Medicaid Adult Quality Measures: Understanding the Target Population

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 

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

5. Medicaid and CHIP Enrollment by Eligibility Category, FY 2009 (Unduplicated annual enrollment) State Medicaid programs use a variety of service delivery systems: Roughly 70% of Medicaid population is in some sort of managed care arrangement (i.e., managed care, primary care case management). A large portion of Medicaid enrollees with multiple chronic conditions and complex health care needs receive care in a fee-for-service setting. 25.3 % of our beneficiaries in Medicaid are elderly and disabled.State Medicaid programs use a variety of service delivery systems: Roughly 70% of Medicaid population is in some sort of managed care arrangement (i.e., managed care, primary care case management). A large portion of Medicaid enrollees with multiple chronic conditions and complex health care needs receive care in a fee-for-service setting. 25.3 % of our beneficiaries in Medicaid are elderly and disabled.

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.

11. Percentage of Total Medicaid Expenditures for Older Adults and Persons with Disabilities, FFY 1980-2005 Since 1980, the percentage of total Medicaid expenditures for 25% of the beneficiaries has been relatively steady at 70%...this includes all Medicaid expenditures � primary and LTC supports and services.Since 1980, the percentage of total Medicaid expenditures for 25% of the beneficiaries has been relatively steady at 70%...this includes all Medicaid expenditures � primary and LTC supports and services.

12. Long-Term Care Expenditures by Payer: United States, 2005 Medicaid is the largest payor of LTC in the US, paying for about half of all LTC in the US.. The LTC includes both institutional and community services.Medicaid is the largest payor of LTC in the US, paying for about half of all LTC in the US.. The LTC includes both institutional and community services.

13. Medicaid Institutional and Community-Based Expenditures in Dollars, FFY 1980-2005 Spending for community-based long-term care services rose to 45% of all Medicaid long-term care costs. So it is almost equal to that of institutional care. In FY 2008, long-term care represented 32.1 percent of total Medicaid spending, which equaled $331.8 billion. More than half of those expenditures remain in institutional settings, with some States still spending more than 2/3 of their long term care resources in institutional settings. Spending for community-based long-term care services rose to 45% of all Medicaid long-term care costs. So it is almost equal to that of institutional care. In FY 2008, long-term care represented 32.1 percent of total Medicaid spending, which equaled $331.8 billion. More than half of those expenditures remain in institutional settings, with some States still spending more than 2/3 of their long term care resources in institutional settings.

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% I/DD (Intellectual/Developmental Disabilities) Enrollment in an I/DD or mental retardation (MR)/DD waiver, use of an intermediate care facility (ICF)-MR, or relevant diagnosis codes on inpatient or HCBS service records SMI (Serious Mental Illness) Enrollment in an MI waiver, use of an inpatient psychiatric facility, or relevant diagnosis codes on inpatient or HCBS service records 65+ All HCBS participants who are 65 or older Under 65 with physical disability All others who are under age 65 (includes, for example, traumatic brain injury and HIV) Notes: Overlap among I/DD, SMI, and 65+ allowed Also includes: Subset of Developmental Disabilities Group (autism, CP) Brain Injury Dementia Stroke Subset of Mental Illness Subset of Medically Fragile Conditions I/DD (Intellectual/Developmental Disabilities) Enrollment in an I/DD or mental retardation (MR)/DD waiver, use of an intermediate care facility (ICF)-MR, or relevant diagnosis codes on inpatient or HCBS service records SMI (Serious Mental Illness) Enrollment in an MI waiver, use of an inpatient psychiatric facility, or relevant diagnosis codes on inpatient or HCBS service records 65+ All HCBS participants who are 65 or older Under 65 with physical disability All others who are under age 65 (includes, for example, traumatic brain injury and HIV) Notes: Overlap among I/DD, SMI, and 65+ allowed Also includes: Subset of Developmental Disabilities Group (autism, CP) Brain Injury Dementia Stroke Subset of Mental Illness Subset of Medically Fragile Conditions

15. Medicaid LTC Beneficiaries (in millions), 2003  A majority of people receiving Medicaid LTC are in community settings. A majority of people receiving Medicaid LTC are in community settings.

16. Medicaid LTC Spending Distributed by Target Population, FFY 2005 Most long-term care supports two major population groups, older adults and people with physical disabilities (aged/disabled or A/D) or people with developmental disabilities (DD). Most long-term care supports two major population groups, older adults and people with physical disabilities (aged/disabled or A/D) or people with developmental disabilities (DD).

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 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 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

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�