Essential Elements of a State Rebalancing Effort

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. A Balancing Act • Reports on Medicaid LTC spending and participation for older people and adults with physical disabilities for the 1st 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

3. 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%)

4. Bad News: Almost Three-Fourths of Medicaid LTC $$ Go to Nursing Homes 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

5. 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

6. 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.

7. 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.

8. 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.

9. 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

10. 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

11. Pace of Change Matters Current trends in balancing = 50/50 spending balance achieved in 2019 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).

12. 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.

13. 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

14. Rhode IslandMedicaid LTC Spending in is Unbalanced, 2007

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

16. Medicaid LTC Spending in Washington is Balanced, 2007

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

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

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

20. 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.

21. 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.

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

23. 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?

24. 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

25. 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?

26. 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?

27. 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?

28. 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

29. 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

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