson, MSPH Division of Quality, Evaluation, and Health Outcomes Family and Children’s Health Programs Group Center for Medicaid, CHIP and Survey & Certification Anita Yuskauskas, PhD Disabled and Elderly Health Programs Group Center for Medicaid, CHIP and Survey & Certification

2. The Center for Medicaid, CHIP and Survey & Certification: Our Mission To help States make Medicaid and CHIP the best programs they can be and to contribute to the broader goal of improving health care for all Americans Beneficiaries are our focus Partnerships are critical to success

3. Identifying a Core Set of Quality Measures for Adults in Medicaid October 2010 October 2010 March 2011 March 2011 May/June/July 2011 May/June/July 2011 10/18/10 1 st meeting of AHRQ ‘s Subcommittee to the National Advisory Council 10/25/10 Medicaid listening session for State comments on SNAC recommended core measures set 03/01/11Public comment period end for the Federal Register Notice on recommended core measures set TBD2 nd meeting of AHRQ’s SNAC to discuss final recommendations for core measures set 07/30/11 Prioritization for measure enhancement and development December 2011 December 2011 12/30/11Initial core set published for use by States and other stakeholders January 2012 January 2012 01/01/12 Adult Quality Measures Program November/ December 2010 November/ December 2010 11/02/10Stakeholder Listening Sessions 12/30/10 Publication of Federal Register Notice on the recommended core measures set

4. Medicaid's Influence in the Health Care Market Health insurance coverage –~ 60 Million children, adults, elderly, including people with physical, developmental, and intellectual disabilities. Assistance to Medicare Beneficiaries –8.8 Million elderly and people with disabilities (19% dual eligible) Long-term care Assistance –Medicaid pays for 40% of long-term care services –1 Million nursing home residents –2.8 Million community-based residents Source: Kaiser Family Foundation, based on 2003 Medicare Current Beneficiary Survey (MCBS) and the 2003 Medicaid Statistical Information System (MSIS) Summary File.

5. 5 Children Other Adults, Under 65 yrs. Blind/Disabled Adults, Under 65 yrs. Elderly, Over 65 yrs. Medicaid and CHIP Enrollment by Eligibility Category, FY 2009 (Unduplicated annual enrollment) Source: US Dept of Health and Human Services, 2009 CMS Statistics; CMS Pub. No.034497 08/2009 49% 27% 15% 9%

6. Source: US Dept of Health and Human Services, 2009 CMS Statistics; CMS Pub. No.034497 08/2009 ALMOST 27 MILLION ARE ADULTS (21 and older) Medicaid and CHIP Enrollees by Age, FY 2006* *Enrolled at some point during fiscal year.

7. Understanding the Adult Medicaid Population: Overall Adult Health (under 65 yrs) One in five Medicaid adults (men & women) describe their general health as fair or poor. One in seven Medicaid adults (men & women) have fair or poor mental health. 2009 Government Office of Accountability study found that adult Medicaid enrollees ages 21-64: – Majority had at least one potentially serious health condition. – 57 % were overweight, had diabetes, high cholesterol, high blood pressure, or a combination of these conditions. – Twice as likely to have diabetes compared to privately insured adults (13:7). Sources: Kaiser Family Foundation: Low-Income Adults Under Age 65 — Many are Poor, Sick, and Uninsured, June 2009. Government Office on Accountability: Study on Medicaid Preventive Services, August 2009.

8. Understanding the Adult Medicaid Population: Maternal & Reproductive Health Women comprise the majority of the adult Medicaid population. Nearly 2 of 3 of adult women on Medicaid are in their reproductive years (19-44). Medicaid covers 4 of 10 births and approximately 2 of 3 publically-funded family planning services, including: – Prenatal and post-partum care – Gynecological services – Testing and treatment of sexually transmitted diseases Sources: National Institute for Reproductive Health Kaiser Family Foundation: Health Reform: Implications for Women’s Access to Coverage and Care, December 2009.

9. Understanding the Adult Medicaid Population: Complex Health Care Needs People with intellectual, physical, & developmental disabilities as well as the dually-eligible often have complex health care needs. Non-elderly Medicaid enrollees with disabilities are more likely to have 3+ chronic conditions (e.g., cardiovascular, psychiatric, central nervous system conditions) than enrollees without disabilities. People eligible for both Medicaid/Medicare are referred to as the “Duals”: – 3 in 5 dually-eligible have multiple chronic conditions – Roughly 37% have cardiovascular disease – 20% have 1+ mental cognitive condition (i.e., Alzheimer's disease, other dementia) Sources: CHCS: The Faces of Medicaid II Recognizing the Care Needs of People with Multiple Chronic Conditions, October 2007. The Kaiser Family Foundation: Chronic Disease and Co‐Morbidity Among Dual Eligibles: Implications for Patterns of Medicaid and Medicare Service Use and Spending, July 2010.

10. Understanding the Adult Medicaid Population: Adults and the Elderly with Long-term Care Needs

11. Source: CMS Form 64 Reports, adjusted for price increases based on the Skilled Nursing Facility Input Price Index. Percentage of Total Medicaid Expenditures for Older Adults and Persons with Disabilities, FFY 1980-2005

12. Source: Georgetown University Long-Term Care Financing Project Long-Term Care Expenditures by Payer: United States, 2005

13. Source: CMS Form 64 Reports, adjusted for price increases based on the Skilled Nursing Facility Input Price Index. Medicaid Institutional and Community-Based Expenditures in Dollars, FFY 1980-2005

14. Describing Medicaid LTC Population Using HCBS Large: 2.2 million individuals 2/3 dually eligible for Medicare and Medicaid Mean age 56; 61% female Diverse: Tremendous State variation in characteristics of the HCBS population Subpopulations, average percentage of the HCBS population: – I/DD: 26% – SMI: 13% – Under 65 with physical disability: 24% – 65+: 44% Source: MAX and MedPAR data, 2005

15. Medicaid LTC Beneficiaries (in millions), 2003 Sources: CMS Medicaid Statistical Information System State Summary Datamart and Kaiser Family Foundation. The community services total includes personal care and HCBS waiver beneficiaries. This total may include duplicates.

16. Medicaid LTC Spending Distributed by Target Population, FFY 2005 Source: CMS Form 64 Reports

17. Challenges Defining the Medicaid LTC Population Wide variety of diagnostic categories in LTC Wide range of settings Wide range of service provider types and qualifications Wide range of measurement sets: no standardization No standard “treatment intervention”, i.e., service definitions & service delivery models

18. LTC: Social & Needs-Based Service Delivery System Generally consists of services and supports to address chronic & long term conditions Promotes maximum qualities of life in community settings Not primary health care Services can include: -Personal Care -Home Health (nursing, medical supplies & equipment, appliances for home use, optional PT/OT/Speech/Audiology -Rehabilitative Services -Targeted Case Management -Self-directed Personal Care -HCBS for the Elderly & Disabled -Other

19. Ongoing HCBS Measurement Efforts at CMS 1915(c) Assurance-Based Measures – The assurances relate to six domains: Level of Care; Plan of Care; Health and Welfare; Provider Qualifications, Administrative Authority; Financial Accountability – Performance measures will directly align with assurances MFP Longitudinal QOL survey on all MFP participants Tracking changes from institution through the first two years in community Domains include living situation, choice and control, access to personal care, respect/dignity, community integration/inclusion, overall life satisfaction, health status. Individual level outcomes for quality of care: subset of DRA health and welfare clinical outcomes HCBS Experience Survey (CAHPS®) - Kicked off June 2010 – Experience of care measures

20. Ongoing HCBS Measurement Efforts at CMS National Balancing Indicator Project –Measure states’ progress in providing a person-centered, balanced system of long-term services and supports. –18 LTSS indicators based on six domains:  Sustainability  Self-Determination/Person Centeredness  Prevention  Community Integration & Inclusion  Shared Accountability  Coordination & Transparency

21. The “Triple Aim” Per Capita Cost Experience Of Care Population Health