Rebalancing Long Term Care in Maine: Policy Options and Considerations

Transcription

1 Rebalancing Long Term Care in Maine: Policy Options and Considerations HCBS Waiver Conference September, 2010 Julie Fralich, Muskie School of Public Service Elizabeth Gattine, Maine, Office of Elder Services

2 Balancing the LTC System in Maine What is a balanced long term care system? Overview of the Lewin projection model Results and use of the projection model Policy Options and Considerations 10/7/2010 2

3 Definitions: populations, services, settings and expenditures How should populations be defined? Older adults, adults with disabilities, people using behavioral health services, people with brain injury, people with developmental disabilites How should settings be defined? Nursing Facility, Residential care, Assisted Living, Adult Family Home, at home What are the attributes of the settings that define a setting as more or less restrictive? Do we need a different set of standards that include those attributes? How should use of services be compared? Number of users on ave. in a month; over course of the year; point in time Expenditures: what services should be included? What about mental health and community support services; rehab services, other 10/7/2010 3

4 Overview of Lewin Model Focused on older adults and people with disabilities Four factors used to estimate future use of long term care services Population projection by age groups Use rates by service Nursing home trends Supply of residential care beds Model allows user to choose certain assumptions 10/7/2010 4

5 Data Sources Mainecare claims data (expenditures and users all LTC services) Nursing Facility MDS data for use by all payors Residential Care MDS data for use by all payors State funded home care data MED Assessment data and state financial data Data by county by age group 10/7/2010 5

6 Population projections Population projections by age group Population by income categories (above or below poverty) Estimates of number of people with ADL or IADL needs in the general population 10/7/2010 6

7 Nursing Facility Trends Model calculates historical trends in use of nursing homes MaineCare and all payors (and their interaction) User can specify assumptions for future use of nursing homes and create scenarios Use rates will decline, increase, stay the same Model estimates impact of nursing home changes on use of other services 10/7/2010 7

8 Use rates of services Model uses historical service use rates for MaineCare members, by county, by age group Applies those use rates to population projections 10/7/2010 8

9 Output of model Projected users by service by age group by county MaineCare all services Total nursing facility and residential care Projected expenditures by service MaineCare Projected number of beds by county NFs Residential Care 10/7/2010 9

10 Population projections in Maine 2008 to Number of Persons (in thousands) Age Groups Source: 10/7/

11 Population changes by age group in Maine 2008 to % Population change in thousands % Percent change in population +8% +25% +30% +11% % -6% -16% Age Groups Age Groups Source: 10/7/

12 Average Monthly Number of Maine All-Payer NF Residents, SFY SFY ,368 7,872 Total residents, all ages 7,621 7,209 7,496 3,888 3,414 3,331 3,242 3,305 Age 85+ 2,803 2,779 2,657 2,503 2,576 1, Age Age Under 65 SFY 2000 SFY 2004 SFY 2006 SFY 2008 SFY 2009 Source: Based on MDS assessment data 10/7/

13 Average Monthly Number of MaineCare NF Residents, SFY SFY ,431 2,589 Total MaineCare residents, all ages 4,978 4,717 4,761 4,756 2,223 2,025 2,039 2,041 Unknown Age 85+ 1,729 1,678 1,615 1,629 1, Age Age Under 65 SFY 2000 SFY 2004 SFY 2006 SFY 2008 SFY 2009 Source: Based on MaineCare claims data 10/7/

14 Percent of Population Residing in a Nursing Facility, by Age Groups, SFY State Fiscal Year Percent of total population by age All Ages Age Age Age 85+ Age Group Sources: Maine MDS assessment data, and 10/7/2010 Population projections 2008 Woods and Poole Economics, Inc.. 14 Projections are uncertain and future data may differ substantially from Woods & Poole projections

15 Percent of Population Who Were MaineCare NF Residents, by Age, 2000 to 2009 State Fiscal Year Percent of total population by age group All Ages Age Group Sources: MaineCare claims data, and 10/7/2010 Population projections 2008 Woods and Poole Economics, Inc.. Projections are uncertain and future data may differ substantially from Woods & Poole projections 15

16 Change in Monthly Ave. Number of Case Mix Residential Care Residents, SFY Number of Residents 3,820 3,959 4,075 4,069 3,089 1,316 1, Other Payer 1,098 1,991 2,504 2,951 3,124 3,134 MaineCare SFY 2000 SFY 2004 SFY 2006 SFY 2008 SFY 2009 Source: Based on MaineCare claims data and case mix residential care assessment data 10/7/

17 Number of All Payer Residential Care Residents by Age, SFY Total number of residents (for whom age is known) 3, , , ,075 4, Under 65 Age ,258 1,292 1,253 1,329 Age Age 85+ 1,267 1,574 1,685 1,925 1,783 SFY 2000 SFY 2004 SFY 2006 SFY 2008 SFY 2009 Source: Case mix residential care assessment data 10/7/

18 Percent of Population who were all-payer residential care residents SFY State Fiscal Year Percent of total population by age group All Ages Age Group Sources: Case mix residential care assessment data, and 10/7/2010 Population projections 2008 Woods and Poole Economics, Inc.. 18 Projections are uncertain and future data may differ substantially from Woods & Poole projections

19 Percent of Maine pop. by age group who were MaineCare residential care residents, SFY State Fiscal Year Percent of total population by age group All Ages Age Group Sources: MaineCare claims data, and 10/7/2010 Population projections 2008 Woods and Poole Economics, Inc.. Projections are uncertain and future data may differ substantially from Woods & Poole projections 19

20 Long Term Care Needs Model Projections We can vary the model s assumptions about changes in disability rates, nursing facility use rates, and service caps. The following charts illustrate the results of two scenarios: Scenario 1 assumes a continued decline, within age groups, of the percent of population residing in nursing facilities. Scenario 2 assumes that NF use rates will end their decline and remain fixed at 2008 percentages. Both scenarios assume the state will maintain a fixed cap on the number of case mix residential care beds. 10/7/

21 Actual and Projected Number of MaineCare Nursing Facility Residents*, SFY ,500 5,431 Scenario 2 5,326 Number of MaineCare Residents 4,978 4,717 4, Actual 4,689 Scenario 1 4,294 4, State Fiscal Year * Excludes MaineCare residents in out-of-state nursing facilities Source: MaineCare claims data and Lewin Model projections 10/7/

22 Actual and Projected Number of MaineCare Case Mix Residential Care Residents, SFY ,300 3, Actual 3,134 Scenario 1 3,206 Number of MaineCare Residents 2,504 2,980 Scenario 2 3,176 1,991 1, State Fiscal Year Source: MaineCare claims data and Lewin Model projections 10/7/

23 Actual and Projected Number of Users of MaineCare Home and Community Based Services, SFY ,000 4,519 4, Actual 4,218 Scenario 1 4,939 Scenario 2 4,796 Number of 4,171 MaineCare Service Users 4,045 3, State Fiscal Year 10/7/2010 Source: MaineCare claims data and Lewin Model projections 23

24 Projected LTC Users in Maine MaineCare Service Users 12,153 (100%) 4,722 (39%) 3,386 (28%) 4,045 (33%) 12,741 (100%) 4,294 (34%) 3,508 (28%) 4,939 (39%) 13,594 (100%) 5,326 (39%) 3,472 (26%) 4,796 (35%) Nursing Facility Residential Care HCBS Programs Actual 2008 Scenario 1 Scenario (Projected) 10/7/

25 MaineCare Expenditures MaineCare Expenditures (in millions) $366.8 (100%) $352.5 (100%) $403.5 (100%) $241.6 (66%) $219.1 (62%) $271.3 (67%) $81.4 $84.0 $83.2 (22%) (24%) (21%) $43.8 $49.4 $49.0 Actual 2008 Scenario 1 Scenario (Projected) Note: Expenditures and percentages reported above differ from expenditures in Medstat report due to differences in the services included in the analysis. 25

26 Use of Model Use of model Presentations with advocacy groups Legislative presentations (NF bed supply) Meetings with providers CON review Review of applications for residential care beds Budgeting 10/7/

27 Considerations Model relies on historical trends policy makers need to develop goals and assumptions for future trends NF use drives the model; interplay between increase use of home care and decrease use of NF would refine the model Hard to book savings for NF reductions when arguing for more home care use 10/7/

28 Policy Options and Challenges Require Vision Leadership Resources Political will 10/7/

29 Why Do We Need Rebalancing? State Demographics: Maine has one of the oldest populations in U.S. and is first in median age. Consumer preference : Most Mainers with long term care needs would rather remain in their own homes and communities than go to a LTC facility. Financial Considerations: MaineCare expenditures are increasing for more expensive long term facility care but are not increasing for less expensive HCBS.

30 Policy Options and Challenges 1. Decrease nursing facility bed supply. 2. Limit increase in number of residential care beds. 3. Increase choice and ease of access to home and community based services. 4. Facilitate diversion of people from nursing facilities. 5. Utilize financial incentives, including national health care reform.

31 1. Nursing Home Bed Supply There is an uneven distribution of beds across Maine counties (per 1,000 persons age 65+ in SFY 2008): Nursing facility beds range from 49 in one county (Aroostook) to 16 in another (Waldo). Residential care facility beds range from 36 in one county (Androscoggin) to 3 in another (Sagadahoc). Total beds range from 71 in one county (Aroostook) to 28 in another (Sagadahoc) In short, there is a lack of balance in geographic distribution of these services.

32 1. Nursing Facility Bed Supply Maine s LTC facilities are aging with significant financial implications. Based on DHHS Licensing and Certification estimates: 47 nursing facilities with 2,498 beds (36% of the total beds) are in need of renovation and replacement. 40 residential care facilities with 1,257 beds (41% of total beds) are in need of renovation or replacement.

33 1. Nursing Facility Beds Estimated replacement costs could exceed $233 million: Estimated cost of replacing nursing facility beds is $109, ,000 per bed. Replacing 457 beds= estimated $50-59 million. Estimated cost of replacing residential bed is $80,000-95,000 per bed. Replacing 530 beds =estimated $42-50 million. Substantial rehabilitation costs run 70,000-$80,000 per bed. Using 50,000 estimated cost, cost of renovating all 2,677 nursing facility and residential care beds in need of renovation+ $133+ million.

34 2. Limit Increase in Residential Care Beds Over time, the number of residential care beds has increased. Between 2000 and 2008, residential care facilities increased their share of LTC users by 9 percentage point.

35 3.Increase Choice and Ease of Access As a result of several recent legislative bills, Maine is working through an improvement process to look at current state and desired future state. Similar process is in place for Direct Care Worker Task Force (another key component). Focus on integration within Department

36 3.Facilitate Discharge/Diversion from Nursing Facilities Grant opportunities such as Money Follows the Person (Maine has applied for planning grant). Continue to support medical eligibility assessment process and consumer education. MDS 3.0, Section Q. Partner with AAAs/ADRCs.

37 5. Financial Incentives Maine is in the initial stages of transitioning its MaineCare programs to managed care. Consider initiatives available as part of National Health Care Reform.

38 Our Vision Although there are challenges to each of the above, we continue to work toward our vision of rebalanced LTC system in which more people will no longer assume that nursing home is inevitable as people age and can no longer take care of themselves.