The Changing Face of Long Term Care

Transcription

1 The Changing Face of Long Term Care Thomas H. Dennison, Ph.D. Professor of Practice in Public Administration Director, Program in Health Services and Management Senior Research Associate, Aging Studies Institute

2 The Foundations of the Formal Long Term Care System in the United States In 1536 King Henry VIII, in a dispute with the Catholic Church, closed all the monasteries and their long term care facilities. In 1546 the King appointed a board of local citizens to oversee the management of long term care facilities throughout England. In 1601 the first Queen Elizabeth required each local community to care for the elderly in their own homes as long as possible, then to provide care in a facility. In 1722 England enacted the Poor Law (equivalent to today's Medicaid law) believing that sick and poor elderly could better be cared for in institutions than at home.

3 Formal LTC in The Americas The American colonies followed the English pattern, establishing similar institutions for the poor in Philadelphia (1722), New York City (1734) and Charleston, South Carolina (1735). Subsequently, most American cities and counties established homes for the aged, which flourished over the 18th and 19th centuries. Act of NYS Legislature requiring counties to establish poor farms passed in Causes of Dependency *Intemperance *Debauchery *Vagrancy *Bastardy *Lunacy *Blindness *Sickness *Lameness *Old Age *Idiocy

4 Formal Long Term Care = Asylums Institutions for those who could not be cared for at home by family. Local governments of the time favored group housing and as a result, all kinds of people the physically incapacitated, orphans, the mentally ill and insane, etc. ended up living in Almshouses.

5 The Social Movement in the 19 th Century Fraternal and church groups began founding Homes for the Aged out of concern for worthy individuals of their own ethnic or religious background who might have to spend their last days alongside the most despised in society in an Almshouse.

6 The Facilities Differentiated Not only were more worthy elderly people moved from the Almshouses, but other groups started providing for young people, the blind, the insane, etc. By the 1920 s nearly 70% of all residents in nursing homes were the elderly poor. Nursing Homes became synonymous with the poor elders with no other place to go..

7 The Federal Government! In 1935 the Federal Government (for the first time) got involved; the Social Security Act gave elders purchasing power to buy care. And opened the door to for-profit Facilities

8 Medicare and Medicaid Medicaid and Medicare (1965) contributed to several facets of the long term care system: Expansion of service options; Increased utilization and cost; and The artificial distinction between social and medical services.

9 The Care Continuum and Its Sources of Payment Community Services (Private Pay) Medicaid Services Medicare Services Meals on Wheels Adult Day Care Custodial Home Care Outpatient Drugs Subacute Care OutPatient Services Social Services Assisted Living Facilities Custoridal Long Term Care Physician Rehabilitation/Skilled Care Hospital

10 Other Models of Long Term Care Expanded in the 1970s and1980s The reasons are obvious: aging of the baby boom population; severe fiscal pressures; the disproportionate share of costs absorbed by those with serious long-term conditions; and an ongoing over-reliance on institutional care.

11 Medicare and Medicaid, Again Medicare and Medicaid have been behind this growth of services. Purchasing power has driven expansion of services. What Medicare and Medicaid pays for, grows. And the long term care system is now made up of various types of actors. FORM HAS FOLLOWED FINANCING

12 Variation in Sponsorship, NYS

13 $6,000 Operating Performance Per Bed, Voluntary and Private, NYS $5,000 $4,000 $3,000 $2,000 $1,000 Private Voluntary $ $1,000 -$2,000 -$3,000 -$4,000 Source: Cost Reports for all nursing facilities, filed with the New York State Department of Health for Data obtained from Healthcare Association of New York State 13

14 Home Care Sponsorship For-profit, or proprietary, home health agencies were banned from Medicare until 1980 but now account for a majority of the agencies that provide such services. For-profit agencies scored slightly but significantly worse on overall quality indicators compared to nonprofits (77.18 percent and percent, respectively) Compared to nonprofits, proprietary agencies also had higher costs per patient ($4,827 versus $4,075), were more profitable, and had higher administrative costs. Cabin, et al. HEALTH AFFAIRS 33, NO. 8 (2014):

15 Does Sponsorship Matter? A review and meta-analysis of 82 studies comparing quality of care in for-profit and not-for-profit nursing facilities reported that nearly all the studies found higher quality, higher staffing, and fewer pressure sores in notfor-profit facilities. Not-for-profit facilities had better outcomes on four key measures of quality: "More or higher quality staffing;" Lower prevalence of pressure ulcers; Lower prevalence of restraints; and Fewer government-cited deficiencies. Center for Medicare Advocacy

16 Meanwhile, Health Care Costs are Increasing and Long Term Care is in the Cross-Hairs Health spending growth has outpaced growth of the U.S. economy, for both the public and private sectors

17 Medicaid Spending on Long Term Care Medicaid is the largest payer of long-term services and supports (LTSS), which includes home and communitybased services (HCBS). In Federal Fiscal Year (FY) 2013, federal and state governments spent $146 billion on Medicaid LTSS, which represented 34 percent of all Medicaid spending. Trueven Health Analytics. Medicaid Expenditures for Long-Term Services and Supports (LTSS) in FY 2013: Home and Community-Based Services were a Majority of LTSS Spending (June 30, 2015)

18 A Shift in Philosophy of Care Our long term care system, which grew from the institution, and has been fed by Medicare and Medicaid has undergone a shift in philosophy over the past 20 years with a much stronger focus on community based care as: More consistent with societal values, and Less expensive?

19 Medicaid HCBS Expenditures as a Percentage of Total Medicaid LTSS Expenditures, FY

20 Long Term Care Transitions into the Mainstream Financial pressures on the acute care system push hospitals and insurers to find less expensive ways to provide care. Rehabilitation Programs, Sub-acute Services, Less Expensive Options.

21 Today s Nursing Home: The Canary in the Coal Mine for Long Term Care? A tale of two cities Fewer Elderly Customers Younger Clients Shorter Stays More Clinically Complex Higher Levels of Obesity

22 Percent of the Population in Nursing Homes, Selected Age Ranges, NYS 20.00% 18.00% 16.00% 14.00% 12.00% 10.00% 8.00% 6.00% 4.00% 2.00% 0.00% Source: Cost Reports for all nursing facilities, filed with the New York State Department of Health for Data obtained from Healthcare Association of New York State 22

23 0.18% 0.16% 0.14% 0.12% Population in Nursing Homes, NYS 0.10% 0.08% NYC Other NYS 0.06% 0.04% 0.02% 0.00% Source: Cost Reports for all nursing facilities, filed with the New York State Department of Health for Data obtained from Healthcare Association of New York State 23

24 Annual Number of Long Stay Residents and Short Stay Patients, All NYS Source: Minimum Data Set (MDS) data for all New York State Nursing Homes ; analysis provided by Leading Age New York /EQUIP for Quality under CMS DUA #08591 and NYS DUA#

25 LOS by 30 Day Intervals, NYS Days 1-3 months 3-6 months 6-12 months months 24+ months Source: Cost Reports for all nursing facilities, filed with the New York State Department of Health for Data obtained from Healthcare Association of New York State 25

26 Percent Obese Patients and Residents, 30% All NYS 25% 20% 15% Long Short 10% 5% 0% Source: Minimum Data Set (MDS) data for all New York State Nursing Homes ; analysis provided by Leading Age New York /EQUIP for Quality under CMS DUA #08591 and NYS DUA#

27 Change in Internal Processes Increased Numbers of Admissions Billing Complexities Mixing Diverse Populations Quality of Life versus Care Short Term Patients and Long Term Residents

28 Nursing Home Beds and Admissions, 300,000 NYS Number of Beds and Admissions 250, , , ,000 Beds Admissions 50, Source: Cost Reports for all nursing facilities, filed with the New York State Department of Health for Data obtained 3/3/16 from Healthcare Association of New York State 28

29 Days of Care by Payer, NYS NYS Medicare Medicaid Private Other Total % 78.6% 11.1% 1.0% 100.0% % 78.0% 11.5% 0.6% 100.0% % 77.8% 11.7% 0.7% 100.0% % 78.4% 12.1% 0.7% 100.0% % 78.1% 12.3% 0.6% 100.0% % 77.8% 12.4% 0.6% 100.0% % 77.9% 11.9% 0.6% 100.0% % 77.7% 11.4% 0.7% 100.0% % 77.4% 10.7% 0.7% 100.0% % 76.9% 10.6% 0.8% 100.0% % 76.3% 10.8% 0.6% 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% Medicare Medicaid Private Other % 75.7% 11.0% 1.0% 100.0% % 75.5% 11.0% 1.0% 100.0% % 76.1% 10.0% 1.2% 100.0% % 76.1% 10.1% 1.2% 100.0% 10.0% 0.0% Source: Cost Reports for all nursing facilities, filed with the New York State Department of Health for Data obtained from Healthcare Association of New York State

30 Percent of Residents with Cognitive Impairments, NYS 80.0% 70.0% 60.0% 50.0% 40.0% Long Short 30.0% 20.0% 10.0% 0.0% Source: Minimum Data Set (MDS) data for all New York State Nursing Homes ; analysis provided by Leading Age New York /EQUIP for Quality under CMS DUA #08591 and NYS DUA#

31 So? What does this all mean to the long term care system?

32 Change in the Inter-organizational Field Transaction Costs New Partners New Boundaries Models of Managed Care Medicaid Managed LTC Fully-Integrated Dual Advantage Plans (FIDAs) Accountable Care Organizations Attributed Lives

33 What s Next for Long Term Care Providers? The long term care system is now part and parcel of the greater health care system. Inter-organizational interdependency is greater and integration of care must be stronger as ACO models proliferate. Access to Medicaid patients will be moderated by managed care.

34 What s Next? We are going to see a greater blending of Medicare and Medicaid. We are going to see a greater blurring of the lines between social and medical services. We are going to need to recognize and act on our interdependencies as providers. And, we are going to need to make sure that people (whether they are residents or patients, not get lost in the shuffle).