Medicaid Reform: The Opportunities for Home and Community Based Providers
ILS Background & Experience Care Management Company founded in 2001 Focuses on Duals, Medicaid ABD and Managing Medicaid Long term Care Costs Clients are principally MCOs Currently serving almost 2 million Medicaid and/or Medicare Members in about 40 states
Our Services Comprehensive Case Management & Coordination Managed Long Term Care Services Nutrition Services & Home Delivered Meals Care Transition & Post Discharge Services Population risk stratification, assessment, care plans and case management Back office, administrative and coordination services for MLTC plans Nutrition care management, education & meals services Patient centered care transition, post discharge coordination and coaching
The Challenge Aging of Population and related costs of chronic diseases and Long term Care Difficult to manage costs of disabled person (acute and LTC) Increase in Medicaid Eligibles Limited State Budgets and competition for resources at State Level
Proportion of Medicaid LTSS Spending for HCBS Among Aged/Disabled $264 Billion 1 1 Avalere analysis of the 2008 CMS National Health Expenditures data; the National Investment Center for the Seniors Housing and Care Industry MAP Data and Analysis Service data; and data from Burwell, B., Sredl, K., and Eiken, S. Medicaid expenditures for LTC services, 1996 2008.
HCBS Spending as a Percent of Medicaid Long Term Care Spending By State, 2009 1 WA ME OR CA AK NV ID AZ UT MT WY CO NM ND SD NE KS OK TX MN WI IA MO AR LA IL MS NY MI PA OH IN WV VA KY NC TN SC AL GA FL VT NH MA CT NJ DE MD D.C. RI 50%+ 40% to 49.9% 30% to 39.9% <30% HI 1 HCBS spending includes HCBS expenditures authorized under Sections 1915(c) and 1915(j) of the Social Security Act including MR/DD; the home health benefit; the optional personal care benefit; the Program of All Inclusive Care for the Elderly; and select HCBS expenditures authorized under Section 1115 of the Social Security Act. It does not include HCBS spending under Section 1915(i) of the Social Security Act, spending through managed care programs, or spending authorized under Section 1115 that was not clearly allocated to community basedlong term care. Reliable fee for service data do not exist for Arizona and Vermont. Source: Analysis of data from the CMS Form 64 performed by Eiken, S., Sredl, K., Burwell, B., Gold, L. Medicaid Long Term Care Expenditures, FY 2009. HCBS Clearing House, August 2010. http://hcbs.org/moreinfo.php/nb/doc/3325/medicaid_long_term_care_expenditures_fy_2009
Medicaid Costs for Dual Eligibles TENNESSEE Inpatient 1.35 % Outpatient 2.06 % Physician 5.62 % LTC 86.91 % Home Health 2.12 % Hospice 1.94 % TOTAL 100.00 %
Profile of Medicaid Costs Duals account for more than 40% of costs, but represent less than 20% of Eligibles LTC is more than 80% of Duals Medicaid costs LTC costs are 60% aged, 40% disabled Costly ABD population, Duals and LTC remain in uncoordinated FFS systems
State Approaches Capitation to include costs of acute and long term Care Development of integrated Medicare/Medicaid programs Evolution of Managed Fee for Service models Enhanced PCCM models ACOs and Medical Homes
Re Balancing The only way to reduce or contain the cost of Long term Care is to rebalance; i.e. shift proportion of institutional care toward community Capitation moves responsibility for rebalancing from State to MCOs
Features of Capitated Programs MLTC State Pays MCO a Risk Adjusted Capitation Rate 75/25 Community Facility Blend Duals 1500 4500 3750 Medicaid Only 2200 5500 4675 Blended rate reductions lag rebalancing progress Claims may be paid by MCO or fiscal intermediary If MCO pays claims, MCO can establish provider reimbursement Capitated Programs are moving from voluntary to mandatory
Florida s Medicaid Reform Currently have 20,000 in principally community based Nursing Home Diversion Program Beginning in late 2012 all Medicaid will move to mandatory capitated programs for both acute and LTC, community and nursing home residents Enrollment in capitated LTC will grow from 20,000 to 80,000+ $ will grow from $350 million to more than $3 billion HCBS $ will grow $30 million for each 1% rebalancing
Integrated Medicare/Medicaid programs PACE Programs Medicare Dual Eligible ( DE ) Special Needs Plans with a crossover Medicaid Contract Medicaid Plans expanding by creating DE SNPs State initiated Dual Integrated Care Demonstrations
New Opportunity for States CMS announced in its July 8 th letter to States (SMDL #11 008) financial models to promote integration. CMS will give States Medicare monies to manage if they create integrated Health Systems Medicare and Medicaid Acute and LTC MCO Capitated or Coordinated FFS Model Want fast track implementation Must file letter of intent by October 1, 2011
Enhanced Fee For Service Models Patient Centered Care Management Medical Homes Accountable Care Organizations Provider Service Networks States can implement with current fiscal intermediary, providers
Patient Centered Care Management Individual Assessments Medicare SNPs ABD Pop. California Medical Homes Accountable Care Org. Risk Stratification Individual Care Plans Interdisciplinary Care Team Case Manager Care Transition Program
Intel s expertise in technology + GE s deep healthcare experience History of innovating to solve hard problems Industry leadership and advocacy Proven world class quality We collaborate with you to create human centered solutions that improve lives.
New Funding Sources for HCBS Rebalancing produces significant additional funding for HCBS. Need to expand provider capacity and choice Need to create new provider options, for example: Housing/group homes Adult Daycare Morphing of facility providers to provide community based care Need for provider contracting/credentialing and oversight Increased need for care coordination and case management Integrated programs and Medicare Special Needs Plans can fund HCBS Services with Medicare Capitated programs can fund services that are not cost effective in uncontrolled FFS environment Significant potential for private pay products / cost sharing
Aging Network and HCBS Provider Strategies Be partners with and advisors to MCOs Establish Provider networks Move up the food chain Establish MCOs, BUT do not be exclusive Mobilize multiple funding sources Develop capabilities to provide Care Transition Services
Aging Network and Care Transition Services Care Transition Can Foster Nursing Home Diversion NH Access to Hospitals Promoted Institutional LTC Similar Access Makes HCBS an Alternative CMS Committed to Care Transition and Aging Network Role CCTP Is Just the Beginning Real Goal Is All Medicare Private Pay Programs for Medicare Patients Should Accompany Care Transition Support Medicaid Savings Also Possible with Care Transition
Can the Aging & Disability Networks position themselves to take advantage of historic Federal and State opportunities?
ILS Enterprise Solutions ILS enterprise systems and experience support rapid implementations with MCO s ILS core competencies enable seamless integration with Medicare MCO s Medicare Savings would produce significant new Medicaid Funding Program would contain LTC costs CMS permits direct negotiation with health plans
Nestor Plana, President & CEO E mail: nplana@ilshealth.com Ray Noonan, Executive Vice President, Finance E mail: rnoonan@ilshealth.com Josefina Carbonell, Senior Vice President, Long Term Care and Nutrition E mail: jcarbonell@ilshealth.com Frank Burns, former HHS Deputy Assistant Secretary for Program Operations E mail: fburns15@verizon.net
OPPORTUNITIES for Home and Community Based Providers National HCBS Conference September 13, 2011 1
MLTC = OPPORTUNITIES for HCBS MLTC = Win/Win Win MLTC = Results (for the engaged only) 2
Why? because we have a common mission RESULTS: changed lives & compelling numbers How? ENGAGE 3
WHY? SNF Hospital Skilled Nursing Facility Home Ambulatory Care Clinic Hospice Rehabilitation Facility Hospice 4
WHY? HCBS Waiver Services Nursing Home Care CONSUMER/FAMILY Behavioral Health Acute Health Medicare 5
RESULTS Community Choices Act of 2008 (CHOICES) Legislation restructured LTC Integrated Services SPOE Expanded Access Care Coordination 6
RESULTS: CHOICES In Home Capability MONITORING HCBS ACUTE ADVISORY Risk Stratification HRA MEDICARE CONSUMER DIRECTION NURSING HOME 7
Right Service, Right Time, Right Setting CHOICES for consumers Most Restrictive Money Follows the Person Specialty Unit within a Nursing Facility Nursing Facility Assisted Living/ Residential Care Least Restrictive Adult Care Home Adult Foster Care Home Home or Apartment 8
RESULTS: CHANGED LIVES James: "It's the best thing that ever happened to me, and I'm excited to be home with my wife and grandkids. Priscilla: This program gave me my independence back. 9
RESULTS: HCBS Perspective The program is the right thing to do. This is the wave of the future. The program is highly successful for consumers. Billing is much smoother, quicker, better cash flow. 10
11 RESULTS: BALANCE
12 RESULTS: Population Shift
13 HCBS OPPORTUNITY
HOW? ENGAGE Recognize common missions/goals Leverage strengths of ALL stakeholders Use lessons learned Define roles/responsibilities 14
Percentage of Medicaid LTC Expenditures in Nursing Home A/D Population (2007) Interim State Population Projections File Source: U.S. Census Bureau, Population Division, Interim State Population Projections, 2005 15