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
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
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
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
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
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
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
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
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
Population projections in Maine 2008 to 2020 220 232 220 224 2008 2015 2020 Number of Persons (in thousands) 169 164 149 152 184 173 185 179 184 104 69 89 28 31 0-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ Age Groups Source: 10/7/2010 10
Population changes by age group in Maine 2008 to 2020 +79.9 +77% +45.3 +11.4 Population change in thousands +11.7 +20.4 +3.0 +5% Percent change in population +8% +25% +30% +11% -20.3-11.6-12% -6% -16% -34.9 0-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ Age Groups 0-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ Age Groups Source: 10/7/2010 11
Average Monthly Number of Maine All-Payer NF Residents, SFY 2000 - SFY 2009 8,368 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 1,057 995 935 845 948 620 684 698 618 668 Age 75-84 Age 65-74 Under 65 SFY 2000 SFY 2004 SFY 2006 SFY 2008 SFY 2009 Source: Based on MDS assessment data 10/7/2010 12
Average Monthly Number of MaineCare NF Residents, SFY 2000 - SFY 2009 5,431 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 1,624 648 614 567 583 600 454 450 470 470 490 Age 75-84 Age 65-74 Under 65 SFY 2000 SFY 2004 SFY 2006 SFY 2008 SFY 2009 Source: Based on MaineCare claims data 10/7/2010 13
Percent of Population Residing in a Nursing Facility, by Age Groups, SFY 2000-2009 State Fiscal Year 2000 2004 2006 2008 2009 Percent of total population by age All Ages Age 65-74 Age 75-84 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
Percent of Population Who Were MaineCare NF Residents, by Age, 2000 to 2009 State Fiscal Year 2000 2004 2006 2008 2009 Percent of total population by age group All Ages 65-74 75-84 85+ 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
Change in Monthly Ave. Number of Case Mix Residential Care Residents, SFY 2000-2009 Number of Residents 3,820 3,959 4,075 4,069 3,089 1,316 1,008 951 935 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 10/7/2010 16
Number of All Payer Residential Care Residents by Age, SFY 2000-2009 Total number of residents (for whom age is known) 3,820 466 3,087 521 392 3,958 470 511 4,075 4,065 415 438 484 515 Under 65 Age 65-74 442 1,258 1,292 1,253 1,329 Age 75-84 985 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 10/7/2010 17
Percent of Population who were all-payer residential care residents SFY 2000-2009 State Fiscal Year 2000 2004 2006 2008 2009 Percent of total population by age group All Ages 65-74 75-84 85+ 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
Percent of Maine pop. by age group who were MaineCare residential care residents, SFY 2000-2009 State Fiscal Year 2000 2004 2006 2008 2009 Percent of total population by age group All Ages 65-74 75-84 85+ 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
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. 10/7/2010 20
Actual and Projected Number of MaineCare Nursing Facility Residents*, SFY 2000-2015 5,500 5,431 Scenario 2 5,326 Number of MaineCare Residents 4,978 4,717 4,722 2009 Actual 4,689 Scenario 1 4,294 4,000 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 State Fiscal Year * Excludes MaineCare residents in out-of-state nursing facilities Source: MaineCare claims data and Lewin Model projections 10/7/2010 21
Actual and Projected Number of MaineCare Case Mix Residential Care Residents, SFY 2000-2015 3,300 3,124 2009 Actual 3,134 Scenario 1 3,206 Number of MaineCare Residents 2,504 2,980 Scenario 2 3,176 1,991 1,800 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 State Fiscal Year Source: MaineCare claims data and Lewin Model projections 10/7/2010 22
Actual and Projected Number of Users of MaineCare Home and Community Based Services, SFY 2000-2015 5,000 4,519 4,536 2009 Actual 4,218 Scenario 1 4,939 Scenario 2 4,796 Number of 4,171 MaineCare Service Users 4,045 3,500 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 State Fiscal Year 10/7/2010 Source: MaineCare claims data and Lewin Model projections 23
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 2 2015 (Projected) 10/7/2010 24
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 2 2015 (Projected) Note: Expenditures and percentages reported above differ from expenditures in Medstat report due to differences in the services included in the analysis. 25
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 10/7/2010 26
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 10/7/2010 27
Policy Options and Challenges Require Vision Leadership Resources Political will 10/7/2010 28
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.
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.
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.
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.
1. Nursing Facility Beds Estimated replacement costs could exceed $233 million: Estimated cost of replacing nursing facility beds is $109,000-130,000 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.
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.
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
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.
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.
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.